Overview of nicotine replacement therapy

Nicotine replacement therapy (NRT) is available in several formulations, categorised by onset of effect:

slow-acting NRT—transdermal patch
medium-acting NRT—gum, lozenge and inhalator
fast-acting NRT—mist spray.

Almost everyone who smokes tobacco is likely to benefit from slow-acting NRT with a patch; after stopping smoking, people who use nicotine patches show reduced brain activation in areas involved in craving compared to those who use placeboLiberman, 2018. However, those who only smoke in highly specific cue-driven situations may not require a patch (eg those who smoke after work with specific friends).

Combination NRT uses a slow-acting nicotine patch with an as-required medium-acting and/or a fast-acting formulation to control cravings; this is more effective than nicotine monotherapyCahill, 2016. The pattern of nicotine delivery during combination NRT mimics that from tobacco smoking, with a constant baseline and bursts of nicotine during the day. Advise patients that they can choose to reduce their smoking at their own pace when they feel their cravings reduce.

Note: Combination NRT using a patch plus a medium-acting and/or fast-acting formulation is more effective than nicotine monotherapy.

Individual requirements for NRT are highly variable and based on the severity of dependence. Some patients (eg those who smoke within 30 minutes of waking) require very large doses of NRT, which may involve the use of 2 or 3 patches along with medium- and fast-acting NRT. When NRT is not effective, the usual causes are inadequate dosage and incorrect use.

Note: When NRT is not effective, the usual causes are inadequate dosage and incorrect use.

Patches, gum and lozenges are subsidised by the Pharmaceutical Benefits Scheme (PBS) as monotherapies; see the PBS website for current information. Inhalators and mist spray are not PBS-subsidised but are substantially cheaper than tobacco smoking. Prescribing only according to PBS funding will result in underdosing; to prescribe adequate treatment, combination NRT is needed using a mix of PBS-subsidised and nonsubsidised items.

The minimum course of NRT is 12 weeks, but longer treatment is more effective; see Review of nicotine replacement therapy.