Derbyshire County Stop Smoking Service NRT Formulary 2013-14
In Derbyshire County, Nicotine Replacement Therapy (NRT) is supplied by requisition (and by FP10 in some
circumstances including A) in an area where no Pharmacy handles Requisitions. B) When NRT is cautioned
including recent Heart Attack or Stroke (see Appendix 3 for full list).
All NRT products are currently available (see appendix 1 & 2).
However please note that NRT products have now been categorised into first, second and third line products
based on cost.
First line products should be offered in the first instance. If second or third line products are used, a
justification should be stated on the Standard Monitoring Form.
First Line:
Nicorette Invisi 16 hr patches
Nicotinell 24 hr patches
Niquitin CQ 24 hr patches
Nicorette Gum 4mg
Nicorette Gum 2mg
Second line: Niquitin CQ Lozenge 4mg
Nicotinell Lozenge 2mg
Niquitin CQ Mini-lozenge 4mg & 1.5mg
Third line:
Nicorette QuickMist
Nicorette Inhalator
Nicorette Cools Lozenge 4mg & 2mg
Niquitin Oral Film 2.5mg
Niquitin CQ Gum 4mg
Niquitin CQ Gum 2mg
Niqutin CQ Lozenge 2mg
Nicorette Microtab
Nicorette Nasal Spray
To keep within budget and reduce wastage, it is important that Stop Smoking Advisers use a dependency
score to determine whether no NRT, single use NRT or combination NRT is most appropriate for each client.
Please print off The Fagerström Test for Nicotine Dependence (FTND) adapted by DCSSS and attach to each
Client record. See below (or Appendix 4 for a print-friendly version).
To monitor NRT usage, all Pharmacies have access to e-STOP. It is required that every issue of NRT under a
requisition is recorded on e-STOP (www.pharmperform.com). All Requisitions requested by Accredited
Advisers, Stop Smoking Advisers and Specialist Stop Smoking Advisers will be monitored by e-STOP. This is
why it is important that evidence of decision-making processes around NRT requests are documented using
FTND.
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 1 of 14
The Fagerström Test for Nicotine Dependence (FTND)
Use the following test to score a client’s level of nicotine dependence.
Please tick ( ) one box for each question
How soon after waking do you smoke your first cigarette?
Within 5 minutes
5-30 minutes
31-60 minutes
60+ minutes
3
2
1
0
10 or less
11 – 20
21 – 30
31 or more
0
How many cigarettes a day do you usually smoke?
Do you find it difficult to refrain from smoking in places where it is
forbidden? e.g. cinema
Which cigarette would you most hate to give up?
Yes
No
The first one in
the morning
Any Other
Do you smoke more frequently during the first few hours after waking
than during the rest of the day?
Yes
No
Do you smoke when you are so ill that you are in bed most of the
day?
Yes
No
2
3
0
1
0
0
Total Score
SCORING
0-2 = Low dependence. Limited benefit from NRT
3-4 = Dependent. Consider single use NRT
5 or above = Highly dependent:
 If client has never made a serious quit attempt, consider single use NRT first.
 If client has previously stopped smoking successfully on one product, consider single use
NRT first.
 If client has made multiple quit attempts, or experiences strong withdrawal symptoms making
them vulnerable to relapse, consider combination therapy
Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: A
revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addictions 1991;86:1119-27 adapted by
DCSSS May 2013
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 2 of 14
Advisers should offer each client the appropriate level of NRT according to their level of dependence and
should take the following points into account:
 Client’s previous quit attempts may also provide assistance in deciding which products may be suitable.
 Carbon monoxide monitoring should also be used where appropriate to assess nicotine dependency and
accompany the questions above.
 Remember to consider cautions when advising clients on NRT. Refer client onto Physician where
appropriate (Please see Appendix 3).
 Combination therapy should be a patch as the primary product and an intermittent dose product as back up.
The client should only use half the maximum daily dose of their second (intermittent dose) product.
 Whilst choice of product should largely be based on client preference, first line products are preferable over
second line products and second line over third line.
o
Where there are clear brand choices, Nicorette 4mg & 2mg Gum should ideally be requested over
other gum. Nicotinell 2mg Lozenge should ideally be requested over other 2mg lozenges. Niqutin CQ
mini-lozenges should be requested over Nicorette Cools Lozenges.
o
Quickmist, Oral Film, Nasal Spray, Microtab & Inhalator are more expensive than the first-line and
second-line products, hence their status as thirdline products. All first-line products should be
discussed with clients. Second & third-line products can also be discussed, but their use must be
justified by the Adviser.
