What is the recommended starting dose of nicotine (NRT) patch for a patient smoking 1 pack per day (ppd)?

Nicotine Patch Dosing for 1 Pack Per Day Smokers

For patients smoking 1 pack per day (20 cigarettes), the recommended starting dose is a 21 mg nicotine patch. 1, 2, 3

Dosing Rationale and Schedule

The appropriate nicotine patch dose is determined by daily cigarette consumption:

• For smokers of >10 cigarettes per day (which includes 1 ppd smokers), start with 21 mg patch daily 1, 2
• For smokers of ≤10 cigarettes per day, start with 14 mg patch daily 1, 3

Standard Step-Down Schedule for 1 PPD Smokers

• Weeks 1-4: 21 mg patch daily
• Weeks 5-6: 14 mg patch daily
• Weeks 7-8: 7 mg patch daily 3

Optimizing Treatment Success

Combination Therapy

• Consider adding a short-acting NRT form (such as nicotine lozenge or gum) to the patch for better craving control 2
• When using lozenges or gum, the strength should be determined by time to first cigarette:
  • If first cigarette is ≤30 minutes after waking: 4 mg strength
  • If first cigarette is >30 minutes after waking: 2 mg strength 1, 2

Administration Tips

• Apply patch once daily to clean, dry, hairless skin
• Hold for 10 seconds after application to ensure adhesion
• Apply a new patch at the same time each day
• Use a different skin site for each new application
• Wash hands after applying or removing the patch 3

Common Pitfalls to Avoid

1. Underdosing: Starting with too low a dose (14 mg) for a 1 ppd smoker can lead to inadequate nicotine replacement and withdrawal symptoms 2

2. Premature discontinuation: Treatment should continue for at least 8-12 weeks for optimal effectiveness 2

3. Failing to address breakthrough cravings: Using the patch alone without a short-acting NRT form may lead to breakthrough cravings and relapse 2

4. Smoking while using the patch: This can lead to nicotine toxicity and should be avoided 2

5. Improper patch placement: Applying to areas with hair, lotion, or oil can reduce absorption

Safety Considerations

• Common side effects include local skin reactions (15.8% of users), nausea, and sleep disturbances 2
• If vivid dreams occur, the patch may be removed at bedtime and a new one applied in the morning 3
• Blood nicotine levels from NRT remain significantly lower than from smoking cigarettes, reducing risk of nicotine-related adverse effects 2

The evidence clearly shows that appropriate NRT dosing doubles the chance of successful smoking cessation, with combination NRT being more effective than single forms (RR 1.25,95% CI 1.15 to 1.36) 2, 4.