There were 848 participants in the online survey, including 436 daily users of nicotine gum, 68 occasional (non-daily) users and 344 non-users. Among the 434 daily gum users who indicated their smoking status, there were 349 former smokers (80%), 80 current smokers (18%) and 5 never smokers (1.2%). The median age of these 5 never smokers was 44 years (range 38 to 59 years), they comprised 3 women and one man (one missing answer), and 3 people who lived in the USA and one in the UK (one missing answer).
Compared with the 429 ever smokers who used the gums daily, the 5 never smokers tended to have higher nicotine gum dependence scores for all FTND-gum, CDS-gum and NDSS-gum scales, but statistically significant differences were observed only for the NDSSgum Tolerance score (never smokers: median = 0.73, ever smokers: median = -1.0, Mann-Whitney U-test: p = 0.03), which represents a difference of 1.5 standard deviation units. Three of the 4 never smokers who answered this NDSS question, but only 14% of ever smokers answered "extremely true" to: "compared to when I first started using nicotine gum, I can use many, many more nicotine gum now before I start to feel nauseated or ill" (chi-square = 13.2, p = 0.01). In addition, the duration of the current episode of nicotine gum use was longer in the 5 never smokers than in the 429 ever smokers (median = 6 years vs 0.8 years, Mann-Whitney U-test: p = 0.004).
We obtained more information by e-mail from 4 of the 5 never smokers who used the nicotine gum daily. Three of these 4 people confirmed that they had never smoked, but one woman said she had smoked a few cigarettes occasionally. Three said they had never used smokeless tobacco, but one man said he had used small amounts of tobacco snuff as a child, decades before he started using the nicotine gum. They authorized us to report their comments.
E., female, 38, USA, was using the nicotine gum for 2 years, used 5 gums/day
"I've never smoked. My sister had some nicotine gum when she was trying to quit smoking, and I happened to try a piece. It seemed to wake me up and give me an energy boost, which I liked. I don't drink coffee, so I use the gum to wake me up when I'm feeling drowsy."
S., female, 39, USA, was using the nicotine gum for 10 years, used 15 gums/day
"I have never smoked cigarettes. I started using nicotine gum by chance, when a medical student offered them to me to try. I still use them because I am addicted to nicotine, and can not seem to quit using them even if have tried."
In e-mail messages, these two participants (E. and S.) answered that they had never used smokeless tobacco, had never abused or been dependent on other substances and had never been diagnosed with a psychiatric illness. In the online questionnaire, these 2 never-users of tobacco reported addiction levels to the gum of 95 and 98 on a scale of 0–100, FTND-gum ratings of 2 and 5, CDS-gum ratings of 44 and 56 and NDSS-gum ratings of -0.9 and 0.42.
Both answered "extremely true" to: "I use nicotine gums because I am addicted to them" and: "I use nicotine gum because I a cannot stop using them" and: "I use nicotine gum to deal with stress". Both reported that stopping using all NRT products would be "very difficult". Both "fully agreed" with: "after a few hours without chewing a nicotine gum, I feel an irresistible urge to chew one", "I am a prisoner of nicotine gum" and: "after chewing a nicotine gum, I am able to concentrate better". Both "seriously considered" stopping NRT in the next 6 months. One had made a serious attempt to stop using the gums during the previous year, during which she felt a "very strong" urge to use nicotine gum. This failed quit attempt lasted 30 days.
In the online survey, three additional participants reported being never smokers. Two of them could be further contacted by e-mail:
G., female, 59, USA, was using the nicotine gum for 10 years, used 10 gums/day
"During the time [my husband] was a smoker, I was a "social smoker". I would smoke at parties [his cigarettes] and occasionally at home after dinner or with a drink. I never bought or carried cigarettes with me, I only smoked his or on occasion my co-worker's. [...] About 15 years ago, my husband [...] started chewing prescription Nicorette, and I chewed it occasionally as well. When it became available over the counter, we both just continued to chew it, and I became more and more addicted to it. I started with one or two pieces occasionally, then one or two a day, and finally up to a dozen pieces a day, and continued at the rate for several years, maybe 4–5 years [...]. It is really awful to be addicted to a substance, and I reached a point where my throat hurt, my teeth hurt, I had a headache most days, [...] but I still kept chewing. And it is so expensive – I was spending over a $100 a month on it."
In an e-mail message, this participant (G.) said she had never used smokeless tobacco and had never abused or been addicted to other substances. She had been diagnosed with depression after a severe traumatic stress and took antidepressants (paroxetine) for several years after that. She said: "I think the depression was a natural reaction to [the traumatic stress]. Nicotine was part of my self-medication duringall this".
A., male, 49, UK, was using the nicotine gum for 6 years, used 20 gums/day
This participant reported that he had occasionally used small quantities of tobacco snuff as a child, between the age of 11 and 14, but not any more since then. He also said he had suffered from depression and had been prescribed fluoxetine by his family doctor. He reported:
"I have never smoked any tobacco product or even marijuana in my life. I have experimented with LSD, psilocybin, amphetamines but not currently using any of these. Several years ago, purely out of interest I bought a pack of nicotine gum to see what the effect of nicotine would be. I remember feeling quite ill [...]. It was about a year or so later [...], I remembered my pack of nicotine gums and started to use them maybe two or three times a day. I didn't expect that I would ever become addicted [...]. Within a short period of time I was using 15 pieces per day. Just as people say about smoking, I genuinely enjoyed using the gum [...]. On several occasions I stopped using it 'cold turkey'. The symptoms were mainly light headedness and difficulty in concentration, most of the time I just bought more gums – like a smoker [...]. Most of my life I have suffered from depression [...]. I hadn't considered until then that nicotine could have such a stabilising effect. I would very much like to quit. The gum is very expensive [...]. Nicotine gum is a form of self-medication [...]. I would argue that my state of mind has become more calm and regulated since using nicotine gums and reverts to previous, unsatisfactory state when I stop using nicotine gums. [...] I started using the illicit drugs above shortly before using nicotine gums on a regular basis."
These two participants (G. and A.) reported levels of addiction to the gums of 80 and 95 on a 0–100 scale, FTND-gum ratings of 5 and 6, CDS-gum ratings of 50 and 55 and NDSS-gum ratings of -0.21 and 0.67. Both answered "extremely true" to: "I use nicotine gums because I am addicted to them". Both had made a serious attempt to stop using NRT in the previous year, but only one reported more details about that quit attempt, which lasted 60 days and was accompanied with "very strong" urges to use nicotine gum. Both reported usually chewing their first gum of the day 10 minutes after waking up, both "fully agreed" with: "after a few hours without chewing a nicotine gum, I feel an irresistible urge to chew one", "the idea of not having any nicotine gum causes me stress", "sometimes I drop everything to go out and buy nicotine gums", "chewing a nicotine gum calms me down when I am stressed", and: "after chewing a nicotine gum, I am able to concentrate better".