From the Guidelines
Nicotine withdrawal symptoms can be effectively managed through a combination of medication and behavioral strategies, with a minimum of 12 weeks of combination NRT or varenicline recommended for the initial quit attempt, as stated in the 2016 NCCN clinical practice guidelines in oncology 1.
Medication Options
- Nicotine replacement therapy (NRT) is first-line and includes patches, gum, lozenges, nasal spray, or inhalers
- Non-nicotine options include bupropion SR or varenicline
- Combining NRT with bupropion or varenicline can increase success rates, as supported by the Cochrane network meta-analysis data published in 2013 1
Behavioral Strategies
- Behavioral therapy, tailored to the patient’s nicotine dependence and previous quit attempts, provides strategies for coping with nicotine withdrawal symptoms, identifying smoking triggers, and addressing other patient-specific barriers to and facilitators of smoking behavior change 1
- Motivational counseling is beneficial for all patients, including those unwilling to quit, and includes exploring the smoker’s feelings, beliefs, ideas, and values to identify areas for change towards willingness to quit 1
- Specialized treatment centers may consider providing smoking cessation therapy targeted specifically to patients with cancer, with access to counselors or group leaders experienced in the treatment of patients with cancer 1
Withdrawal Symptoms
- Withdrawal symptoms typically peak within 1–2 weeks after quitting and then subside, as stated in the 2016 NCCN clinical practice guidelines in oncology 1
- Symptoms may include irritability, anxiety, difficulty concentrating, increased appetite, and intense cravings
- Weight gain is also a common symptom, with a mean weight gain attributable to smoking cessation of 2.8 and 3.8 kg in males and females, respectively, as reported in the 2010 Annals of Oncology study 1
From the Research
Nicotine Withdrawal Symptoms
- Nicotine withdrawal symptoms can be distressing for smokers trying to quit, and nicotine replacement therapy (NRT) was developed to overcome these symptoms 2.
- NRT provides effective treatment for tobacco dependence, typically doubling success rates compared with placebo 3.
- The rationale for combining NRT medications is that smokers may need both a slow delivery system to achieve a constant concentration of nicotine to relieve cravings and tobacco withdrawal symptoms, as well as a faster acting preparation that can be administered on demand for immediate relief of breakthrough cravings and withdrawal symptoms 3.
Treatment Options for Nicotine Withdrawal
- Different modes of NRT administration include inhalation and buccal or transdermal absorption 2.
- Orally administered non-nicotine drugs such as varenicline and bupropion are also regarded as first-line treatments, either used alone or as an adjunct to NRT 2.
- Combination NRT has the potential to provide effective treatment of tobacco dependence in persons whose dependence is refractory to currently available treatments 3.
- Combination pharmacotherapy is indicated for highly nicotine-dependent smokers, patients who have failed with monotherapy, and patients with breakthrough cravings 4.
Effectiveness of Nicotine Replacement Therapy
- The odds ratio for abstinence with NRT compared to control was 1.74 (95% confidence interval 1.64 - 1.86), indicating that NRT is effective in achieving abstinence from cigarettes 5.
- The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker 5.
- There is promising evidence that bupropion may be more effective than NRT (either alone or in combination) 5.
- Combination NRT has been shown to be effective in relieving withdrawal and enabling cessation, but the findings are not robust and additional research is warranted to better understand the magnitude and generality of the benefits of combination therapy 3.