Nicotine Replacement Therapy (NRT)
Self Learning Package
Name: _________________________________________________
Professional Role: ________________________________________
Ward/Dept/Division: ______________________________________
Nicotine Replacement Therapy Self Learning Package
Date of Issue: Feb 2012
Date of Review: Feb 2014
Author: Professional Development Unit and CDHB Hospital Smokefree Co-ordinator
Page 1
Contents
page
Introduction
3
Learning objectives
3
Assessment criteria
3
Recommended Reading
3
Principles
4
Contraindications & Precautions
5
Mental Health Patients
7
Pregnancy and Breast Feeding
7
Dosage
8
NRT Products
9
Monitoring
10
Charting NRT – Documentation
11
Cessation Support
12
References
13
Assessment form
14
Feedback
15
Nicotine Replacement Therapy Self Learning Package
Page 2
Introduction
This workbook is a tool to help Registered Nurses and other Allied Health professionals develop
increased confidence in promoting and providing Nicotine Replacement Therapy (NRT) for all
clients or patients who smoke.
Pre Requisite
You will need to have already completed and gained the certificate for the ABC
“ABC Smoking Cessation Course” and have become a Quitcard Provider for NRT
The administration of Nicotine Replacement Therapy is only authorised for those nurses who
have successfully completed the online smoking cessation package
www.smokingcessationabc.org.nz or have attended an authorised ABC / NRT face-to-face
training session
Learning Objectives
Engagement with this workbook will give the opportunity for increased familiarity with the
New Zealand Smoking Cessation Guidelines (2007), The ABC for Smoking Cessation Quick
Reference Card and Quit Cards. On completion of this workbook the participant will be able
to:
1. Competently and confidently promote, assess and monitor NRT for patients who smoke
and wish to quit, chart NRT, and document the process.
2. Describe the process for referring a patient or client to the Quitline or other smoking
cessation services.
3. Identify priority population groups and know where to access information pertaining to
their usage of NRT.
The ABC Smokefree team is available to support you to confidently administer NRT to a
patient – please contact the Hospital Smokefree Coordinator (80263) for further training or
support.
Assessment Criteria
1. Completion of the ABC Smoking Cessation E-learning Course
(www.smokingcessationabc.org.nz) or attendance at an ABC / NRT face-to-face training
session.
2. Complete the attached assessment
3.
On completion, this assessment sheet at the back should be to be sent via internal mail to
your Nurse Educator to be credited with one hour Professional Development
4. If anything in this workbook is unclear, or you have any questions, contact your Nurse
Educator or Smokefree Coordinator ext 80263
Nicotine Replacement Therapy Self Learning Package
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Recommended Reading
The “Limited Nurse Prescribing for NRT” document is available on the CDHB internet (first
line manuals Vol twelve ) or from your Hospital Smokefree Co-ordinator (80263) and in
the Fluids and Procedures Manual – please familiarise yourselves with these documents.
A useful flowchart for administering NRT is available in the first line manual Vol 12 or at
the back of this workbook
CDHB Clinical Pharmacological Bulletin (March 2009): Nicotine Replacement Therapy
(NRT) – managing inpatient nicotine dependence
Blue Book – available on CDHB Intranet (look under Nicotine Dependent Patients)
CDHB Smokefree Policy – Health and Safety Manual Vol 6 pg.127
New Zealand Smoking Cessation Guidelines -www.moh.govt.nz/tobacco
Definition of Limited Nurse Prescribing (LNP): The administration of Nicotine Replacement
Therapy, which is a non prescription medicine (that can be freely purchased across the counter of a
pharmacy), without a doctor‟s prescription, for specified patients following stated limitations (see
below).
Principles
Abstinence from tobacco results in a very well defined tobacco withdrawal syndrome, which
includes a range of mood and physiological symptoms. Nicotine has a short half-life
(approximately 2 hours) and it is not uncommon for symptoms to appear in this timeframe.
