What is the best nicotine replacement therapy recommendation for a patient who smokes 20 cigarettes a day and smokes their first cigarette after 60 minutes awake?

The recommendation of a 21 mg nicotine patch for a patient who smokes 20 cigarettes a day and waits for 60 minutes before smoking their first cigarette is based on the patient's level of nicotine dependence. A key aspect in determining the appropriate nicotine replacement therapy (NRT) dosage is the number of cigarettes smoked daily, as well as the first cigarette timing after waking.

Since this patient smokes a significant number of cigarettes daily, the higher-dose patch (21 mg) is appropriate to address their higher levels of nicotine dependence. The fact that they wait an hour to smoke their first cigarette suggests they have a notable level of control over their smoking behavior when they first wake up, yet smoking 20 cigarettes indicates a strong addiction overall.

Using the 21 mg patch allows for sustained nicotine delivery throughout the day, which helps to alleviate withdrawal symptoms and cravings effectively. The recommended duration of therapy (28-42 days) aligns with clinical guidelines that suggest using the patch consistently for an adequate period, which supports the long-term effort to quit smoking.

The other options provide lower doses of nicotine or different dosing regimens that may not adequately support a patient with this level of dependence, possibly leading to insufficient relief from cravings and withdrawal symptoms.