Recommending nicotine replacement therapy​

Rationale for recommending the NRT patch

The goal in recommending the patch is to meet patients' nicotine needs, allowing them to feel, for the most part, comfortable throughout the day.

By providing relief from the symptoms of nicotine withdrawal, NRT makes it easier for patients to focus on making behavioural changes in their lives.

The patch will not treat sudden cravings or urges caused by environmental or emotional cues.

The patch also will not make someone quit – it is not a substitute for motivation. However, if used in the appropriate dose, the patch will make the process of quitting much easier.

How to use the patch

The standard way of using NRT is as follows:

• The sustained release patch provides a maintenance dose of nicotine throughout the day and night. Instruct patients to put on the patch the night before their quit date to ensure a therapeutic nicotine level upon waking in the morning. In case of interrupted sleep, they may switch to mornings.
• The patient should stick the patch on the upper torso on easily reachable, bare skin. Patches should be replaced every 24 hours and put on different skin areas to avoid irritation.
• Recommend that patients use nicotine chewing gum or a nicotine inhaler as needed, or on a breakthrough basis, in much the same way that immediate-release morphine is provided to patients taking MS Contin for pain. This allows patients to titrate their level of nicotine. There is evidence that concurrent use of the patch and an immediate-release NRT (e.g., inhaler, gum or lozenge) is more effective than the patch alone (Bohadana et al., 2000).

The patient can also use NRT before beginning the quit attempt:

• Nicotine gum or an inhaler can be used as a substitute for cigarettes as a way of preparing to quit. Because it takes time to learn how to use both delivery systems, patients often benefit from some experimentation before actually trying to quit.
• Using immediate-release NRT before the quit date allows patients to begin to disconnect the emotional and habitual cues associated with smoking from the experience of having a cigarette.
• Applying a patch before the quit attempt encourages patients to significantly reduce their smoking and can increase their confidence in their ability to quit. Most patients are somewhat uncomfortable about smoking while on the patch, which serves as a check on their smoking.

Determining the patch dose

Several tools have been designed to objectively assess the appropriate patch dose. The most well-known tool is the Fagerström Test for Nicotine Dependence.

For most people who smoke one pack per day or less, the following is a reasonable starting point:

• more than 15 cigarettes per day: 21 mg patch (Step 1)
• seven to 15 cigarettes per day: 14 mg patch (Step 2)
• fewer than seven cigarettes per day: 7 mg patch (Step 3).

People who smoke one pack per day absorb 1.8 mg to 26.8 mg of nicotine (usually 16 mg to 20 mg), depending on how they smoke.

Monitoring the patch dose

If the patch dose is adequate, the patient should feel relatively comfortable between cravings. The patient may still have strong urges during the day, but most of the time will not feel physical cravings or discomfort. A persistent need for a cigarette or no improvement while on the patch strongly suggests that the dose is inadequate.

If the dose is inadequate, the patient will experience some of the ongoing physical discomfort of withdrawal, including irritability, dysphoria, restlessness, anxiety, insomnia, headache, decreased concentration and strong cravings.

If the dose is too high, the patient will experience symptoms of nicotine overdose, including nausea, cramps, dizziness, palpitations and dysphoria.

Increasing the nicotine dose

The use of larger doses of nicotine by patients who smoke heavily and who are highly tolerant to the effects of the drug makes theoretical sense.

For a patient who smokes heavily, a good starting point is to recommend one 21 mg patch per pack of cigarettes smoked per day.

If a patient experiences symptoms of withdrawal on a 21 mg patch, the dose should be increased. Recommend that the patient increase the dose in 7 mg increments, every three to seven days.

Patients who smoke two packs per day will experience a reduction in nicotine levels if they use 42 mg of nicotine (two 21 mg patches) daily.

The Nicotine Dependence Clinic at the Centre for Addiction and Mental Health routinely uses doses from 21 mg to 42 mg (in addition to immediate-release NRT as needed). Doses as high as 84 mg (four 21 mg patches) have been used successfully with patients who smoke very heavily.

Significantly higher smoking cessation rates have been observed with high-dose nicotine patches (more than 22 mg) compared with standard dose nicotine patches (less than 22 mg) (Canadian Agency for Drugs and Technologies in Health, 2014).

Duration of NRT

It is recommended that the patch and other forms of replacement should be used for as long as needed to maintain or prolong abstinence. The Lung Health study demonstrated that long-term NRT use is safe (Murray et al., 2009).

NRT product monographs recommend approximately two to three months of use, which is the length of time these products were used in early clinical trials. Many patients are not ready to stop using NRT after three months.

To prevent relapse, patients should be instructed to taper off NRT slowly. This helps them adjust to lowering nicotine levels (e.g., three to four weeks for every level).