What is the recommended dose of nicotine replacement therapy (NRT) for a patient who smokes 5 cigarettes per day?

Nicotine Replacement Therapy Dosing for 5 Cigarettes Daily

For a patient smoking 5 cigarettes per day, start with a 14 mg (24-hour) or 15 mg (16-hour) nicotine patch combined with 2 mg nicotine gum used 8-12 times daily as needed for breakthrough cravings. 1

Patch Dose Selection

• Light smokers consuming fewer than 10 cigarettes per day should not use the standard 21 mg patch 1
• The 14 mg (24-hour) or 15 mg (16-hour) patch is specifically recommended for this smoking level 1
• This lower-dose approach provides approximately 2-3 mg of nicotine replacement per cigarette smoked, which aligns with optimal dosing 2

Why Combination Therapy is Essential

Combination NRT (patch + fast-acting form) nearly doubles quit rates compared to patch alone, achieving 36.5% abstinence at 6 months versus 23.4% for single-form NRT (RR 1.25,95% CI 1.15-1.36) 1, 3

• The patch provides steady baseline nicotine levels throughout the day to prevent withdrawal symptoms 1
• The 2 mg gum addresses breakthrough cravings that occur despite patch use 1
• Use 8-12 pieces of gum per day as needed, employing the "chew and park" technique 1, 4

Proper Gum Technique

• Chew slowly until a peppery taste emerges, then park the gum between cheek and gum 4
• Nicotine must be absorbed through the oral mucosa—swallowed nicotine is therapeutically ineffective 4
• Avoid food or beverages 15 minutes before and after gum use, as acidic drinks interfere with absorption 1

Treatment Duration

• Continue combination NRT for a minimum of 12 weeks 1, 5
• Longer duration therapy (>14 weeks) shows superior results to standard 8-12 week courses 1
• After 12 weeks, gradually taper over 6-12 weeks rather than stopping abruptly 1, 5

Follow-Up Schedule

• Schedule follow-up within 2 weeks after starting pharmacotherapy 1
• Conduct additional assessments at 12 weeks and at the end of therapy if extended 1
• Monitor for nicotine withdrawal symptoms, which typically peak within 1-2 weeks of quitting 1

Critical Pitfall: Under-Dosing

The most common error is inadequate nicotine replacement. Recent observational data from 84,667 patients shows that doses below 2 mg of NRT per cigarette smoked per day are associated with significantly poorer outcomes 2

• For 5 cigarettes daily, this translates to needing approximately 10-15 mg total daily nicotine replacement 2
• The 14-15 mg patch plus 2 mg gum (8-12 pieces) provides this adequate replacement 1
• If the patient continues smoking at subsequent visits, consider increasing the patch dose to 21 mg rather than maintaining inadequate dosing 2

When to Escalate Therapy

If the patient fails to achieve abstinence by week 4 with the initial regimen:

• First escalation: Increase patch dose to 21 mg while continuing 2 mg gum 1
• Second escalation: Switch to varenicline 1 mg twice daily for 12 weeks 1
• Throughout all steps, maintain intensive behavioral counseling support 1

Behavioral Support Component

• Combine pharmacotherapy with at least 4 counseling sessions over 12 weeks 1
• Brief counseling (≥3 minutes) at each clinic encounter increases effectiveness 1
• Telephone counseling is effective when providing at least 3 calls 1

Safety Considerations

• NRT is safe even in patients with cardiovascular disease, as blood nicotine levels from combination NRT remain significantly lower than from smoking 1
• Very few people become addicted to NRT itself 6, 1
• Common side effects include mouth irritation from gum and local skin reactions from patches, both typically resolving within one week 1, 7