Nicotine addiction explained — and how medications can help

NOT TOO KOOL –

July 27, 2021 – Addiction is now understood to be a chronic neurological disorder that, like other chronic diseases, responds to treatment. Ideally, management of nicotine addiction combines medications to suppress cravings with counseling to help patients reprogram their behavior, just like treatments for high blood pressure and type 2 diabetes often combine medication with counseling for stress management or behavior change.

The FDA has given varenicline (Chantix) an indication for smoking cessation. It works by blocking and partly activating the nicotine binding spot in the central nervous system, reducing the pleasurable effects of smoking while also reducing withdrawal by releasing dopamine (the chemical that signals brain reward) — though in lower amounts than nicotine. Large studies have found varenicline to be effective and well tolerated: compared to those who received placebo, smokers who received varenicline while trying to quit were more than two and a half times more likely to be cigarette-free one year after entering the trial.

Recently, efforts to help smokers quit were dealt a setback when nine lots of varenicline were recalled because some tablets could contain levels of potential carcinogens called nitrosamines above the acceptable limit set by the FDA. This information is surely of concern to smokers, though given the enormous burden of cigarette smoking on health, the risk-benefit ratio may still be in favor of using medication for people who can successfully quit. Indeed, the FDA has indicated that there is no immediate risk to people taking varenicline and is not recommending that people stop using it, though the recall may result in shortages.

Nicotine replacement medications, such as gums, lozenges, or patches, can also help people quit smoking by relieving symptoms of withdrawal, which are often a major obstacle to quitting. Because oral ingestion and skin absorption of nicotine are slower and result in much lower peak levels than smoking, these forms of nicotine are less rewarding than inhaled nicotine, and can help smokers taper off with fewer withdrawal symptoms and cravings. Bupropion, an antidepressant (brand names Wellbutrin, Zyban, and others), also can help smokers quit by mimicking the effects of nicotine, thus reducing withdrawal symptoms.