TABLE 8.
Highlights of Recommended Behavioral and Pharmacotherapy Tobacco Treatment Modalities for Prescribers*
| Timing of Behavioral Interventions† | ||
|---|---|---|
| <3 min of tobacco status assessment with cessation counseling at each clinic encounter | >3–10 min of tobacco status assessment with cessation counseling at each clinic encounter | >10 min of tobacco status assessment with cessation counseling at each clinic encounter |
| Treatment | Dosing‡ | Precautions | |
|---|---|---|---|
| NRT* | |||
| Patch | 21 mg, 14 mg, or 7 mg | Starting dose: 21 mg for ≥10 CPD; 14 mg for <10 CPD |
Local irritation possible; avoid with skin disorders; may remove for sleep if needed |
| Gum | 2 mg or 4 mg | Starting dose: 4 mg if first tobacco use is ≤30 min after waking; 2 mg if first tobacco use is >30 min after waking; maximum of 20 lozenges or 24 pieces of gum/d. Chew and park gum* |
Hiccups/dyspepsia possible; avoid food or beverages 15 min before and after use |
| Lozenge | 2 mg or 4 mg | ||
| Nasal spray | 10 mg/mL | Starting dose: 1–2 doses/h (1 dose=1 spray each nostril); maximum of 40 doses/d |
Local irritation possible; avoid with nasal or reactive airway disorders |
| Oral inhaler | 10-mg cartridge | Starting dose: Puff for 20 min/cartridge every 1–2 h; maximum 16 cartridges/d |
Cough possible; avoid with reactive airway disorders |
| Other§ | |||
| Bupropion (Zyban [GlaxoSmithKline], Wellbutrin SR [GlaxoSmithKline]) | 150 mg SR | 150 mg once daily (am) for 3 d; then 150 mg twice daily; may use in combination with NRT (S4.5-21) | Avoid with history/risk of seizures, eating disorders, MAO inhibitors, or CYP 2D6 inhibitor |
| Varenicline (Chantix [Pfizer]) | 0.5 mg or 1 mg | 0.5 mg once daily (am) for 3 d; then 0.5 mg twice daily for 4 d; then 1 mg twice daily (use start pack followed by continuation pack) for 3–6 mo | Nausea common; take with food. Renal dosing required. Very limited drug interactions; near-exclusive renal clearance. |
CPD can guide dosing. 1 CPD is ≈1–2 mg of nicotine. Note: Use caution with all NRT products for patients with recent (≤2 wk) MI, serious arrhythmia, or angina; patients who are pregnant or breastfeeding; and adolescents.
Timing of assessment relates to ICD-10 coding.
Dose and duration can be titrated on the basis of response (S4.5-21).
The FDA has issued a removal of black box warnings about neuropsychiatric events (S4.5-20, S4.5-21).
am indicates morning; CPD, cigarettes smoked per day; FDA, U.S. Food and Drug Administration; ICD-10, International Classification of Diseases, Tenth Revision; MAO, monoamine oxidase; NRT, nicotine replacement; and SR, sustained release.