What is a recommended regimen for a patient to quit smoking using nicotine replacement therapy (NRT) products such as patches and gum?

Comprehensive Smoking Cessation Regimen with Nicotine Replacement Therapy

Combination nicotine replacement therapy (NRT) using a nicotine patch plus a short-acting NRT (such as gum or lozenge) is the most effective approach for smoking cessation, doubling the chance of successful quitting compared to using a single NRT product. 1, 2

Initial NRT Regimen

Step 1: Patch + Short-Acting NRT (Weeks 1-6)

• Use one 21 mg nicotine patch daily if smoking more than 10 cigarettes per day 3, 1
• Apply patch to clean, dry, hairless skin; hold for 10 seconds 3
• Change patch at the same time each day 3
• Supplement with nicotine gum (use 2 mg if first cigarette is >30 minutes after waking; use 4 mg if first cigarette is within 30 minutes of waking) 4, 1
• Use gum every 1-2 hours as needed for breakthrough cravings 4, 5
• Proper gum technique: chew slowly until it tingles, then "park" between cheek and gum until tingle fades, then repeat for about 30 minutes 4
• Do not eat or drink 15 minutes before or during gum use 4

Step 2: Patch + Short-Acting NRT (Weeks 7-9)

• Switch to 14 mg nicotine patch daily 3, 5
• Continue supplementing with nicotine gum, but reduce frequency to every 2-4 hours 4, 5

Step 3: Patch + Short-Acting NRT (Weeks 10-12)

• Switch to 7 mg nicotine patch daily 3, 5
• Reduce gum use to every 4-8 hours 4, 5

Behavioral Support (Essential Component)

• Combine pharmacotherapy with behavioral support to optimize success rates 3, 1
• Minimum of 4 counseling sessions during the 12-week treatment period 1, 2
• Focus on identifying smoking triggers and developing coping strategies 2, 6
• Schedule follow-up within 2-3 weeks of starting therapy to assess progress 1, 2

Dosing Considerations

• For heavy smokers or those with significant withdrawal symptoms, consider higher-dose patch (up to 42 mg/day by using multiple patches) 1, 5
• Use at least 9 pieces of gum per day during the first 6 weeks for optimal results 4, 7
• Maximum: 24 pieces of gum per day 4
• Do not wear patch more than 24 hours as it loses effectiveness and may irritate skin 3

Follow-up and Adjustments

• Assess smoking status and medication side effects within 2-3 weeks of starting therapy 1, 2
• Evaluate again at 12 weeks and at the end of therapy 1
• If withdrawal symptoms persist, consider extending treatment beyond 12 weeks 1
• If relapse occurs, intensify treatment by either increasing NRT dose or adding bupropion 1

Common Pitfalls to Avoid

• Inadequate dosing of NRT (particularly not using enough gum) 4, 7
• Premature discontinuation of therapy before the full 12-week course 1, 6
• Using NRT without concurrent behavioral support 3, 6
• Improper gum technique (chewing too quickly or swallowing nicotine) 4, 1
• Not addressing breakthrough cravings with short-acting NRT 1, 5

Special Considerations

• Nicotine withdrawal symptoms typically peak within 1-2 weeks of quitting 1, 2
• Patients who don't quit immediately may succeed later after withdrawal symptoms subside 1
• If experiencing vivid dreams, remove patch at bedtime and apply a new one in the morning 3
• For persistent cravings, consider extending therapy to 6 months or longer 1
• Combination NRT with long-term patch plus gum shows the highest abstinence rates (36.5% at 6 months) compared to single NRT products 2, 5

Remember that NRT is not a magic cure but significantly increases the chances of successful quitting when used correctly and combined with behavioral support 1, 6.