Choosing the right nicotine replacement therapy (NRT)
By Nancy Kupka, PhD, RN Oct 04, 2022 • 12 min
Quitting smoking is hard, but it can be done. The main reason quitting smoking is so challenging is that nicotine is physically addictive. The people who are most successful at quitting use a combination of nicotine replacement therapy (NRT) and prescription medications to help them stop smoking. In fact, using NRT increases your chances of quitting by 50% to 70%. NRT gives you small amounts of nicotine without the other harmful chemicals in tobacco and relieves some of the physical withdrawal symptoms, such as cravings, headache, dizziness and irritability.
There are five types of NRT available in the U.S. — the transdermal nicotine patch, nicotine gum, nicotine lozenge, nicotine nasal spray and nicotine inhaler. Nasal sprays and nicotine inhalers require a prescription. Vapes, hookahs and e-cigarettes are not NRT. Check with your healthcare provider before starting NRT if you have heart problems or other chronic illnesses, are pregnant or breastfeeding, or if you are under 18 years of age. You can also speak with a pharmacist to help you decide the right choice for you.
Look at the label for information about the recommended doses for each product, which are based on how much you smoke, and be careful not to overuse NRT products. But the amount you smoke isn’t the only factor in helping you determine what will work for you. Ask yourself the following questions to help you choose the best NRT for you:
Do you want or need something in your mouth to help keep from reaching for a cigarette? Do you want flexibility with flavors or when to use the product? Consider using gum or lozenges.
Are you looking for once-a-day convenience? Think about using a patch.
Do you wear dentures or have other dental work that may interfere with some NRT products, such as gum or lozenges? Consider a patch or nasal spray.
Do you have any allergies or conditions that may make you unable to use certain products? Talk with a pharmacist to make sure you are not inadvertently taking an allergen.
Transdermal nicotine patch
Transdermal nicotine patches provide nicotine throughout the day once applied to the skin. Each day you have to remove the old patch and apply a new patch to a clean, dry area of your body that is not hairy. Your arms, thighs, stomach, chest or back may be good options. Rotate the places on your body where you apply the patch to decrease your chance of having skin irritation. Avoid using the same place by at least a week. Never cut the patch in half or in smaller pieces because that may cause you to get too much or too little nicotine. If you begin to experience trouble sleeping, you can remove the patch at bedtime.
- The patch can be worn under clothing, so no one will know it's there
- Nicotine is released constantly throughout the day, so you can change the patch each day and forget about it. You won't have early morning withdrawal symptoms since you will get nicotine while you sleep, but you might want to remove it at night if you experience sleep disturbances.
- It may be covered by health insurance if you have a prescription
- You cannot adjust the dose to quickly manage withdrawal symptoms or cravings
- The patch may cause headaches, skin reactions, such as itching, burning or redness at the spot where it is applied, or sleep disturbances, such as insomnia or vivid dreams
- The patch is not recommended if you have any skin conditions like psoriasis or rashes. This is because the patch could make those conditions worse or your body may get too much or too little nicotine.
Nicotine gum is available in a variety of flavors, including original, cinnamon, fruit, mint and orange. Dosage is based on when you have your first cigarette of the day and how many cigarettes you smoke every day.
Begin by chewing one piece of gum every one to two hours for the first six weeks. Decrease to one piece every two to four hours during weeks seven through nine, and then finish up treatment by chewing one piece every four to eight hours during weeks 10–12.
Nicotine gum is not like normal gum that you chew when you want to and stop when you don't. This gum should be chewed slowly until you feel a tingling sensation and then "parked" in an area of your mouth. Once the tingling fades, repeat the process and "park" the gum in a different area of your mouth. Continue this for 30 minutes until the tingling sensation fades completely, which means that the nicotine in the gum is gone. You should avoid eating or drinking for 15 minutes before and after chewing nicotine gum, and limit to no more than 24 pieces a day.
- Nicotine gum helps to satisfy oral cravings
- You can adjust the dose quickly by chewing another piece of gum to manage withdrawal symptoms or cravings
- Using the gum can lead to mouth and jaw soreness, hiccups, indigestion and excessive salivation
- The gum may be difficult to use for people with dentures or other dental work
Nicotine lozenges also come in several flavors. Appropriate dosage is based on when you have your first cigarette of the day. The directions for using lozenges are slightly less complicated than with gum. Start with one lozenge every one to two hours for the first six weeks, and then use one lozenge every two to four hours during weeks seven through nine. After that, use one lozenge every four to eight hours during weeks 10–12. Allow the lozenge to dissolve over 20–30 minutes in different areas of your mouth. Do not chew or swallow the lozenge and avoid eating or drinking for 15 minutes before and after use. Do not use more than 20 lozenges per day.
- Nicotine lozenges help satisfy oral cravings
- You can adjust the dose quickly by sucking on another lozenge to manage withdrawal symptoms or cravings
- Nicotine lozenges may cause stomach upset, heartburn, gas, headaches, hiccups and coughing
- The lozenges may make it difficult to fall asleep
Nicotine nasal spray
Nicotine nasal spray is available as a prescription, and it provides 0.5 mg of nicotine with each spray. You can use up to five doses (which equals one to two sprays in each side of the nose), as often as every hour, being mindful to use at least eight doses per day but not more than 40 doses (80 sprays) per day. Make sure to avoid sniffing, swallowing or inhaling through your nose when administering the dose. You should not use the spray for longer than six months.
- The dose can be adjusted quickly to manage withdrawal symptoms or cravings
- The nicotine nasal spray requires many doses, which can lead to nose or throat irritation
- Side effects include headaches, sneezing, runny nose, tearing or cough
- You should wait five minutes after a dose before driving or operating heavy machinery because of side effects
The nicotine inhaler looks like a plastic cigarette holder and requires a prescription. It consists of a mouthpiece and a cartridge that contains nicotine. This is different from a JUUL or a vape.
Using the nicotine inhaler is different from using other types of inhalers, such as those for asthma. The nicotine inhaler is "puffed" on by inhaling the medicine into the back of your throat or "puffing" in short breaths. Do not inhale into your lungs as you would a cigarette, but instead keep the puff in your mouth. It takes 20 minutes of active puffing to use up the entire 4 mg dose. If you use it for less than 20 minutes, the inhaler can be stored for later use with the same cartridge for up to 24 hours. Throw away whatever is left after 24 hours, making sure to dispose of it away from children and pets.
Start by using at least six cartridges a day (with a maximum of 16 per day) and decrease over time. Most people use the inhaler for three months and then slowly decrease their daily use over the next six to 12 weeks. Also, avoid eating or drinking for 15 minutes before or during use.
- The inhaler can mimic the "puffing" from a cigarette, helping to satisfy oral urges
- It quickly helps with withdrawal symptoms
- The inhaler requires a lot of doses
- Side effects include mouth and throat irritation
In summary, whatever you choose to use, be sure to:
- Talk with your healthcare provider before you use NRT if you have chronic illness, are pregnant or breastfeeding, or are under 18 years of age.
- Follow the directions carefully, and do not overuse NRT. If you start experiencing side effects, know that they often go away if you use less NRT.
For some people, using more than one type of NRT at a time can be more effective than using only one method alone. However, this could result in too much nicotine in your system. Speak with your provider or pharmacist if you plan to combine different types of NRT.
If you smoke 10 cigarettes or more a day, talk with your provider to determine if you would benefit from a prescription medication as well as an NRT.
If you or someone you care about wants to quit smoking, healthcare providers at in-store clinics are on hand to support you in your plans to be tobacco-free.
Clinically reviewed and updated October 2022.