Nicotine Replacement Therapy (Nicoderm, Habitrol, Nicorette, Nicotinell, generics)

1. Cochrane systematic review -- Nicotine replacement therapy versus control for smoking cessation

• First-line pharmacotherapy for smoking cessation, used alone or in combination (a patch for steady baseline nicotine delivery plus an as-needed fast-acting gum or lozenge for breakthrough cravings), to reduce nicotine withdrawal symptoms and cravings during a quit attempt.
• Combination therapy (patch plus gum or lozenge) is more effective than any single form used alone.

• Smoking cessation is strongly recommended in pregnancy. NRT may be used if non-pharmacologic counselling alone has not succeeded, since the risks of continued smoking are greater than the risks of NRT itself — use the lowest effective dose and involve the prescriber/obstetric provider in the decision.

• May be used. Take doses (especially fast-acting gum or lozenge) after breastfeeding rather than immediately before, to minimize infant nicotine exposure.

• No specific dose adjustment required; use standard adult dosing based on baseline cigarette consumption.

• Not established for routine use under 18 years of age; specialist-directed use only in adolescent smokers.

• Patch: choose starting strength by baseline cigarette use — 21 mg/24h (or 15 mg/16h) if smoking 10 or more cigarettes/day, 14 mg/24h (or 10 mg/16h) if fewer. Apply one patch daily to clean, dry, hairless skin, rotating application sites. Step down in strength over approximately 6-10 weeks per the product-specific schedule.
• Gum: 2 mg if smoking fewer than 25 cigarettes/day, 4 mg if 25 or more/day. Chew slowly until a tingling or peppery taste appears, then "park" between cheek and gum until the taste fades, repeating this cycle for about 30 minutes per piece. Up to 24 pieces/day; taper over approximately 8-12 weeks.
• Lozenge: 2 mg or 4 mg, selected by time-to-first-cigarette after waking. Allow to dissolve slowly over 20-30 minutes without chewing or swallowing whole. Up to 20 lozenges/day; taper over approximately 8-12 weeks.
• Combination therapy (patch plus gum or lozenge for breakthrough cravings) is a recognized, more effective strategy than monotherapy for patients with strong cravings on a single form.

If overdose is suspected, seek emergency medical attention immediately or contact your regional Poison Control Centre without delay.

• Nicotine toxicity (nausea, vomiting, dizziness, tachycardia, and in severe cases seizures) can occur with excessive or inappropriate use, particularly if a patient continues smoking while also using full-dose NRT, or if a child accidentally ingests gum or lozenges, or chews on a used patch. Remove any patch and seek medical attention for suspected overdose.

• Patch: local skin irritation or erythema at the application site; vivid dreams or sleep disturbance if worn overnight.
• Gum/lozenge: mouth or throat irritation, hiccups, dyspepsia, jaw discomfort with prolonged chewing.

Serious side effects require immediate discussion with the prescriber or emergency care.

• Severe or spreading skin reaction to the patch.
• Signs of nicotine toxicity (see Overdose) with inappropriate use.

• Recent myocardial infarction, unstable angina, or serious arrhythmia — NRT is generally still preferred over continued smoking in these patients, but discuss timing with the prescriber.
• Significant dermatologic conditions affecting patch application sites.

• Known hypersensitivity to nicotine or any component of the formulation.

• Stopping smoking itself (independent of NRT) can raise serum levels of several drugs metabolized via CYP1A2 (e.g., theophylline, clozapine, some tricyclic antidepressants) — dose adjustments to those other drugs, not the NRT, may be needed after a quit attempt.

• Acidic beverages (coffee, soft drinks, juice) taken shortly before or during gum/lozenge use reduce buccal nicotine absorption — avoid eating or drinking for about 15 minutes before and during use.

• Patch: apply in the morning to a new site; remove after 16 or 24 hours depending on the product.
• Gum/lozenge: use as needed for cravings, or on a fixed schedule during early cessation.

• Store at room temperature, away from children and pets — used and unused patches, gum, and lozenges retain enough nicotine to be dangerous if ingested or chewed by a child or pet; fold used patches in half, sticky side together, before disposal.

• Nicotine replacement therapy roughly doubles your chance of successfully quitting smoking compared with willpower alone, and combining a patch with an as-needed gum or lozenge works better than either alone.
• Keep using your quit-smoking medication even if you slip and smoke a cigarette — don't discard the whole attempt.
• Store all forms safely away from children and pets; a chewed patch or swallowed gum/lozenge can be dangerous for a small child.
• Tell your pharmacist about all your other medications when you quit smoking, since stopping smoking itself (not the NRT) can change how your body handles some other drugs.