Does NRT work for everyone?

Clinical
By
Jennifer Kyi
-
NRT

While effective for many, smoking cessation strategies are not a one-size-fits-all approach.

Nicotine replacement therapy (NRT) aims to reduce cravings and withdrawal symptoms by delivering nicotine in a safer, slower release form than smoking.1,2 NRT is a first-line pharmacotherapy for smoking cessation if clinically appropriate, and is shown to be effective.3 Pharmacists can also help to reframe past quit attempts as valuable learning opportunities for patients.

Here are some key NRT troubleshooting considerations pharmacists should consider.

Is the dose high enough?

NRT is safer than smoking and has low addictive potential.4 It is often under-dosed in practice, which can undermine a patient’s confidence in treatment.2,4,5 Patients may receive an inadequate dose, use NRT inconsistently or discontinue treatment prematurely.

When used at optimal doses, evidence shows NRT increases quit success.2 Pharmacists should use a nicotine dependence assessment tool (e.g. Quit Centre’s NRT tool) for dosage guidance and encourage proactive use of faster-acting NRT in anticipation of a trigger or cravings. Patients who have stopped smoking after an initial 8-week course of NRT may also benefit from a follow-up course.4

For some patients, combination NRT (patch and faster-acting form) may be appropriate. Combination NRT is equally as effective as varenicline and more effective than NRT monotherapy for smoking cessation.4

Does technique impact efficacy?

Incorrect use of NRT may lead to reduced nicotine absorption, increased adverse effects and reduced confidence in treatment.

To ensure maximum absorption, counselling points could include:

  • chewing and parking nicotine gum
  • moving lozenge slowly from side to side in the mouth
  • rotating patch sites to minimise skin irritation
  • using mouth spray under the tongue or inside the cheek
  • avoiding acidic drinks for 15 minutes before using faster-acting NRT to improve absorption through oral mucosa.4,6,7*

Patients may expect that NRT will completely eliminate withdrawal symptoms or cravings, or they may confuse NRT-related adverse effects with withdrawal. NRT, when clinically appropriate, is safe for most patients.1 Guiding conversations about what to expect, common adverse effects and when referral is recommended, can help reduce premature discontinuation.

Adverse effects from NRT may include:

  • local irritation (skin, mouth)
  • hiccups
  • cough (may be a result of swallowed nicotine)
  • nausea (may be technique related)
  • sleep disturbances.6,7

In comparison, nicotine withdrawal symptoms are temporary, typically occurring within 24 hours after the last cigarette and lasting up to 2–4 weeks.3 They may include irritability, difficulty concentrating, anxiety, insomnia or increased appetite.3 

How can ‘slip-ups’ provide a blueprint for success?

Tobacco dependence is a chronic condition3 underpinned by nicotine dependence. Many patients require multiple quit attempts and ongoing support before achieving long-term cessation.3,8 So past experiences, including slip-ups and lapses, can provide valuable learning opportunities.

NRT, together with behavioural support, increases the odds of success.1 Behavioural support guides people through making a quit attempt, coping with cravings and withdrawal and adapting to a life without smoking. Quitline provides free multi-session behavioural intervention tailored to the individual, including support with using NRT. Pharmacists can directly refer patients to Quitline, with follow-up appointments, behavioural support and ongoing monitoring being important for patients’ quit success. 

While evidence specifically addressing vaping cessation is still emerging, it is reasonable to use the same strategies that are used for smoking cessation to provide support to patients who are seeking to stop vaping. 

*Refer to PSA Professional practice guidelines for pharmacists: Nicotine dependence support for more details.

References

  1. Greenhalgh EM, Dean E, Stillman S, et al. Pharmacotherapies for smoking cessation. In: Greenhalgh EM, Scollo MM, Winstanley MH, eds. Tobacco in Australia: facts and issues. Melbourne: Cancer Council Victoria. 2024. At: https://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-16-pharmacotherapy
  2. Veldhuizen S, Behal A, Zawertailo L, et al. Adequacy of nicotine replacement and success quitting tobacco in clinical populations: an observational study. Drug Alcohol Depend 2023;244:109755.
  3. Royal Australian College of General Practitioners. Supporting smoking cessation: a guide for health professionals. East Melbourne: RACGP. 2021. At: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation
  4. Sansom L, ed. Nicotine dependence. Australian Pharmaceutical Formulary and Handbook  [updated 15 Jan 2026].. At: https://apf.psa.org.au/treatment-guidelines-pharmacists/nicotine-dependence
  5. Henningfield JE, Fant RV, Buchhalter AR, et al. Pharmacotherapy for nicotine dependence. CA Cancer J Clin 2005;55(5):281–99.
  6. Australian medicines handbook: nicotine. 2026. At: https://amhonline.amh.net.au/
  7. Quit Centre; Pharmaceutical Society of Australia. Yarning nicotine replacement therapy (NRT): pharmacist supporting Aboriginal and Torres Strait Islander people who smoke. Melbourne: Quit Centre. 2024. At: https://d3hn5ot9fqwxos.cloudfront.net/uploads/downloads/YarningNRT_Booklet_FEB_26.pdf
  8. United States Department of Health and Human Services. Interventions for smoking cessation and treatments for nicotine dependence. In: Smoking cessation: a report of the Surgeon General. Washington DC: US DHHS. 2020. Chapter 6. At: https://www.ncbi.nlm.nih.gov/books/NBK555596/