Nicotine Replacement Therapy

April 2017

Nicotine replacement therapy (NRT) can help enormously with the withdrawal effects of smoking .

There are many different NRT products and doses available, therefore to ensure success, finding the right product and prescribing the correct dose is crucial for each individual.
  • The current smoking rates in England are 21% overall.
  • Between April 2008 and March 2009 48% successfully quit using NRT
  • NRT comes as many different products including patches, gum, nasal spray, dissolvable tablets for under the tongue and more. .
  • They are available over the counter in pharmacies, on prescription and at some stop smoking clinics. .
  • NRT in conjunction with counselling and support increases the success rate by 70%.
  • NRT delivers approximately a third of the nicotine that smoking cigarettes would have provided.
  • NRT is slowly absorbed into the blood stream through the skin with patches, the mucous membrane of the mouth with the tablets and the inhalator.
  • It is recommended that NRT is used for a minimum of 8 - 12 weeks and can be continued for up to 6 months dependent on the smoker.
  • NRT is safe as it is the 4000 chemical in a cigarette which is toxic and dangerous.
  • The side effects of NRT are minimal.
  • There are no cardiovascular contraindication for the use of nicotinic substitutes.



The risk of becoming addicted to NRT is approximately 1 in 20, however NRT is still safer than smoking.



NRT is safer than smoking during pregnancy. Monitoring, support and encouragement is imperative for pregnant women when quitting and using NRT products.




Patients taking a medicine called Theophylline (for lung conditions) will need specialist monitoring whilst taking NRT as it can increase the theophylline levels.


Patches



Patches are stuck on the skin, and the nicotine is absorbed gradually into the bloodstream. It takes effect approximately 30 minutes after putting it on and remains in place for either 16 or 24 hours depending on the type of patch being used.
  • Patches come in various doses to accommodate how heavy a smoker is and so that over a period of time the dose can be reduced and eventually the patch stopped.
  • Different patches :
    • 24 hours patch: small 10 cm2, 7 Mg, delivering 7 milligrams of nicotine during the 24 hour period.
    • 24 hours patch: average 20 cm2, 14 Mg (14 Mg of nicotine is delivered)
    • 24 hours patch: large 30 cm2, 21 Mg (21mg of nicotine is delivered)
    • 16 hours patch: small 5 mg (5mg of nicotine is delivered)
    • 16 hours patch: average 10 mg (10 mg of nicotine is delivered)
    • 16 hours patch: large 15 mg (15 mg of nicotine is delivered)
  • The absorption of nicotine depends on the size of the patch and the length of time it remains on the skin.
  • Patches are successfully used for approximately a 12 week period which during this period the dose is gradually reduced and then stopped.
  • Patches are usually placed on the top of the arm or thigh, but must not be placed on the chest or close to the heart. Rotate where you place the patch to a different arm or leg each day.
  • Replace the patch or use a new one in the morning.
  • Take care not to touch the adhesive part of the patch.
  • 16 hours patches are removed anytime after 6 p.m but not worn during the night.
  • Patches do not cause dependence.
  • NRT is available over the counter at pharmacies or on prescription. Seeing your doctor for a prescription is advisable so you can access the appropriate support and counselling.


Smoking whilst wearing a patch can cause nicotine overdose, therefore remove the patch if you can't resist the urge to smoke.



The absorption of nicotine from a patch continues for 2 hours after removal. This should be taken into account if deciding to smoke a cigarette or planning your bedtime.


Allergy to patches

  • A localised skin reaction around the patch can occur and is usually caused from the adhesive. If this occurs change the brand of patch or swap to another type of NRT product.

of the patch

NRT Gum


Gum comes as 2 doses - 2 and 4 mg and if smoking 18 cigarette or more a day then you need to start with 4mg dose using 10 - 15 pieces a day. This is approximately 1 piece every hour.
  • The gum must be chewed slowly until the taste gets strong. You then pocket the gum between your gum and cheek. When the taste fades, start to chew again.
  • Gum lasts for approximately 20 - 30 minutes.
  • Chewing the gum too quickly can cause unpleasant side effects such as heartburn and a sore throat.

Inhalator

  • The inhalator is a plastic nozzle which looks like a cigarette. It opens up so a nicotine cartridge can be inserted.
  • The smoker inhales on the inhalator several times in order to absorb the nicotine.
  • Each cartridge lasts for approximately a hour, therefore last for 3 x 20 minute sessions.
  • You should use between 6 - 12 cartridges a day for the initial 8 weeks, then reduce this by half.
  • The inhalator is particularly good for those smokers who need to do something with their hands and miss the hand to mouth action.

