What are the directions for nicotine replacement therapy (NRT) prescriptions, including dosing and treatment options?

Nicotine Replacement Therapy Prescription Directions

For most smokers (≥10 cigarettes/day), start with combination NRT: a 21 mg/24-hour nicotine patch plus a short-acting form (2-4 mg gum, lozenge, or nasal spray) for a minimum of 12 weeks. 1, 2

Initial Dose Selection

Patch dosing:

• Heavy smokers (≥10 cigarettes/day): Start with 21 mg/24-hour patch 1, 2, 3
• Light smokers (<10 cigarettes/day): Start with 14-15 mg patch (24-hour or 16-hour formulation) 1, 3
• Very heavy smokers (≥20 cigarettes/day): Consider 25 mg or higher doses (up to 42-44 mg) if standard dosing proves inadequate 1

Short-acting NRT selection (to combine with patch):

• Nicotine gum: 2 mg for lighter smokers; 4 mg for highly dependent smokers (≥20 cigarettes/day) 4, 1
• Alternative options: Nasal spray, inhalator, or lozenges provide similar efficacy 4
• Dosing frequency: Use 8-12 pieces of gum per day as needed for breakthrough cravings 1

Why Combination Therapy is Superior

Combination NRT (patch + short-acting form) nearly doubles quit rates compared to patch alone, achieving 36.5% abstinence at 6 months versus 23.4% for monotherapy (RR 1.25,95% CI 1.15-1.36). 1, 5 This approach is recommended as first-line primary therapy by the National Comprehensive Cancer Network. 1, 2

Administration Instructions

Patch application:

• Apply each morning to clean, dry, hairless skin on upper body or outer arm 1, 3
• Rotate application sites daily to prevent skin irritation 1, 3
• 16-hour patches: Remove before bedtime 1
• 24-hour patches: Wear continuously 1

Gum technique (critical for efficacy):

• Chew slowly to allow nicotine absorption through the mouth—swallowed nicotine is wasted 4
• The taste may be unpleasant initially but most patients adapt within a week 4

Treatment Duration

Minimum 12 weeks for initial quit attempt, with potential extension to 6-12 months to promote continued cessation. 1, 2 Longer duration (>14 weeks) shows superior results to standard 8-12 week courses. 1, 2, 5

Follow-Up Protocol

• First follow-up: Within 2 weeks after starting pharmacotherapy 1, 2, 3
• Subsequent follow-up: At minimum 12-week intervals during therapy 1, 2
• Monitor for nicotine withdrawal symptoms, which typically peak within 1-2 weeks of quitting 1

Preloading Strategy

Consider starting NRT 2-4 weeks before quit date while still smoking (preloading), which may increase quit rates by 25% (RR 1.25,95% CI 1.08 to 1.44). 1, 5 This approach allows steady nicotine levels to build, suppressing withdrawal symptoms more effectively. 1

Dose Adjustments for Inadequate Response

If 21 mg patch proves insufficient:

• Increase to 35 or 42 mg patch 2
• Ensure adequate use of short-acting NRT for breakthrough cravings 1
• Verify proper gum chewing technique (slow chewing, not swallowing) 4

Special Populations

Cardiovascular disease:

• NRT is safer than continued smoking and does not increase cardiovascular risk 4, 1, 3
• Blood nicotine levels from NRT remain significantly lower than from smoking 1, 5
• Package inserts may advise consultation, but evidence supports safety even post-myocardial infarction 4

Pregnancy:

• Benefits of NRT likely outweigh risks of continued smoking 1, 3
• Consult with obstetrician before initiating 1, 3
• Evidence shows RR 1.32 (95% CI 1.04-1.69) for abstinence near delivery 6

Age restrictions:

• Some products (patch, inhalator) not recommended for patients under 18 years 4, 1
• Nicotine gum labeling does not carry this restriction 4

Safety Profile

Common side effects:

• Local skin reactions at patch site 2, 5
• Mouth irritation from gum/lozenges 4
• Nausea, sweating, mood changes, sleep disturbances 1, 2

Serious adverse events are extremely rare. 5, 6 Chest pains or palpitations occur infrequently (OR 1.88,95% CI 1.37-2.57) and are typically non-ischemic. 6 Very few people become addicted to NRT itself. 4, 1

Critical Success Factors

Combine pharmacotherapy with behavioral counseling to maximize effectiveness—this increases quit rates from 8.6% to 15.2% compared to brief advice alone. 1 Provide at least 4 behavioral therapy sessions, with greatest effect seen in 8+ sessions totaling 91-300 minutes of contact. 1

Common Pitfalls to Avoid

• Inadequate dosing: Ensure sufficient nicotine doses to control withdrawal symptoms 4, 1
• Premature discontinuation: Maintain treatment for at least 12 weeks even through brief slips 1, 2
• Monotherapy when combination is indicated: Single-form NRT is less effective than combination therapy 1, 5
• Improper gum technique: Patients must chew slowly and avoid swallowing to achieve adequate nicotine absorption 4
• Failure to provide behavioral support: Pharmacotherapy alone is less effective than when combined with counseling 1