NRT is an effective smoking cessation aid, and works primarily by reducing the severity of
urges to smoke (craving) and other tobacco withdrawal symptoms. It is therefore an
appropriate treatment for the management of these symptoms, even if the patient does not
wish to quit smoking long-term.
Nicotine should be offered to all inpatients who currently smoke,
or who have been smokefree for less than 30 days
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Do You Know the Answers to These Questions?
This pre test covers information that you should have learned in the ABC E learning course.
If you are unsure of any of these questions, please check in the E-learning module at
www.smokingcessationabc.org.nz
1. Which two questions do you ask to determine someone‟s level of nicotine dependence?
(Tick two boxes)

how many years have you smoked for?

how soon after waking do you have your first cigarette?

how many cigarettes do you smoke in a day?

how many of your family members smoke?
2. What does ABC stand for in smoking cessation?
ABC3. What is the main purpose of taking NRT?
4. What is a Quit Card? (tick one box)

a card telling someone they should quit

a subsidy card that provides 8 weeks of a nicotine product for $3

a card with the Quitline number on it

a type of credit card for people who spend too much money on cigarettes
5. List the 3 nicotine products subsidised in NZ:
1.
2.
3.
Nicotine Replacement Therapy Self Learning Package
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Patient Group
Patients who:
Smoke and would not otherwise be able to
remain smokefree and/or are suffering from
nicotine withdrawal.
Are aged 18 years or over (NRT can be
administered to people aged 12 -17 yrs 1, with
a prescription from the medical team).
Have given verbal consent.
Inpatients identified as current
smokers should be offered
appropriate NRT, whether or
not they wish to quit long term.
This should enable them to be
more comfortably smokefree
during their hospital stay. This
may be crucial, especially for
those admitted with cardiorespiratory illness and/or
needing oxygen treatment.
Contraindications
Do not use patches with people who have an allergy to sticking plaster
Precautions
(note that these are not contraindications)
In general, any risk of using NRT would be expected to be less than the risk of
continued smoking.
NRT typically delivers less nicotine then smoking and less rapidly. More importantly, it does
provide the many other hazardous substances found in tobacco smoke.4,5 However in the
following patients, nurses should obtain agreement from a consultant or registrar before
administering NRT.
Patients who have suffered a serious cardiovascular event (eg MI) or stroke within in
the previous two weeks or with poorly controlled cardiovascular disease (see note 1)
Patients with unstable or worsening angina pectoris
Patients with serious cardiac arrhythmias
Patients on medications known to be affected by NRT e.g. theophylline
Patients undergoing skin flap surgical procedures (see note 2)
If these patients indicate that they are likely to continue to smoke, NRT lozenges or gum
(intermittent supply) is the preferred option.
Note 1: NRT has not been found to increase the risk of acute MI, stroke or sudden death.6
NRT can be used in patients post-MI once their blood pressure and heart rate have
stabilised
Note 2: There is evidence to show that tobacco use impairs wound healing.9 Nicotine may
play a role in this and so it is advisable that patients are tobacco free and nicotine free
before surgery. However, when a patient is still smoking, NRT presents less risk than
continued smoking
Nicotine Replacement Therapy Self Learning Package
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Mental Health Patients
Smoking stimulates the metabolism of clozapine and olanzapine. When a patient on these
medicines gives up smoking, their blood concentrations of either clozapine or olanzapine will
increase over the next two to four weeks. They can be given NRT, but ensure that the
consulting psychiatrist is aware that the patient has stopped smoking, as the dosage of these
drugs may need to be reduced.
NRT for Pregnant & Women who are breast-feeding
Although using nicotine products during pregnancy is not without risk, the main benefit of
using NRT is the removal of all other toxins contained in tobacco smoke. Furthermore, NRT
typically provides far less nicotine then tobacco smoke. Current expert opinion is that NRT
can be considered safe to use in pregnancy following an assessment of the risks and
benefits.4,7 In general, nicotine products such as lozenges, should be used in preference to
patches , as they deliver a lower total daily nicotine dose then patches4, and the supply is
intermittent. If patches are used, they should be removed overnight.
