What is the recommended regimen for starting nicotine gum (nicotine replacement therapy) for smoking cessation?

Nicotine Gum Regimen for Smoking Cessation

For optimal smoking cessation outcomes, nicotine gum should be dosed according to time to first cigarette after waking, with 4mg strength for those who smoke within 30 minutes of waking and 2mg for those who smoke after 30 minutes of waking, following a 12-week schedule of 1 piece every 1-2 hours (weeks 1-6), every 2-4 hours (weeks 7-9), and every 4-8 hours (weeks 10-12).

Dosing Selection

Strength Selection

• Choose strength based on nicotine dependence:
  • 4mg gum: For smokers who have their first cigarette within 30 minutes of waking 1
  • 2mg gum: For smokers who have their first cigarette more than 30 minutes after waking 2

Dosing Schedule

Follow this 12-week schedule as indicated on FDA labeling 2:

• Weeks 1-6: 1 piece every 1-2 hours
• Weeks 7-9: 1 piece every 2-4 hours
• Weeks 10-12: 1 piece every 4-8 hours

Proper Usage Technique

1. Do not eat or drink for 15 minutes before or while chewing the gum 2
2. Chew-and-park technique:
   • Chew slowly until you feel a tingling sensation
   • "Park" the gum between your cheek and gum until the tingling fades
   • Resume chewing when tingling is gone
   • Repeat this cycle for about 30 minutes per piece 2
3. Minimum effective dosage: Use at least 9 pieces per day during the first 6 weeks 2
4. Maximum daily limit: Do not exceed 24 pieces per day 2

Managing Cravings

• If experiencing strong or frequent cravings, a second piece may be used within the hour 2
• Avoid using pieces continuously one after another, as this may cause side effects like hiccups, heartburn, or nausea 2

Effectiveness and Outcomes

• Nicotine gum doubles or triples abstinence rates compared to placebo 1
• The 4mg strength is particularly effective for highly dependent smokers, showing significantly better outcomes than 2mg gum in this population 3, 1
• Combination therapy (nicotine patch plus gum) is more effective than single NRT and should be considered for those with significant withdrawal symptoms 4, 5

Common Pitfalls to Avoid

1. Insufficient dosing: Many users don't use enough gum. Ensure at least 9 pieces per day during the first 6 weeks 2
2. Improper chewing technique: Chewing too quickly or continuously reduces effectiveness and increases side effects 6
3. Premature discontinuation: Complete the full 12-week treatment course for best results 2
4. Eating/drinking too close to gum use: This reduces nicotine absorption 2
5. Inadequate treatment of withdrawal: Consider combination therapy (patch + gum) for those with severe withdrawal symptoms 4, 5

Side Effects and Management

Common side effects include hiccups, heartburn, nausea, throat irritation, and mouth soreness 4, 2. These can be minimized by:

• Using proper chew-and-park technique
• Not chewing too rapidly
• Avoiding continuous use of multiple pieces
• Ensuring proper placement in the mouth

For patients who experience significant side effects with gum, consider alternative NRT forms like patches or lozenges 4.