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Smoking cessation - Management
Which dose of nicotine replacement therapy should I prescribe and for how long?
- Smokers must use sufficient nicotine replacement therapy (NRT) in order to achieve good success rates. As insufficient use is the main problem with intermittent (non-patch) formulations of NRT some expert reviewers advise regular hourly use with topping-up as needed for all intermittent formulation products.
- NRT patches:
- Patches are available in two preparations (16-hour and 24-hour), each with three strengths:
- 16-hour patch: 15 mg, 10 mg, 5 mg (Nicorette®).
- 24-hour patch: 21 mg, 14 mg, 7 mg (Nicotinell®, NiQuitin®).
- Patches are usually prescribed in a programme of reducing doses over 8–12 weeks (see Table 1).
- NRT gum:
- Gum is available in two strengths: 2 mg and 4 mg.
- People who smoke more than 20 cigarettes per day should start treatment with the 4 mg gum.
- People who start using the 2 mg gum and find they need to use more than 15 pieces per day should use the 4 mg gum.
- NRT lozenges:
- Lozenges are available in four strengths: 1 mg, 1.5 mg, 2 mg, and 4 mg.
- Nicotinell®:
- For people with low–moderate dependency (less than 20 cigarettes per day), 1 mg lozenges are preferable.
- For people with moderate–strong dependency (20 to 30 cigarettes per day), 1 mg or 2 mg lozenges are acceptable, depending on the person's characteristics and preference.
- For people with strong dependency (more than 30 cigarettes per day), 2 mg lozenges are preferable.
- Niquitin®:
- For people who have their first cigarette of the day more than 30 minutes after waking up, 2 mg lozenges are suitable.
- For people who have their first cigarette of the day within 30 minutes of waking up, 4 mg lozenges are preferable.
- NRT sublingual tablets:
- Sublingual tablets are available as 2 mg tablets only.
- People who smoke 20 cigarettes or more each day should start taking two tablets (4 mg) sublingually each hour.
- People who smoke fewer than 20 cigarettes per day should start taking one tablet (2 mg) sublingually each hour. This can be increased to two tablets (4 mg) each hour if the person fails to stop smoking or has significant withdrawal symptoms.
- Duration of NRT in people maintaining abstinence from cigarettes is usually 8–12 weeks (depending on which form of NRT is used and which dose is initiated), followed by a gradual reduction in dose. Use should normally be restricted to the licensed duration of the form of NRT used. See Table 1 for the licensed duration of different NRT products.
- Most people do not need to use NRT for longer than 3 months. However, more dependent smokers may need to use NRT for longer, and if treatment is stopped too soon these people might relapse [McRobbie and McEwen, 2005].
Table 1. Licensed dose and duration of nicotine replacement therapy products.
Formulation | Number of cigarettes smoked per day | Licensed dose and duration* |
|---|
16-hour Patch (Nicorette®) | Any | Use 15 mg/16 hours patch daily for 8 weeks, then Use 10 mg/16 hours patch daily for 2 weeks, then Use 5 mg/16 hours patch daily for 2 weeks. |
24-hour Patch (Nicotinell®) | 20 or more per day | Use 21 mg/24 hours patch daily for 3–4 weeks, then Use 14 mg/24 hours patch daily for 3–4 weeks, then Use 7 mg/24 hours patch daily for 3–4 weeks. |
Less than 20 per day | Use 14 mg/24 hours patch daily for 3–4 weeks, then Use 7 mg/24 hours patch daily for 3–4 weeks. |
24-hour Patch (NiQuitin CQ®) | 10 or more per day | Use 21 mg/24 hours patch daily for 6 weeks, then Use 14 mg/24 hours patch daily for 2 weeks, then Use 7 mg/24 hours patch daily for 2 weeks. |
Less than 10 per day | Use 14 mg patch for 6 weeks, then Use 7 mg patch for 2 weeks. |
Nasal spray | Any | Use one spray in each nostril as required for 8 weeks (up to 64 sprays/day), then reduce gradually over the next 4 weeks. |
Inhalator | Any | Inhale when there is an urge to smoke. Initially use 6–12 cartridges daily for up to 8 weeks, then reduce gradually over the next 4 weeks. |
Gum | More than 20 per day | Chew one piece of 4 mg gum slowly for about 30 minutes when there is an urge to smoke. Reduce gradually over 3 months; when daily use is 1–2 pieces of gum, stop. |
20 or less per day | Chew one piece of 2 mg gum slowly for about 30 minutes when there is an urge to smoke. (Note: people needing more than 15 pieces per day should use 4 mg gum). Reduce gradually over 3 months; when daily use is 1–2 pieces of gum, stop. |
Lozenge | Any | Suck 1 lozenge every 1–2 hours for 6 weeks, then Suck 1 lozenge every 2–4 hours for 3 weeks, then Suck 1 lozenge every 4–8 hours for 3 weeks, then withdraw gradually over 3 months. |
Sublingual tablet | More than 20 per day | Use 2 tablets (4 mg) sublingually each hour (maximum 40 tablets/day). Continue for at least 3 months then gradually reduce; when daily use is 1–2 tablets, stop. |
20 or less per day | Use 1 tablet (2 mg) sublingually each hour. Continue for at least 3 months then gradually reduce; when daily use is 1–2 tablets, stop. |
* Recommended duration for adolescents (12–18 years old) is 12 weeks. |
Clarification / Additional information
- Dosage instructions vary between brands of NRT, therefore it seems sensible to prescribe NRT by brand name.
Basis for recommendation
- Higher doses of NRT may be more effective in people who smoke more cigarettes per day, and in those who are more highly dependent:
- In a Cochrane review of NRT and smoking cessation, the pooled results of four randomized controlled trials (RCTs) of highly dependent smokers found a significant benefit of 4 mg gum compared with 2 mg gum (relative risk 1.43, 95% CI 1.12 to 1.83). In low-dependence or unselected smokers, there was no evidence of a dose effect.
- The pooled results of six RCTs comparing a high-dose patch to a standard-dose patch suggested that higher doses may provide a small benefit (relative risk 1.15, 95% CI 1.01 to 1.30).
[Stead et al, 2008]
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