Nicotine Replacement Therapy: Dosing Guidance

Once a smoker expresses an interest and willingness to begin treatment, the next step is to assess their smoking habits and level of nicotine dependence in order to determine the right Nicotine Replacement Therapy (NRT) dose. A full assessment should include:133

  • Degree of nicotine dependence
  • Frequency of nicotine use
  • Products used
  • History of previous quit attempts

STEP 1. Determine the level of nicotine dependence

The Modified Fagerström Nicotine Tolerance Scale is a quick tool to assess a patient’s level of nicotine dependence to help determine the initial dose of NRT. It measures a patient’s degree of nicotine dependence, which helps predict how difficult quitting will be and, therefore, how intense treatment should be.133

Questions to ask your patients:134

  1. How soon after you wake up do you smoke your first cigarette?
  2. Do you find it difficult to refrain from smoking in places where it is forbidden?
  3. Which cigarette would you hate most to give up?
  4. How many cigarettes per day do you smoke?
  5. Do you smoke more during the first hours of waking than during the rest of the day?
  6. Do you smoke even when you are ill enough to be in bed most of the day?

The patient is given a score of 1-10, where 1 is the lowest degree of nicotine dependence and 10 is the highest. If the patient’s score indicates a moderate to high level of dependence (5 or greater), pharmacotherapy plus behavioural therapy is warranted.134 Learn how to score the Fagerström Scale

STEP 2. Assess tobacco use history and prior quit attempts

The next step is to determine how many cigarettes a patient smokes a day75 and how long they have been smoking.135 It is also important to document the use of any other tobacco products such as cigars, pipes, and electronic cigarettes.133

Other relevant questions to ask:

  1. Where do you smoke most often?
  2. Do you smoke socially or alone (or both)?
  3. Have you made any previous attempts to quit, and if so, how many and what methods were used (e.g. willpower alone [“cold turkey”], NRT, prescription medications)?

Consider probing further to determine the patient’s perception of the cause of relapse and which methods they feel worked best for them.135

Getting patients started on Combination NRT

Combination NRT (long-acting nicotine patch + rapid-acting oral form of NRT) yields among the highest abstinence rates* compared to other pharmacological interventions.109 Combination NRT therapy should be encouraged when quitting with monotherapy has not been successful.113,114

NicoDerm Step 1 Nicotine Patches with Combination NRT
Long-acting NRT (patch) reduces background cravings + Rapid-acting NRT (gum, lozenge, inhaler or spray) helps alleviate breakthrough cravings and provides sensory stimulation

Combining NRT formulations allows the patient to tailor therapy as needed based on specific environmental or emotional triggers. Learn more about Combination NRT

*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

Determining the right format

To determine the right NRT format, a patient’s preferences and history of previous quit attempts should be taken into account. Below is a summary of key factors to consider for each format:136

Long-acting NRT
Patch
  • Delivers a continuous release of nicotine, providing constant withdrawal relief over 24 hours, making it the simplest to use
  • Compliance might be more straightforward; however, the patient cannot adjust the nicotine dose in response to sudden cravings and triggers
  • For patients who want more control of their dose or for those who smoke only in certain situations or in response to certain triggers, adding one of the oral formats could be very beneficial
Rapid-acting NRT
Gum
  • One of the most commonly used rapid-acting NRT forms
  • Provides peak nicotine levels in just 25 minutes, so is effective in relieving breakthrough cravings
  • To be effective and avoid excess side effects, proper chewing technique (“chew and park”) is required
  • In patients with poor dentition and those with dental appliances, other rapid-acting formats such as the lozenge or spray may be more appropriate
Lozenge
  • Comparable pharmacokinetic profile to the gum
  • Simpler to use than the gum, so is an option for patients in which proper chewing technique is unreliable
  • Helps manage breakthrough cravings
  • Dissolves completely in the mouth
Inhaler
  • Addresses the physical dependence of smoking and the sensory and behavioural aspects of smoking, so is an excellent option for patients who are attached to the hand-to-mouth ritual of smoking
Spray
  • Instant-release mouth spray
  • Most rapid-acting NRT format
  • Gets to work on cravings in just 60 seconds, so is very effective in relieving breakthrough urges to smoke

Determining the right dose of Combination NRT

Nicoderm in addition to a rapid acting NRT helps alleviate nicotine cravings
  • If strong cravings return when attempting downward titration of the NRT patch, consider advising patients to remain at the higher dose for longer
  • NRT can be used for 10-12 weeks or longer if necessary
  • Oral formats can be used after discontinuation of NRT patch, as required113

Adapted from Reid et al., 2016.113

IMPORTANT: Instruct patients to not chew more than one piece of NICORETTE® Gum at a time or more than 20 pieces per day; and to chew once or twice and park between their cheek and gums for 1 minute. Repeat for 30 minutes.18 Discard. Use the NICORETTE® Inhaler as needed up to a maximum of 12 cartridges per day. Each cartridge lasts for approximately 20 minutes of frequent continuous puffing. For each oral NICORETTE® product, acidic food and beverages like coffee must be avoided 15 minutes prior to use.