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Medically reviewed by, Russell Braun RPH
Smoking is the leading cause of preventable death in the United States according to the Centers for Disease Control (CDC). Smokeless tobacco also causes many health problems including cancer, heart disease and stroke.
Why is smoking so hard to quit?
Nicotine is highly addictive and leads to your body becoming physically dependent. As a result of this dependence, withdrawal symptoms arise when trying to quit. Withdrawal symptoms are the number one reason why people who try to quit smoking fail.
Nicotine Replacement Therapy (NRT)
NRT is available to help with the physical withdrawal symptoms. Due to the highly addictive nature of nicotine, psychological treatment in addition to NRT will result in the best chance of quitting for good.
The Food and Drug Administration (FDA) has approved several forms of NRT. They do not all contain nicotine. Some will require a prescription and others are over the counter. People who struggle with quitting may have better outcomes by using more than one NRT at a time.
|Brand Name||Generic Name|
|Nicotrol Inhaler||Nicotine inhaler|
|NIcotrol NS||Nicotine nasal spray|
Over the counter
|Band Name||Generic Name|
|Nicoderm CQ||Nicotine transdermal patch|
|Nicorette||Nicotine polacrilex gum|
The evidence that smoking is detrimental to your health is overwhelming. Below is a list of major medical organizations that strongly encourage quitting and recommend NRT.*
- American Cancer Society
- Centers for Disease Control
- American Lung Association
- The Agency for Health Care Policy and Research
- The American Heart Association
- American College of Gastroenterology
- The American College of Rheumatology
- American Psychiatric Association
*This list does not contain all the organizations that recommend NRT.
Nicotine patches are sold over the counter (which means they do NOT require a prescription) so understanding how they should be used is important. Here is what you need to know.
How do nicotine patches work?
Nicotine patches are applied to the skin and deliver a steady amount of nicotine throughout the day. The amount of nicotine in the patch is slowly released over 24 hours. Patches need to be changed on a daily basis.
Releasing the nicotine in a steady amount throughout the day helps adjust the body to nicotine levels that are consistent. Smoking offers bursts of nicotine throughout the day and that rise and fall in blood levels of nicotine make for mini withdrawals symptoms throughout the day. This leads to smokers feeling they “need” another cigarette. Consistent nicotine blood levels is one of the key benefits of the patch over other forms of NRT.
As the mini withdrawal symptoms subside you are still receiving nicotine. Then over time, you can move to patches that have lower amounts of nicotine. This has been shown to be an effective way to help smokers quit.
Typical withdrawal symptoms the patch can help subside include:
- Weight gain
- Urge to snack
- Mood swings
How to decide between 7mg, 14mg or 21mg patch?
In order to determine how many milligram (mg) patch you should pick you need to figure out the number of cigarettes you smoke each day. You need to be honest about this and not say a half a pack when it is really a pack per day. Too low of a dose of NRT will make it more likely you will not succeed in kicking the habit.
Here are some general equivalents*
|Product||Approximate amount of Nicotine|
|1 Large Cigar||5mg|
1 pack of cigarettes has 20 cigarettes, if you were smoking 1 pack per day you were taking 20mg of nicotine. If you smoke a half a pack that is 10 cigarettes and around 10mg of nicotine.
Nicotine patches come in 7mg, 14mg and 21mg strengths. As you can see the 21mg strength is almost an exact replacement of nicotine for a person smoking 1 pack per day. That is why most smokers start out on the 21mg patch.
Step 1 is a 21mg patch
- Anyone who smokes 10 cigarettes per day or more should start here.
Step 2 is a 14mg patch
- Anyone who smokes less than 10 cigarettes per day should start here.
Step 3 is a 7mg patch
- No tobacco user should start here, this step is only for weaning down explained below.
Patients who start on step 1 (21mg patch) should use this strength for 6 weeks. After 6 weeks it is time to drop down to the 14mg strength. The 14mg patches should be used for 2 weeks. Finally, go to step 3, the 7mg strength and use that for 2 weeks. After that you have completed the steps you should no longer need the nicotine replacement.
Those who smoke 10 cigarettes a day or less will start on step 2 (14mg patch). They should use the 14mg patch for 6 weeks. After 6 weeks drop down to step 3 for 2 weeks. After that stop wearing patches and hopefully your dependence on nicotine is gone.
Some people do end up needing a longer timeframe. You should discuss if that is right for your with your doctor or pharmacists. Remember, using NRT is always a better option than smoking.
Do I have to wear the patch for 24 hours?
Typically, the patch should be worn for 24 hours so that the entire 21mg dose can be absorbed through the skin.
However, NRT should be customized to fit your needs!
If you have strong cravings for a cigarette in the morning then you would want to wear the patch for 24 hours. However, if you never smoke after dinner then it might not make sense to wear the patch all night. The other option many people opt for is to wear it for 16 hours (or your time you are awake) and remove prior to bedtime.
Somewhere between 16 to 24 hours is the optimal time to wear the patch. Wearing it less than that will cause you to have a suboptimal dose of nicotine replacement.
Can you wear 2 nicotine patches at once?
The dosing that is approved by the FDA is great if you smoke one pack per day or less. What about people who smoke more than a pack per day? Are they really successful with the 21mg dose?