Regarding breast-feeding and NRT use, nicotine freely passes in and out of breast milk
depending on the concentration of nicotine in maternal blood (which is, in turn, affected by
cigarette consumption, frequency of breast-feeding and time between smoking and breastfeeding).4 Due to the relatively low oral availability of nicotine,8 it is unlikely that this very
low level of exposure is harmful to the infant.7 The importance of continuing to breast-feed,
regardless of smoking status, should be stressed.
Women in labour should be encouraged to take NRT only if smoking is the alternative.
The Smokechange service is able to provide support for pregnant or recently
birthed women, either in hospital or at home – call them on 0800 226 242
Knowledge check
By now you should know:
How to access the Limited Nurse Prescribing for NRT document
Who the Limited Nurse Prescribing procedures are for
Who should not be prescribed NRT without consulting the doctor
Assessing Dependence
Ask two questions:How many cigarettes do you smoke per day?
How soon after waking do you smoke or wish to smoke your first cigarette?
Patients who smoke within 30 minutes of waking are considered highly dependent.2
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Be aware that:People tend to under-report the number of cigarettes they smoke each day
People who have only recently cut down are likely to compensate by inhaling the
smoke from the fewer cigarettes more deeply
Dosage/ What Dose to Provide?
Cigarette
consumption
More than
10/day
Recommended NRT dose
Nicotine patch 21mg/24 hours + nicotine gum OR lozenge for PRN use
Dose depends on time to first cigarette:
- if <30 minutes after waking use 4mg gum OR 2mg lozenges
- if >30 minutes after waking use 2mg gum OR 1mg lozenges
Less than
10/day
Nicotine gum OR lozenge for PRN use
Dose depends on time to first cigarette:
- if <30 minutes after waking use 4mg gum OR 2mg lozenges
- if >30 minutes after waking use 2mg gum OR 1mg lozenges
If nil by mouth or does not tolerate gum or lozenges use a nicotine patch
14mg/day and if necessary titrate up to 21mg/day
A patient can use as much NRT as it takes for them to feel comfortable. In the rare case
that a patient is gets too much nicotine, they will begin to feel nauseous. If this happens,
try the medium strength (14mg) patch or suggest using fewer lozenges / gum.
Note:These recommended dosages are very conservative
Under-dosage causes failure of the drug to prevent nicotine cravings – many
smokers need more NRT than the guidelines recommend.
Combination Therapy
Many smokers are best cared for by providing combination therapy (patches +
lozenges /gum) which are safe and shown to be more effective then single products
alone. 3
Patches offer a sustained amount of nicotine during the day, with the lozenge / gum
being used „when necessary (ie PRN) to treat break-through cravings.
Lozenges and gum release nicotine more quickly then patches.
Young People (12 – 17years)
For young people who smoke more than 10/day – same as above
For those who smoke fewer than 10/day, offer low strength lozenge (1mg) or gum
(2mg) initially. Monitor after 24 hours and if cravings not controlled, increase the
dosage
Consult relevant parental consent guidelines before administering NRT to patients 1215 years
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NRT Products Available within the CDHB
NRT patches (21mg and 14mg), lozenges (2mg and 1mg), gum (4mg and 2mg) and
inhalers can be accessed from the CDHB Hospital pharmacies. Detailed information
about how to use all of these products is found in the Clinical Pharmacological Bulletin:
NRT – managing inpatient nicotine dependence (intranet, clinical pharmacy department,
bulletins, 2010).
Ward Stock will most often include only 3 products - 21mg patches and both 1mg and 2mg
lozenges – as these products alone or in combination will address the immediate needs of
almost all patients
Product Dosage
Use
Patches
21mg/24h
Apply to clean, non-hairy, dry and unbroken
skin. Apply new patches to fresh skin site
daily. Do not use old site for 3 days. Some
redness may occur at site of placement.
