4.1. Therapeutic indications

Nicorette Fruit 4 mg Lozenge relieves and/or prevents craving and nicotine withdrawal symptoms in nicotine dependence, such as those arising from the use of tobacco or electronic cigarettes. It is indicated to aid quitting or reduction prior to quitting, to assist those who are unwilling or unable to use such products, and as a safer alternative to smoking tobacco for smokers and those around them.

This product is indicated in pregnant and lactating women making a quit attempt.

4.2. Posology and method of administration

Adults and children over 12 years of age

The strength of lozenge to be used will depend on the smoking/vaping habits of the individual. In general, if the patient smokes 20 or less cigarettes a day, 2 mg nicotine lozenge is indicated. If more than 20 cigarettes per day are smoked, 4 mg nicotine lozenge will be needed to meet the withdrawal of the high serum nicotine levels from heavy smoking.

Light to moderate vapers (e.g. vape infrequently or use low strength e-liquid) should start with 2 mg nicotine lozenge. If the 2 mg nicotine lozenge does not relieve the urge to vape, 4 mg nicotine lozenge should be used. Heavy vapers (e.g. vape frequently or use high strength e-liquid) should use 4 mg nicotine lozenge.

This product should be used whenever the urge to smoke or vape is felt or to prevent cravings in situations where these are likely to occur.

Patients willing or able to stop smoking/vaping immediately should initially replace all their cigarettes/e-cigarettes with the lozenge and as soon as they are able, reduce the number of lozenges used until they have stopped completely.

Patients aiming to reduce cigarettes/e-cigarettes should use the lozenges, between smoking/vaping episodes, as needed, to prolong smoke/vape-free intervals and to reduce their use as much as possible.

As soon as they are ready patients should aim to quit smoking/vaping completely.

Most patients require 8 to 12 lozenges per day, not to exceed 15 lozenges.

When making a quit attempt behavioural therapy, advice and support will normally improve the success rate. Those who have quit smoking/vaping but are having difficulty discontinuing with the lozenge are recommended to contact their pharmacist or doctor for advice.

For those using the 4 mg lozenges, switching to the 2 mg lozenges may be helpful when stopping treatment or reducing the number of lozenges used each day.

Method of administration

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. You should not chew or swallow the lozenge.

4.3. Contraindications

Hypersensitivity to any of components of the lozenge.

This product is contraindicated in children under the age of 12 years.

4.4. Special warnings and precautions for use

Any risks which may be associated with the use of NRT are substantially outweighed in virtually all circumstances by the well-established dangers of continued smoking. The risks of continued vaping are not yet established.

A risk-benefit assessment should be made by an appropriate healthcare professional for patients with the following conditions:

Underlying cardiovascular disease: In stable cardiovascular disease this product presents a lesser hazard than continuing to smoke. However dependent smokers currently hospitalised as a result of myocardial infarction, unstable or worsening angina including Prinzmetal angina, severe dysrhythmia or cerebrovascular accident and who are considered to be haemodynamically unstable and/or who have uncontrolled hypertension should be encouraged to stop smoking with non-pharmacological interventions. If this fails, this product may be considered, but as data on safety in this patient group are limited, initiation should only be under medical supervision. The risks of continued vaping are not yet established.

Diabetes Mellitus: Patients with diabetes mellitus should be advised to monitor their blood sugar levels more closely than usual when quitting and NRT is initiated as reductions in nicotine induced catecholamine release can affect carbohydrate metabolism.

Renal and hepatic impairment: Use with caution in patients with moderate to severe hepatic impairment and/or severe renal impairment as the clearance of nicotine or its metabolites may be decreased with the potential for increased adverse effects.

Phaeochromocytoma and uncontrolled hyperthyroidism: Use with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma as nicotine causes release of catecholamines.

Gastrointestinal disease: Nicotine may exacerbate symptoms in patients suffering from oesophagitis, gastric or peptic ulcers and NRT preparations should be used with caution in these conditions. Ulcerative stomatitis has been reported.

Seizures: Potential risks and benefits of nicotine should be carefully evaluated before use in subjects with a history of epilepsy as cases of convulsions have been reported in association with nicotine.

Danger in children: Doses of nicotine tolerated by adult and adolescent smokers or vapers can produce severe toxicity in children that may be fatal. Products containing nicotine should not be left where they may be misused, handled or ingested by children, see section 4.9 Overdose.

Transferred dependence: Transferred dependence is rare and is both less harmful and easier to break than smoking dependence.

