What is the recommended nicotine replacement therapy for a patient who smokes one pack of cigarettes per day?

Nicotine Patch Dosing for Pack-Per-Day Smokers

For a patient smoking one pack (20 cigarettes) per day, start with a 21 mg/24-hour nicotine patch combined with a short-acting NRT form (such as 4 mg nicotine gum) for at least 12 weeks. 1

Initial Patch Selection

• The 21 mg/24-hour patch is the standard starting dose for smokers consuming ≥10 cigarettes per day 1
• The 21 mg/24-hour patch provides superior craving control throughout the day compared to 15 mg/16-hour patches, with consistently better control not only during morning hours but over the entire 2-week abstinence period 2
• For pack-per-day smokers, the 21 mg dose provides adequate nicotine replacement while remaining safe, as blood nicotine levels from patches stay significantly lower than from smoking 1

Combination Therapy is Essential

Combination NRT (patch + short-acting form) should be prescribed as first-line therapy, not reserved as rescue treatment after monotherapy fails 3

• Combination NRT achieves 36.5% abstinence at 6 months versus 23.4% for patch alone (RR 1.27,95% CI 1.17-1.37) 4
• This approach nearly triples cessation success compared to placebo (OR 2.73,95% CI 2.07-3.65) 1
• Pair the 21 mg patch with 4 mg nicotine gum for pack-per-day smokers 1

Short-Acting NRT Options

• 4 mg nicotine gum: Use 8-12 pieces per day as needed for breakthrough cravings 1
• Instruct patients to chew slowly to allow nicotine absorption through the mouth, not swallowing 1
• Alternative short-acting forms include nicotine lozenges, nasal spray, or inhaler, all with similar efficacy 3

Treatment Duration

• Prescribe NRT for a minimum of 12 weeks for the initial quit attempt 1
• Longer duration (>14 weeks) shows superior results to standard 8-12 week courses 1
• Consider extending therapy up to 6-12 months if needed to prevent relapse 1

Patch Administration Instructions

• Apply the 21 mg patch to clean, dry, hairless skin on the upper body or outer arm each morning 1
• Rotate application sites daily to prevent skin irritation 1
• The 24-hour patch should be worn continuously, providing steady nicotine levels throughout the day and night 2

Consider Preloading Strategy

Starting NRT 2 weeks before the quit date while still smoking (preloading) increases quit rates by 25% (RR 1.25,95% CI 1.08-1.44) 4

• Preloading is particularly beneficial for smokers with lower nicotine dependence 5
• This approach allows patients to adapt to NRT while still smoking, reducing the shock of complete nicotine withdrawal 4

Follow-Up Protocol

• Schedule follow-up within 2 weeks after starting pharmacotherapy 1
• Conduct additional periodic follow-up at minimum 12-week intervals 1
• Monitor for nicotine withdrawal symptoms, which typically peak within 1-2 weeks of quitting 1
• Assess medication adherence and side effects at each visit 3

Essential Behavioral Support

All pharmacotherapy must be combined with behavioral counseling, which increases quit rates from 8.6% to 15.2% compared to brief advice alone 3

• Provide at least 4 counseling sessions, with greatest effect seen in 8+ sessions totaling 91-300 minutes 3
• Include practical problem-solving skills training and identification of high-risk situations 3

Safety Considerations

• NRT is safe even in patients with cardiovascular disease, as blood nicotine levels remain significantly lower than from smoking 1, 3
• Common side effects include local skin reactions, nausea, mood changes, and sleep disturbances, but these are typically mild 1
• Very few people become addicted to NRT itself 5
• For pregnant smokers, benefits of NRT likely outweigh risks of continued smoking, but consult an obstetrician before initiating 1

Critical Pitfalls to Avoid

• Underdosing: Pack-per-day smokers require the full 21 mg patch, not lower doses 1
• Monotherapy failure: Not starting with combination therapy from the outset reduces success rates by nearly 50% 3
• Premature discontinuation: Stopping before 12 weeks is the most common reason for treatment failure 3
• Inadequate behavioral support: Pharmacotherapy alone without counseling significantly reduces effectiveness 3
• Insufficient treatment duration: Maintaining treatment for at least 12 weeks is essential, with many patients benefiting from longer courses 1

If Initial Treatment Fails

If combination NRT fails, switch to varenicline 1 mg twice daily for 12 weeks while maintaining intensive behavioral counseling 3

• Varenicline is the most effective single-agent pharmacotherapy when combination NRT is unsuccessful 3
• Bupropion SR is an alternative option, particularly for patients with comorbid depression 3