Tobacco Background

The use of tobacco products, including electronic cigarettes (vapes/e-cigarettes), remains the leading cause of death and preventable diseases in the US. Smoking tobacco leads to many diseases including lung disease, cardiovascular disease, and many types of cancer. The smoking of combustible tobacco forms such as cigarettes, are responsible for the most tobacco-related diseases and deaths in the US.¹ Nicotine replacement therapy (NRT) is considered a first-line therapy for smoking cessation and nicotine dependence. NRT is often combined with other first-line agents such as varenicline and bupropion; however, NRT can also be used alone.³ Due to the prevalence, potential for disease burden, and difficulty in ceasing tobacco use, proper NRT pharmacotherapy is crucial for successful cessation. 

Adults who use tobacco products often have difficulties quitting due to dependence on the main addictive component of cigarettes: nicotine. Nicotine is an alkaloid that is produced in tobacco plants and can also be chemically synthesized as an additive in e-cigarettes and smokeless tobacco products. When nicotine is consumed, it diffuses into tissues and selectively binds to nicotinic cholinergic receptors that are located throughout the body. The binding of nicotine to these receptors ultimately results in a dopamine release, among other neurotransmitters, stimulating the reward pathway within the limbic system, which produces pleasure, stimulation, and mood modulation.

Long-term use tobacco products create nicotine dependence and quitting “cold turkey” can cause intense withdrawal symptoms such as increased urges, irritation, restlessness, difficulty concentrating, insomnia, increased appetite, anxiety, and depression among others. Because of this, the choice of therapy selection is crucial in increasing the chance of success in smoking cessation.²

NRT Pharmacotherapy Overview

As discussed above, the proper use of NRT greatly increases the likelihood for patient success in smoking cessation. There are many different dosage forms for NRT and choosing the one most suitable for individual patients is crucial for successful treatment. The following information examines the variety of treatment options available that can be tailored to patients based on their characteristics.

Goal of therapy: to minimize and relieve nicotine withdrawal symptoms through the use of nicotine without the use of tobacco or e-cigarettes.

Therapy Selection:

• Tailored to patient preference, accounting for contraindications and comorbidities
• Combination NRT: consists of the use of a long-acting agent (patch) and a short acting agent (lozenge, gum, nasal spray, etc.)

Nicotine Patches:

• Initial dose selection: based on how many cigarettes are smoked daily
  • >10 cigarettes/day: 21mg/day for 6 weeks (step 1), THEN 14 mg/day for 2 weeks (step 2), THEN 7 mg/day for 2 weeks (step 3)
  • ≤10 cigarettes/day: 14 mg/day for 6 weeks (step 2), THEN 7 mg/day for 2 weeks (step 3)
• Administration: remove backing and apply one patch to clean, dry, and hairless site on skin on the upper body in the morning
  • Remove the old patch prior to applicaon of a new one
  • Rotate administration sites to avoid skin irritation
• Dose titration: can increase to higher dose if experiencing withdrawal symptoms or decrease dose if experiencing side effects
• Dosage form related side effects: skin irritation, insomnia, vivid dreams
• Dose tapering: patches are marketed to be tapered over 12 weeks; however, dosing customization can be conducted with best clinical judgement

Nicotine Lozenges:

• Initial dose selection: based on how soon after waking the first cigarette is smoked and is used as needed for cravings
  • <30 minutes: begin with 4 mg lozenges
  • ≥30 minutes: begin with 2 mg lozenges
• Administration: place in mouth between gums and cheek, let dissolve over 30 minutes. Do not chew
  • Avoid acidic beverages (eg. carbonated drinks, coffee, etc.) before and during lozenge use as this reduces nicotine absorptionDo not eat or drink 15 minutes before using gum or when lozenge is in use
  • Minimize swallowing while dissolving, occasionally switch lozenge side to side in mouth
• Patient specific factors: may be better suited for patients with dentures, poor dentition, or temporomandibular joint (TMJ) disease as compared to gum formulations
• Dose titration: can increase to higher dose if still experiencing withdrawal symptoms
  • For best initial results, use at least 9 lozenges per day
• Dosage form related side effects: mouth ulcers or irritation
• Dose tapering: reduce number of lozenges used daily gradually over 6 weeks

Nicotine Gum:

