Nicotine Replacement Therapy (NRT)

gum__patch_therapy.jpgNRT is the most common medication used by Australian smokers. It is available in 2 main forms:

All can be purchased over-the-counter, however nicotine patches are available on a doctor’s prescription with a government subsidy and a substantial cost saving.

The electronic cigarette (e-cigarette) also delivers nicotine and is being used by some people to assist quitting. Click here to download an information sheet on e-cigarettes and click here to read a brief article.

 

NRT is safe!

Nicotine is the main cause of addiction to smoking but has few significant health effects. It is the other 7,000 other ingredients in tobacco smoke such as tars and carbon monoxide which cause disease.

Nicotine replacement products generally work more slowly, and the amount of nicotine in the bloodstream is less than that from smoking. That makes nicotine medications much safer and much less addictive than cigarettes. Also, after you have smoked for a while, you body becomes used to nicotine and is more tolerant of it.

Click below for more about the safety of NRT:
How safe is nicotine replacement therapy?
How much nicotine is too much?
Can you get addicted to nicotine gum or lozenges?

Golden rules for using NRT 

1. Use sufficient nicotine

It is vital to take enough NRT to relieve cravings and withdrawal symptoms. Some people metabolise nicotine faster and need larger doses to get the same effect. Standard doses of NRT provide about half the nicotine your body receives on average when smoking.

Nicotine lozenge and gum are available as 4mg or 2mg pieces (or 1.5mg in the case of the minilozenges). Be sure to use the 4mg product if you smoke within 30 minutes of waking.

The doses recommended by the manufacturers are:

  • Patch. Most smokers need the full strength patch (21mg patch/24 hours or 15mg patch/16 hours). Only light smokers (

  • Mouth spray: Up to 64 sprays per day

  • Nicotine lozenges: 9-15 pieces per day.

  • Minilozenges: 1.5mg mini lozenges: 9-20 pieces per day. 4mg mini lozenges: 9-15 pieces per day

  • Nicotine gum. 2mg gum: 8-20 pieces. 4mg gum: 4-10 pieces.

  • Inhalator: 3-6 cartridges per day

  • Oral strips: up to 15 per day

 

Don’t be afraid to increase the dose if you still have cravings or withdrawal symptoms. Many failures from using NRT are due to underdosing.

Sometimes side-effects mistakenly reported from NRT are actually due to nicotine withdrawal symptoms. You may need more NRT rather than less!

Are you getting enough nicotine? Click here for more.

2. Take the full course of NRT

A full course of NRT is at least 8-12 weeks. Many smokers get overconfident early in the treatment, but don’t realise they are doing well because of the treatment. Stopping medication too early often leads to relapse.

Also, it takes time to break the smoking habit and NRT keeps you comfortable while you unlearn many years of smoking behaviour.

Long term use of NRT (months or years) may increase success rates further and is much safer than continuing to smoke. Click here for more about the importance of taking a full course of NRT.

3. Start the nicotine patch 2 weeks before quitting

Starting the patch 2 weeks before Quit Day is twice as effective as starting it on the day you quit. Smoking while using the patch is safe.

4. Continue the patch after a lapse

Do not remove the patch if you have a slip-up as it helps prevent you from going back to regular smoking. Using the patch while smoking is safe.

5. Use quick-acting forms of NRT to treat cravings

Oral forms of NRT (mouth spray, lozenge, gum and inhalator) are effective in relieving cravings, for example when triggered by stress, coffee or alcohol. Ideally, they should be used in anticipation of a craving whenever possible. Nicotine mouth spray gives the fastest relief of cravings.

After quitting, it is a good idea to carry some quick acting NRT to relieve cravings, as they can continue to occur for months or years.

6. Use NRT correctly

The incorrect use of NRT makes it less effective and causes more side-effects. It is important to follow the instructions carefully (see below). Do not drink or eat immediately before and while using oral NRT as this reduces the absorption of nicotine in the mouth.

video_icon-small.jpgView this video for instructions on using the various nicotine replacement products.

 

Combination therapy

The best results from NRT are from combining a nicotine patch for a steady, slow dose of nicotine with a quick-acting form of NRT (mouth spray, gum, lozenge or inhalator) for breakthrough cravings.

Combinations work better than single forms of treatment and are recommended for most smokers. They are safe and are usually well tolerated.

 

Nicotine patches

Nicotine-patch.jpgNicotine patches are the most popular form of NRT. A patch is applied to the skin daily and delivers a steady dose of nicotine through the day.

