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10-minute module
HELP CUSTOMERS STOP SMOKING FOR GOOD
IMPROVING QUIT RATES WITH COMBINATION NRT
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Tobacco dependence is a powerful addiction and chronic relapsing clinical condition.1
Most smokers want to quit, with half of them setting a goal to quit at least once a year. However, many do so without support, despite the fact that most smokers who aim to quit unaided relapse.1
Pharmacy teams should encourage all smokers to stop for good by motivating them, advising on a nicotine replacement therapy (NRT) treatment plan personalised to their needs, and supporting them with their stop smoking journey.
LEARNING OBJECTIVES
After completing this module, you will be able to understand:
Your role in supporting customers and the government’s ambition to make England smokefree by 2030
The implications of smoking and the effectiveness of NRT and combination therapy
How to make shared decisions with customers for effective smoking cessation
THE SCIENCE OF SMOKING1-3
Quitting smoking can be difficult due to tobacco dependence and withdrawal symptoms.1 Many may think of smoking as just a habit that is easy to give up, but recognising how nicotine can cause dependence can help you empathise with your customer’s struggle and understand how to break the cycle.
Click on the numbers below to follow the tobacco dependence cycle.
SMOKING
Smoking tobacco delivers nicotine into the body, which is addictive, but not hazardous. However, there are over 5,000 harmful chemicals that are produced during the combustion of tobacco in cigarette smoke which, when inhaled, are responsible for negative health effects and many diseases. Some of these toxins include tar, carbon monoxide and carcinogens.1
NICOTINE TRAVELS TO THE BRAIN
When inhaled, nicotine is delivered to the brain and acts on receptors (nicotinic acetylcholine receptors) that play a major role in the mechanisms that lead to and sustains nicotine addiction.2 A key reason why nicotine is particularly addictive is because when inhaled, it is delivered very quickly to the brain1 (about 10 seconds)3 so its effects are almost instant.
DOPAMINE RELEASE
Nicotine acts on the receptors that trigger the release of the chemical dopamine (amongst other neurotransmitters), which stimulates positive feelings. This craving for dopamine and the positive feelings associated with it can lead to severe dependence.3 With repeated smoking, nicotine accumulates in the body, resulting in changes in nicotinic receptors and a greater level of tolerance.2
DROP IN DOPAMINE
Although nicotine stimulates dopamine, the surge is temporary and as nicotine levels decline, so do the positive feelings. This absence of nicotine can lead to unpleasant withdrawal symptoms and the urge to smoke again.2 Withdrawal symptoms can have a rapid onset with symptoms occurring in as little as 20 minutes after the last cigarette.1
CRAVING FOR CIGARETTE
The brain will seek another dopamine boost to combat the harsh withdrawal effects and with cigarettes providing rapid relief, many relapse and smoke again. Often cravings worsen when certain triggers occur (e.g. stress) and people seek the dopamine boost to help manage the effects.1
WITHDRAWAL EFFECTS can be incredibly difficult to manage and affects nearly all smokers who try to quit at some point, which is why many relapse. Although severity can vary from person to person, some symptoms such as depression and night-time awakening can impact quality of life;1 therefore it is important to be empathetic and recognise the importance of combating these symptoms.
Click the tab below to understand common nicotine withdrawal symptoms. The duration indicates the average time people typically experience the side effect after quitting, while the prevalence indicates the percentage of people who quit who experience the relevant symptom.
NICOTINE WITHDRAWAL SYMPTOMS1
| NICOTINE WITHDRAWAL SYMPTOM | DURATION | PREVALENCE |
|---|---|---|
| Urge to smoke | >2 weeks | 70% |
| Increased appetite | >10 weeks | 70% |
| Depression | <4 weeks | 60% |
| Restlessness | <4 weeks | 60% |
| Poor concentration | <2 weeks | 60% |
| Irritability/aggression | <4 weeks | 50% |
| Mouth ulcers | >4 weeks | 40% |
| Night-time awakening | <1 week | 25% |
| Constipation | >4 weeks | 17% |
| Light-headedness | <48 hours | 10% |
MANAGING TRIGGERS4
As well as nicotine withdrawal effects, smokers can also experience cue-induced cravings. Smoking triggers can vary from person to person, as can craving intensity. However, they often fall into one of four categories – emotional, pattern, social and sensory.4 Helping your customer identify their triggers can help them avoid them, where possible, or learn to manage them in healthier ways.
