The Best and Worst Nicotine Patches for Quitting Smoking
Quitting smoking is no easy task. Smoking is the number one cause of preventable deaths in the United States, and nicotine replacement therapy (NRT) has given many smokers the ability to transition between cigarette smoking and being entirely nicotine-free (and smoking-free). One of the most popular NRTs is the nicotine patch.
Nicotine patches, approved by the FDA in 1991, are a go-to product for those looking to quit cigarettes, cigars, or e-cigarettes. According to a study published in the Archives of Internal Medicine, nicotine patches have the highest compliance rate of any other NRT.
“Nicotine patches are what I would call the smoothest delivery,” said Quinn Pack, MD, a preventive cardiologist and adjunct associate professor of medicine at Tufts University School of Medicine.
“They cause a slow and sustained rise of nicotine in the blood, but to be most effective, they should be combined with an ad-lib nicotine replacement product to deal with the acute cravings gum, nasal spray, or lozenges.”
So, how do they work? The patches provide a controlled dose of nicotine that's absorbed through the skin during the day; this reduces the effects of withdrawal.
Over time, users apply patches in decreasing strengths, allowing them to gradually wean themselves off of nicotine.
Patches can be worn up to 24 hours, and daily doses range primarily from to 21mg to 14mg to 7mg over the course of 8 to 12 weeks.
According to Dr. Pack, it takes on average about 7 to 10 seconds for a puff of smoke to deliver nicotine to the brain, and that rapid rise in nicotine contributes to how addictive it is. Nicotine patches are much slower, typically taking 2 to 3 hours.
Whether you’re smoking or vaping, choosing a reliable nicotine patch product is vital when you’re looking to take this big step. So, if you’re looking to ditch the cigarettes or Juuls, here are some nicotine patches on the market to try out and some to steer clear of.
Good for: Heavy smokers.
NicoDerm CQ patch is great for those who smoke more than 10 cigarettes a day because they offer the highest dose of nicotine approved by the FDA. Dr. Pack says those who smoke multiple packs of cigarettes each day should always start with the highest dose to combat cravings. He's even found benefits with patients who used 43mg patches.
NicoDerm CQ patches are made with Extended Release SmartControl Technology that helps provide an immediate steady flow of nicotine throughout the day. Once the step 1 pack is completed, you can switch to the next two steps, which provide smaller daily doses. The packages come with 14 patches and are sold for $40, or $118 for all three steps.
Good for: Smokers who also want a hotline and other support.
Habitrol Nicotine Transdermal System Patch is similar to NicoDerm with packs that progressively lower the provided dose. The system not only uses a time-release technology in its patches to reduce cravings, it also offers a behavioral support program to increase your chances of quitting.
The program offers a call-in hotline and self-help guide, helpful for those who find themselves slipping up during their journey. Two weeks' worth of Habitrol patches are $27; all three steps with 8 weeks' worth of patches are $85.
These patches are the most prescribed by physicians and pharmacists.
«Natural» patches, KONGDY Anti-Smoke and Fullthrottle on Demand Zero Nicotine patches are made with herbal ingredients. They claim to help alleviate the symptoms of nicotine withdrawal in a natural way. Some ingredients include oats, skullcap, and licorice root, which companies claim help calm the nervous system and ease stress and anxiety.
Un other brands, these patches contain no nicotine. The natural ingredients are advertised to decompose existing nicotine in the body and cleanse the body of smoking-related toxins. Dr.
Pack, however, says there is no real evidence to support those ideas. (Of course, quitting smoking, by itself, will help rid the body of smoke-related toxins.
Here's how your body repairs itself after quitting.)
The journey toward quitting smoking can be tough, but supplementing with nicotine replacement can help.
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Nicotine replacement therapy (NRT) is for those who want to quit smoking, as abruptly quitting can cause withdrawals and cravings. Nicotine withdrawal occurs after smoking cigarettes discontinues suddenly. Using NRT helps reduce the motivation of smoking cigarettes because the body still gets nicotine from another safer method.
Nicotine comes in a patch, lozenge, inhalers, spray, and gum forms and can provide the body the dose of nicotine that it previously got from cigarettes.
