Tobacco Use Disorder: How to Break the Chain

Matthew F. Watto, MD; Paul N. Williams, MD; Stuart K. Brigham, MD


March 22, 2021

This transcript has been edited for clarity.

Matthew F. Watto, MD: We are The Curbsiders. I'm Dr Matthew Frank Watto, joined by Dr Stuart Kent Brigham and the great Dr Paul Nelson Williams.

Paul N. Williams, MD: We are going to be talking about our podcast with Dr Steve Baldassarri from Yale, when we discussed tobacco cessation and how to help counsel our patients through this process. It's challenging for patients and sometimes frustrating for clinicians, but Dr Baldassarri gave us a couple of really high-yield pearls. Stuart, what did you take away from this in terms of helping your patients?

Stuart K. Brigham, MD: I love the idea of approaching it with both a long-acting and a short-acting treatment for smoking cessation. Nicotine patches, varenicline, and bupropion are the long-acting options, and the short-acting treatments are nicotine lozenges, nicotine gum, inhalers, or — if you like torture — the nasal sprays. If you like to fight the insurance company, then try the inhalers, which I have been unsuccessful in getting approved for patients.

Watto: The nasal spray is the quickest acting, or was it the inhaler? One of those is quickest acting; being close to the brain, it must be the nasal spray. Apparently it burns quite a bit, and some people don't like it. It's expensive and it's hard to get approved. That's probably why I've never seen anybody on it. Paul, what are you using for short-acting replacement?

Williams: I favor the nicotine gum. My patients seem to favor it because it seems to be the least hassle to get approved. It's the easiest to explain how to use. It's less burdensome overall among short-acting formulations.

Watto: He talked about the long-acting as being the controller. It's like asthma or diabetes, where you need both agents. I had never thought about it or been taught about it that way. Go figure, Paul — addiction medicine wasn't taught in this country until about the past 3 years. Paul, what's your pearl for this one?

Williams: Funny you should mention the nicotine gum. Dr Baldassarri snuck in a two-for-one pearl there. He mentioned gauging the severity of addiction by how quickly someone lights up a cigarette after they roll out of bed in the morning, which I think is a great question to ask when you are interviewing patients about their tobacco history. You can use that to determine the dosage of the nicotine gum. Usually, when it pops up in the electronic health record, I just pick the dose that seems right. This was a better formula than I had been using. So essentially, the patient who lights up within 30 minutes of waking has a pretty significant addiction, and you would start with the higher-dose nicotine gum, the 4 mg variety. If it takes them longer than a half-hour to light up — if they brush their teeth or make their coffee first — you can probably go with the 2 mg dose and that will be adequate for the short-acting formulation.

Watto: I was taught to tell the patients to take the nicotine patch off if they are going to smoke because they can get nicotine poisoning or become nauseous. Dr Baldassarri told us the opposite. He said if patients have to smoke when they are wearing a nicotine patch, you need to increase the dose because they are having too many cravings and aren't getting their nicotine fix. And Dr Chan, an addiction fellow, mentioned that when she starts people on the gum, she tells them that because the gum can take an hour to kick in and satisfy their craving, they should just start chewing the gum throughout the day to get ahead of nicotine craving, rather than waiting until the craving begins.

Dr Baldassarri said that sometimes patients will get a little jittery or nauseous with the gum. He tells patients to remember what it was like when they had their first cigarette; that might be what nicotine toxicity feels like. But in the experience of addiction medicine experts, underdosing is the norm. What really blew my mind is that patients should be on nicotine replacement for months to years and that you might need to taper them off nicotine replacement. They aren't going to use this just for a couple of weeks. We are treating a chronic problem, similar to opioid or alcohol use disorder.

Williams: We see this in clinical practice, too. Something that makes me laugh and frustrates me is when someone who's a three-pack-a-day tobacco user is given a 7 mg patch when they're hospitalized — like a postage stamp on their arm. We expect that to cover their cravings and wonder why they are irritable. That point really resonated with me.

Brigham: If these pearls blow your mind and sound smoking hot to you, and you aren't breathing a sigh of fresh air, listen to our full podcast, #252 Smoking Cessation Unfiltered.  

Watto: You can also join our mailing list and get a PDF copy of our show notes every week.

Thank you for watching.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube