Choice of formulation of nicotine replacement therapy

Combination nicotine replacement therapy is recommended for most patients because it is more effective than nicotine monotherapy.

Nicotine patches are available as a 24-hour preparation (left on all day) or a 16-hour preparation (removed at night). The 24-hour patch provides continuous nicotine exposure to receptors when the person is not smoking (eg during sleep) Hukkanen, 2005 and offers better control of morning cravings than the 16-hour patchAubin, 2006 Shiffman, 2000. The 24-hour patch is preferred over the 16-hour patch except in:

pregnancy Bar-Zeev, 2018
people who have been troubled by nightmares with the 24-hour patch.

The mist spray mimics the delivery of nicotine into the bloodstream in rapid ‘hits’, while the gum, lozenge and inhalator take slightly longer to work. Inhalators mimic the experience of holding a cigarette and inhaling. Gum is generally cheapest, but correct use is important (‘chew and park’, not continuous chewing).

Correct use of nicotine replacement therapy—patient information summarises the correct use, advantages and adverse effects of NRT formulations, and can be used to help patients choose a suitable formulation. The Quit website also has patient information on the correct use and advantages of each formulation and how to address adverse effects. The Quit Centre webpage has tools for health professionals including videos on how to demonstrate use of each formulation to patients.

Table 1. Correct use of nicotine replacement therapy—patient information
Printable table
slow-acting formulations patch medium-acting formulations gum inhalator lozenge fast-acting formulations mist spray
Patch slow acting: takes 2 to 6 hours for peak effect
How much to use	21 mg in 24 hours OR 25 mg in 16 hours.
How to use	Apply a patch to clean, dry, hairless skin. Rotate site daily to avoid adhesive build up, which can reduce nicotine absorption.
Advantages	Cost is subsidised by the PBS [NB1]. Gives a constant supply of nicotine. Using the 24-hour patch can reduce morning cravings.
Adverse effects and other considerations	If you have nightmares with the 24-hour patch, change to using the 16-hour patch. Skin irritation from adhesive might require change of brand. Use the 16-hour patch if pregnant.
Gum medium acting: takes 20 minutes for peak effect
How much to use	4 mg every 1 to 2 hours as required; to control strong urges, a second piece of gum can be chewed after 30 minutes. Usual maximum dose is 16 pieces in 24 hours.
How to use	Chew gum to release flavour and produce a tingling sensation, then park in cheek pouch to absorb nicotine. When tingling stops, repeat the ‘chew and park’ cycles for up to 30 minutes or until all flavour is gone. Try not to swallow saliva while chewing (swallowing saliva or the gum inactivates the nicotine). Chewing more often or harder doesn’t release more nicotine.
Advantages	Cost is subsidised by the PBS [NB1]. Keeps mouth busy and engaged. Can be used without others noticing.
Adverse effects and other disadvantages	Can cause taste changes, throat irritation, hiccups and indigestion.
Inhalator medium acting: takes 20 to 30 minutes to peak effect
How much to use	Puff from a 15 mg cartridge as required. Usual maximum dose is 1 cartridge per hour and 6 cartridges in 24 hours.
How to use	Place cartridge in tube to pierce it and access nicotine. Breathe normally or puff through the plastic tube. A cartridge that is being regularly used will last about 40 minutes.
Advantages	Allows for the familiar experience of smoking.
Adverse effects and other disadvantages	Cost is not subsidised by the PBS. Can cause cough, taste changes and throat irritation.
Lozenge medium acting: takes 20 minutes to peak effect
How much to use	4 mg every 1 to 2 hours as required. To control strong urges, a second lozenge can be sucked after 30 minutes. Usual maximum dose is 16 lozenges in 24 hours.
How to use	Keep the lozenge in the cheek pouch (where absorption occurs) to get maximal absorption. Try not to swallow saliva while the lozenge is dissolving (swallowing saliva or the lozenge inactivates the nicotine). Crunching or hard sucking of the lozenge doesn’t release more nicotine.
Advantages	Cost is subsidised by the PBS [NB1]. Keeps mouth busy and engaged. Can be used without other people noticing.
Adverse effects and other disadvantages	Can cause taste changes, throat irritation, hiccups, indigestion.
Mist spray fast acting: takes 10 minutes to peak effect
How much to use	1 to 2 sprays every 15 minutes as required. Usual maximum dose is 4 sprays per hour (or 64 sprays in 24 hours).
How to use	Spray under the tongue, avoiding the lips. Do not inhale or swallow while spraying. Approximately 140 sprays are in each unit.
Advantages	Rapid action, most closely mimicking nicotine effect from cigarette.
Adverse effects and other disadvantages	Cost is not subsidised by the PBS. Can cause hiccups, increased salivation, throat irritation.
Note: PBS = Pharmaceutical Benefits Scheme NB1: The PBS subsidises the use of one form of nicotine replacement therapy (NRT) at a time; to use combination NRT will require addition of nonsubsidised form(s). Adapted from the Albany Psychiatric Unit (Western Australia) patient information sheet on correct use of nicotine replacement, 2022.