Can we get more out of NRT?

Author and presenter:
Hayden McRobbie
Senior Clinical Research Fellow, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, UK

Abstract
Nicotine replacement therapy (NRT) is the most widely used medicine for smoking cessation (e.g. 67% of NHS-SSS patients using NRT last year). It is typically started when a person stops smoking and a standard dose is used for 8 to 12 weeks and then stopped. Despite its good track record people who use NRT still have a less than 20% chance of quitting for a year or more. This may in part be due to the fact that many smokers are under-dosed. In some smokers the standard dosing is sufficient
while in others much higher doses may be needed. It is also likely that using NRT only after stopping smoking is not an optimal treatment strategy. There are modest data to show that higher degree of nicotine replacement is associated with greater quit rates. The Cochrane Review on NRT for smoking cessation identified six studies comparing quit rates associated with combination NRT use (e.g. patch plus a short acting NRT product) compared with single product use and one study comparing
combination NRT use with no NRT. Combing these studies shows a clear advantage of combination vs. single product NRT use (RR = 1.35; 95% CI: 1.11 – 1.63). An additional seven studies compared higher dose patches (e.g. 44 mg/24 hours) with standard doses (21 mg/24 hours). Overall there was a small increase in long-term quit rates (RR = 1.15, 95% CI: 1.01 – 1.30). Current data also suggest that using NRT for two or more weeks prior to quitting increases quit rates above the standard approach of using NRT from the quit day. There has traditionally been a ‘one size fits all’ approach with dosing of NRT. This is at odds with the disease where people exhibit varying degrees of tobacco dependence.
There is very little individualisation of treatment for tobacco dependence as there is in the management of other chronic diseases. Declaration of Interest: Hayden McRobbie has received honoraria for speaking at research symposia and received benefits in kind and travel support from, and has provided consultancy to the manufacturers of smoking cessation medications.