Click through the carousel to understand some common smoking triggers.
EMOTIONAL TRIGGERS4
As we saw above, nicotine stimulates dopamine, sometimes known as the ‘happy hormone’. Many people smoke to combat intense emotions such as:
Stress and anxiety
Loneliness
Boredom
Anger
Sadness
Discuss with your customer that some of these feelings they are experiencing could be related to nicotine withdrawal effects which are relieved when they smoke. However, smoking is not a healthy or sustainable way to manage these emotions. In fact, after 4 weeks of stopping, people report significantly less stress and anxiety, and improved mood.1 You could recommend your customer finds activities to help them to relax, such as taking a walk, exercising or practicing mindfulness. You should signpost your customer to their GP if there are any concerns about mental health.
PATTERN TRIGGERS4
Pattern triggers are essentially smoking habits or routines that people adopt that are connected to certain activities.
Some examples may include:
Drinking coffee
Finishing a meal
Watching TV
Drinking alcohol
Taking a work break, e.g. a ‘cigarette break’
Although people associate these activities with smoking, they could change this by transferring the feeling to another activity. For example, they could change their routine by avoiding alcohol or going for a walk in their work break.
SOCIAL TRIGGERS4
Social triggers are associated with other people who smoke. This can be difficult for the smoker, particularly if they live with another smoker. Some triggers include:
Going to a bar (drinking alcohol is also a trigger)
Going to party or celebration
Seeing someone smoke or being with friends who smoke
It can be challenging to avoid people who smoke; however, customers should ask their friends and family to not smoke around them and support them with their journey. Although it can be difficult to avoid social events, if they are socially triggered, they should be encouraged to avoid places where people smoke, e.g. a smoking area.
SENSORY TRIGGERS4
For long-term smokers the body is used to receiving regular nicotine doses and certain sensory triggers can enhance this, including:
Craving the taste of a cigarette
Smelling cigarette smoke
Handling cigarettes, lighters and matches
The need to do something with their hands or mouth
These physical triggers can be avoided by distraction. Taking up activities and distracting the mind from the trigger is a key way to do this: for example, keeping the hands busy by squeezing a stress ball to avoid the repetitive smoking motion.
Although these tips are useful, relapse rates are high without support.
Customers can increase their chances of success with nicotine replacement therapy.
NICORETTE COMBINATION THERAPY
Nicotine replacement therapy (NRT) provides the body with therapeutic doses of nicotine through a safer alternative method than cigarettes. It is the toxins in cigarette smoke such as tar, lead, cyanide and ammonia that cause smoking related disease and death, not the nicotine. NRT helps to manage cravings and withdrawal symptoms, therefore reducing the urge to smoke.5
COMBINATION THERAPY combines a long-acting and short-acting NRT format.
NRT COMBINATION THERAPY CAN INCREASE QUIT RATES BY 27%
COMPARED WITH THE USE OF A SINGLE NRT FORMAT.6
Click on the products to discover more about the different formats of Nicorette NRT products.7-15
NICORETTE INVISIPATCH (SLOW RELEASE)
16-hour patch specifically designed to be removed at night, so as not to add to the sleep disturbance caused by nicotine withdrawal.
STRENGTHS AVAILABLE: 10mg, 15mg, 25mg
MAXIMUM DOSE: 1 patch daily
NICORETTE QUICKMIST (FAST RELEASE)
Clinically proven to start relieving cravings in 30 seconds (2x1mg spray).9
Indicated for both smoking cessation and nicotine vaping cessation.
STRENGTHS AVAILABLE: 1mg/spray
MAXIMUM DOSE: 64 sprays in any 24 hour period
NICORETTE QUICKMIST SMARTTRACK (FAST RELEASE)
The first stop smoking NRT spray that uses near field communication to connect to a behavioural support app. Clinically proven to start relieving cravings in 30 seconds (2x1mg spray).9
STRENGTHS AVAILABLE: 1mg/spray
MAXIMUM DOSE: 64 sprays in any 24 hour period
NICORETTE GUM (FAST RELEASE)
Relieves tough cravings. For those who like chewing gum to control cravings.
Icy White flavour also improves teeth whiteness.
