Tobacco Use Disorder (TUD)
Claire Willman
Background
- All patients should be screened for nicotine use (smoking, chewing, and vaping of nicotine containing products).
- Nicotine withdrawal is one of the most common reasons that patients leave the hospital before medically advised.
- Hospitalized patients receiving pharmacotherapy for nicotine use have higher rates of cessation.
Management
- Combination therapy is superior to single therapy alone.
- Nicotine Replacement Therapy.
- Basal:
- Transdermal nicotine patch provides sustained levels of nicotine.
- > 10 cigarettes (1/2 pack) per day: 21 mg patch.
- < 10 cigarettes (1/2 pack) per day: 14 mg patch.
- Remove overnight, abnormal dreams and nightmares are a common if not removed.
- Bolus
- Gum/ Lozenge provides immediate nicotine for breakthrough cravings.
- First cigarette within 30 minutes of waking: 4 mg gum/lozenge.
- First cigarette after 30 minutes of waking: 2 mg gum/lozenge.
- Patients smoking 1+ packs per day will likely still require 4 mg gum/lozenge.
- Order q1h PRN as patients will titrate utilization as they would with their outpatient nicotine.
- Chew and park method for nicotine gum; sublingual absorption needed to bypass first metabolism.
- Other medications:
- Varenicline
- Equivalent efficacy to combination NRT for smoking cessation.
- Limited utility in the inpatient setting due to side effect tolerability and need for dose titration over multiple days.
- Bupropion
- Effective but less efficacious than combination NRT and varenicline.
- Limited utility in the inpatient setting due to dose titration over a week and delay in steady state blood levels.
- Contraindicated in those with seizure disorder and those at risk of seizures.
