Indications: can be used in place of cigarettes after abrupt cessation of smoking, or alternatively to reduce the amount of cigarettes used in advance of making a quit attempt. Nicotine replacement therapy can also be used to minimise passive smoking, and to treat cravings and reduce compensatory smoking after enforced abstinence in smoke-free environments

Cautions: Most warnings for nicotine replacement therapy also apply to continued cigarette smoking, but the risk of continued smoking outweighs any risks of using nicotine preparations. Nicotine replacement therapy should be used with caution in haemodynamically unstable patients hospitalised with severe arrhythmias, myocardial infarction, or cerebrovascular accident, and in patients with phaeochromocytoma or uncontrolled hyperthyroidism. Care is also needed in patients with diabetes mellitus—blood-glucose concentration should be monitored closely when initiating treatment.

Specific cautions for individual preparations are usually related to the local effect of nicotine. Oral preparations should be used with caution in patients with oesophagitis, gastritis, or peptic ulcers because swallowed nicotine can aggravate these conditions. The gum may also stick to and damage dentures. Acidic beverages, such as coffee or fruit juice, may decrease the absorption of nicotine through the buccal mucosa and should be avoided for 15 minutes before the use of oral nicotine replacement therapy. Care should be taken with the inhalation cartridges in patients with obstructive lung disease, chronic throat disease, or bronchospastic disease. The nasal spray can cause worsening of bronchial asthma.

Patches should not be placed on broken skin and should be used with caution in patients with skin disorders.

hepatic impairment Nicotine replacement therapy should be used with caution in moderate to severe hepatic impairment.

Renal impairment: Nicotine replacement therapy should be used with caution in severe renal impairment.

Pregnancy: The use of nicotine replacement therapy in pregnancy is preferable to the continuation of smoking, but should be used only if smoking cessation without nicotine replacement fails. Intermittent therapy is preferable to patches but avoid liquorice-flavoured nicotine products. Patches are useful, however, if the patient is experiencing pregnancy-related nausea and vomiting. If patches are used, they should be removed before bed.

Breast-feeding: Nicotine is present in milk; however, the amount to which the infant is exposed is small and less hazardous than second-hand smoke.

Note: Nicotine patches are a prolonged-release formulation and are applied for 16 hours (with the patch removed overnight) or for 24 hours. If patients experience strong cravings for cigarettes on waking, a 24-hour patch may be more suitable. Immediate-release nicotine preparations (gum, lozenges, sublingual tablets, inhalator, nasal spray, and oral spray) are used whenever the urge to smoke occurs or to prevent cravings. The choice of nicotine replacement preparation depends largely on patient preference, and should take into account what preparations, if any, have been tried before. Patients with a high level of nicotine dependence, or who have failed with nicotine replacement therapy previously, may benefit from using a combination of an immediate-release preparation and patches to achieve abstinence. All preparations are licensed for adults and children over 12 years

Side Effects: Some systemic effects occur on initiation of therapy, particularly if the patient is using high strength preparations; however, the patient may confuse side effects of the nicotine-replacement preparation with nicotine withdrawal symptoms. Common symptoms of nicotine withdrawal include malaise, headache, dizziness, sleep disturbance, coughing, influenza like symptoms, depression, irritability, increased appetite, weight gain, restlessness, anxiety, drowsiness, aphthous ulcers, decreased heart rate, and impaired concentration. Mild local reactions at the beginning of treatment are common because of the irritant effect of nicotine. Oral preparations and inhalation cartridges can cause irritation of the throat, gum, lozenges, and oral spray can cause increased salivation, and patches can cause minor skin irritation.

The nasal spray commonly causes coughing, nasal irritation, epistaxis, sneezing, and watery eyes; the oral spray can cause watery eyes and blurred vision. Gastro- intestinal disturbances are common and may be caused by swallowed nicotine. Nausea, vomiting, dyspepsia, and hiccup occur most frequently. Ulcerative stomatitis has also been reported. Dry mouth is a common side-effect of lozenges, patches, oral spray, and sublingual tablets.

Lozenges cause diarrhoea, constipation, dysphagia, oesophagitis, gastritis, mouth ulcers, bloating, flatulence, and less commonly, taste disturbance, thirst, gingival bleeding, and halitosis. Palpitations may occur with nicotine replacement therapy and rarely patches.

Dose: Nicotine medicated chewing gum who smoke fewer than 20 cigarettes each day should use 1 piece of 2- mg strength gum when the urge to smoke occurs or to prevent cravings; individuals who smoke more than 20 cigarettes each day or who require more than 15 pieces of 2-mg strength gum each day should use the 4-mg strength. Patients should not exceed 15 pieces of 4-mg strength gum daily. If attempting smoking cessation, treatment should continue for 3 months before reducing the dose.

Administration Chew the gum until the taste becomes strong, then rest it between the cheek and gum; when the taste starts to fade, repeat this process. One piece of gum lasts for approximately 30 minutes. Nicotine transdermal patches As a general guide for smoking cessation, individuals who smoke more than 10 cigarettes daily should apply a high-strength patch daily for 6–8 weeks, followed by the medium strength patch for 2 weeks, and then the low-strength patch for the final 2 weeks; individuals who smoke fewer than 10 cigarettes daily can usually start with the medium-strength patch for 6–8 weeks, followed by the low-strength patch for 2–4 weeks. A slower titration schedule can be used in patients who are not ready to quit but want to reduce cigarette consumption before a quit attempt.

If abstinence is not achieved, or if withdrawal symptoms are experienced, the strength of the patch used should be maintained or increased until the patient is stabilised.

Patients using the high-strength patch who experience excessive side effects, that do not resolve within a few days, should change to a medium-strength patch for the remainder of the initial period and then use the low strength patch for 2–4 weeks.

Administration Patches should be applied on waking to dry, non-hairy skin on the hip, trunk, or upper arm and held in position for 10–20 seconds to ensure adhesion; place next patch on a different area and avoid using the same site for several days.