Diet & Nutrition

How safe are nicotine replacements?

It is similar to using methadone long-term instead of heroin.

By Clair Weaver
To smokers, nicotine replacement therapy is presented as a logical treatment in the often fraught battle to quit cigarettes. But critics argue NRT is not the panacea that pharmaceutical companies would have us believe. So who is right?
Like most smokers, Kate wishes she’d never taken up her habit. At 56, she’s been addicted for the best part of 40 years. Sure, she’s tried to quit – even staying off cigarettes for up to a year on a few occasions – but she inevitably relapses.
But now, with hopes of becoming a grandmother in coming years, she’s ready to try and quit again. Concerned she doesn’t have the willpower to do it on her own, she’s going to try nicotine patches on the recommendation of her local chemist.
In many ways, Kate’s experience is typical: she’s tried multiple times to quit and although the logical side of her brain wants to stop, there are emotional and physical connections to smoking that are harder to break. So is nicotine replacement therapy [NRT] the answer?
It’s testament to Australia’s strong public health advocacy and progressive government policies that we have one of the world’s lowest smoking rates at 12.8%. Only 20 years ago, it was a very different picture with one in four of us puffing away. However, most people who have quit between then and now are likely to have done so unassisted, according to Simon Chapman, professor in public health at the University of Sydney.
“The data tells us that between 2/3 and 3/4 of people who used to smoke and don’t now quit without any assistance,” says Prof Chapman, a pioneering tobacco control activist. “I am not anti-medication but people ought to be encouraged and inspired by the fact that a lot of people have quit without assistance.”
Dr Colin Mendelsohn, a GP and tobacco treatment specialist who receives funding from pharmaceutical companies GlaxoSmithKline and Johnson & Johnson that produce NRT brands like Nicabate and Nicorette, claims the odds of quitting long-term totally unassisted are low. He says clinical trials show NRT can improve success rates by 60 per cent.
The problem is, points out Prof Chapman, relapse rates are high on all quit methods and the conditions of a clinical trial are very different to the real world.
A recent development in smoking is its shift in classification from bad habit to medical condition. Today “tobacco use disorder” is listed in the latest version of the psychiatric bible, the Diagnostic and Statistical Manual.
And this is where the pharmaceutical companies come in with medicines. Among them are NRTs in various forms (including patches, lozenges, gum and inhalers) and prescription drugs that interfere with the effects of nicotine on the brain like Champix and Zyban (also sold as Clorpax or Prexaton). Of these, NRT is most easily available, over the counter in pharmacies or supermarkets.
NRT works by giving users a dose of nicotine, which is the addictive ingredient in cigarettes. Although nicotine has negative health effects, it is far less harmful to your health on its own and in a controlled dose than smoking cigarettes, which contain 7,000 chemicals including 70 known carcinogens.
The theory is that by continuing to take nicotine, smokers can more comfortably work on ridding themselves of the behavioural or ritual side of their habit. “We find most people don’t need [NRT] anymore after the 12-week period,” says Luke Atkin of Quit Victoria, part of a nationwide phone hotline network funded by state and territory governments.
But The Weekly’s Professor Kerryn Phelps says she hardly ever recommends NRT to patients. “Quitting smoking without nicotine is better,” she says. ““What you are doing [with NRT] is replacing an addictive cocktail of dangerous chemicals with a single addictive chemical.” She warns nicotine can have side-effects like interrupted sleep, headaches and palpitations.
Once upon a time smoking was très chic, now Australia boasts the world's lowest smoking rates at 12.8 per cent.
At his smoking cessation clinic in Sydney, Dr Mendelsohn, who is also vice-president of the Australian Association of Smoking Cessation Professionals, says he recommends NRT along with counselling and support to about 80 per cent of his patients.
As well as funding from companies that produce NRT products, Dr Mendelsohn is on the advisory board for Champix, the smoking cessation drug made by Pfizer. But he says this doesn’t influence him in his work. “I am a professional and I do what I think is best for my patients,” he says.
Controversially, Dr Mendelsohn believes the main problem with NRT is that smokers aren’t taking high enough dosages nor staying on it for long enough. Pre-menopausal women, in particular, he says need higher doses as they metabolise nicotine faster – and even more so if they are pregnant.
But even though NRT is a less harmful delivery system than cigarettes, doctors know that nicotine is not good for an unborn baby’s brain, lung development nor growth. Another period when the brain is undergoing major development - and nicotine could therefore pose a risk - is adolescence.
In Australia, all smokers aged 12 and over can get access to cheap or free NRT while trying to quit under the Pharmaceutical Benefits Scheme. If they want more after the standard 12-week course, however, they have to pay for it out of their own pocket. And at about $50 for a two-week pack of patches or $30 for a large box of gum, it isn’t cheap.
“There’s plainly a commercial agenda,” says Prof Chapman. Some ex-smokers continue to use NRT for years. Dr Mendelsohn has no objections: “It is similar to using methadone long-term instead of heroin,” he says.
At Sydney Integrative Medicine, there’s a different approach. Prof Phelps focuses on helping patients figure out their motivation for smoking and develop new behaviours, such as replacing a ritual cigarette with a pot of herbal tea and enlisting the support of friends. “The actual physical addiction doesn’t last very long,” Prof Phelps adds.
Is there a right way to butt out?
As for Kate, whom we met at the beginning of this story, evidence suggests she will have a better chance of quitting if she gets support from the people around her. While NRT may assist, she has a lot of work to do in breaking other parts of her well-entrenched habit.
Smokers are advised they can either stop or gradually taper their cigarette consumption when they start using NRT. Dr Mendelsohn says there are no safety concerns about smoking and using NRT at the same time, despite the fact doing both significantly increases the user’s overall nicotine intake. But Prof Phelps doesn’t recommend smoking and using NRT at the same time because of her concerns about the effects of high levels of nicotine on health and ability to quit.
E-cigarettes – battery-operated devices resembling cigarettes that create a vapour, usually containing nicotine, for inhalation - are not approved by the national medicines regulator, the Therapeutic Goods Administration, for use in Australia, although they have shown promising early results as a quitting aid. There are concerns about labelling, impurities, leaking cartridges, potential for child poisoning, renormalising smoking behaviour, a new smoking gateway, discouraging quitting and creating a new market for the tobacco industry to get involved in.
If you want advice on quitting smoking, seek advice from your GP or call the national Quitline on 13 78 48
A version of this article originally appeared in the October 2014 issue of The Australian Women's Weekly.

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