What is the recommended protocol for using nicotine patches (nicotine replacement therapy) in a hospital setting for smoking cessation?

Recommended Protocol for Nicotine Patch Therapy in Hospital Settings

For hospitalized smokers, a combination of nicotine patch therapy with a short-acting nicotine replacement therapy (NRT) should be initiated, starting with a 21 mg/24-hour patch for patients who smoke more than 10 cigarettes per day, along with behavioral counseling for a minimum of 12 weeks. 1, 2, 3

Initial Assessment and Dosing

• Assess smoking status of all patients on admission and advise smokers about the hospital's smoke-free policy 4
• For patients who smoke ≥10 cigarettes per day, start with a 21 mg/24-hour nicotine patch 1, 3
• For lighter smokers (<10 cigarettes per day), consider starting with a lower dose patch (14-15 mg) 3
• If the 21 mg patch is not effective in controlling withdrawal symptoms, consider increasing to 35 or 42 mg patch 1, 2, 3

Combination Therapy Approach

• Combine the nicotine patch with a short-acting NRT form for optimal effectiveness 1, 2, 3
• Short-acting options include nicotine gum (2 mg or 4 mg), nasal spray, or inhalator 4, 3
• Combination NRT has shown superior abstinence rates (36.5% at 6 months) compared to monotherapy 4, 2

Administration Instructions

• Apply the patch to clean, dry, hairless skin on the upper body or outer arm each morning 3
• Rotate application sites daily to prevent skin irritation 3
• For 16-hour patches, remove before bedtime; for 24-hour patches, wear continuously 3

Duration and Follow-up

• Continue NRT for a minimum of 12 weeks for the initial quit attempt 1, 2, 3
• Schedule first follow-up within 2 weeks after starting pharmacotherapy 1, 2
• Conduct additional follow-up at minimum 12-week intervals during therapy 1, 2
• Consider extending therapy up to 6-12 months to promote continued cessation if needed 1, 2

Safety Considerations

• NRT appears safe for patients with cardiovascular disease, though package inserts may advise consultation with a healthcare provider 4
• Common side effects include local skin reactions, nausea, vomiting, sweating, mood changes, and sleep disturbances 4, 1
• Blood nicotine levels from NRT are significantly less than from smoking cigarettes, making toxicity rare 1, 2

Behavioral Support Components

• Provide at least 4 sessions of behavioral therapy during each 12-week course of pharmacotherapy 2
• Include skills training, social support, and motivational interviewing in behavioral therapy 2
• Address smoking triggers and develop coping strategies 2
• Use patch with a behavioral support program as indicated in product labeling 5

Common Pitfalls to Avoid

• Inadequate dosing: Only 7.1% of hospitalized smokers receive NRT during hospitalization, representing a significant missed opportunity 6
• Premature discontinuation: Encourage continued therapy for the full treatment course, even if the patient has brief slips 1, 2
• Insufficient treatment duration: Maintain treatment for at least 12 weeks 1, 2, 3
• Failure to combine with behavioral support: NRT is most effective when combined with counseling 2, 5
• Not offering alternative treatments after failed quit attempts: Consider switching pharmacotherapy if initial attempts fail 2

Special Populations

• For pregnant smokers, consultation with an obstetrician is recommended before initiating NRT 4, 3
• Some NRT products are not recommended for people under 18 years of age 4, 3
• Patients admitted for respiratory diseases may be more receptive to quitting interventions 7