Lozenges
1mg, 2mg
Apply 1 patch daily. Leave patch on for
24hours.
Initial onset can take 1-2 hours,
reaching peak concentration in 6-12
hours.
Suck one lozenge every 1-2 hours.
Usual dose 8-12 / day. Maximum of
25 (1mg) and 15 (2mg) lozenges /day.
When used in combination with
patches, lozenges should be sucked
only if there are break through
cravings (ie PRN use).
*Gum
2mg or
4mg
Chew and park 1 piece slowly for
30min. Usual dose 8-12/day.
Maximum of 25 (2mg) or 15 (4mg)
pieces/day.
Time to peak concentrations: ~2030min.
Inhaler
10mg
Dose usually 6-12 inhaler cartridges
daily.
Time to peak concentrations: ~15min
Use in combination with nicotine
patch: use 14mg/24h patch with 4-5
inhaler cartridges daily (max 12/day)
When urge to smoke is felt, suck the lozenge
until taste becomes strong, then park (tuck
between the cheek and gum). Repeat when
taste dissipates (each lozenge should last for
around 30 minutes).
When urge to smoke is felt, chew 1 piece of
gum until taste becomes strong: rest gum
between the cheek and gum, chew again
when taste fades; continue for 30min.
Mild adverse effects include hiccups, upset
stomach.
Use whenever there is an urge to smoke. Use
approx 6 cartridges for smokers of < 24
cigarettes/day and up to 12 cartridges for >40
cigarettes/day. Adverse effects include
mouth/throat irritation and cough which
usually resolve with continued use.
Nicotine Replacement Therapy Self Learning Package
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Monitoring
Craving / Urges to Smoke
All people commenced on NRT should be monitored
to assess how they are feeling in terms of urges to
smoke.
Approximately 24 hours after starting NRT, ask:
How often have you felt the urge to smoke in
the past 24 hours?
How strong have those urges been?
If experiencing a lot of urges to smoke or if urges
are strong, ask if patient would like to increase
dosage or try combined therapy (patch +lozenge,
even patch + patch for very heavily addicted
smokers). The aim of these questions is to assess
patient‟s tolerance and comfort level, with the
overall goal of keeping the patient comfortably
Smokefree
When monitoring
effectiveness of NRT it can
be useful to offer the
patient a 1 – 5 scale to
describe their intensity of
nicotine craving. 1
representing ‘totally fine
without smoking’ and 5
representing ‘I’d kill for a
smoke’. Anything 3 or up
requires additional NRT.
Symptoms of Overdose
Nicotine overdose, from NRT, in smokers is unlikely to occur. Smokers are used to large
quantities of nicotine from their tobacco smoke. It is far more common to underdose
smokers with NRT
Symptoms of nicotine overdose include nausea, vomiting, salivation, abdominal pain,
diarrhoea and sweating. Reduce dosage if these symptoms are experienced.
Knowledge Check
By now you should know:
How to determine someone’s nicotine dependence and what dose to provide
What dose to provide young people aged 12-16 years
The different precautions when offering NRT and how to respond to them
That NRT is always much safer than continuing to smoke
How and when to monitor a patient’s cravings
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Documentation
Ensure that smoking status and any intervention provided is recorded on the appropriate
documentation forms
Charting NRT Patch
Enter date
Medication - „Nicotine Patch‟
Dose - „21mg / 24hour‟
Route – „topical‟
Frequency Times & Duration - „use one patch daily‟
Signature, printed name and role (e.g „RN‟)
Charting NRT Lozenge
Enter date
Medication – „Nicotine Lozenge‟
Dose – „2mg (high)‟ or „1mg (low)‟
Route – „PO‟ (oral)
Frequency Times & Duration – use hourly / prn
Signature, printed name and role (e.g „RN‟)
Risk Assessment Form C24009A / Smoking cessation Form C120001
Please also document on risk assessment/smoking cessation form, so that all health
professionals caring for the patient can access this information:
That NRT has been started
Other relevant information e.g. brief advice given
Any referrals for smoking cessation support
You may wish to provide more detailed information in the clinical notes.
