Nicotine Replacement 🚭
Inpatient guide to nicotine replacement therapy (NRT) in Irish hospitals. Ward approach, combination NRT, and product table for patches, gum, lozenges, and inhalator.
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Fagerström nicotine dependence test
Score dependence and get HSE-aligned NRT suggestions
1. How soon after waking do you smoke your first cigarette?
2. Do you find it difficult to refrain from smoking in places where it is forbidden?
3. Which cigarette would you hate most to give up?
4. How many cigarettes do you smoke per day?
5. Do you smoke more during the first hours after waking than during the rest of the day?
6. Do you smoke even when you are ill enough to be in bed most of the day?
Educational aid only. Confirm local inpatient protocol and formulary.
Fagerström test: Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991 Sep;86(9):1119-27. doi: 10.1111/j.1360-0443.1991.tb01879.x. PMID: 1932883.
Nicotine replacement products
Patches, gum, lozenges, and inhalator
| Product | Type | Dose | Route | Frequency | Indication | Notes |
|---|---|---|---|---|---|---|
| Nicotine patch 21 mg/24 h | Slow-acting | 21 mg | Transdermal | Apply daily (am) | Inpatient withdrawal; combination NRT base | Nicorette / NiQuitin; steady 24 h release; rotate site; taper 21 → 14 → 7 mg over ~12 weeks |
| Nicotine patch 25 mg/16 h | Slow-acting | 25 mg | Transdermal | On waking; remove at bedtime | Light–moderate smokers; insomnia on 24 h patch | Nicorette / NiQuitin; less nocturnal nicotine; not ideal for early-morning cravings; add fast-acting NRT prn |
| Nicotine gum 4 mg | Fast-acting | 1 piece | Buccal | prn / hourly with patch | Breakthrough cravings; combination NRT | Nicorette / NiQuitin; chew–park–chew; if ≥20/day or smoke within 30 min of waking; max 15/day |
| Nicotine gum 2 mg | Fast-acting | 1 piece | Buccal | prn | Light–moderate smokers | <20 cigarettes/day; first cigarette ≥30 min after waking |
| Nicotine lozenge 4 mg | Fast-acting | 1 lozenge | Sublingual | prn / hourly with patch | Cravings; combination NRT | Nicorette / NiQuitin; dissolve slowly between cheek and gum; do not chew or swallow |
| Nicotine lozenge 2 mg | Fast-acting | 1 lozenge | Sublingual | prn | Light–moderate smokers | Use 2 mg strength if <20 cigarettes/day |
| Nicorette inhalator | Fast-acting | 1 cartridge | Inhalation | prn | Hand-to-mouth habit; combination NRT | ~10 mg/cartridge over ~40 min; up to 6 cartridges/day |
Nicotine patch 21 mg/24 h
Slow-actingDose:21 mg
Route:Transdermal
Frequency: Apply daily (am)
Indication: Inpatient withdrawal; combination NRT base
Notes: Nicorette / NiQuitin; steady 24 h release; rotate site; taper 21 → 14 → 7 mg over ~12 weeks
Nicotine patch 25 mg/16 h
Slow-actingDose:25 mg
Route:Transdermal
Frequency: On waking; remove at bedtime
Indication: Light–moderate smokers; insomnia on 24 h patch
Notes: Nicorette / NiQuitin; less nocturnal nicotine; not ideal for early-morning cravings; add fast-acting NRT prn
Nicotine gum 4 mg
Fast-actingDose:1 piece
Route:Buccal
Frequency: prn / hourly with patch
Indication: Breakthrough cravings; combination NRT
Notes: Nicorette / NiQuitin; chew–park–chew; if ≥20/day or smoke within 30 min of waking; max 15/day
Nicotine gum 2 mg
Fast-actingDose:1 piece
Route:Buccal
Frequency: prn
Indication: Light–moderate smokers
Notes: <20 cigarettes/day; first cigarette ≥30 min after waking
Nicotine lozenge 4 mg
Fast-actingDose:1 lozenge
Route:Sublingual
Frequency: prn / hourly with patch
Indication: Cravings; combination NRT
Notes: Nicorette / NiQuitin; dissolve slowly between cheek and gum; do not chew or swallow
Nicotine lozenge 2 mg
Fast-actingDose:1 lozenge
Route:Sublingual
Frequency: prn
Indication: Light–moderate smokers
Notes: Use 2 mg strength if <20 cigarettes/day
Nicorette inhalator
Fast-actingDose:1 cartridge
Route:Inhalation
Frequency: prn
Indication: Hand-to-mouth habit; combination NRT
Notes: ~10 mg/cartridge over ~40 min; up to 6 cartridges/day
💡 Ward approach
- Use the Fagerström test above to score nicotine dependence and guide product choice.
- Offer cessation support early in the admission.
- Ask, Advise, Act: ask smoking status; advise that the best quit rates come with medication plus behavioural support; act by prescribing NRT and referring to HSE Quit.
- Document cigarettes/day, time to first cigarette, and previous quit attempts/NRT use.
- Start NRT within hours of admission to prevent withdrawal (irritability, poor concentration, restlessness, increased agitation).
- Combination NRT is first-line when varenicline is not used: a nicotine patch (slow-acting) plus a fast-acting product (gum, lozenge, or inhalator) for breakthrough cravings, typically hourly prn.
- Match patch strength to nicotine dependence per HSE: full-strength for month 1 is typically 21 mg/24 h or 25 mg/16 h, guided by cigarettes/day and time to first cigarette. Combine with a fast-acting product; titrate if withdrawal persists. Confirm local hospital formulary and protocol.
- Continue NRT for 8–12 weeks where possible; arrange GP prescription and HSE Quit referral (Quitline 1800 201 203) at discharge.
⚠️ Cautions
- Recent MI (<2 weeks) or serious arrhythmia: use NRT with caution; patch may be preferable to repeated fast-acting doses; discuss with cardiology if unsure.
- Pregnancy: if the patient smokes, NRT can still be used and increases the chance of stopping. Discuss with the stop smoking adviser, midwife, pharmacist, or obstetrician before starting.
- Patch: rotate application site; remove before MRI; skin irritation: try alternate brand or 16 h patch.
- Insomnia or vivid dreams on 24 h patch: switch to 25 mg/16 h patch (remove at bedtime) or reduce dose.
- Nil by mouth: patch remains appropriate; fast-acting gum/lozenge if the patient can use them.
- Do not cut patches in half; this alters nicotine delivery.
🚨 When to escalate
- Persistent severe withdrawal, agitation, or covert smoking despite adequate combination NRT → senior review; consider dose increase, alternate fast-acting product, or varenicline/bupropion if appropriate.
- Pregnant smokers: discuss NRT with stop smoking adviser, midwife, pharmacist, or obstetrician; refer to HSE Quit.
- Psychiatric inpatients: NCG No. 28 has specific recommendations; do not assume patients are unmotivated to quit.
- Chest pain, palpitations, or syncope after NRT → assess urgently; may indicate excessive dose or unrelated pathology.