A study done by the Mayo Clinic looked at the safety and efficacy of wearing more than one patch. The patients used smokeless tobacco not cigarettes, but overall wearing two 21mg patches was found to be safe and effective.
Not all patients would need two 21mg patches, you should figure your amount of nicotine per day and dose based on that.
An example would be the 1.5 pack per day smoker. They get approximately 30mg of nicotine per day from 30 cigarettes. Those patients may have better outcomes from using a 21mg and a 7mg or 28mg per day, or a 21mg and a 14mg for 35mg per day.
Can the patch be combined with other NRT?
If you plan on using more than one patch you should make sure you talk to your doctor. They may want you to combine with other NRT’s such as gum, nasal spray or inhaler for cravings during the day and stick with one patch. Many patients find this to be an effective method.
The gum in particular will give you an oral fixation that you miss when you stop smoking. Also, it delivers a similar amount of nitocine as a cigarette and is used for a similar duration. Check out more on using nicotine gum as an additional replacement therapy.
How do you use the patch?
The best practices for applying the patch are:
- Apply to clean, dry skin
- Do not apply lotion before applying
- Apply a whole patch, do NOT cut or tear the patch before applying
- It can be applied anywhere below the neck to anywhere above the waist
- Change the patch every day at the same time
- Apply to a different area every day (you can apply to the same spot more than once just try to space it out by a few days)
- The patch is waterproof and can get wet in the shower
- If the patch starts to come off, you can tape it on with medical tape
- Do not apply to areas of skin that scraped, scratched or burned
Nicoderm CQ is the brand of patch available in the United States. There are many generic equivalents that offer the better value than brand name. Below are some example prices.
Nicoderm CQ 21mg, 14 patches $38.90 on Amazon.com
Nicotine Transdermal System 21mg, 14 patches $29.95 on Amazon.com
Habitrol 21mg, 28 patches $32.00 on Amazon.com
Rugby Nicotine Transdermal System 21mg, 14 patches, $19.90 on Amazon.com
Can you use Insurance?
The benefits of using NRT are so great compared to the disastrous health effects of smoking that many insurances today may cover NRT.
Current laws require certain government insurances such as Medicare and Medicaid to cover tobacco cessation without charge to patients. There has been much debate over this and there are loopholes for insurers. Therefore, you insurance may not cover NRT.
You should still ask!
Tobacco cessation includes counseling services and the five FDA approved forms of NRT.
- You must get a prescription from your doctor for this to be covered.
- Your health insurance website should provide details of the program.
- If you don’t want to search the web call the number on the back of your prescription drug card to see if this is covered for you.
What happens if you smoke a cigarette while on the patch?
The best way to try and quit is to obtain your NRT before you the date you set as your quit date. Once you have that you should do your best to not smoke or have cigarettes where you can get to them.
Due to the addictive nature of nicotine this is often easier said than done. What if you are wearing a patch and slip up and have a cigarette?
The medical answer is that you should not do that. You are getting nicotine from two sources and you may have side effects from too much nicotine.
You slipped up, should you take off the patch?
If you allow yourself to smoke one more you will get in a habit of doing that while using patches. Reaffirm to yourself why you want to quit and set a goal to not smoke again with a patch on. Talk to your accountability partner or counselor you are working with. Do these things while keeping the patch on! That will reinforce you are on this to kick the habit and not allow you an easy reason to fall back into smoking.
If you take the patch off simply because you slipped and smoked one cigarette you risk smoking again.
Can you put a nicotine patch on after smoking?
Smoking a cigarette gives you a small burst of nicotine into the bloodstream. That nicotine level in your blood will fall shortly after smoking. What should you do if you slipped up and had a cigarette in the morning before your patch is applied? As long as you are not going to smoke again, then put your patch on. It will help you fight cravings and nicotine from the patch does not immediately enter the bloodstream.
Side effects of the patch
Side effects can vary from person to person and not everyone will get all of them. Many people have trouble telling true side effects from the patch from withdrawal symptoms.
Common side effects
- Skin irritation (itching and redness)
- Problems sleeping including: insomnia, vivid dreams
Less common side effects
- Rapid heartbeat
Does nicotine patch raise blood pressure?
Nicotine acts on the parasympathetic central nervous system in the body. It actually produces effects to slow the heart rate and lower blood pressure. When people experience high blood pressure or increased heart rate it is normally due to withdrawal. The NRT is not providing enough nicotine compared to when they were smoking and the dose may need to be increased.
If you have side effects try these key tips
- Rotate to different sites on your body
- Try a different brand of patch
- Use the patch for 16 hours a day instead of 24
Don’t stop trying to quit!
Everyone fails at things in life.
Thomas Edison failed thousands of times before he created the lightbulb. What was important was that he kept trying.
That is no different in your journey to stop smoking. Keep trying, until you suceed! If you fail that is okay, learn something about your habits and apply that to your next attempt.
Studies have shown that combining counseling, an accountability partner and NRT have the highest rate of success. Controlling withdrawal symptoms make one less obstacle for people to overcome.
Key things to remember are to use high enough doses of NRT to prevent withdrawal. Also, combining different forms of NRT may provide the best symptom control.
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Share your story!
Have you used nicotine patches? How well did it work for you? Please chime in below with your comments and thoughts below