What is the recommended protocol for prescribing nicotine gum (Nicotine Replacement Therapy - NRT) in a smoking cessation program?

Nicotine Gum Prescription Protocol for Smoking Cessation

For effective smoking cessation, nicotine gum should be prescribed based on time to first cigarette after waking, with 4 mg gum for those who smoke within 30 minutes of waking and 2 mg gum for those who smoke later, following a 12-week schedule of gradually decreasing usage. 1, 2

Dosing Selection

• Select appropriate nicotine gum strength based on nicotine dependence level:
  • 4 mg gum for highly dependent smokers (first cigarette within 30 minutes of waking) 1, 2
  • 2 mg gum for less dependent smokers (first cigarette more than 30 minutes after waking) 1, 2
  • 4 mg gum is more effective than 2 mg gum for heavy smokers (≥20 cigarettes per day) 3

Administration Schedule

• Follow a 12-week tapering schedule: 3, 1
  • Weeks 1-6: 1 piece every 1-2 hours (minimum 9 pieces daily)
  • Weeks 7-9: 1 piece every 2-4 hours
  • Weeks 10-12: 1 piece every 4-8 hours
  • Do not exceed 24 pieces per day 1

Proper Usage Instructions

• Instruct patients on correct chewing technique: 3, 1
  • Chew slowly until a tingling sensation is felt
  • "Park" the gum between cheek and gum when tingling occurs
  • When tingling fades, resume chewing
  • Repeat cycle for approximately 30 minutes per piece
  • Avoid eating or drinking 15 minutes before and during gum use 1

Combination Therapy Options

• Consider combination NRT for better outcomes: 3
  • Nicotine patch + nicotine gum provides higher long-term quit rates than single form (25% higher success rate) 3
  • Combination therapy is safe and more effective than monotherapy 3

Treatment Duration Considerations

• Minimum treatment duration should be 12 weeks 3
• Consider extending therapy to 6 months or longer for continued cessation support if needed 3
• Long-term nicotine gum use (>14 weeks) may provide better abstinence rates than standard duration 3

Follow-up Protocol

• Schedule follow-up within 2-3 weeks of starting pharmacotherapy 3
• Additional periodic follow-up during therapy at minimum 12-week intervals 3
• Monitor for withdrawal symptoms, which typically peak within 1-2 weeks of quitting 3

Special Considerations

• Nicotine gum can be used for gradual smoking reduction before complete cessation 4
• Patients who reduce smoking before quitting are more likely to achieve abstinence 4
• Support from health professionals enhances effectiveness but is not essential for NRT to work 3

Common Pitfalls and Solutions

• Incorrect chewing technique: Emphasize the "chew and park" method to avoid swallowing nicotine, which reduces effectiveness 3
• Underdosing: Ensure patients use at least 9 pieces daily during first 6 weeks for optimal results 1
• Premature discontinuation: Encourage completion of full treatment course even if occasional slips occur 3
• Inadequate dosing for highly dependent smokers: Ensure heavy smokers receive 4 mg strength 3, 2
• Concurrent food/beverage consumption: Advise patients to avoid eating/drinking 15 minutes before and during gum use 1

Safety Information

• NRT is safe and effective when used correctly 3, 5
• Nicotine withdrawal symptoms may include irritability, depression, and craving 3
• Common side effects include mouth irritation and unpleasant taste initially, which typically resolves within a week 3
• Risk of addiction to NRT is low compared to cigarettes 3