STRENGTHS AVAILABLE:
2mg gum: For those who smoke 20 or less cigarettes per day
4mg gum: For those who smoke more than 20 cigarettes per day
MAXIMUM DOSE: 15 pieces per day
NICORETTE LOZENGE (FAST RELEASE)
Starts to fight cravings in just 2 minutes.
Dual-layer flavour technology designed to aid compliance.
STRENGTHS AVAILABLE:
2mg lozenge: For those who smoke 20 or less cigarettes per day
4mg lozenge: For those who smoke more than 20 cigarettes per day
MAXIMUM DOSE: 15 pieces per day
NICORETTE INHALATOR (FAST RELEASE)
Mimics hand-to-mouth ritual of smoking.
Each cartridge lasts for approximately 40 minutes of total intense use.
STRENGTHS AVAILABLE: 15mg
MAXIMUM DOSE: 6 cartridges per day
NICORETTE NASAL SPRAY (FAST RELEASE)
Rapid uptake of nicotine for fast relief of cravings.
STRENGTHS AVAILABLE: 0.5mg/spray
MAXIMUM DOSE: 64 sprays in any 24 hour period
NICORETTE MICROTAB (FAST RELEASE)
Flexible and discreet: dissolves over 30 minutes.
STRENGTHS AVAILABLE: 2mg
MAXIMUM DOSE: 40 tablets per day
RECOMMEND NICORETTE NRT COMBINATION THERAPY:NOTHING IS MORE EFFECTIVE AT HELPING YOUR PATIENTS QUIT SMOKING FOR GOOD.*6
*Compared to single NRT or other smoking cessation medications available OTC.
You could offer your customer the following dosing schedule using the Nicorette InvisiPatch, based on the number of cigarettes smoked and their format preferences. NRT products are typically used for 8-12 weeks:1,7-10
| NUMBER OF CIGARETTES | PATCH STRENGTH | FLEXIBLE FORMAT DOSE |
|---|---|---|
| 1-9 | Start with 15mg patch | 2mg gum OR 2mg lozenge OR mouthspray |
| 10-20 | Start with 25mg patch | 2mg gum OR 2mg lozenge OR mouthspray |
| 21+ | Start with 25mg patch | 4mg gum OR 4mg lozenge OR mouthspray |
Refer to individual Summary of Product Characteristics for information on dosage.
CUSTOMER SCENARIO
Work through the following customer scenario and consider what advice and treatment you would offer.
Nicola is a 33-year-old woman who has asked for some advice to stop smoking as she is trying to get pregnant. She tells you that she has tried a 24-hour patch before, but she didn’t like wearing the patch at night. She also found herself struggling with cravings in the day, particularly during her breaks in her work shift and when she left work. She tells you that she typically smokes about 15 cigarettes per day which is less than her partner; however, recent stress has made her cravings worse.
FROM THE INFORMATION NICOLA HAS PROVIDED
YOU, WHAT WOULD YOU CHOOSE TO DO NEXT?
OFFER MONOTHERAPY NRT
ALMOST CORRECT!Nicola has tried monotherapy with the 24-hr patch before; however, she may benefit from additional support on this occasion.
OFFER COMBINATION THERAPY
CORRECT!Combination therapy could significantly improve her chances of successfully quitting.
OFFER SELF-CARE ADVICE ALONE
INCORRECT!Using willpower alone has a low chance of success.1
Nicola is very pleased when you tell her that she is suitable for treatment and that a combination of a long-acting patch and a short-acting format could improve her chances of quitting by 27% compared to monotherapy alone.6 She tells you that she wants the FASTEST-ACTING OPTION.
As Nicola tells you that one of the reasons she relapsed was because she didn’t like wearing the 24-hr patch at night, you choose the 16-hour Nicorette® Invisi 15mg patch.
Click on the button below to understand the benefits of using a 16-hour patch vs a 24hr patch.
16-HOUR NICORETTE PATCH
Formulated to deliver small doses of nicotine over a 16-hour period, morning to evening to mimic a smoker’s natural smoking pattern.7
Unlike 24-hour patches, as it is specifically designed to be removed at night before sleep,7 it does not add to the sleep disturbance caused by nicotine withdrawal.16
NICOLA'S DAILY ROUTINE
Nicola can apply the patch in the morning when she wakes, it will be on and working during her working hours achieving maximum plasma nicotine concentration approximately 9 hours7 later when she leaves work, when she usually craves a cigarette.
