Nicotine replacement therapy
The use of NRT approximately doubles the likelihood of a person being able to quit smoking long-term; one in 14 people
who would not otherwise have stopped smoking will do so for at least six months following a course of NRT.15 Several
studies suggest that in people who are unmotivated to quit within the next month, the use of NRT results in an increased
number of quit attempts and marginally higher rates of abstinence.21 NRT may therefore act as a quit catalyst
for patients who smoke and who report that they are not yet ready to stop.21 Offering patients who smoke the
opportunity to trial different forms of NRT before they attempt to quit may also improve their choice of NRT and result
in better treatment adherence.
Most people who are attempting to quit smoking do not use enough NRT.22 Patients who are heavily dependent
on cigarettes may gain benefit from increasing the dose of nicotine, e.g. wearing two patches, to replicate the levels
of nicotine that reach the brain when they are smoking. Combining NRT products, e.g. using a nicotine patch and nicotine
gum, is more effective than using a single NRT product.15 If patients begin to feel nauseous when using NRT
they can be advised to reduce the frequency or dose of the product.22
Subsidised NRT can be prescribed by general practitioners and registered Quit Card Providers. Subsidised supplies of
NRT may also be obtained by general practices using a Practitioner Supply Order. Pharmacists can supply subsidised NRT
that is prescribed on a normal prescription (maximum quantity 12 weeks) or a Quit Card (maximum quantity 8 weeks) at a
cost of $5; these will be dispensed in four-week quantities. Pharmacists are not able to prescribe subsidised NRT unless
they are part of a special regional programme, e.g. Canterbury DHB.
Nicotine replacement therapy should be continued for at least eight weeks; the normal treatment course is 12 weeks.23 Patients
who feel they are still gaining benefit from treatment can continue to use NRT for longer periods.23 If patients
wish to use NRT as a way of reducing cigarette consumption, prior to quitting, then cigarette use should be reduced to
half at six weeks and completely stopped at six months.23
In order to determine an appropriate NRT regimen, New Zealand guidelines recommend combining the time until the first
cigarette with the total number of cigarettes a person smokes each day (Figure 2). The amount of time
that passes after waking until a person smokes their first cigarette is a useful guide when assessing nicotine dependence;
New Zealand guidelines use smoking within an hour of waking as a sign of high tobacco dependence,22 smoking
within five minutes of waking is a sign of severe dependence.10
Nicotine patches are fully subsidised in New Zealand and available in 7mg, 14 mg and 21 mg patches.
These should be pressed in place on dry, clean and hairless skin, and replaced daily.22 Patches may cause
some dermal erythema.22 If patients report disturbed sleep while using nicotine patches then they should be
removed at night.
Nicotine gum is available in 2 mg and 4 mg formulations. It is recommended that nicotine gum be used
regularly by people who are attempting to quit smoking.22 The 4 mg formulation is indicated for people who
are highly dependent on tobacco, i.e. smoking within an hour of waking. The gum should be bitten to liberate a peppery
flavour. The gum should not be chewed continuously as swallowed nicotine can result in gastrointestinal disturbance. It
can be placed between the cheek and gum and chewed again when the taste fades, and disposed of after 30 minutes.22,
Nicotine lozenges are available in 1 mg and 2 mg formulations. It is recommended that lozenges be used
regularly when nicotine cravings occur.22 The 2 mg formulation is indicated for people who are highly dependent
on tobacco, i.e. smoking within an hour of waking.
All people who wish to quit smoking can use NRT, including people with cardiovascular disease and women
who are pregnant or breastfeeding, if they would otherwise continue to smoke.22 When discussing the use of
NRT with a woman who is pregnant or breastfeeding perform a risk assessment and consider “Can she quit without NRT?” If
not, NRT is safer than smoking. A study involving over 1700 pregnant women who used NRT found no significant association
between NRT use and decreased infant birth weight.24 Pregnant women who are using nicotine patches should
remove them overnight.22 Adolescents aged 12 years or over can also be prescribed NRT,22 however,
the use of NRT alone is unlikely to address the reasons why an adolescent has begun, and continues to smoke.
Nicotine inhalators (15 mg nicotine cartridges) and nicotine mouth spray (1 mg nicotine per dose) are
available as unsubsidised NRT products. Nicotine inhalators can be puffed on for 20 minutes every hour, and the cartridge
replaced after three hours.22 One cigarette puff is equivalent to approximately ten inhalator puffs.22 Nicotine
mouth sprays are also recommended for regular use, or for when cravings occur.22 After priming the pump, direct
one spray to the inside of each cheek. Advise patients to resist swallowing for several seconds after application to achieve
For further information see the “Guide to prescribing nicotine replacement therapy
(NRT)” available from: www.health.govt.nz
Electronic-cigarettes – the jury is still out
Electronic-cigarettes are a topic in smoking cessation that is evolving rapidly, both in terms of device design and
evidence of effectiveness. The devices electronically vaporise a solution made up of propylene glycol and/or glycerol,
nicotine and flavourings, that users inhale rather than burning tobacco leaves.26 The solution is held in cartridges that
are inserted into the device.26 These devices are different to nicotine inhalators.
The body of research on electronic-cigarettes is small, but growing quickly, and opinion is divided as to the potential
harms or benefits to personal or public health.27 Currently, no electronic cigarette products have been approved under
the Medicines Act for sale or supply in New Zealand and therefore it is illegal to sell an electronic-cigarette that contains
nicotine.26 It is also illegal for electronic-cigarettes, with or without nicotine, to be sold as smoking cessation aids,
or for an electronic-cigarette that resembles a tobacco product to be sold to a person under the age of 18 years.26 However,
electronic-cigarettes are available on international websites as smoking cessation aids and many people who smoke are
interested in using them for that purpose.
Electronic-cigarettes are considered by experts to be less harmful than conventional cigarettes, however, short-term
adverse effects have been attributed to exposure to propylene glycol including eye and respiratory irritation.28 The aerosol
that electronic-cigarettes produce contains a number of cytotoxic and carcinogenic chemicals that may pose long-terms
risks to women who are pregnant.28 These compounds are present at levels one to two orders of magnitude lower than is
present in tobacco smoke, but at higher levels than is found in nicotine inhalers.28
Both the Ministry of Health and WHO recommend that people who smoke should be encouraged to quit using a combination
of approved NRT products, i.e. patches, lozenges and gum.26 The Ministry of Health intends to assess new evidence as it
arises regarding the safety and appropriateness of the use of electronic-cigarettes as smoking cessation aids.