Skin irritation caused by adhesive is a common adverse event from nicotine patches. Rotating the location of each patch to a different hairless body area is the best way to prevent or combat skin irritation. If rotating the location of the patch does not relieve irritation, patients can apply a thin layer of an OTC hydrocortisone 1% cream to the affected site 2 to 4 times a day after gently washing the area.5 Instruct patients to avoid using occlusive dressings over the topical application.
Nicotine replacement patches also have been reported to cause vivid dreams and insomnia.3 These side effects may be caused by nighttime nicotine absorption, which might be avoided by switching to a different NRT product or removing the 24-hour patch when going to bed.4
Combining treatments
Many patients experience nicotine cravings while using the nicotine replacement patch. Stressful situations and events can trigger a patient’s desire for nicotine and withdrawal symptoms that a patch that delivers a continuous amount of nicotine over 24 hours cannot alleviate. Combining different forms of treatment could combat these symptoms.2,3,5
Combination therapy might consist of using sustained-release bupropion or a nicotine patch with rapid-acting NRT products such as a lozenge, gum, nasal spray, or inhaler. In Mr. T’s case, clinicians recommend that he use nicotine polacrilex gum in addition to the patch to quell his cravings. Also, he is instructed to stop using electronic cigarettes because they are considered tobacco products, are not regulated by the FDA, and may contain toxic substances.6
Instruct patients who use nicotine gum to employ the “chew and park” method.4 First, they should chew the gum very slowly until they notice a minty taste or tingling feeling, then “park” the gum between the cheek and gums for 1 to 2 minutes to allow nicotine to be absorbed across the gum lining. After 2 minutes or when tingling ceases, patients should slowly resume chewing until a tingling or minty taste returns and then “park” the gum again in a different area of the gums. Tell patients to repeat the “chew and park” method until there is no more taste or tingling (approximately 30 minutes). Explain that chewing the gum too fast may result in nausea or lightheadedness and patients should refrain from eating or drinking 15 minutes before or while using the gum. Mr. T is instructed to use the gum only when the urge to smoke is overbearing, and not regularly.
The nicotine polacrilex gum is more viscous than ordinary chewing gum and may stick to or possibly damage dental work such as fillings, dentures, crowns, and braces. An acceptable alternative is the nicotine polacrilex lozenge. Advise patients who want to try lozenges to:
- place the lozenge in the mouth and allow it to dissolve slowly over 20 to 30 minutes (during this time patients may experience a tingling sensation as nicotine is released)
- rotate the lozenge to different areas of the mouth every few minutes to lessen irritation
- avoid chewing or swallowing the lozenge because doing so will lead to improper release of nicotine and side effects, including nausea, hiccups, and heartburn
- refrain from eating or drinking 15 minutes before or while using the lozenge.
For many patients, the breadth of pharmacologic agents available for smoking cessation has made quitting a more attainable goal. OTC smoking cessation products are available in most drug stores, which gives smokers easy access to taking this important step. Counseling patients on the proper use of OTC products may help them successfully stop smoking.7
Although a patient’s medical history, including cardiac status, must be considered before starting specific agents, in many instances patient preference is the prevailing factor when choosing therapy. Often, the risks of continued smoking outweigh the risks of using smoking cessation products. OTC smoking cessation products may be an appropriate first-line treatment for many individuals before trying prescription medications, such as bupropion or varenicline.
For patients
- Treat Tobacco. www.treatobacco.net.
- Smokefree.gov mobile application. http://smokefree.gov/apps.
- Medline Plus. Quitting smoking. www.nlm.nih.gov/medlineplus/quittingsmoking.html.
- Quit for Life Program. www.quitnow.net.
- American Lung Association. Stop Smoking. www.lungusa.org/stop-smoking.
For clinicians
- Agency for Health Research and Quality. Treating tobacco use and dependence: 2008 update. www.ahrq.gov/path/tobacco.htm#clinicians.
Drug Brand Names
- Bupropion SR • Zyban, Wellbutrin SR
- Fluoxetine • Prozac
- Varenicline • Chantix