 As third line products and due to low popularity, the Microtab and Nasal spray should only be used if the
client states a really strong preference and has previously been successful with them for several months.
 The first NRT request must be based on maximum use of product (to the nearest pack-size, ideally plus or
minus 5). Based on client usage, this can be modified for further requests.
 Some products can be used to reduce smoking as a step towards stopping completely and for harm
reduction. DCSSS Advisers should only request products when smokers want to stop smoking completely
but can provide brief advice on cutting down.
 In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may require up to a
maximum of 12 weeks.
References
1. DoH (2012) NHS Stop Smoking Services, Service and Monitoring Guidance 2012-2013. Department of
Health
2. NICE (2008) PH10 Smoking Cessation Services. National Institute for Health & Clinical Excellence
3. Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence:
A revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addictions 1991;86:1119-27,
adapted by DCSSS 30/10/12
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 3 of 14
Appendix 1 - NRT Product Cost per product and brand (Pricing is based on MIMS: Monthly Index of Medical
Specialities, October 2012)
First line products
Product
Brand
Daily
maximum
use
Weekly
maximum
use
Pack sizes
(Suggested
weekly supply
based on
nearest pack
size)
Nicotinell
(Buff)
24 hr
Patch
21mg (£9.97)
14mg (£9.40)
7mg (£9.11)
1
7
7
21mg (£9.97)
14mg (£9.97)
7mg (£9.97)
7
14 (21mg only)
Step one (21mg
patches) come in a
weekly (7) and
fortnightly (14) pack
at £18.79. This can
only be used for
Supply 5 of a
Requisition, thus is
only relevant if the
client stays on Step
One patches for
longer than 4 weeks.
1
7
7
14 (25mg Only)
Step one (25mg
patches) come in a
weekly (7) and
fortnightly (14) pack
at £16.35. This can
only be used for
Supply 5 onwards
under a Requisition,
thus is only relevant
if the client stays on
Step One patches for
longer than 4 weeks.
Nicorette
(Invisi)
16 hr
patch
4mg
Gum
2mg
Gum
25mg (£9.97)
15mg (£9.97)
10mg (£9.97)
Step one (21mg
patches) comes in a
weekly (7) and in a
three-weekly (21)
supply
Different strengths
are different prices
Niquitin CQ
(Buff & Clear)
24 hr
patch
Additional
Information
including amount of
product per day
(based on nearest
pack size)
1
Nicorette
(Original,
freshmint,
Freshfruit, Mint,
Icy White)
15
Nicorette
(Original,
freshmint,
Freshfruit, Mint,
Icy White)
15
7
105
105
105
105
7 days
7 days
Weekly Cost
including 5% VAT
10.47 (Step 1
only)
8 week course:
80.75
Manufacturer’s
recommended
course:119.62
(12 wks: 4 wk-4
wk-4 wk)
10.47
8 week
course:83.75
Manufacturer’s
recommended
course:103.48
10 wks: 6wk-2wk2wk
10.47
8 week
course:83.75
Manufacturer’s
recommended
course:118.08
(12 wks: 8wk-2wk2wk)
11.87
Original, freshmint,
Freshfruit, Mint
12.05
Icy White
9.73
Original, freshmint,
Freshfruit, Mint
9.83
Icy White
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 4 of 14
Second line products
Product
Brand
4g
Lozenge
2mg
Lozenge
Niquitin CQ
(Original, Mint)
Nicotinell
(Mint)
Daily
maximum
use
Weekly
maximum
use
Pack sizes
(Suggested
weekly supply
based on nearest
pack size)
Additional Information
including amount of
product per day (based
on nearest pack size)
Weekly
Cost
including
5% VAT
15
105
72+36
7.2 days
15.85
15
105
96+12
7.2 days
13.22
(16.05)
Mint
4mg
MiniLozenge
Niquitin CQ
(Mint)
15
105
60+20+20
6.6 days (£2.43 per day)
NB with all oral
products, it is difficult to
predict cost per 8-12
week course, as number
of oral product used
daily varies from client
to client and week to
week
1.5mg
MiniLozenge
Niquitin CQ
(Mint, Cherry)
15
105
60+20+20
6.6 days (£2.43 per day)
(16.05)
Mint,
Cherry
Additional Information
including amount of
product per day (based
