What is the recommended nicotine replacement therapy (NRT) regimen for a 66-year-old male patient with moderate nicotine dependence, as indicated by a Fagerstrom Test for Nicotine Dependence (FTND) score of 5, who smokes 9 cigarettes per day and wants to quit smoking using over-the-counter (OTC) therapy?

Nicotine Replacement Therapy Recommendation for a 66-Year-Old Male with Moderate Nicotine Dependence

For this 66-year-old male patient with moderate nicotine dependence (FTND score of 5) who smokes 9 cigarettes per day and wears full dentures, the recommended nicotine replacement therapy regimen is: Weeks 1-6: 14 mg patch/day; weeks 7-8: 7 mg patch/day.

Rationale for Dosing Selection

Assessment of Nicotine Dependence

• The patient has an FTND score of 5, indicating moderate nicotine dependence
• He smokes 9 cigarettes per day (≤10 cigarettes/day), which classifies him as a lighter smoker
• His first cigarette is smoked 2 hours after waking, suggesting moderate dependence

Appropriate Dosing Based on Guidelines

• The National Comprehensive Cancer Network and American Academy of Pediatrics guidelines recommend initial NRT dosing based on cigarettes smoked per day 1, 2
• For lighter smokers (≤10 cigarettes/day), a 14 mg patch is the appropriate starting dose 2
• A step-down approach is recommended, with 14 mg patch for weeks 1-6, followed by 7 mg patch for weeks 7-8 2

Special Considerations for This Patient

• The patient wears full dentures, which makes oral NRT options (gum, lozenges) potentially problematic
• Transdermal patches are easier to use and don't require oral manipulation, making them ideal for patients with dentures 1
• The 21 mg patch is typically recommended for heavier smokers (>10 cigarettes/day), making it excessive for this patient 2

Implementation Strategy

Application Instructions

• Apply one patch daily to clean, dry skin on the upper body or outer arm
• Apply the patch at the same time each day
• Rotate application sites to prevent skin irritation
• Do not smoke while using the patch to avoid nicotine toxicity 2

Duration of Therapy

• Complete the full 8-week course (6 weeks of 14 mg, 2 weeks of 7 mg)
• Premature discontinuation increases relapse risk 2
• Some patients may benefit from extended therapy beyond 8 weeks if needed 1

Monitoring and Follow-up

Initial Follow-up

• Schedule follow-up within 2-3 weeks to assess efficacy and side effects 2
• Monitor for common side effects including:
  • Local skin reactions at application site (reported in ~15.8% of users)
  • Nausea, vomiting, sweating
  • Sleep disturbances 2

Adjusting Therapy if Needed

• If the patient experiences persistent cravings or withdrawal symptoms:
  • Consider adding a short-acting NRT form for breakthrough cravings (though this may be challenging with dentures)
  • Consider extending the duration of the 14 mg patch before stepping down 1, 2

Relapse Prevention

• Continue periodic monitoring at minimum 12-week intervals 2
• If relapse occurs, consider resuming NRT with additional behavioral support 2

Efficacy and Expectations

• NRT doubles the chance of successful smoking cessation 3
• Combination with behavioral counseling significantly improves success rates 1, 2
• The patient should be advised that NRT reduces withdrawal symptoms but does not eliminate them entirely 1
• The risk of becoming dependent on NRT is low compared to continued cigarette smoking 2

Important Caveats

• Blood nicotine levels from NRT remain significantly lower than from smoking cigarettes 1
• NRT is not a complete replacement for cigarettes and does not replace the need for willpower 1
• The patient should be advised about expected weight gain (average 5 kg) when quitting smoking, but reminded that the health benefits of cessation far outweigh this risk 2