Stopping smoking: Polycyclic aromatic hydrocarbons in tobacco smoke induce the metabolism of drugs metabolised by CYP 1A2 (and possibly by CYP 1A1). When a smoker stops smoking, this may result in slower metabolism and a consequent rise in blood levels of such drugs. This is of potential clinical importance for products with a narrow therapeutic window, e.g. theophylline, clozapine and ropinirole.

Choking hazard: Lozenges can represent a choking hazard, therefore keep out of the reach of children. Use with caution in individuals with aspiration and swallowing problems.

Excipients:

This medicine contains less than 1 mmol sodium (23 mg) per lozenge, that is to say essentially 'sodium-free'. This medicine also contains a small amount of sulphites, coming from the flavour, which may rarely cause severe hypersensitivity reactions and bronchospasm.

4.5. Interaction with other medicinal products and other forms of interaction

No clinically relevant interactions between nicotine replacement therapy and other drugs have definitely been established. However nicotine may possibly enhance the haemodynamic effects of adenosine i.e. increase in blood pressure and heart rate and also increase pain response (angina-pectoris type chest pain) provoked by adenosine administration.

4.6. Fertility, pregnancy and lactation

Pregnancy

Stopping smoking is the single most effective intervention for improving the health of both the pregnant smoker and her baby, and the earlier abstinence is achieved the better. Ideally smoking cessation during pregnancy should be achieved without NRT. Nicotine passes to the foetus and affects its breathing movements and circulation. The effect on the circulation is dose-dependent. However, if the mother cannot (or is considered unlikely to) quit without pharmacological support, NRT may be used as the risk to the foetus is lower than that expected with smoking tobacco. Stopping completely is by far the best option but if this is not achievable this product may be used in pregnancy as a safer alternative to smoking. Because of the potential for nicotine-free periods, intermittent dose forms are preferable, but patches may be considered as an alternative if there is significant nausea and/or vomiting. If patches are used they should, if possible, be removed at night when the foetus would not normally be exposed to nicotine.

There is no or limited data regarding the effect of vaping in pregnancy.

Use of NRT by the pregnant smoker/vaper should only be initiated after advice from a health care professional.

Lactation

Nicotine should be avoided during breast-feeding. The relatively small amounts of nicotine found in breast milk during NRT use are less hazardous to the infant than second-hand smoke. Intermittent dose forms would minimize the amount of nicotine in breast milk and permit feeding when levels were at their lowest.

There is no or limited data regarding the effect of vaping in lactating women.

Use of NRT by breast feeding smokers/vapers should only be initiated after advice from a health care professional. Women should use the product as soon as possible after breastfeeding.

Fertility

In females tobacco smoking delays time to conception, decreases in-vitro fertilization success rates, and significantly increases the risk of infertility.

In males tobacco smoking reduces sperm production, increases oxidative stress, and DNA damage. Spermatozoa from smokers have reduced fertilizing capacity.

The specific contribution of nicotine to these effects in humans is unknown.

There is no or limited data regarding the effect of vaping on fertility.

4.7. Effects on ability to drive and use machines

This product has no or negligible influence on the ability to drive and use machines.

4.8. Undesirable effects

Effects of Smoking Cessation

Some symptoms may be related to nicotine withdrawal associated with stopping smoking. These can include: irritability/aggression, frustration/anger, dysphoria/depressed mood, anxiety, restlessness, poor concentration, increased appetite/weight gain, urges to smoke (cravings), night-time awakenings/sleep disturbance, decreased heart rate, dizziness, presyncopal symptoms, cough, constipation, gingival bleeding or nasopharyngitis.

Increased frequency of aphthous ulcer may occur after stopping smoking. The causality is unclear.

Effects of Vaping Cessation

The nicotine withdrawal effects of vaping cessation have not been established, however it is anticipated that many of the effects relating to nicotine withdrawal will be the same as those seen with tobacco smoking cessation.

Adverse Drug Reactions

This product may cause adverse reactions similar to those associated with nicotine given by other means, including smoking and vaping, and these are mainly dose-dependent. At recommended doses this product has not been found to cause any serious adverse effects. Excessive consumption of this product by those who have not been in the habit of inhaling tobacco smoke or vaping could possibly lead to nausea, faintness or headaches.

Most of the undesirable effects reported by the patient occur during the first 3-4 weeks after start of treatment. During the first few days of treatment irritation in the mouth and throat may be experienced. Most patients will get used to this sensation after the first few days.