on nearest pack size)
Weekly
Cost
including
5% VAT
Third Line Products
Product
Brand
Daily
Maximum
Use
QuickMist
1mg per
squirt
Nicorette
(Mint)
64
3
Dbl+Single
15mg
Inhalator
Nicorette
6
42
20+20
6.66 days
29.46
4mg Cools
Lozenge
Nicorette
(Mint)
15
105
80+80
Only comes in packs of
80 (client would have 55
extra) 10.66 days (£2.26
per day)
24.11
2mg Cools
Lozenge
Nicorette
(Mint)
15
105
80+20
6.66 days
15.39
Oral Film
Niquitin
(Mint)
15
105
60+15+15+15=105
7 days
(15=3.19. 60=10.21)
22.45
4mg Gum
Niquitin CQ
(Mint)
15
105
96+12
7.2 days
12.26
2mg Gum
Niquitin CQ
(Mint)
15
105
96+12
7.2 days
12.26
7.2 days (£1.72 per day)
12.42
Mint, fruit,
classic
4mg Gum
Nicotinell
(Mint, fruit,
classic,
Icemint,
liquorice)
Weekly
Maximum
Use
Pack Sizes (Suggested
weekly supply based
on nearest pack size)
96+12
Mint, fruit,classic
15
105
72+72
Icemint
7.5 days maximum use
9.6 days (£1.81 per day)
96+24
liquorice
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 5 of 14
32.82
17.41
Icemint
8 days
14.24
liquorice
2g
Lozenge
Niquitin CQ
(Original,
Mint)
2 mg
Microtab
Nicorette
(Original)
40
Nasal
Spray
0.5mg per
squirt
Nicorette
(Original)
64 sprays
15
72+36
7.2 days
15.85
280
100+100+100
7.5 days
For a 4mg dosage, 2
microtabs can be used
simultaneously
41.32
2
2 bottles
6.2 days
28.14
105
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 6 of 14
Appendix 2 – NRT Products
24-hour Patch (Nicotinell, NiQuitin CQ)
Apply once a day, at the same time each day and preferably soon after waking, to a dry, clean
and non-hairy skin site and wear continuously for 24 hours.
Method
Avoid applying to any skin which is broken, red or irritated. After 24 hours the used patch should
be removed and a new patch applied to a fresh skin site. The patch should not be left on for
longer than 24 hours. It is recommended that skin sites should not be reused for at least seven
days.
Whilst patches may be removed before going to bed if desired, use for 24 hours is
recommended to optimise the effect against morning cravings.
Patches are presented in three strengths (sometimes referred to as Step 1, 2, 3): 21mg, 14mg,
and 7mg.
Maximum daily dose: 1 patch
Dosage
Manufacturer’s dosage recommendations vary; what follows are general guidelines – refer to
product SPC for more detail:
• 20+ cigarettes daily – start with 21mg patch
• Fewer than 10 cigarettes – start with 14mg patch
• 10-20 cigarettes – consider additional factors e.g. CO reading; err on side of higher dose
After an initial period (4-8 weeks) clients may wish to gradually reduce the dose of their patch for
the remainder of their treatment. This is not essential.
The optimum treatment period is 8-12 weeks.
Duration of
treatment
Additional info
(inc. side
effects)
Weekly supply
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may
require up to a maximum of 12 weeks.
It can be good practice to apply 24 hour patch before going to bed, the night before a quit
attempt.
If pregnant women do not tolerate a 16hr patch and use a 24hr patch as an alternative, they
must remove it before going to bed.
Patches can cause some redness and/or irritation on the skin site, most cases of which are mild
and resolved within 48 hours. Waiting a few moments between removing backing and applying
patch to skin can reduce these symptoms. Because of these side effects, clients with know skin
sensitivity, or conditions (e.g. eczema, psoriasis) should consider an alternative NRT.
7 patches (based on maximum use & nearest pack size)
16-hour Patch (Nicorette Invisi)
Method
Dosage
Instructions for application are identical to those for the 24-hour transdermal patch. The key
distinction being that the 16-hour patch is intended for use throughout the day time only, being
applied on waking and removed at bedtime.
Nicorette Invisi (semi-transparent): 25mg, 15mg, 10mg.