Countersigning
The medication chart (MR4) does not need to be countersigned by a Doctor when
you have charted NRT.
If you are unsure about what you have charted, please discuss your concerns with
a Doctor or contact the Hospital Smokefree Co-ordinator on 80263 for advice.
Knowledge Check
By now you should know:
What information to include in the patient’s Medication Chart (MR4)
What an example Medication Chart looks like
What to include in the patients Clinical Notes
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Cessation Support
Patients should be advised and encouraged to quit smoking. It is not uncommon for patients
to use their time in hospital as a springboard into a quit attempt, and staff can help to
motivate this.
CDHB Internal Support
The Hospital Smokefree Co-ordinator (80263) is available to provide advice and
support to staff, who may be dealing with complex situations
Quitpacks are available in all wards – these contain information on cessation
programmes available in the community, information on NRT and Quitcards which,
when completed by an authorised health professional, provide highly subsidised
access to NRT from a community pharmacy
Staff Cessation – any staff member wishing to quit can contact the Hospital Smokefree
Co-ordinator on 80263 for free NRT and cessation support
Referral to Cessation Programmes
Smoking Cessation form C24009D can be used directly as a referral form for patients who
consent to be referred to a community cessation programme.
Quitline – fax completed form to (04) 460 9879. The CDHB has an arrangement with
Quitline, and any referrals from CDHB divisions will result in a phone call to the patient
within 24hours of discharge. Patients can also self refer by
Ph 0800 778 778.
The time for
General Practice – Ph or fax form to the patient‟s GP. Most
referring inpatients is
Christchurch GP teams provide a full cessation programme
at discharge. Other
(PEGS) and all GP teams would be able to provide some
people - ED
cessation support
patients, outpatients,
Aukati Kaipaipa – for Maori women and their whanau. This
family and friends
is an intensive programme providing face-to-face home
can be referred at
based, long term support. Ph 0800 425 700 or fax form to
anytime.
(03) 374 0499
Smokechange – for pregnant women and women with
young babies, this programme provides intensive, homebased support. Ph 0800 226 242 or fax form to (03) 379 9946
Pacific Trust Canterbury – quit coach is available to support Pacific patients either in
hospital or at home. Ph 366 3900
Asthma Canterbury – cessation support for patients with asthma or COPD.
Ph 366 5235
Knowledge Check
By now you should know:
How to refer patients/caregivers for ongoing cessation support in the community
How to provide further cessation information and Quitcards
Who to contact for staff cessation support
Nicotine Replacement Therapy Self Learning Package
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References
1. Ministry of Health (2007). New Zealand Smoking Cessation Guidelines. Wellington: Ministry
of Health
2. Heatherton, T.F., Kozlowski, L.T., Frecker, R.C., & Fagerstrom, K.O. (1991). The
Fagerstrom Test for nicotine dependence: A revision of the Fagerstrom Tolerance
Questionnaire. British Journal of Addiction, 86(9):1119-27.
3. Stead, L.F., Perera, R., Bullen, C., Mant, D., & Lancaster, T. (2008). Replacement therapy
for smoking cessation. Cochrane Database Systematic Review, (1):CD000146
4. Benowitz, N., & Dempsey, D. (2004). Pharmacotherapy for smoking cessation during
pregnancy. Nicotine Tobacco Research, 6 Suppl 2:S189-202.
5. McRobbie, H.,& Hajek, P. (2001). Nicotine replacement therapy in patients with
cardiovascular disease: guidelines for health professionals. Addiction, 96(11):1547-51.
