Not All Nicotine-Replacement Products Are Equal

Blacks, obese do better on nasal spray, while whites have more success with patch

MONDAY, March 15, 2004 (HealthDayNews) -- Which nicotine-replacement product will work for you may depend on what kind of smoker you are.

According to a new study, blacks, the obese and those highly dependent on nicotine may have better luck quitting smoking if they use nicotine-laden nasal sprays, while whites, the non-obese and low-dependent types appear to have a better chance with the nicotine patch.

If the findings are borne out in larger trials, the day might come when "doctors might be able to choose the type of nicotine-replacement therapy based on some measures from the smoker, to pick the therapy that's going to be most effective," says study author Caryn Lerman, a professor of psychiatry at the University of Pennsylvania's Abramson Cancer Center.

Her team's study appears in the March 15 issue of Annals of Internal Medicine.

Despite decades of warnings about the dangers of smoking, a quarter of all American adults still light up. One bright spot in the war against smoking has been the emergence of nicotine-replacement agents such as nicotine patches, chewing gum and nasal sprays.

While quit rates for smokers on nicotine-replacement therapy remains low -- only about 10 percent to 15 percent of users remain nonsmokers for more than six months -- they do seem to help, "doubling the quit rate of people that go cold turkey," says Dr. Michael Thun, a spokesman for the American Cancer Society.

But are some nicotine-replacement products better than others? In their study, Lerman and her team assigned nearly 300 smokers with an expressed interest in quitting to either the Nicoderm patch or Nicotrol nasal spray. With the patch, a steady flow of nicotine is absorbed into the body via the skin, while the spray eases cravings with a quick spritz of nicotine-loaded mist.

According to the researchers, smoking abstinence rates at six months were similar for both groups -- about 12 percent for those using the spray and 15 percent for patch users. Those numbers are in keeping with previous studies into the effectiveness of nicotine-replacement agents.

More intriguing were results regarding which products worked best for specific types of individuals. Whites, the non-obese and low-dependency smokers had better luck quitting over the long term if they used the patch rather than the nasal spray, the researchers found.

On the other hand, blacks, smokers who were obese (a body mass index of 30 or higher) and smokers who were highly dependent on nicotine fared much better if placed on the spray.

Lerman says there are theories -- as yet untested -- explaining why the spray may work better for these types of smokers. Obese smokers "may have more of a need for reinforcement from things like food -- but also nicotine," she explains.

"The patch provides steady levels of nicotine and it's sort of 'passive' nicotine replacement, there's nothing the smoker is doing," Lerman says. "But with the spray, when a smoker feels the need for that rush of nicotine they can use the nasal spray. The nicotine goes to the brain more rapidly and provides more positive reinforcement."

This theory may also explain why the spray works better for highly nicotine-dependent individuals, as well, she says.

The smoking habits of blacks may explain why they have higher quit rates on the spray compared with those seen in white smokers. According to Lerman, menthol cigarettes are more popular among black smokers than whites, and smokers looking to replace the added sensory 'kick' of menthol may get greater satisfaction from a nasal spray than from the passive patch.

Also, "there are studies showing that [blacks] smoke their cigarettes more efficiently, they may inhale more deeply, take more puffs, and extract more nicotine," Lerman says. "So again, in that same vein, a replacement method that produces that rush of nicotine may be more pleasurable."

Thun, head of epidemiological research at the American Cancer Society, says he welcomes any fresh insights into helping smokers quit.

"Quitting smoking is hard. It's comparable in difficulty to quitting heroin, cocaine and other illegal street drugs," he says. "Any approach that makes it easier for smokers to succeed in quitting is a major advance."

Friends and family can be key in keeping smokers away from cigarettes over the long-term, and Thun suggests getting kids in on the act, as well.

"When my sister quit -- which was extremely hard -- she was very attached to my kids," he notes. "They made a calendar, and they gave her stickers. She could put stars on the calendar if she didn't smoke that day. They gave her other suggestions, too. It really brings out the best in you -- one does not want to let kids down."

Thun worries, though, that a recent slump in sales of nicotine-replacement products might be linked to recent moves by the tobacco industry. "There's a big concern that a substantial subgroup of smokers may be placing their hopes -- falsely -- in novel nicotine-delivery devices that the tobacco industry has developed," he says.

These products include so-called "light" cigarettes, smokeless tobacco and other products. "They all contained the same amount of nicotine, so they were in no way effective steps towards quitting," Thun says. "Quitting is hard, it takes a lot of guts. But these alternatives are false promises."

Both Thun and Lerman believe the ultimate goal -- quitting smoking for good -- is within each smoker's reach.

"What we need to do is design better treatments and also to be able to tailor-treat individual smokers," Lerman says. She cautions, however, that the results of this small study need to be validated in larger trials. However, "if there is a smoker who's highly nicotine-dependent and who is obese, and maybe they've tried the nicotine patch before, it may be worthwhile to ask their physician to prescribe the nicotine nasal spray and try that as an alternative," Lerman says.

The nicotine patch is available in the United States either by prescription or over-the-counter. The nicotine nasal spray is currently available only by prescription.

Lerman's study was funded by grants from the National Cancer Institute and the National Institute on Drug Abuse.

More information

For help in quitting smoking, visit the American Cancer Society or the National Cancer Institute.

SOURCES: Caryn Lerman, Ph.D., professor, department of psychiatry, Abramson Cancer Center, University of Pennsylvania, Philadelphia; Michael Thun, M.D., head, epidemiological research, American Cancer Society, Atlanta; March 15, 2004, Annals of Internal Medicine
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