What is the correct starting combination Nicotine Replacement Therapy (NRT) for a patient who smokes half a pack of cigarettes per day?

From the Guidelines

For a patient who smokes half a pack of cigarettes per day, the recommended starting Nicotine Replacement Therapy (NRT) would be a 14 mg/day nicotine patch combined with a short-acting NRT form such as 2 mg nicotine gum as needed for breakthrough cravings, given that their first cigarette is 1 hour after waking, which suggests a lower nicotine dependence level 1.

Key Considerations

• The patient's smoking level is approximately 10 cigarettes per day, which guides the dosing of NRT according to the number of cigarettes smoked per day (CPD) 1.
• The nicotine patch provides a steady dose of nicotine throughout the day, helping to manage withdrawal symptoms, while the short-acting NRT (in this case, 2 mg nicotine gum) is used as needed to address breakthrough cravings 1.
• The choice between 2 mg and 4 mg nicotine gum is based on the timing of the first cigarette after waking; since this patient's first cigarette is after 1 hour, the 2 mg gum is appropriate 1.

Application and Usage

• The nicotine patch should be applied once daily to clean, dry, non-hairy skin, rotated to different sites each day, and worn for 16-24 hours.
• The short-acting NRT (2 mg nicotine gum) should be used as needed when cravings occur, typically up to 24 pieces per day, with proper technique (for gum: chew until peppery taste emerges, then "park" between cheek and gum).

Duration and Adjustment

• Treatment typically continues for 8-12 weeks, with possible gradual reduction in patch strength (to 7 mg/day) after 4-6 weeks based on withdrawal symptoms and cravings 1.
• This regimen is appropriate for moderate smokers and helps manage withdrawal symptoms while reducing the reinforcing effects of smoking.

From the FDA Drug Label

if you smoke more than 10 cigarettes per day, use the following schedule below: Weeks 1 thru 2 Weeks 5 and 6 Weeks 7 and 8 Step 1 Step 2 Step 3 Use one 21 mg patch/day Use one 14 mg patch/day Use one 7 mg patch/day if you smoke 10 or less cigarettes per day, start with Step 2 for 6 weeks, then Step 3 for 2 weeks

The patient smokes ½ pack of cigarettes a day, which is equivalent to 10 cigarettes per day.

• The correct starting dose of the nicotine patch is 21 mg for patients who smoke more than 10 cigarettes per day, but since the patient smokes exactly 10 cigarettes per day, we should consider the instruction for 10 or less cigarettes per day.
• For patients who smoke 10 or less cigarettes per day, the instruction is to start with Step 2, which is 14 mg.
• The nicotine gum dose is not specified in the label for combination therapy, but based on common practice, 4 mg is often used for patients who smoke more than 10 cigarettes per day, and 2 mg for those who smoke less.
• Since the patient smokes 10 cigarettes per day, and considering the options provided, the most appropriate combination would be Nicotine patch 14 mg (as the patient is instructed to start with Step 2) and Nicotine gum 2 mg or 4 mg.
• Given the options, Nicotine patch 14 mg, apply 1 patch daily + Nicotine gum 2 mg, 1 piece every 1-2 hours as needed, max 24 pieces or Nicotine patch 14 mg, apply 1 patch daily + Nicotine gum 4 mg, 1 piece every 1-2 hours as needed, max 24 pieces could be considered, but the label does not provide a clear recommendation for the gum dose in combination therapy.
• However, the provided label does not directly support the use of Nicotine gum 4 mg for a patient smoking 10 or less cigarettes per day in combination with the patch, but common practice and other guidelines might.
• Therefore, based on the information given and common clinical practice, the best choice among the provided options, considering the patient's smoking habit, would be Nicotine patch 14 mg, apply 1 patch daily + Nicotine gum 2 mg, 1 piece every 1-2 hours as needed, max 24 pieces 2.

From the Research

Combination NRT Recommendation

To determine the correct starting combination NRT recommendation for a patient who smokes half a pack of cigarettes per day, we need to consider the evidence from various studies.

• The patient's smoking habits: half a pack of cigarettes per day, with the first cigarette 1 hour after waking up.
• The goal of combination NRT: to replace nicotine from cigarettes and ease the transition to abstinence.

Evidence from Studies

• A study published in 2019 3 found that combination NRT (fast-acting form + patch) results in higher long-term quit rates than single-form NRT.
• The same study found that 21 mg patches are more effective than 14 mg patches, and that 4 mg gum is more effective than 2 mg gum for highly dependent smokers.
• Another study published in 2002 4 states that NRT doubles the chance of success for those who try to stop smoking, and that it reduces withdrawal symptoms.
• A review of the literature published in 2013 5 found that combination NRT likely represents the most promising strategy to enhance NRT efficacy.

Correct Starting Combination NRT Recommendation

Based on the evidence, the correct starting combination NRT recommendation for a patient who smokes half a pack of cigarettes per day is:

• Nicotine patch 21 mg, apply 1 patch daily + Nicotine gum 4 mg, 1 piece every 1-2 hours as needed, max 24 pieces.

This recommendation is supported by the studies mentioned above, which suggest that combination NRT with a 21 mg patch and 4 mg gum is an effective strategy for smoking cessation, especially for highly dependent smokers.