Nicotine

Abstract

Though the use of tobacco has been declining, smoking continues to be the leading preventable cause of morbidity and mortality in the United States. The primary addictive compound in tobacco is nicotine, a nicotine receptor agonist which causes stimulant effects. Nicotine also triggers the dopamine reward pathway, which contributes to its addictive properties. Treatment of tobacco use disorder should ideally consist of both behavioral and pharmacological interventions. First-line behavioral treatment often consists of cognitive behavioral therapy (CBT) and motivational interviewing (MI). First-line pharmacological treatments include combination nicotine replacement therapy (NRT), varenicline, and bupropion. There is some evidence that varenicline and combination NRT are the most effective. However, selection of therapy should be based on patient-specific factors, as use of some medications are contraindicated in certain populations. Combination NRT should be dosed based on the patient’s nicotine dependence as assessed through a validated scale such as the Heaviness of Smoking Index. Electronic cigarettes are becoming increasingly popular; however, their efficacy as smoking cessation aids has not yet been established, and their use comes with some risks.

Review Questions

• 1. CK is a 67-year-old Asian American female with history of schizophrenia, hyperlipidemia, and hypertension who presents to your primary care clinic for her yearly check-up. She is insured through a private healthcare insurance company. Which of DL’s demographic characteristics have been associated with a higher prevalence of smoking?

  • A. Gender

  • B. Age

  • C. Mental health diagnosis

  • D. Ethnicity

  • E. Insurance coverage

  Answer: C

  Explanation: Individuals with mental health diagnoses have higher rates of smoking compared to the general population. Males, aged 24–65, American Indian, Alaska native, or multiracial, uninsured or insured by Medicaid have a higher prevalence of smoking (none of which categories CK falls into—female, age >65, Caucasian, has private insurance).

• 2. AH is a 52-year-old male with no prior medical history who is interested in nonpharmacological therapy for his tobacco use disorder. He has never received any nonpharmacological therapy for his TUD and has never received psychotherapy. Which of the following nonpharmacological therapies is most commonly and widely used, and would be most appropriate for treatment of AH’s tobacco use disorder?

  • F. Acceptance and commitment therapy (ACT)

  • G. Cognitive behavioral therapy (CBT)

  • H. Dialectical behavioral therapy (DBT)

  • I. Exposure therapy

  • J. Mindfulness-based therapy

  Answer: B

  Explanation: Cognitive behavioral therapy (CBT) is the most commonly and widely used nonpharmacological therapy for Tobacco Use Disorder. Since AH has never received any nonpharmacological therapy or psychotherapy and has no comorbidities, CBT would be the most appropriate as a first-line therapy.

• 3. LK is a 37-year-old male with history of epilepsy, bipolar disorder type II, and tobacco use disorder who was discharged 1 week ago after being hospitalized for suicidal ideation. He smokes 2 packs of cigarettes per day and smokes his first cigarette within 5 minutes after waking up and has never tried any pharmacotherapy for TUD. Which would be most appropriate pharmacological treatment option for LK?

  • A. Nicotine patch monotherapy

  • B. Nicotine patch with nicotine gum

  • C. Bupropion

  • D. Varenicline

  • E. Clonidine

  Answer: B

  Explanation: Combination nicotine replacement therapy is the most appropriate choice since it is a first-line pharmacological therapy and safest option in this patient. Since this patient was recently hospitalized for suicidal ideation, varenicline would not be appropriate since it has only been shown to be safe in patients who have had stable psychiatric symptoms for 6 months. Bupropion is contraindicated given his history of epilepsy. Nicotine patch monotherapy and clonidine are not as effective as combination NRT.

• 4. TL is a 28-year-old female with tobacco use disorder. She smokes 1.5 packs of cigarettes per day and smokes her first cigarette 45 minutes after waking up. Which strength of nicotine patch and nicotine lozenge would be most appropriate to initiate in TL based on her level of tobacco dependence?

  • A. 21 mg nicotine patch with 4 mg nicotine lozenge

  • B. 21 mg nicotine patch with 2 mg nicotine lozenge

  • C. 14 mg nicotine patch with 4 mg nicotine lozenge

  • D. 14 mg nicotine patch with 2 mg nicotine lozenge

  • E. 7 mg nicotine patch with 2 mg nicotine lozenge

  Answer: B

  Explanation: Using the HIS, TL has 3 points (1 point for smoking 30–60 min after waking and 2 points for smoking 30 cigarettes/day) and moderate tobacco dependence. Therefore, she should be initiated on the 21 mg nicotine patch with the 2 mg nicotine lozenge.

• 5. SH is a 30-year-old female who is interested in using electronic cigarettes to quit smoking and presents to your clinic to learn more about them. Which of the following statements would be the most accurate for you to tell SH regarding electronic cigarettes?

  • A. Electronic cigarettes appear to deliver fewer harmful chemicals to the body than conventional cigarettes.

  • B. Electronic cigarettes are regulated by the FDA.

  • C. Electronic cigarettes are FDA-approved for treatment of tobacco use disorder.

  • D. Electronic cigarette use does not carry a risk for nicotine dependence.

  • E. Only previous/current smokers use electronic cigarettes.

  Answer: A

  Explanation: Electronic cigarettes appear to deliver fewer harmful chemicals to the body than conventional cigarettes. They are not regulated by the FDA, are not FDA-approved for treatment of tobacco use disorder, and carry a risk for nicotine dependence. Electronic cigarettes are increasingly used among youth/adolescents and may serve as a gateway to conventional cigarettes.