This activity outlines the indications, mechanism of action, methods of administration, significant adverse effects, contraindications, monitoring, and toxicity of NRT, so providers can direct patient therapy to help them in smoking cessation.
Identify the indications for using nicotine replacement therapy.
Summarize the physiological/therapeutic effects of nicotine and how it assists in smoking cessation.
Review the possible adverse effects of nicotine replacement therapy.
Outline the importance of collaboration and communication among interprofessional team members to improve outcomes and treatment efficacy for patients who might benefit from therapy with nicotine replacement therapy for smoking cessation.
Access free multiple choice questions on this topic.
Nicotine replacement therapy (NRT) is for those who want to quit smoking, as abruptly quitting can cause withdrawals and cravings. Nicotine withdrawal occurs after suddenly discontinuing smoking cigarettes. Typical withdrawal symptoms include mood changes, diaphoresis, headaches, insomnia, and poor cognition.
These symptoms usually peak at two to three days after quitting smoking. Using NRT helps reduce the motivation of smoking cigarettes because the body still gets nicotine from another safer method. Evidence has shown that using NRT helps increase the chances of quitting by about 50% to 70%.
Withdrawals include restlessness, more than usual hunger, feeling depressed or irritable, and craving another cigarette.
Nicotine comes in a patch, lozenge, inhalers, spray, and gum forms and can provide the body the dose of nicotine that it previously got from cigarettes. Using these forms of NRT increases the chances of success of quitting smoking and is FDA approved.
NRT contains less nicotine than the average cigarette and has a slower effect on the body. It does not contain the harmful chemicals of cigarettes, such as tar.
It is a strong recommendation to start using an NRT 1 to 2 weeks before quitting or right after quitting cigarettes.
Bupropion is also an antidepressant with smoking cessation effects and can be combined with the nicotine patch for a higher chance of success.
Nicotine is an alkaloid and is only produced in tobacco. It is a tertiary amine that has pyrrolidine and pyridine rings. It binds selectively to nicotinic-cholinergic receptors in multiple locations.
The brain, neuromuscular junctions, adrenal medulla, and the ganglia all have these receptors. When a person inhales nicotine through smoking cigarettes, it diffuses through the lungs into the circulation, eventually going to the brain.
It affects the reward center in the limbic system and has a stimulating effect on the cortex. Dopamine in the frontal cortex, mesolimbic area, and corpus striatum is released — dopamine helps deliver the pleasurable experience. NRTs try to mimic the nicotine response from smoking.
Higher doses of NRTs will have more of a rewarding feeling, whereas lower doses of nicotine have more of a stimulating effect.
Forms of NRT do not need to be prescribed by a doctor; most are available over the counter. Patients should follow directions for each form of NRT. Even though there are different brands and forms, evidence shows no more significant effect of one type of NRT over another.
Although some studies show no benefit to using NRT for longer than eight weeks, others have found that a longer duration of treatment with nicotine patches may be associated with an improved smoking cessation rate.
The initial dosing usually has its basis on the number of cigarettes smoked per day, and heavier smokers should use increased strength/dose of nicotine therapy. NRT products can be used if a patient is still smoking.
Nicotine patches come in different brands, where some patches are designed for 24 hours at 5-mg to 52.5-mg dosages, where the higher doses are for heavier smokers. Other patches are designed to be only worn 16 hours a day and come in 5-mg to 25-mg doses.
Patches require an application to a non-hairy, dry, clean area of the arm or upper body. Press onto skin for 10 seconds. Apply to a different area each time. Treatment is for about 8 to 10 weeks. The highest dose is started for patients over 45 kg who smoke more than 10 cigarettes per day.
The nicotine patch is the easiest NRT to use, and it provides the most continuous nicotine delivery among all other NRT products.
Nicotine gum is available in different doses as well, at 2 mg and 4 mg. It is commonly used as a short-acting NRT. The patient chews the gum slowly until it tingles and chews until the tingle disappears. Chew when the urge to smoke strikes. Recommended is 8 to 12 pieces of gum. To improve absorption, smokers should avoid acidic beverages such as coffee or carbonated drinks.