Maximum daily dose: 1 patch
As per 24-hour patches, heavier smokers should start on the highest dose patch, with the Invisi
particularly recommended for those smoking 20+ cigarettes daily.
8-12 weeks. See 24-hour patch for comments re: dose reduction.
Duration of
treatment
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may
require up to a maximum of 12 weeks.
Additional info
(inc. side
effects)
Refer to information on 24-hour patch
Weekly supply
7 patches (based on maximum use & nearest pack size)
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 7 of 14
Chewing Gum (Nicorette, Nicotinell, NiQuitin)
Method
Chew until flavour becomes strong, park between the gum and cheek, chew again when flavour
weakens, continue to chew and park as required. One piece lasts about 30 minutes of such use,
the gum will be exhausted.
Nicotine is absorbed through the lining of the mouth. If you swallow it the nicotine is wasted and
you may experience hiccups or indigestion.
Offered in 2mg and 4mg presentations and a range of flavours (original, mint, fruit, liquorice).
Dosage
Use the gum regularly to maintain complete abstinence from smoking. Sufficient gums should be
used, usually 8-12, up to a maximum of 15 daily.
The strength of gum to be used will depend on the smoking habits of the individual. In general, if
the individual smokes up to 20 cigarettes a day, 2mg nicotine gum is indicated. If more than 20
cigarettes per day are smoked, 4mg nicotine gum is recommended.
Continue use for up to three months to break the habit of smoking, and then gradually reduce
gum use. When daily use is 1-2 gums, use should be stopped.
Duration of
treatment
The dose and method of use for adolescents (12-18 years) are as for adults, although it is
recommended that treatment does not exceed 12 weeks.
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may
require up to a maximum of 12 weeks.
Smokers who wear dentures may experience difficulty as the chewing gum may stick to, and
may in rare cases damage dentures.
Additional info
(inc. side
effects)
Swallowed nicotine (usually caused by continuous chewing of the gum) can cause hiccups or
heartburn-like symptoms.
Important for clients to persevere for a few days, before discarding
The gum needs to be in the mouth for at least 30 minutes to get optimal effect
Weekly supply
105 pieces of gum (based on maximum use & nearest pack size)
Lozenge (NiQuitin, Nicorette)
Method
One sugar free lozenge should be placed in the mouth and allowed to dissolve. Periodically, the
lozenge should be moved from one side of the mouth to the other, and repeated, until the
lozenge is completely dissolved (approximately 20 – 30 minutes). Clients can use a similar
“parking” technique to the one described for gum.
The lozenge should not be chewed or swallowed whole. Users should not eat or drink while a
lozenge is in the mouth
2mg (all brands) and 4mg (NiQuitin only) presentations and a choice of flavours.
Dosage
Duration of
treatment
Initially, 1 lozenge should be taken every 1-2 hours. The usual dosage is 8-12 lozenges per day.
The maximum daily dose is 15 lozenges.
General guidance on dose:
• 20+ cigarettes daily – use 2mg or 4mg lozenges
• Up to 20 cigarettes – use 2mg lozenges
Consider additional factors e.g. CO reading and err on side of higher dose initially.
8-12 weeks is optimal.
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may
require up to a maximum of 12 weeks.
Swallowed nicotine (usually caused by continuous sucking of the lozenge) can cause hiccups or
heartburn-like symptoms.
All lozenges are sugarfree
Additional info
(inc. side
effects)
Each NiQuitin Lozenge contains 15 mg of sodium. Nicotinell Mint 1 mg lozenge contains 9.8 mg
of sodium per piece.
People on a low sodium diet should take this into account. Nicorette Lozenge does not refer to
any sodium content.
Weekly supply
The lozenge needs to be in the mouth for at least 30minutes to get optimal effect
105 lozenges (based on maximum use & nearest pack size)
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 8 of 14
Mini Lozenge (NiQuitin CQ)
Method
Use only one lozenge at a time. Place lozenge in mouth and allow to dissolve, periodically
moving it from one side of the mouth to the other. The mini lozenge needs to be in the mouth for
at least 10 minutes to achieve optimal effect.
The lozenge should not be chewed or swallowed whole. Users should not eat or drink while a
lozenge is in the mouth.
Offered in 1.5mg and 4mg presentations and a choice of flavours (mint, cherry).
Dosage
Duration of
treatment
Additional info
(inc. side
effects)
Weekly supply
Clients should be advised to use the Mini Lozenges whenever they have an urge to smoke.