Allergic reactions (including symptoms of anaphylaxis) can occur during the use of the product.

The adverse reactions observed in patients treated with oral nicotine formulations during clinical trials and post-marketing experience are listed below by system organ class (SOC). Frequencies are defined in accordance with current guidance as: very common (≥1/10); common (≥1/100, <1/10); uncommon (≥1/1 000, <1/100); rare (≥1/10 000, <1/1 000); very rare (<1/10 000); not known (cannot be estimated from the available data).

Body System

Reported adverse event (Preferred Term)

Incidence

Immune system disorders

Hypersensitivitya

Common

Anaphylactic reactiona

Not known

Psychiatric disorders

Abnormal dreams*

Uncommon

Nervous system disorders

Headachea#

Very common

Burning sensationc

Common

Dizziness

Common

Dysgeusia

Common

Paraesthesiaa

Common

Seizures

Not known

Eye disorders

Blurred vision

Not known

Lacrimation increased

Not known

Cardiac disorders

Palpitationsa

Uncommon

Tachycardiaa

Uncommon

Atrial fibrillation

Very rare

Vascular disorders

Flushinga

Uncommon

Hypertensiona

Uncommon

Respiratory, thoracic and mediastinal disorders

Cough**

Common

Sore mouth or throat

Very common

Throat irritation**

Very common

Bronchospasm

Uncommon

Dysphonia

Uncommon

Dyspnoeaa

Uncommon

Nasal congestion

Uncommon

Sneezing

Uncommon

Throat tightness

Uncommon

Gastrointestinal disorders

Hiccups****

Very common

Nauseaa

Very common

Abdominal pain

Common

Diarrhoea***

Common

Dry mouth

Common

Dyspepsia

Common

Flatulence

Common

Salivary hypersecretion

Common

Stomatitis

Common

Vomitinga

Common

Eructation

Uncommon

Glossitis

Uncommon

Oral mucosal blistering and exfoliation

Uncommon

Paraesthesia oral***

Uncommon

Dysphagia

Rare

Hypoaesthesia oral***

Rare

Retching

Rare

Dry throat

Not known

Gastrointestinal discomforta

Not known

Lip pain

Not known

Musculoskeletal and connective tissue disorders

Pain in Jawb

Uncommon

Muscle tightnessb

Not known

Skin and subcutaneous tissue disorders

Hyperhidrosisa

Uncommon

Pruritusa

Uncommon

Rasha

Uncommon

Urticaria**

Uncommon

Erythemaa

Not known

General disorders and administration site conditions

Fatiguea

Common

Astheniaa

Uncommon

Chest discomfort and pain a

Uncommon

Malaisea

Uncommon

Allergic reactions including angioedema

Rare

a Systemic effects; b Tightness of jaw and pain in jaw with nicotine gum formulation

c At the application site

*Identified only for formulations applied during the night

**Higher frequency observed in clinical studies with inhaler formulation.

***Reported the same or less frequently than placebo

****Higher frequency observed in clinical studies with mouth spray formulation

# Although the frequency in the active group is less than that of the placebo group, the frequency in the specific formulation in which the PT was identified as a systemic ADR was greater in the active group than the placebo group.

Reporting of Suspected Adverse Reactions.

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Symptoms: Symptoms of overdose with nicotine from this product may occur in smokers/vapers who have previously had a low nicotine intake from cigarettes/e-cigarettes or if other sources of nicotine are used concomitantly with this product.

Acute or chronic toxicity of nicotine in man is highly dependent on mode and route of administration. Adaptation to nicotine (e.g. in smokers/vapers) is known to significantly increase tolerability compared with non-smokers/vapers. The minimum lethal dose of nicotine in a non-tolerant man has been estimated to be 40 to 60 mg. Symptoms of acute nicotine poisoning include nausea, vomiting, increased salivation, abdominal pain, diarrhoea, sweating, headache, dizziness, disturbed hearing and marked weakness. In extreme cases, these symptoms may be followed by hypotension, rapid or weak or irregular pulse, breathing difficulties, prostration, circulatory collapse and terminal convulsions.

Management of an overdose: All nicotine intake should stop immediately and the patient should be treated symptomatically. Artificial respiration should be instituted if necessary. Activated charcoal reduces the gastro-intestinal absorption of nicotine.

Doses of nicotine that are tolerated by adult smokers/vapers during treatment may produce severe symptoms of poisoning in children and may prove fatal. Suspected nicotine poisoning in a child should be considered a medical emergency and treated immediately.