What is the recommended dosage of Nicorette (nicotine replacement therapy)?

Nicotine Replacement Therapy (Nicorette) Dosing

For smokers consuming ≥10 cigarettes per day, start with a 21 mg/24-hour nicotine patch combined with a short-acting NRT form (2 mg or 4 mg gum) for a minimum of 12 weeks. 1

Initial Dose Selection

Patch Dosing by Cigarette Consumption

• ≥10 cigarettes per day: Start with 21 mg/24-hour patch 1, 2
• <10 cigarettes per day: Start with 14-15 mg patch (24-hour or 16-hour formulation) 3, 1
• Heavy smokers (≥20 cigarettes per day): Consider 25 mg patches or higher doses (up to 42-44 mg) for better efficacy 3

Gum Dosing by Dependence Level

• 2 mg gum: For lighter or less dependent smokers 3, 1
• 4 mg gum: For highly dependent smokers (≥20 cigarettes per day or time to first cigarette ≤30 minutes) 3, 4, 5
• Dosing frequency: Use 8-12 pieces per day as needed for breakthrough cravings 1

Combination Therapy (First-Line Recommendation)

Combination NRT (patch + short-acting form) is the gold standard approach, achieving 36.5% abstinence at 6 months versus 23.4% for patch alone. 3, 1

Recommended Combinations

• 21 mg patch + 2 mg or 4 mg gum (most common) 1
• 21 mg patch + nicotine nasal spray 3, 1
• 21 mg patch + nicotine inhaler 3
• 21 mg patch + nicotine lozenge 1

The combination approach nearly doubles cessation success compared to monotherapy (OR 3.6,95% CI 2.5-5.2 for long-term patch + ad libitum NRT). 3

Treatment Duration

Standard Protocol

• Minimum duration: 12 weeks for initial quit attempt 1, 2
• Standard step-down: 21 mg for 6 weeks → 14 mg for 2 weeks → 7 mg for 2 weeks 2
• Extended therapy: Up to 6-12 months for patients requiring longer support 1, 2

Longer duration (>14 weeks) shows superior results to standard 8-12 week courses. 3, 1

Administration Instructions

Patch Application

• Apply to clean, dry, hairless skin on upper body or outer arm each morning 1, 6
• Rotate application sites daily to prevent skin irritation 1, 6
• 16-hour patches: Remove before bedtime 1
• 24-hour patches: Wear continuously 1

Gum Technique

• Chew slowly to allow nicotine absorption through oral mucosa 1
• Do not swallow nicotine 1
• "Park" gum between cheek and gum after initial chewing 7

Preloading Strategy

Using NRT 2-4 weeks before quit day increases cessation rates (RR 1.25,95% CI 1.08-1.44). 5

This approach allows patients to:

• Reduce cigarette consumption gradually 5
• Familiarize themselves with NRT before complete cessation 5
• Build confidence in the medication's effectiveness 5

When Monotherapy Fails

Immediate Next Step

Add a short-acting NRT form to the existing patch rather than continuing patch alone. 1

Alternative Options

• Switch to varenicline (1 mg twice daily for 12 weeks) 1
• Increase patch dose (e.g., from 21 mg to 25 mg or higher) 3
• Add bupropion SR to existing patch therapy 3

Follow-Up Protocol

• First follow-up: Within 2 weeks after starting pharmacotherapy 1, 6, 2
• Subsequent follow-ups: At minimum 12-week intervals during therapy 1, 2
• Monitor for: Nicotine withdrawal symptoms (peak within 1-2 weeks of quitting) 1

Safety Considerations

Cardiovascular Disease

NRT is safe even in patients with cardiovascular disease, as blood nicotine levels remain significantly lower than from smoking. 3, 1, 6

Common Side Effects

• Patch: Local skin reactions, nausea, vomiting, sweating, mood changes, sleep disturbances 3, 6, 2
• Gum: Jaw fatigue/soreness, hiccupping, burping, nausea 3
• Nasal spray/inhaler: Local irritation 3

Most adverse effects are dose-dependent and resolve within 12 hours if exposure is discontinued. 2

Special Populations

• Pregnancy: Benefits likely outweigh risks of continued smoking; consult obstetrician 1, 6
• Age <18 years: Some NRT products not recommended 1, 6
• Light smokers (<10 cigarettes/day): Limited evidence; use lower doses 3

Critical Success Factors

Behavioral Support Integration

Combining pharmacotherapy with behavioral counseling increases quit rates from 8.6% to 15.2% compared to brief advice alone. 1

• Provide at least 4 behavioral therapy sessions during each 12-week course 1, 6
• Greatest effect seen with 8+ sessions totaling 91-300 minutes of contact 1
• Include skills training, social support, and motivational interviewing 6

Common Pitfalls and Solutions

Inadequate Dosing

Problem: Using insufficient nicotine doses to control withdrawal symptoms 1 Solution: Ensure adequate patch dose based on cigarette consumption and add short-acting NRT for breakthrough cravings 1

Premature Discontinuation

Problem: Stopping NRT before 12 weeks 1, 2 Solution: Encourage continued therapy even through brief slips; maintain treatment for at least 12 weeks 1, 2

Monotherapy When Combination Needed

Problem: Continuing patch alone when withdrawal symptoms persist 1 Solution: Immediately add short-acting NRT rather than abandoning treatment 1

Lack of Behavioral Support

Problem: Relying solely on pharmacotherapy 1 Solution: Integrate at least 4 sessions of behavioral counseling with medication 1, 6