Tablets (Microtabs)

  • Theses small tablets must NOT be sucked, swallowed or chewed. They work through the lining of the mouth and are best placed under the tongue to be dissolved.
  • They come in 2 doses 2mg and 4mg.
  • If you smoked up to 20 cigarettes a day then use one 2mg tablet every hour.
  • If you smoke more than 20 a day then take one 4mg tablets every hour, but no more than 20 tablets a day.
  • After a minimum of 8 weeks then the dose can be gradually reduced until stopped.
  • having a coffee or a fruit juice is not recommended within 15 minutes of taking a tablet because it can affect the level of absorption in the mouth.


Lozenge


Lozenges are available in variety of doses and are absorbed whilst being sucked in the mouth.

Nasal Spray


This has the most rapid form of action, and mimics the sudden increase in nicotine like a cigarette would give. It is sprayed into the nostrils and is great for those who get sudden urges to smoke. Some people find is irritate the nose and throat causing sneezing, coughing and watering of the eyes

Combined use of different NRT products


For those smokers that are having bad withdrawal symptoms and cravings use more than product can really help. It is especially helpful in the first 3 -4 weeks. Most use a patch and then use the inhalator or gum an extra boost for those break through cravings.

It is safe to combine products and there is evidence to suggest that combining increase success of quitting.

Always seek professional help when combining products.


It is possible to take nicotine substitutes and to continue smoking




Following a study completed by the University of Birmingham they found little evidence to suggest that smoking whilst using NRT was dangerous. They also found that 22% sustained reduced smoking and 7% actually quit.
  • For some smokers they feel more in control and comfortable with a reduced intake of smoking.
  • Smokers reduce the amount of cigarettes by substituting a third of their cigarettes with an oral form of NRT.


It is not recommended that patches are used in conjunction with this method of quitting.


Symptoms of nicotine overdose


Below is a list of some of the symptoms of nicotine overdose. Any form of nicotine such as smoking tobacco or the use of NRT products can cause these symptoms. Medical advice must be sort if overdose is suspected.
  • Feeling of dislike of tobacco
  • Headaches
  • Dizziness
  • Increased heart rate and blood pressure and palpitations
  • Nausea and vomiting
  • Diarrhoea
  • Cold sweats
  • Stopping the cause remains the first immediate measure to be taken i.e. stopping the NRT and or smoking. In the large majority of cases, the symptoms disappear.

How to get the right dose of NRT according to your dependence?


The success of your smoking cessation is dependent on the correct type of NRT, it's dose and length of time the NRT is used for.

An insufficient dose of NRT is likely to lead to a failure : It is important to match the dose of NRT with how heavy a smoker is.

The Fagerstroms questionnaire evaluates the level of nicotine addiction and thus the NRT doses are adapted to this.
  • If within 7 days the withdrawal symptoms and the compulsive need to smoke are always present , that means that the dose of the NRT is insufficient.
  • The prescribed nicotine dose depends on the daily use of tobacco and the level of dependence.
  • A high dose of NRT is usually proposed at the beginning of the treatment and then gradually decreased.
  • Heavy smokers are more likely to quit smoking with a higher strength patch or gum than one much lower ie a gum dosed at 4 Mg rather than the 2mg dose.
  • For light smokers the intermittent and occasional use of NRT and some counselling and support can be enough to help someone quit.
  • Heavy smokers require NRT for most of the time and for at least 12 weeks.
  • Always seek professional help in choosing the correct NRT product and dose.

Fagerstroms Nicotine tolerance test - how dependent are you?



0 - 3 points = Low level of Dependence
4 - 6 points = Medium Level of Dependence
7 - 10 points = High Level of Dependence
  • Score from 0 to 3: Low dependence

Will benefit from advice. Pharmacotherapy unlikely to be required. Monitoring of progress and to assess if any difficulty or problems with withdrawal symptoms.
  • Score from 4 to 6: Medium dependence

Professional help and pharmacotherapy advised.
  • Score from 7 to 10: High dependence

Both professional help and pharmacotherapy strongly recommended.

Advice by a professional trained in helping with smoking is strongly recommended

Never quit quitting


It takes on average 3 attempts before a smoker finally quits smoking. Giving up smoking is probably the hardest thing you'll ever have to achieve. Smoking therefore nicotine is the most addictive drug - more so than heroine and cocaine.

If you do not succeed then do not despair = never quit quitting.
  • It takes on average 3 attempts before successfully quitting
  • Each relapse is a step towards stopping smoking.
  • Resume smoking for 6 months and try again.
  • Keep your list of reasons for quitting and keep them by you to help keep you motivated.
  • Do not feel guilty - it is the hardest thing you'll ever do.
  • Focus on the reasons why you relapsed this will help you put in help, support and coping strategies for next time.
  • Avoid smoking the occasional cigarette after quitting as it only takes 3 or more cigarettes to get you hooked again.
  • Relapses are more common for heavy, dependant smokers and can occur 6 months, 1 year or several years later.



http://www.healthline.com/blogs/smoking_cessation/2009/09/nrt-to-reduce-and-eventually-quit.html

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Latest update on July 24, 2013 at 11:48 AM by Jeff.
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