Text adapted in 2021 from Smoking Cessation in The Primary Care Addiction Toolkit (online only). A complete list of Toolkit authors, editors and contributors is available here.
Candidates for NRT
NRT should be recommended to all patients who are interested in quitting or cutting down on smoking.
The only contraindication for NRT is with patients who have current or recent acute coronary syndrome and continue to exhibit symptoms of angina.
Clinical guidelines in Canada emphasize that health care providers should encourage patients who smoke to use approved pharmacotherapy and NRT is the most studied and used first line pharmacotherapy.
The U.S. guidelines include an excellent quick reference guide for clinicians, along with other useful resources for clinicians and patients (which are translated into Spanish) (2008 PHS Panel, 2008).
Is Nicotine Dangerous?
Nicotine has not been shown to cause cancer, chronic obstructive pulmonary disease (COPD) or vascular disease.
It is the delivery system – the cigarette – not nicotine that is responsible for the vast majority of tobacco-related disease. Major adverse effects from using nicotine gum or the nicotine patch are very rare.
Nicotine is a stimulant, like caffeine, and has the potential to stimulate the circulatory system, with an increased risk of arrhythmias and raised blood pressure. Thus, NRT is not recommended for patients with unstable cardiac disease – but then again, neither are cigarettes.
Smoking While on the Patch
Despite the popular belief that smoking while on the patch can be dangerous, there is no evidence to suggest that it may cause heart attacks or stroke like previously thought. However, it can lead to a high level of nicotine in the plasma and symptoms of nicotine overdose as dizziness, nausea, excessive sweating and palpitations. These symptoms are usually self-limited and will go away once a person stopped smoking. If the symptoms are severe or persist, it is recommended to take off the patch until resolution of symptoms occur.
Patients should be advised that if smoking while on the patch, they may not be able to finish a whole cigarette and that they should put out the cigarette if they experience symptoms of nicotine overdose.
Patches can help smokers who choose a “reduce to quit” approach, where patients reduce the number of smoked cigarettes while wearing the patch consistently. Most smokers are able to manage well smoking on the patch by smoking in a lower intensity (i.e. taking in a few puffs) and for many, this is a step in their quit journey.
Rationale for Using Nicotine in Smoking Cessation
The burden of nicotine withdrawal manifests as irritability, low mood, intense craving, and concentration difficulties. It is what keeps smokers addicted to tobacco. The patch provides a fraction of the nicotine delivered by cigarettes that attenuates the nicotine withdrawal to some extent and allows patients to cut down or quit their use of tobacco cigarettes.
It is the cigarette smoke - rather than the nicotine itself that is responsible for morbidity and mortality associated with smoking.
Does NRT Maintain the Addiction?
NRT does not perpetuate the addiction, for the following reasons:
The addictive potential of nicotine, as with all addictive substances, varies with the rate and route of nicotine delivery.
The cigarette is a highly engineered and a carefully designed nicotine delivery system. It is a far more addictive mechanism than nicotine gum or the patch because NRT provides a much lesser effective mechanism of nicotine delivery.
Because nicotine from cigarettes is absorbed through the lungs, it takes only seven to 20 seconds for the drug to reach the brain – faster than an equivalent intravenous injection of nicotine. This rapid delivery results in a faster and more intense response, increasing the pleasurable feedback and thus, the risk of addiction.
With the patch, nicotine levels in the blood rise over hours instead of seconds, resulting in a very slow onset of effects. As a consequence, the patch has very low addictive potential.
Immediate-release NRT (e.g., gum, inhaler, lozenge, spray) provides nicotine to the brain more rapidly than the patch but less rapidly than cigarettes (minutes vs. seconds) and reaches lower plasma nicotine levels. These agents have far less addictive potential than cigarettes.
Using NRT maintains physical dependence on nicotine, but it is not associated with adverse health effects such as seen with smoking. Most people who quit using NRT will stop using NRT at 1 year post quitting.
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. 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 preloading is an approach that can be used with smokers who are reluctant to make a quit attempt but want to use a gradual approach towards quitting
- A patch is given 4 weeks prior to a planned quit attempt, during which patients work on reducing their smoking, improving awareness to smoking triggers and developing health coping skills.
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. Building on existing evidence (Aveyard et al., 2018), the CAN-ADAPTT guide to smoking cessation recommends the following:
- “Light” smokers <10 cigarettes per day (cpd) start with 14mg patch
- “Moderate” smokers 10-29 cpd, start with 21mg patch
- “Heavy” smokers >29 cpd, start with 21+7mg patches
It is recommended to combine patch with one form of short acting NRT (gum, lozenge, inhaler, spray) to use for breakthrough cravings as needed.
Monitoring the Patch Dose
Following initiation of NRT patches, schedule a follow up visit after 1-4 weeks.
If the patient is quit, continue at the same dose. If the patient is still smoking, increase NRT dose according to the remaining number of cigarettes smoked per day:
- 10+ CPD: Add a 21mg patch to current dose
- 6-9 CPD: Add a 14mg patch to current dose
- 1-5 CPD: Add a 7mg patch to current dose
In the case the prescribed dose is causing the patient to experience symptoms of nicotine overdose, including nausea, dizziness, excessive sweating, it should be reduced to the previous tolerated dose.
Maximal Dose of Nicotine Patch
CAN-ADAPTT guidelines recommend the use of up to 4 X 21mg patches simultaneously.
- Duration of NRT
It is recommended that the patch and other forms of replacement should be used for at least 4 weeks with best results among those who use NRT for 8 to 12 weeks (Zhang, Bo et al., 2015).
To prevent relapse, patients should be instructed to taper off NRT by no more than 7mg per week. This helps them adjust to lowering nicotine levels. In the case a patch dose decrease is linked with a burdensome increase in tobacco craving, that dose can be maintained for three to four weeks before an additional decrease is attempted.