Nicotine lozenges are available in 1-mg, 1.5-mg, 2-mg, and 4-mg doses. Users should allow 20 to 30 minutes to dissolve slowly and should not chew or swallow. Recommended is 8 to 12 lozenges daily.
Nicotine inhalation cartridge comes in 10 mg. The cartridge should be inserted into the inhaler then popped into place. Inhale deeply or puff consecutively in short breaths. This type of NRT addresses both the physical and behavioral aspects of dependence. Recommended is 6 to 16 cartridges per day.
Nicotine nasal spray comes in 0.5 mg per spray. The patient should blow their nose before use. Tilt the head back and insert the tip of the bottle, and spray once in each nostril.
Nicotine sublingual tablet comes in a 2-mg dose and is not available in the United States.
Patients should understand not to use two doses back to back. If the patient misses a dose, they should take it as soon as possible. If it is close to the time of the next dose, they can skip the missed dose.
The known adverse effects of nicotine include:
Gastrointestinal symptoms: abdominal pain, dyspepsia, hiccups, diarrhea, nausea, vomiting
Central Nervous System: headache
With the oral/nasal mucosa absorbing NRTs, nose and mouth ulcers and irritation have been reported. Other side effects include excess salivation and swelling of the lips, throat, and tongue.
Transdermal patches have caused some people skin rash or irritation. Topical hydrocortisone 1% cream or ointment is indicated for some patients to relieve skin irritation.
Other: depression, back pain, dizziness, nervousness, drooling, shakiness, cold sweats, hypertension, increased heart rate, and vivid dreams.
Patients should inform their clinician immediately if any of the above side effects occur. Patients who are worried about dependence should receive counsel that nicotine dependence is very rare.
- Hypersensitivity to nicotine. People allergic to soy should not use the nicotine lozenge.
- Nicotine also has drug interactions with adenosine, cimetidine, and varenicline. Adenosine may increase the tachycardia effect of nicotine. Cimetidine may cause an increase in the serum concentration of nicotine.
Varenicline can induce some of the nicotine side effects.
- Pregnant women should also quit smoking during pregnancy. Nicotine crosses the placenta as well as into breast milk. NRT is not a recommended therapy for breastfeeding mothers as the side effects could harm the infant. 
Patients with cardiovascular or peripheral vascular disease should have the risks versus benefits weighed before deciding to start an NRT due to hypertension and increased heart rate side effects. Use caution when starting patients who have had angina or recent myocardial infarction.
Discontinue if palpitations or irregular heartbeats occur.
The liver metabolizes nicotine. Therefore, swallowing pills through the gastrointestinal (GI) system will be subject to first-pass metabolism by the liver, and bioavailability would only be about 20%. This process will reduce the bioavailability of nicotine in the system and possibly cause side effects of the GI.
Hence, the only available methods for nicotine are in a non-pill form, such as a lozenge, sublingual tablets, transdermal patches, gum, inhaler, and sprays. These dose forms let the nicotine enter through the oral or nasal mucosa or skin and bypass the GI system for more extended bioavailability. The route of absorption is pH-dependent.
Acidic foods and drinks can lower the absorption of nicotine. The skin patch releases nicotine at a slower rate. This controlled delivery makes toxicity from nicotine much less ly and prevents any GI side effects from happening.
Symptoms in the rare event that the patient overdoses nicotine include nausea, vomiting, diarrhea, dizziness, difficulty breathing, tachycardia, weakness, or rash.
All interprofessional healthcare team members have a responsibility to educate patients on the harms of smoking. This includes clinicians, mid-level practitioners, nurses, pharmacists, and even mental health professionals.
The patient should be told about the nicotine replacement therapies currently available, and the nurse, pharmacist, and clinician should counsel the patient on optimal usage to enhance the odds of successful treatment. Evidence has shown that using NRT helps increase the chances of quitting by about 50% to 70%.
Withdrawals include restlessness, more than usual hunger, feeling depressed or irritable, and craving another cigarette. Bupropion is also an antidepressant with smoking cessation effects, and clinicians can combine it with the nicotine patch for a higher chance of success.
These patients need continual support and positive reinforcement. Unfortunately, with all therapies, relapse rates are very high. [Level 5]
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