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Smoking cessation - Management
Which formulation of nicotine replacement therapy should I prescribe?

  • There is no evidence of a difference in efficacy between different formulations of nicotine replacement therapy (NRT). Points to discuss with the smoker when choosing a product include:
    • The number of cigarettes smoked per day.
    • The time to the first cigarette of the day.
    • Speed of nicotine delivery.
    • Ease of use.
    • Local irritant effects.
    • Amount of behavioural replacement provided.
    • Ability for the smoker to adjust and titrate the nicotine dose as required.
    • Use of intermittent formulations as required to relieve cravings.
  • Nicotine transdermal patches are available in 16-hour and 24-hour preparations. Steady-state nicotine levels are achieved 6–8 hours after application.
  • Oral products allow nicotine absorption via the buccal mucosa, with peak plasma concentration occurring after 20–30 minutes. Oral formulations include gum, inhalator, sublingual tablets, and lozenges.
  • Nicotine inhalator may provide more behavioural replacement than other products, although there is no good evidence to support this. Nicotine from the inhalator is deposited on the oral mucosa from where it is absorbed.
  • Nicotine nasal spray is the most rapidly acting form of NRT available.
  • For pregnant women intermittent dosing formulations may be preferable to continuous delivery products (i.e. patches); however, patches may be preferred if the woman has nausea during pregnancy. If patches are used, they should be removed before going to bed. Liquorice-flavoured NRT products are not recommended during pregnancy.
  • For breastfeeding woman intermittent dosing formulations are preferable if NRT is used during breastfeeding, and the woman should avoid using the products for at least 1 hour before breastfeeding.
  • All formulations are available on NHS prescription and over-the-counter from pharmacies. NRT patches, gum, inhalator, lozenges, and microtabs are also available from supermarkets and other retail outlets.
Basis for recommendation
  • Pregnancy: intermittent formulations of nicotine replacement therapy (NRT) (e.g. gum, lozenge, spray, sublingual tablet, or inhalator) are recommended by some experts because these usually provide a lower daily dose of nicotine than patches [RCP, 1999; Dempsey and Benowitz, 2001].
  • Breastfeeding: NRT formulations that are used intermittently are preferred as their use can be adjusted to allow the maximum time between their administration and feeding of the infant, to minimize the amount of nicotine in the milk. Breastfeeding within 1 hour of maternal nicotine use (from any source) can significantly increase the levels of nicotine in breast milk [Micromedex, 2005].

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