Version May 2024
| Patients should stop smoking and/or vaping when NRT is initiated. |
| Transdermal patches |
| Patches are available without prescription for adults; a prescription is required in the United States for individuals under 18 years. |
| The advantages of patches are that they are very simple to use and provide steady action over the course of the day. However, patients may need an additional short-acting agent (gum, spray, or lozenge) to respond to acute nicotine craving. |
| Several strengths are available; the patient should follow the package directions to choose the appropriate strength based on their history of tobacco use. Most heavy smokers begin with a high-strength patch (eg, 21 mg/patch) and gradually decrease the strength over 6 to 8 weeks. Patients who are light smokers or who weigh less than 100 lbs (45 kg) should start with a lower-strength patch. |
| Each patch can be used for 24 hours. If patients have problems sleeping, they may prefer to remove the patch at bedtime (16-hour patch). |
| Patches are applied to a clean, dry, hairless area of skin (usually trunk or neck) and removed at the end of the day (16 hours) or the next day (24 hours). |
| Skin irritation is the most common side effect; to minimize this problem, rotate the patch to different sites each day. |
| Gum* |
| Nicotine replacement therapy gum is available in 2 mg and 4 mg strengths without prescription for adults; a prescription is required in the United States for individuals under 18 years. |
| The advantage of nicotine gum is that it increases nicotine levels quickly, so it can be used to respond to an acute craving. For some patients, gum is not effective, because they do not use it often enough or chew for long enough. |
| The nicotine from the gum is absorbed through the oral mucosa and is optimized by a sequence of chewing and "parking" the gum between the cheek and gums. Chewing gum too vigorously usually results in more nicotine being swallowed. This is not dangerous but reduces nicotine absorption and may also cause local irritation and hiccups. |
| Most heavy smokers use the 4 mg strength gum. Patients who are light smokers or who weigh less than 100 lbs (45 kg) should start with the 2 mg strength. |
| Patients with significant symptoms of nicotine dependence typically start with chewing a piece of gum every 1 to 2 hours and use at least 9 pieces a day, up to a maximum of 24 pieces a day. |
| Patients should not eat or drink for 15 minutes before chewing the nicotine gum or while chewing a piece. |
| Each piece of gum should be chewed slowly to release the nicotine. After a few minutes of chewing, the nicotine will be released, indicated by a hot, peppery taste. The gum should then be "parked" between the cheek and gums so that the nicotine can be absorbed. The process of slowly chewing then "parking" the gum should be repeated every few minutes until most of the tingle is gone (about 30 minutes). |
| Lozenge* |
| Oral lozenges are available without prescription for adults; a prescription is required in the United States for individuals under 18 years. |
| Like nicotine gum, lozenges increase nicotine levels rapidly (peak levels at 20 to 30 minutes) and may be helpful for acute nicotine craving. |
| Patients should suck the lozenge until it dissolves; lozenges should not be chewed or swallowed. |
| Most smokers should use the 2 mg dose lozenge. Patients with significant symptoms of nicotine dependence (eg, those who smoke within 30 minutes of awakening) may require the 4 mg lozenge. |
| Patients should start by taking 1 lozenge every 1 to 2 hours during the first few weeks of smoking cessation, then gradually decrease the frequency over the next 2 months. They should not take more than one lozenge at a time or take one lozenge after another. |
| Inhalers* |
| Nicotine inhalers are available by prescription. |
| The inhaler consists of a mouthpiece and a replaceable nicotine cartridge. When the smoker inhales through the cartridge, nicotine vapor is deposited in the mouth and throat and absorbed through the mucosa. |
| The pharmacokinetics of nicotine delivery are similar to gum, but some patients prefer the inhaler because its use mimics the action of smoking and provides some behavioral replacement. |
| Smokers should use the inhaler for a 20-minute puffing session about once an hour. Each cartridge can be used for 4 20-minute puffing sessions. |
| Patients with significant symptoms of nicotine dependence should start with 6 to 16 cartridges per day and gradually decrease over up to 12 weeks. |
| Nasal spray |
| Nicotine nasal spray is available by prescription. |
| Nasal spray produces a more rapid rise in nicotine level than orally absorbed products (gum, lozenge, and inhaler), so it may provide the most rapid relief of nicotine craving symptoms. |
| Studies of nasal spray in adolescents had a high dropout rate due to irritant side effects. |
| The main side effects are nasal irritation and burning, as well as unpleasant taste and smell; all of these tend to improve after a few days of use but may not resolve completely. |
| Proper technique is important to review with patients. They should use 1 spray in each nostril, without sniffing or inhaling, and should not blow their nose for 2 to 3 minutes after spraying. |
| The spray is used at least 8 times per day, with a maximum of 5 doses per hour or 40 doses per day. The frequency of use is gradually decreased over 2 to 3 months. |
| Combination therapy |
| Combining nicotine replacement products increases abstinence rates. |
| The nicotine patch is usually combined with 1 of the oral products (gum, lozenge, or nasal spray). The patch provides a steady level of nicotine to prevent withdrawal symptoms, and the oral product can provide a more rapid surge of nicotine to respond to an acute craving to smoke. |
| If products are combined, the optimal dose may be less than those outlined above. For example, if a patch effectively reduces nicotine craving, a patient may choose to use nicotine gum or lozenge only a few times a day, when they have an acute urge to smoke. |
NRT: nicotine replacement therapy.
* Oral products can be used on a regular schedule to avoid nicotine withdrawal symptoms and can also be used to relieve acute urges to smoke. Each of these may have an initial unpleasant taste, which can be a barrier to correct use; most users become tolerant to the taste within a few days. Patients should not eat or drink acidic beverages (coffee, juice, or soda) for 15 minutes before or during use of these oral products.Table courtesy of Drs. Joseph Rosen and Marianna Sockrider.
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