Smoking Cessation Orders

Indication: For relief of nicotine withdrawal symptoms and used as part of a comprehensive behavioral smoking-cessation program

See guidelines on back for selection of readiness to quit stage, standard dose nicotine replacement therapy (NRT) versus High Dose NRT and selection of patch strength.

1. Degree of Dependence (check all that apply)

	High	Y	Low	Y
Uses tobacco after awakening in the morning	Less than 30 minutes		Over 30 Minutes
Wakes up at night to smoke	If yes than high dependence
Smokes more than 26 cigarettes a day	If yes then high dependence

2. MEDICATIONS: Choose one of each (Basal and PRN)

Basal Nicotine Replacement Therapy

Nicotine Patch, topical every 24 hours, and rotate sites daily.

£ 7 mg

£ 14 mg

£ 21 mg

PRN Nicotine Replacement Therapy

£ Nicotine gum 2mg. Chew one gum slowly every 1 hour prn desire to smoke.

Do not exceed 24 pieces per day. (For low dependence)

£ Nicotine gum 4mg. Chew one gum slowly every 1 hour prn desire to smoke.

Do not exceed 12 pieces per day. (For high dependence)

Non-Nicotine Replacement Therapy

£ Bupropion SR 150mg po daily x 3 days, then one po BID in the am and at noon.

(Do not use if history of seizure)

£ Bupropion XL 150mg po daily.

£ Clonidine 0.1mg tablet. Take ½ tablet po bid

£ Clonidine patch TTS-1 Apply one patch topically once a week.

£ Nortriptyline 25mg po daily at bedtime.

3. Dietary consult

4. Smoking cessation counseling

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