Sufficient lozenges should be used (usually 8-12 at the start of treatment), up to a maximum of
15 daily.
General guidance on dose:
• Up to 20 cigarettes daily – use 1.5mg
• More than 20 cigarettes daily – use 4mg
8-12 weeks is optimal. Reduction of daily dose is encouraged after 6 weeks; when daily use is 12 lozenges, use should be stopped
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may
require up to a maximum of 12 weeks.
No product-specific side-effects identified
Check that clients have enough dexterity to use effectively
All mini lozenges are sugarfree
105 mini-lozenges (based on maximum use & nearest pack size)
Cools Lozenge (Nicorette)
Method
One lozenge should be placed in the mouth and allowed to dissolve. Periodically, the lozenge
should be moved from one side of the mouth to the other and repeated , until the lozenge is
completely dissolved.
The lozenge should not be chewed or swallowed whole. Users should not eat or drink while a
lozenge is in the mouth
Offered in 2mg and 4mg presentations in an icy mint flavour.
Dosage
Duration of
treatment
Additional info
(inc. side
effects)
Clients should be advised to use the Cools Lozenges whenever they have an urge to smoke.
Sufficient lozenges should be used (usually 8-12 at the start of treatment), up to a maximum of
15 daily.
General guidance on dose:
• Up to 20 cigarettes daily – use 2mg
• More than 20 cigarettes daily – use 4mg
8-12 weeks is optimal. Reduction of daily dose is encouraged after 6 weeks; when daily use is 12 lozenges, use should be stopped
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may
require up to a maximum of 12 weeks.
Common Product-specific side-effects include: headache, nausea, stomach discomfort, hiccups,
sore mouth or throat
Check that clients have enough dexterity to use effectively
Cools lozenges are sugarfree
Weekly supply
105 Cools lozenges based on maximum use & nearest pack size)
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 9 of 14
Inhalator (Nicorette)
The cartridge is inserted into the mouthpiece according to the instructions.
Method
When a patient draws air into the mouth through the mouthpiece, nicotine is vaporised and
absorbed through the lining of the mouth. The amount of nicotine from a puff is less than that
from a cigarette. To compensate for less nicotine delivery from a puff it is necessary to inhale
more often than when smoking a cigarette. This is often described as sucking on the inhalator
as though sucking through a straw.
The actual time that the cartridge is active depends on the intensity of use.
15mg = After about 40 minutes of intense use the maximal dose is achieved and it is about then
that the nicotine amounts released from the cartridge begin to fall away, such that the cartridge
is rejected by the user. If used occasionally, the cartridge should be changed after 48 hours.
Maximum daily dose: 15mg: 6 cartridges
Dosage
Duration of
treatment
The number of cartridges, frequency, puffing/inhalation time and technique does vary between
individuals.
Treatment should be limited to 12 weeks.
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients may
require up to a maximum of 12 weeks.
May initially cause some irritation of the throat.
Additional
info (inc. side
effects)
Cartridges may need to be warmed before use on a cold day.
Spare mouthpieces can be bought separately
Check that clients have enough dexterity to use effectively
Weekly
supply
15mg: 40 cartridges (based on maximum use & nearest pack size)
Mouth Spray (Nicorette QuickMist)
Before first use or if the spray hasn’t been used for two days: Prime spray by safely pointing
away from self and others (including pets) and pressing the top of the QuickMist with the
index finger until a fine spray appears.
Method
Dosage
Point the spray nozzle as close to the open mouth as possible. Press the top of the dispenser
to release one spray into the mouth, taking care to avoid the lips. Clients often report that
dosing into the side of the mouth (the cheek) is preferable. Do not inhale while spraying to
avoid getting spray down throat. For best results, avoid swallowing for a few seconds after
spraying.
Mint flavoured oromucosal spray; one spray contains 1mg nicotine.
Use 1 or 2 sprays when cigarettes normally would have been smoked or when cravings
arise. If after the first spray cravings are not contained within a few minutes, a second spray
should be administered. If 2 sprays are required in future, the dose can be delivered as two
consecutive sprays.
Most smokers will require 1-2 sprays every 30 mins to 1 hour.
Clients may use up to 4 sprays per hour. Do not exceed 2 sprays per “dosing episode”
and 64 sprays (4 sprays/hour over 16 hours) in any 24-hour period.
This guidance applies for all users over 12 years of age.
