Tobacco Use Disorder (TUD)

Ben Johnson

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
  • 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 use
    • 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
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