Jackson is a 37-year-old male with a 10-year 1-PPD smoking history. He has no other health history and his last physical exam 6 months ago was normal. He is motivated to quit and has been unsuccessful with OTC smoking cessation products. In the past 3 months, he has intermittently tried nicotine gum and lozenges. He is requesting a prescriptive option. What is your treatment recommendation for this patient? What important medication information regarding adherence, side effects, and follow-up should be included? What non-pharmacologic treatment education should Jackson receive?

Jackson is a 37-year-old male with a 10-year 1-PPD smoking history. He has no other health history and his last physical exam 6 months ago was normal. He is motivated to quit and has been unsuccessful with OTC smoking cessation products. In the past 3 months, he has intermittently tried nicotine gum and lozenges. He is requesting a prescriptive option. What is your treatment recommendation for this patient? What important medication information regarding adherence, side effects, and follow-up should be included? What non-pharmacologic treatment education should Jackson receive?

Jackson Treatment Recommendation

Pharmacological Options

Cessation of smoking is associated with numerous health benefits. Statistically, tobacco smoking accounts for about 480,000 deaths in the United States (Selby & Zawertailo, 2022). The treatment recommendation for Jackson will include pharmacological agents, which are non-nicotine drugs approved by the Food and Drug Administration (FDA) for smoking cessation. The treatment plan should have medications recommended in guidelines for patients with smoking addiction who want to cease smoking. The medications include varenicline, sustained-release bupropion, and nicotine replacement therapies (short- and long-acting) (Selby & Zawertailo, 2022). The medications are available in tablet form for oral formulation and should be taken under prescription due to some of their side effects.

Varenicline, a selective alpha4-beta2 nicotinic receptor partial agonist, works by reducing patients’ cravings for smoking and withdrawal symptoms (Sealock & Sharma, 2019). At the same time, the drug blocks the binding of smoked nicotine to its receptors preventing the exertion of nicotine effects which is the primary addictive compound of tobacco. Due to its partial agonism, varenicline significantly reduces the mesolimbic dopamine system stimulation, which is implicated in nicotine addiction (Sealock & Sharma, 2019).

The patient should be above 18 years old to obtain the prescription, and therefore Jackson needs 0.5mg oral given once daily on day 1 to 3, 0.5mg BD from day 4 to day 7, and from day 8 to week 11, the patient should be on 1mg (Singh & Saadabadi, 2020). Depending on the patient’s response, treatment can be offered for as long as six months (Singh & Saadabadi, 2020). The patient should be advised on compliance with the medication, as failure to comply can result in relapses. Common adverse effects of varenicline include headaches, insomnia, abnormal dreams, and nausea. Others include renal failure, Stevens-Johnson syndrome, and acute pancreatitis (Singh & Saadabadi, 2020). Therefore, Jackson should be monitored closely to ensure his adherence to therapy and to make sure there are minimal side effects.

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Bupropion is an antidepressant medication introduced for smoking cessation in 1997. Its effects on norepinephrine and dopamine and responsible for its clinical features. The inhibition of dopamine reuptake associated with bupropion therapy is very high, making it potent for smoking cessation therapy. Drug reinforcement in addiction is through nicotine’s effects on dopamine receptors; therefore, mitigating it reduces smoking (Sealock & Sharma, 2019).

Jackson can be prescribed with oral bupropion, either immediate or extended-release tablets. Immediate-release tablets are available in 75 and 100mg strength, while extended-release tablets can be 12 and 24-hour hydrochloride salt formulations ranging from 100 to 200 mg tablets (Huecker et al., 2020). The drug can be taken with or without meals. However, as Huecker et al. (2020) established, associated side effects include tachycardia, diaphoresis, weight loss, dry mouth, constipation, and nausea. The patient should be encouraged to adhere to achieve the maximum benefit of the drug. Side effects should be watched out for to necessitate action.

Non-Pharmacologic Options

Counseling and behavioral approaches are effective in encouraging smoking cessation. According to Selby and Zawertailo (2022), using counseling as a stand-alone intervention or as an adjunct to medication results in improved outcomes among patients with smoking addiction. The health care provider can offer Jackson counseling services in scheduled in-person visits, by using telehealth services, or by sending text messages. Brief behavioral interventions that Jackson can be encouraged to try to reduce his smoking include setting a quit day within one month (30 days) as this increases his smoking cessation rate. As Selby and Zawertailo (2022) note, there is enough data linking the effectiveness of brief behavioral intervention therapy and its efficacy in reducing smoking addiction. Other effective behavioral and counseling strategies for smoking cessation that can help Jackson include contingency management, which entails using incentives, group counseling, and text messaging.

Follow-up

This will depend on the intervention taken. Jackson should be followed up every two weeks to monitor his response to prescribed drugs and compliance and ensure the patient is not experiencing any side effects.

References

Huecker, M. R., Smiley, A., & Saadabadi, A. (2020). Bupropion. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470212/

Sealock, T., & Sharma, S. (2019, February 17). Smoking Cessation. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482442/

Selby, P., & Zawertailo, L. (2022). Tobacco addiction. The New England Journal of Medicine, 387(4), 345–354. https://doi.org/10.1056/NEJMcp2032393

Singh, D., & Saadabadi, A. (2020). Varenicline. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534846/

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Jackson is a 37-year-old male with a 10-year 1-PPD smoking history. He has no other health history and his last physical exam 6 months ago was normal. He is motived to quit and has been unsuccessful with OTC smoking cessation products. In the past 3 months, he has intermittently tried nicotine gum and lozenges. He is requesting a prescriptive option. What is your treatment recommendation for this patient? What important medication information regarding adherence, side effects, and follow-up should be included? What non-pharmacologic treatment education should Jackson receive?