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Chapter 67. Smoking Cessation

The patient is a 63-year-old woman with a past medical history of hypertension, tobacco use, type 2 diabetes mellitus, and dental implants/dentures. Comorbid conditions are managed with medications including amlodipine 5 mg by mouth once per day and metformin 1000 mg by mouth twice per day. Her last blood pressure was 122/76 mm Hg and A1C was 6.2% 1 month ago. She is a smoker and has smoked 1.5 packs per day for the past 40 years. She is ready to quit but would prefer to have an “as-needed” medicine available to her for when her cravings become overwhelming. For nicotine replacement therapy, what agent would be best to recommend?

a. Nicotine polacrilex gum.

b. Nicotine lozenges.

c. Nicotine transdermal patch.

d. The patient should avoid nicotine replacement products.

Answer b is correct. The nicotine lozenges provide as needed relief for acute nicotine cravings and do not have dental implant/denture precautions as found with the nicotine gum. She may use up to 20 lozenges in a 24-hour period, but may use as few as she needs to stave off cravings.

Answer a in incorrect. The patient should avoid using nicotine gum because she has dental implants/dentures. This is a warning/precaution for use as the gum may stick to the dental work and cause damage.

Answer c is incorrect: Nicotine patches are not considered useful for managing acute nicotine cravings as they have a delayed onset and prolonged effect as a maintenance medicine. The administration device delivers a low, consistent dose of nicotine that may be weaned as the patient becomes less and less dependent on the physical presence of nicotine in their system. It is not indicated for acute management.

Answer d is incorrect. The patient does not have contraindications to nicotine replacement therapy. She does need to exercise caution when using nicotine gum in the presence of dental implants/dentures, but does not have a warning against using nicotine products. Contraindications of nicotine replacement therapy include recent (<2 weeks) myocardial infarction, serious underlying arrhythmias, serious or worsening angina pectoris, pregnancy and breastfeeding, and adolescents younger than 18 years. Additionally, the gum has a precaution for temporomandibular joint disease, the nasal spray has a warning against use in severe reactive airway disease and underlying chronic nasal disorders (rhinitis, nasal polyps, sinusitis), and the oral inhaler has a warning in bronchospastic disease.

A patient is prescribed a nicotine lozenge for use when he or she experiences cravings for a cigarette. One patient discusses that his strongest cravings occur in the morning and feels that is when the lozenge works the least for him. ...

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