P1.2.1 Nicotine replacement therapy

All forms of nicotine replacement therapy (NRT) appear to be useful in aiding smoking cessation and increase the rate of quitting by 50-70% (Stead 2008) [evidence level I]. NRT is most suitable for nicotine dependent smokers who are motivated to quit. All forms of NRT (at equivalent doses) are similarly effective in aiding long-term cessation. Evidence for efficacy of NRT is strongest in in those who smoke more than 15 cigarettes daily but there is also evidence of benefit in lighter smokers who choose to use pharmacotherapy (Shiffman 2005) [evidence level II). There are a range of forms available in Australia (transdermal patch, gum, inhaler, inhalator, lozenge, mouth spray and oral strip). The choice of type of NRT depends on patient preference, needs and tolerance. NRT is more effective when combined with counselling and behavioural therapy (Schwartz 1987). All forms of NRT should be used for at least eight weeks. Up to date information on the forms of NRT available, PBS listing and initial dosing guidelines are available in the RACGP smoking cessation guidelines (http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/) and the Australian Medicines Handbook (https://shop.amh.net.au/).

NRT is safe in patients with stable cardiac disease such as angina pectoris (Joseph 1996, Mahmarian 1997, Nitenberg 1999) [evidence level II]. NRT should be used with caution in people with recent myocardial infarction, unstable angina, severe arrhythmias and recent cerebrovascular events (Meine 2005) [evidence level III-2]. NRT produces lower peak levels of nicotine than active smoking, so theoretically, should be safer than smoking, even in patients with unstable disease.

Combination NRT: Combining two forms of NRT (patch plus oral form, such as gum or lozenge) has been shown to be more efficacious than a single form of nicotine replacement. The patch provides a steady background nicotine level and the oral forms provide relief for breakthrough cravings as needed. There is evidence from nine trials that this type of combination NRT is more effective than a single type (Stead 2012) [evidence level 1]. Health professionals should encourage smokers to use combined NRT if they are unable to quit using one NRT product alone, or experience cravings using only one form of NRT. Combination NRT can also be recommended as first line treatment.

Pre-cessation nicotine patch: There is evidence to support use of the nicotine patch prior to smoking cessation. A meta-analysis found that the nicotine patch used prior to quit day increased success rates compared to standard therapy (Shiffman 2008) [evidence level 1].

Reduce to quit: There is also evidence for use of NRT to help smokers who are not willing to quit immediately to reduce their tobacco and then progress to quitting. A meta-analysis found that reducing cigarettes smoked before quit day versus quitting abruptly, with no prior reduction, produced comparable quit rates (Lindson 2010).