Nicotine replacements for your patients that smoke

Nicotine withdrawal in smokers peaks over the first three days, but can last for many weeks. Quitting “cold turkey” is not effective for over 90% patients. Therefore, it’s our role as clinicians to support patients trying to quit smoking with nicotine replacement therapy (NRT).

Stephen R. Holt, MD
Stephen R. Holt, MD
23rd Feb 2022 • 5m read

Nicotine withdrawal in smokers peaks over the first three days, but can last for many weeks. Quitting “cold turkey” is not effective for over 90% patients. Therefore, it’s our role as clinicians to support patients trying to quit smoking with nicotine replacement therapy (NRT).

  • How should you prescribe nicotine patches or nicotine gums?
  • What adverse effects should you keep in mind?
  • What’s the most common myth that prevents patients from starting on NRT?

Find out the answers by watching this video, written and presented by Dr. Stephen Holt, Co-Director at Yale Addiction Recovery Clinic, USA.

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Video Transcript

Okay, so you've convinced your patient to quit smoking, and you're ready to discuss the treatment options. Before we look at them in detail, though, let's acquaint ourselves with exactly where nicotine acts in the brain. The relevant pathways for nicotine action in the brain include those dopaminergic projections we talked about earlier, that radiate from the ventral tegmental area or VTA, to the ventral striatum, the dorsal striatum, and the prefrontal cortex.

Like other substances, nicotine acts on the dopaminergic projections from the VTA. Let's focus on a single dopaminergic neuron from one of these pathways as it projects from the VTA to the ventral striatum. The neuron cell body and nicotinic acetylcholine receptors are in the VTA and it's synapse full of dopamine filled vesicles in the ventral striatum.

When a person smokes a cigarette, nicotine rushes into the brain and binds to the nicotinic acetylcholine receptors. This depolarizes the neuron and sends an action potential down the nerve axon. Dopamine, our bodies feel good hormone, is then released into the synaptic cleft reinforcing smoking behavior. In essence, nicotine is hijacking the reward pathways of the brain.

Over time, the number of nicotine receptors on these presynaptic neurons gradually increases. Each receptor is starving for nicotine, smoke a cigarette and those starving nicotine receptors are happy again. Patients who are strongly addicted to smoking will report that they need a cigarette within 30 minutes of waking. They are essentially waking up in nicotine withdrawal which is associated with dysphoria, restlessness, irritability, increased appetite, insomnia, and anxiety.

Withdrawal symptoms peak over the first three days, but they can last for many weeks. Of note, patients often report that they want to quit on their own in a sudden and abrupt manner known as cold turkey. I applaud their determination. It's worth mentioning to them that only 3 to 6% of patients who make an unaided quit attempt are still abstinent at one year.

Patients that just want to cut back on their smoking should be advised that cutting back on smoking rather than quitting doesn't seem to have any significant health benefits. So with those facts in mind, let's talk about our first treatment option, nicotine replacement therapy, or NRT.

NRT replaces cigarette nicotine with other forms of nicotine. This strategy helps patients slowly wean their brains from nicotine while breaking the habit of smoking itself. In essence, it flattens that symptomatic curve. The variety of NRT options has grown considerably over the past 30 years. No longer are we stuck with just patches. We've now got gum, lozenges, inhalers, and even a nasal spray. The most commonly prescribed agents are the patch and the gum, often in combination. Let's look at the patches first.

There are three sizes 7, 14 and 21 milligram patches. Your starting dose for a patch is going to be based on how many cigarettes your patient smokes each day, and the conversion is easy, think one milligram per cigarette. So if a patient smokes five cigarettes per day, round up to a 7 milligram patch. If your patient smokes a pack per day, that's 20 cigarettes, for them start with the 21 milligram patch. If your patient smokes two packs per day, which is 40 cigarettes, then by all means prescribe to 21 milligram patches at once. That's completely okay.

In terms of side effects, the only active ingredient in NRT is you guessed it, nicotine. So there aren't really any novel side effects from the nicotine in nicotine patch, assuming you haven't overdone it with the dose. If your dose is a bit high, your patient may experience nausea, diminished appetite, tachycardia, and increased blood pressure.Dosed appropriately however, the only real side effect from nicotine patches is that some patients experience skin irritation at the site of the patch. If this happens, consider switching to a different brand of patch or a different form of NRT.

Having applied the patch first thing in the morning, your patients may wish to wear their nicotine patch through the night as well in order to stave off that morning craving we mentioned earlier. This is completely fine, but caution your patient that wearing the patch at night may cause issues with insomnia or vivid dreams. By wearing a patch for full 24 hours they are also more likely to have issues with skin irritation.

The most important myth you need to dispel when it comes to prescribing a nicotine patch is the concern that your patient will have a heart attack if they smoke a cigarette or two while wearing a patch, this is completely false and unfortunately, this myth dissuades many patients from putting that first patch on as they are concerned they will slip up and smoke a cigarette. Please just reassure your patient that you'd rather they smoked a few cigarettes while wearing a nicotine patch then not wear a patch at all and never attempt to quit.

Even better prescribed nicotine gum or lozenges, whichever your patient prefers to help your patient with those cravings that creep up during the day. Your two dosing options are two and four milligrams based on the extent of your patient's nicotine dependence, and can be used every one or two hours when they feel a craving. If your patient opts for the gum, be sure to advise them not to chew it like bubblegum. Instead, they should just take a few bites and then tuck it in the side of their mouth for a few minutes before chewing it again.

In terms of duration, experts typically recommend continuing the initial patch dose for four to six weeks, and then going down by seven milligrams every two weeks thereafter. So if you started with a 21 milligram patch, you'd continue this for about six weeks, then go down to a 14 milligram patch for two weeks and conclude with a seven milligram patch for the last two weeks.