REVIEW OF: Palmer AM et al, Am J Prev Med 2025;69(2):107664
STUDY TYPE: Pilot randomized feasibility trial

Nicotine is one of the most addictive drugs, and standard nicotine replacement therapy (NRT) sometimes isn’t strong enough to help patients stop smoking or vaping. This pilot trial tested whether higher doses of NRT could make a difference for adults who wanted to quit both.

Forty-six adults who regularly smoked and vaped were randomly assigned to use NRT for 28 days in one of three dosing regimens. One group received a standard, single 21 mg nicotine patch each day with twenty 4 mg lozenges as needed. Another group received one 21 mg and one 14 mg patch, plus 30 PRN lozenges daily. The highest-dose group used two 21 mg patches plus 40 PRN lozenges. All participants were followed for eight weeks.

People using the mid- and high-dose regimens were significantly more likely to quit both smoking and vaping compared with those on the standard dose. At the end of week 4, about 13% of participants in the higher-dose groups were abstinent from both products, compared with 6% in the standard group. After week 8, roughly one-third of the mid- and high-dose participants remained abstinent, while none of those in the standard group did. On any given day, those using higher NRT doses were four to eight times more likely to be smoke- and vape-free. Notably, the mid- and high-dose NRT groups didn’t separate statistically. Reported side effects—mostly skin irritation and mild nausea—were common but mild and did not require medical care.

CARLAT TAKE
While small, this study supports the principle that heavier nicotine dependence may require heavier replacement. Given that the two higher-dose NRT regimens were statistically equivalent, it would be reasonable to start with 35 mg of patches and only go to 42 mg if needed. Keep side effects and insurance coverage in mind with doses above the maximum, and consult a cardiologist if patients have unstable heart disease.