8-12 weeks is optimal.
Duration of
treatment
Additional info
(inc. side effects)
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients
may require up to a maximum of 12 weeks.
Some side-effects relating to dose administration have been reported during initial use of the
product: coughing, mild oral soft tissue pain, burning lips, dry mouth. As with other oraldosing nicotine products, swallowed nicotine can reduce effectiveness and cause hiccups or
heartburn-like symptoms.
Contains small amount of ethanol (alcohol)
Weekly supply
Three bottles (based on maximum use & nearest pack size)
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 10 of 14
Microtabs (Nicorette)
Place Microtab under tongue or between gum and lip and allow to dissolve (10-20 minutes).
Method
Don’t chew or swallow the Microtab and avoid food and drink while it is in the mouth.
2mg sublingual soluble tablet; choice of original or lemon flavour.
Dosage
Duration of
treatment
Initially, a dose of one tablet per hour or, for heavy smokers (more than 20 cigarettes per
day), two tablets per hour is recommended.
Most smokers require 8 to 12 (up to 20 cigarettes daily), or 16 to 24 tablets per day; do not
exceed 40 tablets daily.
8-12 weeks is optimal. Reduction of daily dose is encouraged after this period and the
treatment should stop when daily use is 1-2 tablets.
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients
may require up to a maximum of 12 weeks.
Additional info
(inc. side effects)
No product-specific side-effects identified.
Weekly supply
260 tablets (based on maximum use & nearest pack size)
Nasal Spray (Nicorette)
Prime spray by placing the nozzle between first and second finger with the thumb on the
bottom of the bottle. Press several times firmly and quickly until a fine spray appears.
Method
Important: Point the spray safely away when priming it. Do not prime it near children or pets.
Insert the spray tip into one nostril, pointing the top towards the back of the nose. Press firmly
and quickly. Give a spray into the other nostril.
Each spray delivers 0.5mg nicotine.
Dosage
Duration of
treatment
Daily limit is 32mg nicotine – i.e. 64 sprays, which is equivalent to two sprays to each nostril
every hour for 16 hours.
Treatment should be limited to 12 weeks. For 8 weeks the patient uses the spray as required,
subject to the maximum described above, to relieve craving.
After this period the patient reduces usage until after 4 more weeks’ treatment has ended. It
is suggested that after 2 weeks into this period, usage will have been reduced by a half and
usage be zero by the last day. Spraying into a single nostril during this period may be helpful
in achieving this.
The dose and method of use for adolescents (12-18 years) are as for adults.
In line with DCSSS protocol, an 8 week supply of NRT is preferable, but some clients
may require up to a maximum of 12 weeks.
May initially cause nasal irritation.
Additional info
(inc. side effects)
Whilst any client can use nasal spray, its speed of action makes it especially suitable for
more dependent smokers (20+ cigarettes per day).
Not necessary to inhale when spraying
Check that clients have enough dexterity to use effectively
Weekly supply
Two bottles (based on maximum use & nearest pack size)
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 11 of 14
Oral Film (Niquitin Strips)
One Strip should be placed on the tongue and then the mouth is closed and the tongue is
pressed gently to the roof of the mouth, allowing the film to dissolve (approx. 3 mins).
Method
The strip must not be chewed or swallowed.
Users should not eat or drink while a strip is in the mouth.
Offered in 2.5mg presentation with a mint flavour.
Dosage
Duration of
treatment
Additional info
(inc. side effects)
Clients should be advised to use Strips whenever they have an urge to smoke. Sufficient
strips should be used (at least 9 a day), up to a maximum of 15 daily.
General guidance on dose:
•
Suitable for client’s who have their first cigarette after 30 minutes of waiting.
8-12 weeks is optimal. Reduction of daily dose is encouraged after 6 weeks; when daily use
is 1-2 strips, use should be stopped
In line with DCSSS protocol, an 8 week supply of NRT is preferable but clients are
entitled to a maximum of 12 weeks supply of NRT where necessary.
Common Product-specific side-effects include: headache, nausea, stomach discomfort,
hiccups, indigestion, dry mouth, slight soreness or irritation of mouth or tongue.
Niqutin strips contain small amounts of ethanol (alcohol), less than 100mg per film.
Strips are sugarfree.