Nicotine levels will drop as she sleeps and when she wakes, and nicotine levels are low, she can repeat the process with a new patch.
NICORETTE LOZENGE
Nicola chooses to use the Nicorette Lozenge alongside her patch as you tell her that it can help to fight cravings in just 2 minutes.10
THIS COMBINATION will work well with Nicola’s routine as she will have background doses of nicotine delivered by the patch and fast-acting relief from the lozenge that she can use to manage her cravings when they strike; for example, during her breaks.
OTHER POINTS TO SHARE WITH NICOLA
If Nicola becomes pregnant, she should seek further advice from a healthcare professional. Ideally, smoking cessation during pregnancy should be achieved without the help of NRT. However, if Nicola cannot (or is considered unlikely to) quit without pharmacological support, NRT may be used as the risk to the fetus is lower than expected with smoking tobacco.4
As her partner also smokes, it is important that they support her by trying to quit smoking too. Women who live with a smoker are 6x more likely to smoke throughout pregnancy compared with women who do not live with a smoker, and are more likely to relapse when the baby is born.17 There are also the risks of second-hand smoke exposure that could affect the whole family as it has serious health consequences to pregnant women and unborn babies.1
Nicola should be shown how to correctly use the NRT products and when and how to taper down and stop NRT use once she is ready and confident that she won't relapse and start smoking again.
Nicola can download the Nicorette Stop Smoking app to create a personalised quit plan, monitor her nicotine usage and receive helpful hints and tips.
1. NCSCT. NHS Standard Treatment Plan for Inpatient Tobacco Dependence. 2023.
Available at: https://www.ncsct.co.uk/library/view/pdf/NHS-Standard-Treatment-Plan-for-Acute-Inpatient-Tobacco-Dependence.pdf
2. Benowitz NL. Nicotine addiction. N Engl J Med. 2010 Jun 17 ;362(24):2295-303. doi: 10.1056/NEJMra0809890. PMID: 20554984; PMCID: PMC2928221.
3. Jarvis MJ. Why people smoke. BMJ. 2004 Jan 31;328(7434):277-9. doi: 10.1136/bmj.328.7434.277. PMID: 14751901; PMCID: PMC324461.
4. Smokefree.gov. Know your triggers. 2024. Available at: https://smokefree.gov/challenges-when-quitting/cravings-triggers/know-your-triggers
5. Sandhu A, et al. Nicotine Replacement Therapy. 2023. In: StatPearls. Treasure Island (FL)
6. Theodoulou A, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2023
Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308.pub2/full#0
7. Nicorette® Invisi 25 mg Patch. Summary of Product Characteristics Oct 2024.
8. Nicorette® QuickMist. Summary of Product Characteristics. Dec 2022.
9. Danielsson T, et al. 2024. ‘Effect of nicotine mouth spray on urges to vape: A randomized, placebo-controlled, pharmacodynamic clinical trial in exclusive e-cigarette users.’ Addiction. doi: 10.1111/add.16669
10. Nicorette® 4mg Gum Summary of Product Characteristics. Sep 2021.
11. Nicorette® Cools 4mg Lozenge Summary of Product Characteristics. May 2024.
12. Nicorette® 15mg inhalator. Summary of Product Characteristics. Oct 2024.
13. Nicorette® Nasal Spray Summary of Product Characteristics. Mar 2023
14. Nicorette® 2mg Microtab Summary of Product Characteristics. Sep 2021.
15. Data on file; QuickMist vaping study, 2022
16. Russell MA, et al. Targeting heavy smokers in general practice: randomised contr olled trial of transdermal nicotine pat ches. BMJ. 1993 May 15;306(6888):1308-12. doi: 10.1136/bmj.306.6888.1308. PMID: 8518572; PMCID: PMC1677738.
17. ASH. Evidence into Practice – Supporting partners to quit smoking. 2024. Available at: https://ash.org.uk/uploads/Supporting-partners-to-quit-smoking-v1.pdf?v=1648140223
Online references last accessed January 2025
Product information
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to McNeil Products Limited on 01344 864 042. Calls may be monitored for training purposes.
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UK-NIC-2024-88488 December 2024