Nicotine absorption from the patch is slow and it takes several hours for the patch to have its full effect. Patches are not so helpful for immediate cravings so are usually combined with a faster acting form of NRT, such as the mouth spray, lozenge, gum or inhalator. Sometimes multiple patches are required to relieve cravings and withdrawal symptoms.

There are two types of nicotine patch. Twenty-four hour patches are usually applied on rising and removed the next morning. They help to protect against early morning cravings and may give better craving relief overall. They can be taken off at bedtime if sleep is disturbed. The 16 hour patch that is applied in the morning and removed at bedtime.

Smokers of 10 or more cigarettes per day normally start on a full strength patch (21mg for the 24 hour patches and 25mg for the 16 hour patches). Sometimes 2 or even 3 patches are required to relieve cravings or withdrawal symptoms.

Correct use of nicotine patches

Nicotine patches work best if started 2 weeks before Quit Day. Apply the patch each morning to clean, dry, hairless skin. The patches are generally placed on the upper arm, chest or back, but can probably be applied anywhere if those locations are not convenient. Use a different location each day to avoid skin irritation.

Sometimes patches are applied at bedtime. The nicotine level builds up overnight and gives good protection against morning cravings. However, the higher nicotine levels at night can disturb sleep.

Nicotine patches can be stopped abruptly or you can gradually taper the dose of nicotine over several weeks, by using weaker strength patches. There is no evidence that either method is better than the other.

If you do slip and have a cigarette, it is vital to keep your patch on. There is no risk from smoking while on the patch. However, keeping the patch on will help to stop a slip becoming a full relapse to smoking.

Nicotine patches usually stick on well, but sometimes they fall off, especially in hot and humid conditions. Click here for tips for keeping the patches on. If the patch does fall off, it can be taped on again. Any of the adhesive which remains on the skin after removing the patch can be removed safely with eucalyptus oil.

video_icon-small.jpgClick here to see a video on correct use.

Remembering the patch every day

It can be easy to forget to put your patch on some days and this can make it less effective. Tips to help you remember include keeping your patches in your underwear drawer so you remember to put one on when you get dressed, and keeping one in your handbag, car or desk at work just in case. You could also set the alarm on you smartphone to remind you each morning.

Duration of use

Patches are generally used for 8-12 weeks. However, studies have shown that a 6 month course is more effective and this may be recommended for some people, especially those who are more addicted to nicotine or have a mental illness.

Long-term addiction to the nicotine patches is very uncommon. However, continuing to use nicotine patches is much safer than returning to smoking.

Side effects

Patches can cause skin irritation, redness, itch and rash. This is usually mild, but can be treated with 1% hydrocortisone cream if troublesome. It is important to rotate the application site each day to reduce irritation. Click here for more.

Insomnia and vivid dreams can also occur, but tend to improve with time. However, if severe, you can remove the patch at bedtime or a couple of hours before retiring.

Other possible, but uncommon side effects of the nicotine patch include dizziness, racing heartbeat, headache, nausea, vomiting and muscle aches.

If you are having side-effects, contact me for advice before stopping the patch. Your symptoms may not be due to the patch. For example, you may be having nicotine withdrawal symptoms and may actually need more nicotine replacement.

Cost

With a doctor’s prescription, you can receive one 3-month course of subsidised patches per 12 month period. The cost is $6.10 per script for pensioners and Health care card holders and $37.70 for others.

Patches can also be purchased over-the-counter, without a prescription, for the full retail price. However, this is still cheaper than smoking!

Download the package inserts

Package inserts provide detailed, approved information from the manufacturer.

pdf_icon_30px.jpgNicabate 24 hour patch    pdf_icon_30px.jpgNicotinell 24 hour patch    pdf_icon_30px.jpgNicorette 16 hour patch 

 

Nicotine Mouth Spray

Nicorette-QuickMist.jpg

Figure: Nicorette QuickMist 

Nicotine from the mouth spray (Nicorette QuickMist) is sprayed directly into the mouth and is absorbed much more rapidly than other forms of NRT. It starts to relieve cravings after one minute and delivers its maximum effect in about 10 minutes.

Correct use

Spray under the tongue or onto the inside of the cheek, being careful to avoid the lips and eyes. Do not inhale while spraying and do not swallow for a few seconds after spraying.

Use the mouth spray when cigarettes would normally be smoked or for quick relief if cravings occur.

Do not drink or eat for 10 minutes before and for 5 minutes after using the mouth spray as this reduces the absorption of nicotine in the mouth. Try not to swallow saliva for a minute or two after each spray.

video_icon-small.jpgClick here to see a video on correct use.

