Nicotine Replacement Therapy (NRT)

Introduction

Smoking is the leading cause of preventable morbidity and mortality in the world. Tobacco use causes more than 5 million deaths per year worldwide, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030. In Malaysia, smoking remains one of the top 10 reasons for hospitalization and causes of death. The Global Tobacco Survey 2011 reported 4.75 million smokers aged 15 and above in Malaysia. Tobacco cessation can significantly reduce the risk of smoking-related disease. One of the common smoking cessation treatments available is Nicotine Replacement Therapy (NRT). According to Cochrane Study 2008, NRT increases the rate of quitting by 50% to 70%.

How does NRT works?

NRT works by providing low doses of nicotine; without the other harmful chemicals present in tobacco smoke, to the brain in order to replace the nicotine from cigarette smoke. This approach aims to reduce the craving for nicotine and ease or prevent the withdrawal symptoms associated with stopping smoking.

What are the types of NRT available?

Nicotine replacement product comes in several forms and strengths to accommodate the different needs and level of nicotine addiction of the smokers. Below are the 5 different types of nicotine products available in the market:

1. Nicotine gum
2. Nicotine inhaler
3. Nicotine lozenge
4. Nicotine nasal spray*
5. Nicotine patch

*Not available in Malaysia

These nicotine products are designed with different nicotine delivery mechanism in term of pace and site of absorption. The nicotine gum, inhaler, lozenge and nasal spray deliver nicotine to the brain more quickly compared to patch, but less rapidly than smoking cigarettes. Nicotine is absorbed through the buccal mucosa membrane from the gum, lozenge and inhaler, where as through the nasal mucosa membrane for the nasal spray. In contrast, nicotine patches deliver nicotine dose slowly and passively which is why it is usually used with combination of other NRT products. These varied properties provide the healthcare provider and smokers the choices to choose the products that suit the smokers’ daily routine, smoking habits and degree of nicotine dependence. All these nicotine products work effectively provided they are taken correctly.

What are the regimens for NRT products?

NRT Products	Regimen*
Nicotine gum	2mg gum: recommended for patients who smoke less than 25 cigarettes per day; 4mg gum: recommended for patients who smoke 25 or more cigarettes per day. Chew 1 piece of gum every 1 to 2 hours for the first 6 weeks, followed by 1 piece of gum every 2 to 4 hours for 3 weeks and 1 piece of gum every 4 to 8 hours for the next 3 weeks.
Nicotine inhaler	Each cartridge delivers a total of 4mg nicotine over 80 inhalations. 6 to 12 cartridges per day for the first 8 weeks followed by 3 to 6 cartridges per day for 2 weeks and reduce gradually to zero for the next 2 weeks.
Nicotine lozenge	2mg lozenge: recommended for patients who smoke their first cigarette more than 30 minutes after waking; 4mg lozenge: recommended for patients who smoke their first cigarette within 30 minutes of waking. Suck 1 lozenge every 1 to 2 hours for the first 6 weeks, followed by 1 lozenge every 2 to 4 hours for 3 weeks and 1 lozenge every 4 to 8 hours for the next 3 weeks.
Nicotine patch	Two range of patch are available in the market: 15mg/16hours, 10mg/16hours, 5mg/16hours 21mg/24hours, 14mg/24hours, 7mg/24hours 1 piece of patch 15mg/16hours or 21mg/24hours per day for the first 4 weeks, followed by 1 piece of patch 10mg/16hours or 14mg/24hours per day for 2 weeks and 1 piece of patch 5mg/16hours or 7mg/24hours per day for the next 2 weeks.
Nicotine nasal spray	A dose of nicotine nasal spray consists of one 0.5mg dose delivered to each nostril (1mg total). 1 to 2 doses per hour and increase the dose as needed with a minimal of 8 doses per day and maximum of 40 doses per day in the first 8 weeks. This is followed by gradual reduction of the number of dose to zero for the next 4 to 6 weeks.

* The above are brief guidelines, subject to patients’ condition.

How to use the NRT products?

NICOTINE GUM	Chew 5 to 10 times until it has a peppery taste and provide tingling sensation. Then park the gum between the cheek and gum until the peppery taste or tingling sensation disappears. Chew and park again at another side of the cheek. Repeat this until all the taste from the gum is gone (about 30 minutes).
NICOTINE INHALER	Align marks on the mouthpiece, pull off top. Insert cartridge into the mouthpiece. Twist to close securely. Align marks again and push the top and bottom together firmly. Twist to lock the mouth piece. Inhale deeply or puff continuously for about 20 minutes.
NICOTINE LOZENGE	Place it between gum and cheek and suck slowly until it is fully dissolved (about 3 minutes). It should not be bitten, chewed or swallowed whole.
NICOTINE PATCH	Apply the patch on the skin that is dry, clean and hairless. It can be applied anywhere between the hand to neck (often the upper arm or shoulder), and hip. Remove backing from patch and immediately press onto skin. Seal it tightly. Leave it for 16 hours or 24 hours then remove it. Apply a new one at a different site before going back to the same site (at least 5 days apart).
NICOTINE NASAL SPRAY	Remove the cap of the nasal spray by pressing in the circles on the side of the bottle. Pump into tissue until the fine spray is seen (6 to 8 times). Throw the tissue away. Tilt your head back slightly. Insert the tip of the bottle as far as you comfortably can into one nostril, pointing the tip toward the back of your nose. Breathe through your mouth. Pump the spray firmly and quickly one time. Do not sniff, swallow, or inhale while spraying. If your nose runs, gently sniff to keep the nasal spray in your nose. Wait 2 or 3 minutes before blowing your nose.

What are the side effects of NRT products?

Some of the common side effects associated with the use of nicotine products are:

NRT Products	Side Effects
Nicotine gum	Mouth soreness, hiccups, dyspepsia and jaw ache
Nicotine inhaler	Local irritation in the mouth and throat
Nicotine lozenge	Nausea, hiccups, heartburn, headache and coughing
Nicotine patch	Skin reaction, insomnia and vivid dreams
Nicotine nasal spray	Nasal irritation, nasal congestion and transient changes in sense of smell and taste

What are the special precautions?

Cardiovascular Diseases – NRT is not an independent risk factor for acute myocardial events. NRT should be used with caution among particular cardiovascular patient groups which include those in the immediate (within 2 weeks) ppost myocardial infarction period, those with serious arrhythmias, and those with unstable angina pectoris.

Pregnancy - Pregnant smokers should be encouraged to quit without medication. NRT has yet to be shown being effective for treating tobacco dependence in pregnant smokers and has not been evaluated in breastfeeding patients.

Last Reviewed	:	06 January 2014
Writer	:	Sharon Ong Chin Wen
Accreditor	:	Mohd Dziehan bin Mustapa