• Initial dose selection: based on how soon after waking the first cigarette is smoked and is used as needed for cravings
  • <30 minutes: begin with 4 mg gum
  • ≥30 minutes: begin with 2 mg gum
• Administration: “Chew and park” – chew the gum until nicotine can be tasted (tingling sensation) then “park” gum in the side of the cheek until the taste goes away. Chew the gum again to release more nicotine. Repeat steps for 30 minutes, then spit gum out
  • Avoid acidic beverages (eg. carbonated drinks, coffee, etc.) before and during gum use as this reduces nicotine absorption
  • Do not eat or drink 15 minutes before using gum or when gum is in use
• Patient specific factors: may exacerbate TMJ, damage and/or adhere to dentures and other dental appliances
• Dose titration: can increase to higher dose if still experiencing withdrawal symptoms
  • For best initial results, use at least 9 pieces of gum per day
• Dosage form related side effects: sore jaw, mouth ulcers or irritation
  • Side effects of excess nicotine release due to over-chewing: constipation, headaches, hiccups, nausea, vomiting, abdominal pain, etc.
• Dose tapering: Use as needed and gradually reduce pieces chewed daily over 6 weeks for a minimum duration of treatment of 3 months  

Nicotine Nasal Spray

• Initial dose: 1 to 2 doses per hour, adjusted based on patient response
  • 1 dose is 1 spray per nostril (2 sprays total)
• Administration:
  • Prime pump before first use or if bottle has not been used for ≥24 hours
    • Pump bottle until fine mist appears (6-8 times usually)
    Blow nose prior to administrationSlightly tip head back, insert tip into nostril, breath through mouth and spray once into each nostrilDuring administration: do not swallow, sniff, or inhale through noseWait to blow nose until at least 2-3 minutes following administration
  • Avoid contact with mouth, eyes, and skin
• Dose titration: can increase up 5 doses per hour (10 sprays) with a maximum of 40 doses per day (80 sprays) based on patient response
  • For best initial results, use at least 8 doses (16 sprays) per day
• Dosage form related side effects: throat and nasal irritation (extremely common and limits tolerability), sneezing, tearing, and rhinitis
• Dose tapering/duration: Use beyond 6 months is not recommended, gradually reduce number of daily doses of 4-6 weeks

Duration of Therapy

As opposed to other treatments, NRT does not have a concrete recommendation for treatment duration and is very patient specific. Apart from the nasal spray, NRT can continue indefinitely as the use of NRT is safer than continued smoking. Ideally as NRT progresses, the dosage of the long-acting formulation (patch) is decreased and the dosage and frequency or short-acting formulations are gradually reduced as tolerated until NRT is no longer needed.

Key Takeaways & Tips for Success

Ensuring the appropriate initial doses of NRT is crucial in cessation success as well as proper administration techniques. Choosing the initial dose of long-acting patches based on the number of cigarettes smoked daily as well as the dosage of short-acting agents such as gum or lozenges based on first daily cigarette timing is very important in initiating proper NRT. Similarly, ensuring the patient uses enough short-acting NRT, such as a minimum of 9 pieces of gum daily, can drastically increase their chance of successfully quitting smoking.

Tobacco related complications are the leading cause of preventable disease and deaths in the US.¹ There are many potential pharmacological options for smoking cessation, with NRT being the first-line treatment.³ NRT can be tailored for individual patients for maximum efficacy and have been proven to aid in smoking cessation when initiated properly.

Emily Heutmaker, APPE Student

References

1. Centers for Disease Control and Prevention. (2024). Tobacco product use among adults — United States, 2022: 2022 National Health Interview Survey (NHIS) highlights (Publication No. OSH-NCIS-2024). U.S. Department of Health and Human Services. Available from https://www.cdc.gov/tobacco/media/pdfs/2024/09/cdc-osh-ncis-data-report-508.  
2. Sandhu A, Hosseini SA, Saadabadi A. (2023) Nicotine Replacement Therapy. In: StatPearls. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493148/
3. Rigotti, N. A. (2025). Pharmacotherapy for smoking cessation in adults. UpToDate. Wolters Kluwer. Available from https://www.uptodate.com/contents/pharmacotherapy-for-smoking-cessation-in-adults
4. UpToDate. (2025). Nicotine replacement therapy products: Drug information. Wolters Kluwer. Available from https://www.uptodate.com/contents/pharmacotherapy-for-smoking-cessation-in-adults