CASE 1: Lozenge counseling
Q: LP is a 49-year-old woman with a medical history of hypertension and coronary artery disease. She reports that she smokes 6 cigarettes daily and has her first cigarette with breakfast each day within 10 minutes of waking in the morning. She would like to try nicotine lozenges to help her quit smoking. What recommendations should the pharmacist provide to LP regarding the appropriate use of nicotine lozenges?
A: The pharmacist should ensure that the patient speaks to her doctor before using nicotine lozenges because LP has hypertension and coronary artery disease, and nicotine can increase her blood pressure and heart rate.1 If LP’s doctor advises her that it is safe to use nicotine lozenges, the pharmacist should recommend the 4-mg lozenge, which is recommended for individuals who have their first cigarette within 30 minutes of waking in the morning. The pharmacist should instruct LP to place the lozenge between the gum and the cheek and allow it to slowly dissolve. LP should be counseled that she can use 1 lozenge every 1 to 2 hours and that drinking and eating should be avoided 15 minutes before and during lozenge use. LP can expect to experience some mouth irritation, heartburn, and nausea with lozenge use.2,3
CASE 2: Nicotine patch
Q: KC is a 67-year-old man who has smoked 2 packs of cigarettes per day for the past 20 years. He has decided to quit smoking and approaches the pharmacy requesting assistance with the selection of an OTC nicotine patch. What is an appropriate recommendation from the pharmacist for a nicotine patch regimen?
A: The pharmacist should recommend that KC start with a 21-mg nicotine patch. KC smokes 40 cigarettes per day, and the nicotine 21-mg patch is recommended for initiation in patients who smoke 10 or more cigarettes per day. The 21-mg patch should be worn for at least 6 weeks and then can be tapered down to the 14-mg patch. The 14-mg patch can be used for 2 weeks, followed by a 7-mg patch for 2 weeks. KC should be counseled to apply a new patch each morning to a dry, hairless area. To apply the patch, the backing of the patch should be removed, and the patch should be firmly placed on the skin and held for about 10 seconds. Patch placement should be alternated daily to avoid skin irritation. When removing the patch, KC should fold the sticky ends of the patch together and place the patch in the pouch in which it was originally packaged. This method allows for the safe disposal of the patch in regular garbage.2,4
CASE 3: Patch’s adverse effects
Q: PL is a 38-year-old woman who has decided to quit smoking. She smokes 8 cigarettes per day and has her first cigarette approximately 3 hours after waking up in the morning while she drives to work. She explains that she has been trying nicotine patches for the past 2 weeks, but she is having extreme, vivid nightmares. She emphasizes that these nightmares have been preventing her from getting a good night’s sleep. What counseling points should the pharmacist provide PL regarding the appropriate timing of nicotine patch placement and removal to mitigate this adverse reaction?
A: PL should be counseled that vivid dreams and insomnia are common adverse effects of the nicotine patch. The pharmacist should recommend that PL remove the nicotine patch at bedtime to manage these effects. The pharmacist additionally should counsel PL to seek medical attention for possible alternative smoking cessation options if she continues to experience vivid nightmares and insomnia despite removal of the patch at bedtime.2,5
CASE 4: Nicotine gum
Q: JC is a 58-year-old man who presents to the pharmacy looking for nicotine gum that his physician recommended to help him quit smoking. He has been smoking for more than 20 years and believes it is time to quit because he has recently become a grandfather. He is nervous to quit smoking because he has failed every time he has tried. He further explains that he smokes 1 pack of cigarettes daily and his first cigarette is within 10 minutes of waking in the morning. What dose of nicotine gum should the pharmacist recommend, and what are some additional counseling points that JC should know about?
A: The pharmacist should recommend the 4-mg nicotine gum to JC because he has his first cigarette within 30 minutes of waking in the morning. The pharmacist should thoroughly counsel JC on how to use the nicotine gum. JC should be counseled to briefly chew the gum until his mouth has a tingling sensation. He should then place the gum inside his cheek until the tingling sensation is gone. Each time that tingling sensation is gone after placing the gum in the cheek, he should repeat this chew-and-place method for up to 30 minutes. He should be counseled to have a 4-mg piece of nicotine gum approximately every 1 to 2 hours. Eating and drinking should be avoided within 15 minutes before and during nicotine gum use. Additionally, the pharmacist should counsel on the adverse effects of nicotine gum, including mouth irritation, jaw soreness, heartburn, and nausea.2,5
About the Authors
Kylie Helfenbein, PharmD, is a PGY-2 pharmacy resident at Atlantic Health System in Morristown, New Jersey.
Deanna Fox, PharmD, is a PGY-2 pharmacy resident at Atlantic Health System in Morristown, New Jersey.
Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and a transitions- of-care clinical pharmacist at Morristown Medical Center in New Jersey.
References
Krist AH, Davidson KW, Mangione CM, et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventative Services Task Force recommendation statement. JAMA. 2021;325(3):265-279. doi:10.1001/jama.2020.25019
Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC expert consensus decision pathway on tobacco cessation treatment: a report of the American College of Cardiology task force on clinical expert consensus documents. J Am Coll Cardiol. 2018;72(25):3332-3365. doi:10.1016/j.jacc.2018.10.027
