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Nicotine replacement products have low abuse liability, especially compared to tobacco products. Long-term use of nicotine medications is rare, and likely to be much less risky than smoking cigarettes and therefore an overall health benefit if the individual is no longer smoking.

A distinction must be made between misuse, abuse and dependence.
Misuse can be defined as the extent to which a medication is likely to be used other than for therapeutic purposes. In a study from USA, misuse occurred in a minority (about 20%) of smokers who had used NRT to either reduce their smoking or to relieve withdrawal during smoking restrictions (Levy et al., 2007) [these indications exist in other countries].  Use of NRT by never-smokers is uncommon and rarely causes dependence (Etter, 2007; Hyland et al., 2005; Klesges et al., 2003), despite widespread availability.

Abuse (or harmful use) is defined by ICD and DSM as repeated use that causes harm.  Long-term use of NRT has been studied in only one study (Murray et al., 1996), and this study found no evidence of harm. 

The abuse liability of NRT products is substantially less than that of cigarettes (Royal College of Physicians, 2008). This is in part because of lower doses and slower absorption of nicotine obtained from NRT products compared with nicotine obtained from tobacco smoke inhalation (de Wit, 1998; Henningfield and Keenan, 1993; Le Houezec, 2003). Abuse liability may not be equal across all medications and is likely to be greatest with those products that deliver nicotine rapidly (e.g. nasal spray). Abuse liability also appears to be influenced by the unpleasant side effects of gum, spray and inhaler (Schuh et al., 1997; West et al., 2000). Further, NRT products are more costly and, except for those available over-the-counter, more difficult to obtain than nicotine-containing cigarettes. Thus, their abuse potential is considered to be minimal.

Dependence potential refers to the extent to which those engaging in use of a product have impaired control over use of the product (e.g. cannot stop or use in binges). West et al (2000) comprehensively examined the dependence potential of four currently available NRT products: gum (2 or 4 mg), transdermal patch (15 mg), nasal spray and inhaler (all Nicorette brands). Subjects (n=504) quit smoking and were randomly assigned to use of the products for 12 weeks. Both subjective effects and behavioral dependence (defined as continued use beyond the recommended duration) were assessed. Although some subjects reported that they felt dependent on their NRT product, the percentages of subjects continuing use at three weeks after the recommended stop date were 2% for patch, 7% for gum and inhaler, and 10% for spray.  In addition, in other studies, only a minority of long-term use appears to be due to dependence; most appears to be due to extending the therapeutic efficacy (Hughes et al., 2004; Hughes et al., 2005). Similar results have been obtained in surveys of more real-world settings (Hajek et al., 2007; Shiffman et al., 2003a, Shiffman et al., 2003b).

Levy DE, Thorndike AN, Biener L, Rigotti NA. Use of nicotine replacement therapy to reduce or delay smoking but not to quit: prevalence and association with subsequent cessation efforts. Tob Control. 2007; 16: 384-389.

Etter JF. Addiction to the nicotine gum in never smokers. BMC Public Health. 2007; 7: 159.

Hyland A, Bradford D, Gitchell J. Drug counselor report of adolescents abuse of nicotine replacement therapy. J Addict Dis. 2005; 24: 105-113.

Klesges LM, Johnson KC, Somes G, Zbikowski S, Robinson L. Use of nicotine replacement therapy in adolescent smokers and nonsmokers. Arch Pediatr Adolesc Med. 2003; 157: 517-522.

Murray RP, Bailey WC, Daniels K, Bjornson WM, Kurnow K, Connett JE, Nides MA, Kiley JP. Safety of nicotine polacrilex gum used by 3,094 participants in the Lung Health Study. Lung Health Study Research Group. Chest. 1996; 109(2): 438-445.

Royal College of Physicians. Radical strategies for prevention and harm reduction in nicotine addiction. London: Royal College of Physicians; 2008.

de Wit H. Individual differences in acute effects of drugs in humans: their relevance to risk for abuse. NIDA Res Monogr. 1998; 169: 176-187.

Henningfield JE, Keenan RM. Nicotine delivery kinetics and abuse liability. J Consult Clin Psychol. 1993; 61: 743-750.

Le Houezec J. Role of nicotine pharmacokinetics in nicotine addiction and nicotine replacement therapy: a review. Int J Tuberc Lung Dis. 2003; 7: 811-819.

Schuh KJ, Schuh LM, Henningfield JE, Stitzer ML. Nicotine nasal spray and vapor inhaler: abuse liability assessment. Psychopharmacology. 1997; 130: 352-361.

West R, Hajek P, Foulds J, Nilsson F, May S, Meadows A. A comparison of the abuse liability and dependence potential of nicotine patch, gum, spray and inhaler. Psychopharmacology. 2000; 149: 198-202.

Hughes JR, Pillitteri JL, Callas PW, Callahan R, Kenny M. Misuse of and dependence on over-the-counter nicotine gum in a volunteer sample. Nicotine Tob Res. 2004; 6: 79-84.

Hughes JR, Adams EH, Franzon MA, Maguire MK, Guary J. A prospective study of off-label use of, abuse of, and dependence on nicotine inhaler. Tob Control. 2005; 14: 49-54.

Hajek P, McRobbie H, Gillison F. Dependence potential of nicotine replacement treatments: effects of product type, patient characteristics, and cost to user. Prev Med. 2007; 44: 230-234.

Shiffman S, Hughes JR, Pillitteri JL, Burton SL. Persistent use of nicotine replacement therapy: an analysis of actual purchase patterns in a population based sample. Tob Control. 2003a; 12: 310-316.

Shiffman S, Hughes JR, Di Marino ME, Sweeney CT. Patterns of over-the-counter nicotine gum use: persistent use and concurrent smoking. Addiction. 2003b; 98: 1747-1753. logo
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