Dosage

The recommended dose is 1-2 sprays every 30-60 minutes, up to a maximum of 4 sprays per hour or 64 sprays per day. 

Duration of treatment

A course of 12 weeks is recommended. The number of sprays can be gradually reduced towards the end of treatment.

spray.png

Figure: Spray directly into the mouth every 30-60 minutes

Side-effects

Side-effects from the mouth spray include irritation of the mouth and throat, increased saliva, nausea, dyspepsia, headache and hiccups. 

Cost

The recommended retail price is $39.95 for a single pump spray (150 sprays) and $59.95 for a double pack. However, they are much cheaper at discount pharmacies.

Download the package inserts

Package inserts provide detailed, approved information from the manufacturer.

pdf_icon_30px.jpgNicorette QuickMist

 

Nicotine Lozenges

lozenges-smallerl.jpgNote: there is currently a worldwide shortage of Nicabate lozenges and mini-lozenges. However, Nicorette Cooldrops are available

Like the gum, nicotine lozenges are held in the mouth and release nicotine as they dissolve. Nicotine is absorbed through the lining of the mouth. The lozenges are more discreet than the gum and can be used inconspicuously in public.

The lozenge is available in 2 strengths, 2mg and 4mg. Smokers who have their first cigarette within 30 minutes of waking should take the 4mg lozenge. There is also a popular minilozenge, which is available in 1.5mg and 4mg strengths.

Correct use

Allow the lozenge to dissolve in mouth moving it from side to side from time to time. Try not to swallow saliva excessively. The minilozenges take about 10-15 minutes to dissolve and the regular lozenges take 20-30 minutes. Do not chew or swallow the lozenge.

Like the nicotine gum, the lozenge takes about 30 minutes for the full effect to kick in. It is best used on a regular basis, for example one piece hourly. It can also be used 15 minutes before entering a situation where you may be tempted (e.g. being with other smokers).

Do not eat or drink while the lozenge is in the mouth or for 10-15 minutes before using it, as this reduces the absorption of nicotine into the bloodstream.

video_icon-small.jpgClick here to see a video on correct use.

Dosage

The recommended daily dosages are:

  • Nicorette cooldrop and Nicabate Lozenges: 2mg & 4mg lozenges: 9-15 pieces
  • Nicabate Minilozenges. 1.5mg mini lozenges: 9-20 pieces; 4mg mini lozenges: 9-15 pieces

If in doubt, it is always better to use more rather than less pieces.

Duration of treatment

A 12 week course is recommended.

Side-effects

Lozenges can cause nausea, hiccups, heartburn and flatulence if sucked too quickly or swallowed. Try to make them last longer if this is occurring. Other side-effects include insomnia, dizziness, headache, cough, sore throat.

Cost

The current recommended retail prices are:

  • Mini-lozenge: 20-pack $11.95; 60-pack $30.99.
  • Lozenge: 36-pack $19.99; 72-pack $33.99

Download the package inserts

Package inserts provide detailed, approved information from the manufacturer.

pdf_icon_30px.jpgNicabate lozenges    pdf_icon_30px.jpgNicabate minilozenges

 

Nicotine gum 

Nicotine_gum_3.jpgNicotine gum delivers nicotine to the mouth where it is absorbed into the body through the lining of the cheek.

Nicotine gum is available in two strengths: 2mg and 4mg. If you smoke within 30 minutes of waking you should begin treatment with the 4mg dose.

Correct use of nicotine gum

Nicotine gum should not be chewed like 'chewing gum'. It requires a special chewing technique, called the ‘chew and park’ method. Place one piece in the mouth and chew slowly until you feel a tingling or peppery taste, usually after about 10 chews. Park the gum between your cheek and gums until the tingling goes (usually about a minute). Then chew again slowly until the tingling returns. Repeat this cycle for 30 minutes or until the peppery taste fades and then dispose of the gum.

The nicotine from the gum takes about 30 minutes for the full effect to kick in. It is best used on a regular basis, for example one piece hourly. It can also be used 15 minutes before entering a situation where you may be tempted (e.g. being with other smokers).

It is important not to eat or drink while the gum is in the mouth or for 10 minutes before as this interferes with the absorption of the nicotine into the lining of the mouth.

video_icon-small.jpgClick here to see a video on correct use.

Dosage

The recommended dose is 9-15 pieces of gum per day. If in doubt, it is best to use more rather than fewer pieces.

Duration of treatment

A full course of treatment is 12 weeks. Tapering the amount of gum chewed helps users to stop using it.