Pack sizes are 15 or 60
Weekly supply
60 + 60 pack = 120
For more information on each Nicotine Replacement Product please see individual Summary of Product
Characteristics (SPC) and copies of Patient information leaflets (PIL) found at the electronic Medicines
Compendium (eMC)
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 12 of 14
Appendix 3 – Contraindications, Cautions & Medication Levels
1.1 Contraindications for use of NRT
 Under 12 years of age
 Non-smokers
1.2 Cautions for use of NRT
The following are listed as a caution for using NRT but do not necessarily prevent its use:








Cardiovascular disease, including irregular heart beats (Arrhythmias),and immediately post heart attack (MI)*
Recent stroke (CVA), including minor stroke (TIA)
Over active thyroid gland (Hyperthyroidism)
Diabetes
Rare tumour on adrenal glands (Phaeochromocytoma)
Renal and hepatic impairment
History of gastric or peptic ulcers
Breast feeding
On the first supply of NRT, the pharmacist should check a list of conditions with clients and provide advice accordingly.
* For Accredited Advisers, the LES 2012/2013 states that anyone who wants to use NRT within 6 weeks of having an MI
must get their initial prescription from a GP or Consultant. For Specialist Stop Smoking Advisers the period is 4 weeks.
1.3 NRT & Pregnancy
 Pregnant smokers should always be encouraged to stop smoking without NRT.
 All NRT products are now indicated in pregnant & lactating women (with the exception of the 24 hr patch). There are
also concerns around the use of the liquorice gum in pregnancy due to an established link between a liquorice extract
called glycyrrhizin and pre-term delivery.
 Intermittent dose NRT products; mini lozenge (first line), gum & lozenge (second line) and Cools Lozenge, Inhalator,
Quickmist, Nasal spray or Microtab (third line) are preferable to limit amount of nicotine exposure.
 Some pregnant smokers suffering from nausea prefer patches (16 hrs).
1.4 Effects of Stopping Smoking on Medication Levels
NRT products do not interact with other medications, but stopping smoking can affect certain drugs. When people stop
smoking, the amount of some medications in their blood can alter, often within a few days and subsequently their doctor
may need to adjust the dose.
The medications most commonly affected by stopping smoking are:
 Insulin (for diabetes)
 Warfarin (a blood thinner)
 Theophylline (used for breathing problems)
 Some mental health medications, particularly Olanzapine and Clozapine.
For client’s taking any of these medications, they should inform a medical professional before they stop smoking so that
more regular checks and dose adjusting can be discussed.
Stopping smoking can also affect blood pressure levels. Therefore, if your client takes blood pressure medications they
may need to have their blood pressure checked more frequently initially.
NB. This list does not include all the medications that are affected by stopping smoking. More information can be
obtained
from
DCSSS.
Alternatively
please
see
current
MHRA
advise
at:
www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON087705
References
1. MHRA (2009) ‘Smoking and smoking cessation: clinically significant interactions with commonly used medicines.’ Drug
Safety Update 3:9. www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON087705
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 13 of 14
Appendix 4 – The Fagerström Test for Nicotine Dependence (FTND)
Use the following test to score a client’s level of nicotine dependence.
Please tick ( ) one box for each question
How soon after waking do you smoke your first cigarette?
Within 5 minutes
5-30 minutes
31-60 minutes
60+ minutes
How many cigarettes a day do you usually smoke?
10 or less
11 – 20
21 – 30
31 or more
Do you find it difficult to refrain from smoking in places where it is
forbidden? e.g. cinema
Which cigarette would you most hate to give up?
Yes
No
The first one in
the morning
Any Other
Do you smoke more frequently during the first few hours after waking
than during the rest of the day?
Yes
No
Do you smoke when you are so ill that you are in bed most of the
day?
Yes
No
Total Score
SCORING
0-2 = Low dependence. Limited benefit from NRT
3-4 = Dependent. Consider single use NRT
5 or above = Highly dependent:
 If client has never made a serious quit attempt, consider single use NRT first.
 If client has previously stopped smoking successfully on one product, consider single use
NRT first.
 If client has made multiple quit attempts, or experiences strong withdrawal symptoms making
them vulnerable to relapse, consider combination therapy
Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: A
revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addictions 1991;86:1119-27 adapted by
DCSSS May 2013
Clients CO reading: ______
Time of day CO reading taken: _____________
Date agreed: June 2013
Updated: September 2014
Review date: August 2016 Extended to October 2017
Page 14 of 14