What is the most effective approach for quitting nicotine?

From the Guidelines

The most effective approach for quitting nicotine is a combination of pharmacologic therapy and behavior therapy, with varenicline being the most effective pharmacotherapy agent, as evidenced by a 2023 study 1. This approach leads to the best results for smoking cessation, as supported by the 2016 NCCN clinical practice guidelines in oncology 1. The two most effective pharmacotherapy agents are combination nicotine replacement therapy (NRT) and varenicline, with combination NRT incorporating long-term and fast-acting NRT offering the greatest potential benefits for smokers 1. Some key steps to quitting nicotine include:

• Using nicotine replacement therapy (NRT) such as patches (21mg/24hr for those who smoke more than 10 cigarettes daily, stepping down to 14mg and 7mg over 8-12 weeks), combined with a faster-acting form like nicotine gum (2-4mg as needed) or lozenges to manage breakthrough cravings
• Prescribing medications like varenicline (Chantix, 0.5mg once daily for days 1-3, then 0.5mg twice daily for days 4-7, then 1mg twice daily for 12 weeks) or bupropion (Zyban, 150mg daily for 3 days, then 150mg twice daily for 7-12 weeks) to nearly double the chances of quitting successfully
• Pairing medication with behavioral support through counseling, support groups, or quitlines (1-800-QUIT-NOW)
• Setting a specific quit date, identifying and planning for triggers, and considering gradual reduction before completely quitting
• Utilizing web-based resources such as the American Lung Association Freedom From Smoking, National Cancer Institute, Asian Smokers’ Quitline, and BecomeAnEX, which offer support and guidance for quitting smoking 1 These approaches work by addressing both the physical addiction (medications help manage withdrawal symptoms by either providing controlled nicotine or affecting brain receptors) and psychological dependence (behavioral strategies help break habitual patterns), as noted in the 2016 study 1. Most people require multiple quit attempts before succeeding permanently, so persistence is key even if relapse occurs, as emphasized in the 2016 NCCN clinical practice guidelines in oncology 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Patients must desire to stop smoking and should be instructed to stop smoking completely as they begin using NICOTROL Inhaler. The initial dosage of NICOTROL Inhaler is individualized. Patients may self titrate to the level of nicotine they require. The recommended duration of treatment is 3 months, after which patients may be weaned from the NICOTROL Inhaler by gradual reduction of the daily dose over the following 6 to 12 weeks.

The most effective approach for quitting nicotine involves:

• Setting a quit date: Patients should be instructed to stop smoking completely as they begin treatment.
• Individualized dosage: The initial dosage of NICOTROL Inhaler is individualized, and patients may self-titrate to the level of nicotine they require.
• Gradual reduction: After 3 months of treatment, patients may be weaned from the NICOTROL Inhaler by gradual reduction of the daily dose over the following 6 to 12 weeks.
• Supportive care: Patients are more likely to quit smoking if they are seen frequently and participate in formal smoking cessation programs 2.
• Alternative approaches: Varenicline was evaluated in a double-blind, placebo-controlled trial where patients were instructed to select a target quit date between Day 8 and Day 35 of treatment, and in another study, varenicline was evaluated in a 52-week double-blind placebo-controlled study of 1,510 subjects who were not able or willing to quit smoking within four weeks, but were willing to gradually reduce their smoking over a 12 week period before quitting 3.

From the Research

Effective Approaches to Quitting Nicotine

The most effective approach to quitting nicotine involves a combination of counseling, behavioral interventions, and pharmacologic smoking cessation aids 4, 5, 6, 7, 8.

• Counseling and Behavioral Interventions: Providing counseling and behavioral support can significantly increase the chances of successful smoking cessation 4, 5. Brief physician advice, proactive telephone counseling, group and individual counseling, and use of quit lines are all effective non-pharmacologic interventions 5.
• Pharmacologic Smoking Cessation Aids: Nicotine replacement therapy (NRT), bupropion, and varenicline are all effective pharmacologic smoking cessation aids 4, 5, 6, 7, 8. Combination pharmacotherapy, such as combining NRT with bupropion or varenicline, may be indicated for highly nicotine-dependent smokers or those who have failed with monotherapy 4.
• Comparison of Pharmacologic Aids: Varenicline has been shown to be more effective than single forms of NRT and bupropion in achieving long-term abstinence 7. Combination NRT has also been shown to be effective, and may be equally effective as varenicline 7.
• Other Treatments: Other treatments, such as nortriptyline, clonidine, and cytisine, may also be effective in achieving smoking cessation, although more research is needed to fully understand their benefits and risks 7, 8.

Steps to Quitting Nicotine

Based on the evidence, the following steps can be taken to quit nicotine:

• Get counseling and support: Seek counseling and support from a healthcare professional or a quit line to increase chances of success 4, 5.
• Choose a pharmacologic aid: Select a pharmacologic smoking cessation aid, such as NRT, bupropion, or varenicline, and use it as directed 4, 5, 6, 7, 8.
• Combine treatments: Consider combining pharmacologic aids, such as using NRT with bupropion or varenicline, for increased effectiveness 4, 7.
• Be persistent: Quitting nicotine is a challenging process, and it may take multiple attempts to succeed. Be persistent and do not give up 4, 8.