Some people choose to continue the gum long-term to provide ongoing support. This is much safer than going back to smoking.

Side-effects

Hiccups and nausea can occur if the gum is chewed too rapidly and excessive nicotine is swallowed. Vigorous chewing can also cause jaw discomfort. Some other possible side-effects of the gum include bad taste, throat irritation and a racing heartbeat. Nicotine gum also sticks to dentures and is not suitable for denture wearers.

Cost

Nicotine gum is available over-the-counter without a prescription. The recommended retail price of Nicabate 2mg or 4mg gum is $9.99 for a 24-pack and $28.49 for a 96-pack.

Download the package inserts

Package inserts provide detailed, approved information from the manufacturer.

pdf_icon_30px.jpgNicabate gum    pdf_icon_30px.jpgNicotinell gum    pdf_icon_30px.jpgNicorette gum 

 

Nicotine Inhalator

Nicorette_Inhalator.jpg

           Figure: Nicorette Inhalator

The nicotine inhaler (Nicorette Inhalator) is a hollow plastic tube with a replaceable nicotine cartridge inside. It is good for people who like to handle a cigarette. When you puff on the inhalator, a nicotine vapour (flavoured with menthol) goes into your mouth and is absorbed through the lining of the mouth.
 

Nicorette_inhaler.gif

Figure: A replaceable nicotine cartridge sits inside a hollow pipe.

 

Correct use

Take shallow puffs from the inhalator into the mouth, not deep breaths into the lungs. You can take a puff approximately every 2 seconds or just puff as needed. A good rule of thumb is to puff frequently for about 20 minutes every hour. Replace the cartridge when the taste fades. A cartridge will last about 40 minutes of puffing.

Since the amount of nicotine from a puff of the inhalator is much less than that of a cigarette, about 10 times as many puffs are needed compred to smoking. Each cartridge contains up to about 400 puffs.

Do not eat or drink for 15 minutes before using the inhalator or while using it, as this can reduce the absorption of nicotine and make it less effective.

Rinse the mouthpiece with water several times per week.

video_icon-small.jpgClick here to see a video on correct use.

Dosage

Use 3-6 cartridges per day initially, increasing if needed. Each cartridge contains 15mg of nicotine.

Duration of treatment

A 12 week treatment course is recommended. The number of puffs can be gradually reduced towards the end of treatment.

Side-effects

Side-effects include cough, irritation of mouth and throat, abdominal discomfort, nausea, hiccups and vomiting. Breathing or puffing on the inhaler too deeply will make you cough more.

Cost

The recommended retail price of a starter pack containing a mouthpiece + 4 cartridges is $9.99. A pack of 20 cartridges is also available with a mouthpiece.

Download the package inserts

The package inserts provides detailed, approved information from the manufacturer.

pdf_icon_30px.jpgNicorette Inhalator

 

Nicotine strips

Nicabate-strips-200px.jpgNicotine mouth strips are the latest form of nicotine replacement therapy. The mint flavoured strips are reported to give fast craving control which can help when smokers are exposed to smoking triggers, such as the smell of smoke or stress. 

The thin films are recommended for smokers who are not heavily addicted and who smoke their first cigarette more than 30 minutes after rising. The strips release the same amount of nicotine as 2mg nicotine gum and 2mg lozenge. However, they can be used in combination with nicotine patches for increased potency.

Nicabate_strips_instructions_2.jpg

Each strip is contained in an individual sachet. After opening the sachet, the thin film is place on the tongue. The mouth should then be closed and the film pressed to the roof of the mouth. The strips dissolve completely in about 3 minutes, releasing 2.5mg of nicotine.

The oral strips come in packs of 15 (RRP $14.99) and 60 (RRP $49.99) and can be purchased over-the-counter without a prescription.

Dosage 

The manufaturer recommends a 12 week course using the following schedule:

Weeks 1 to 6: 1 strip every 1 to 2 hours
Weeks 7 to 9: 1 strip every 2 to 4 hours
Weeks 10 to 12: 1 strip every 4 to 8 hours

To help stay smoke-free after the course of treatment, you can use a strip in situations when you experience strong urges.

If the strips are not relieving your urges or withdrawal symptoms, you may need to use them more often or combine them with a nicotine patch.

Side-effects

Side-effects are usually mild and include nausea, throat irritation, hiccups and headache. A study of 200 subjects demonstrated they are as well tolerated as the nicotine lozenge.

Download the package inserts

The package insert provides detailed, approved information from the manufacturer.

pdf_icon_30px.jpgNicabate Strips

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Last Modified: 18-04-2015