6. Hubbard, R., Lewis, S., Smith, C., Godfrey, C., Smeeth, L., Farrington, P., et al. (2005). Use
of nicotine replacement therapy and the risk of acute myocardial infarction, stroke and
death. Tobacco Control, 14(6):416-421
7. Dempsey, D.A., & Benowitz, N.L. (2001). Risks and benefits of nicotine to aid smoking
cessation in pregnancy. Drug Safety, 24(4):277-322
8. Ilett, K.F., Hale, T.W., Page-Sharp, M., Kristensen, J.H., Kohan, R., & Hackett, L.P. (2003).
Use of nicotine patches in breast-feeding mothers: transfer of nicotine and cotinine into
human milk. Clinical Pharmacology & Therapeutics, 74(6):516-24
9. Bartsch, R.H., Weiss, G., Kastenbauer, T., Patocka, K., Deutinger,, M., Krapohl, B.D., et al.
(2007). Crucial aspects of smoking in wound healing after breast reduction surgery. Journal
of Plastic Reconstruction Aesthethetic Surgery, 60(9):1045-9.
Nicotine Replacement Therapy Self Learning Package
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Step
Action
1
An assessment is to be made, including any history of allergies, reactions
or identified precautions to the proposed medicine: e.g. allergy to sticking
plaster
An assessment of nicotine dependence is to be carried out following the
CDHB information risk screening assessment form
2
3
A progress note is entered into the patient‟s clinical notes detailing the
findings of assessment outlined in no‟s. 1-2 above. This progress note will
be signed and dated by the Registered Nurse making the assessment.
4
If the patients‟ smoking status fits the criteria, a Registered Nurse may
administer appropriate Nicotine Replacement Therapy (The RN must have
completed the online ABC training for health professionals). Only
medicines listed and within the ranges shown are permitted to be
administered.
All administration of Nicotine Replacement Therapy is to be accurately
entered on the medication chart (QMR0004), signed by the Nurse and
with the abbreviation RN added and the surname printed in block capitals
(Patches should be entered under the regular medications and lozenges,
inhalers and gum entered under the PRN section).
• All administration is recorded in clinical notes.
• The effects of medication and any adverse reaction are to be recorded
appropriately.
• The medical officer is to be contacted if Nicotine Replacement Therapy
is ineffective or an adverse reaction occurs.
• Provide the patient with the Smokefree Quit Pack
5
The following limitations are to be observed:
• NRT administered and documented on the QMR0004, (When possible
initial consultation with medical staff regarding administration should be
considered).
• Only for administration to persons aged 18 years and above, unless
prescribed by medical staff.
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
Limited Nurse Prescribing for NRT Assessment
Name ___________________________________
Area ____________________________________
All answers to these questions can be found within this workbook.
1)
What are 3 precautions to consider when administering NRT?
2)
When it comes to precautions, what is the key message regarding the safety of NRT in
comparison to continued smoking?
3)
Which NRT products are most safe for pregnant women?
4)
What dose for the patch and lozenge would you initially offer someone who smokes more
than 10 cigarettes per day and has the first cigarette within 30 minutes of waking?
patch
lozenge
5)
6)
What dose for the patch and lozenge would you initially offer someone who smokes some
time after 30 minutes after waking and:a) who smokes 5 cigs/day?
Patch ______ Lozenge ______
b) who smokes 15 cigs/day?
Patch ______ Lozenge ______
What are the 3 criteria for providing NRT to patients?
Nicotine Replacement Therapy Self Learning Package
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7)
How would you know if a patient has been given too strong a dose of NRT?
9)
How would you know if a patient needs a stronger dose of NRT?
10)
What must you do before administering NRT for youth aged 12-15 years?
To be sent to the Nurse Educator in your area for recording learning hours in Data
Base.
Nicotine Replacement Therapy Self Learning Package
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Workbook Evaluation
How easy was it for you to understand the content in this workbook? (please circle)
not at all easy
somewhat easy
easy
very easy
extremely easy
Please provide any suggests that might improve the content in this workbook
and make it easier to understand:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
How confident do you now feel to administer NRT for patients? (please circle)
not at all
confident
somewhat
confident
confident
very confident
extremely
confident
What suggestions do you have that may help to you increase your confidence?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Any other suggestions:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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