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Combination Nicotine Replacement Therapy (NRT)

What is Combination NRT?

Combination NRT is the use of NICODERM® patch PLUS an additional form of short-acting NICORETTE® oral NRT (gum, lozenge, inhaler, QUICKMIST®) on an as needed basis.

Now, you can power up your patient's quit journey by combining NICODERM® and NICORETTE® products.

58% more effective vs NRT monotherapy (patch) to get patients to a successful quit. 133

NICODERM® and NICORETTE®: Now Approved to be Used in Combination

NICODERM + Inhaler OR gum OR lozenge OR QUICKMIST

Combination NRT therapy should be encouraged when quitting with monotherapy has not been successful or if breakthrough cravings occur.113,114

Total abstinence is the ultimate goal. Combination NRT (nicotine patch + an oral form of NRT) yields among the highest abstinence rates* compared to other pharmacological interventions.109

*Estimated 6-month abstinence rates comparing NRT monotherapy (gum, patch, inhaler, lozenge), nicotine patch plus as needed inhaler, gum or lozenge, bupropion (monotherapy and in combination with NRT), and varenicline (monotherapy)109

The first and only NRT in Canada permitted for use in combination as supported by the Health Canada Product License.18,50,60,92,93

Why Combination NRT?

Smokers’ nicotine levels vary throughout the day resulting in a gradual build-up of trough nicotine levels and regular nicotine peaks each time they smoke.111

Graph showing results of a subject study

Monotherapy may not be able to provide both high daily baseline nicotine levels as well as the nicotine levels needed during the craving phase.113

Combination NRT using patch + an oral form of NRT enables coverage of both peak and trough levels of nicotine:

Graph showing results of a subject study

Evidence shows Combination NRT is an effective approach to achieving abstinence:

Versus Monotherapy (patch)

Over 2x more effective vs NRT patch monotherapy (aggregated relative risk of abstinence of combination therapy vs. monotherapy: 1.58 [1.25-1.99] at 12 months)133

Versus Cold Turkey

Nearly 3x more effective vs cold turkey
Compared to cold turkey, smokers using Combination NRT were nearly 3x more likely to quit for good (OR 2.73; 95% CI 2.07-3.65)110

Versus Cold Turkey

Nearly 5x more effective vs cold turkey alone:
Pharmacotherapy combined with HCP support can increase a smoker’s success of quitting by fivefold47

"There is little evidence for concern that either high-dose NRT or combination NRT will result in significant health harm."114

- Carpenter MJ et al, Drugs, 2013.

"Combining a long-acting from of NRT (e.g. nicotine path) with a faster-acting formulation (e.g. nicotine gum) is a highly efficacious and safe smoking cessation treatment."115

- Fucito et al, Nicotine & Tobacco Research, July 2014.

Putting Combination NRT into practice

Who is a good candidate for Combination NRT?

Smokers who:

have used NRT in a previous quit attempt but relapsed while using it


Feel they need something more than a patch or other single form of NRT to keep from smoking.

Meet Four Smokers Who Could Benefit from Combination NRT:

Rhonda has been smoking since age 17. She smoked 1 pack/day (25 king-size) until about 5 years ago when she was diagnosed with type 2 diabetes, after which, she weaned herself to 1/2 pack/day (12).

She smokes within 30 minutes of waking with her morning coffee in the garage. She does not smoke inside the house or wake up at night to smoke. She smokes in the car on her 45-minute trip to and from work, as she finds the drive stressful. She had a bad bout of bronchitis this winter and decided it is time to quit.

With the help of a pharmacist, she applies a 21 mg STEP 1 NICODERM® patch first thing in the morning, but removes it at night since she can’t sleep with it on. She continues to bum the odd cigarette from colleagues since she misses the hand-to-mouth sensation of smoking.

"Sometimes I will put my fingers to my lips thinking that I have a cigarette in my hand, which only makes my cravings worse."

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Mike is married with two kids, aged 9 and 11. He works as a roofer and has a chronic “smoker’s cough” most mornings. He started smoking a pack/day at 16, which slowly increased to 1.5 packs/day. He has tried to quit several times, which began when his father passed away at the age of 55 of a myocardial infarction. He has tried multiple counselling sessions, hypnosis and bupropion.

He has his first cigarette within 3 minutes of waking due to intense cravings before applying the patch. With the patch on, he can wait until he gets to the car to drive to work, coffee in hand.

He has used the 21 mg NICODERM® patch which helped cut down the total number of cigarettes overall, but he found that he could not cope with intense cravings and kept reaching for cigarettes to deal with them. When he increased the patch dose, he found it affected his sleep – this was not an issue with the 21 mg patch.

"I feel really vulnerable. Weak. It stresses me out when I feel a craving coming on. I wish I could control it, but I end up smoking."

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Michelle smokes two packs a day and sometimes more. Often, she will have a smoke in the middle of the night. Michelle’s activity is limited: she has chronic obstructive pulmonary disease (COPD) and experiences shortness of breath (SOB) during minor activities such as hair washing.

Michelle lives alone with no financial income. Because of her COPD, Michelle does not work; smoking is the only way to make her life still enjoyable. She is on optimal treatment for SOB and has experienced several unsuccessful quit attempts in the past. As a result, she doesn't feel confident enough to quit smoking and she feels that it is too late for her anyway.

“I wish I never started smoking. It’s been so long now, I don’t think I can quit. It’s just part of my daily life, you know? I know it’s bad for me, but at this point, what can help me?”

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Henry is married and works in the oil and gas industry. He has a relatively sedentary lifestyle and has hypercholesterolemia (treated with atorvastatin 20 mg/day) and hypertension (treated with hydrochlorothiazide 25 mg and lisinopril 10 mg).

Henry has a 30-year history of smoking 25-30 cigarettes/day. He often travels for work, which involves a lot of driving and he smokes to help pass the time. In a typical month, Henry spends about 10 days on the road. He often goes out with coworkers for drinks after work and entertains clients over drinks. He has tried to quit several times using 21 mg nicotine patches as monotherapy, but was unable to stick to treatment for more than a few weeks. His old habits tied to smoking (driving, drinking) brings on very strong cravings.

Henry is ready to try and quit again and wants to give nicotine patches another shot, but is worried about how he will cope with nicotine withdrawal.

"It gets to the point where the craving is the only thing I can focus on - I can't enjoy a simple night out with my buddies."

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*Off-label dosing.

How can I help my patients power up their quit attempt?

  • Provide support. Find helpful patient support tools here
  • Provide incentives. Coupons for NRT products are available for download

View the CMAJ article discussing Combination NRT