Skip to content

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 (½ pack) per day: 21 mg patch

  • < 10 cigarettes (½ 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