What is the most effective smoking cessation modality?

From the Guidelines

The most effective smoking cessation modality is a combination of behavioral therapy and pharmacotherapy, as it has been shown to increase tobacco smoking cessation rates compared to either usual care or pharmacotherapy alone. This approach is supported by the US Preventive Services Task Force recommendation statement, which found that combining behavioral and pharmacotherapy interventions leads to higher cessation rates 1. The most effective pharmacotherapy agents are combination nicotine replacement therapy (NRT) and varenicline, with high-intensity behavior therapy with multiple counseling sessions being the most effective form of behavioral therapy 1.

Some key points to consider when implementing this approach include:

• Starting medication 1-2 weeks before the quit date and combining it with counseling to double success rates
• Setting a specific quit date, identifying triggers, developing coping strategies, and seeking support from healthcare providers or quit lines (1-800-QUIT-NOW) to improve long-term abstinence rates
• Using a long-acting nicotine patch (21 mg/24 hours for those smoking >10 cigarettes daily, stepping down over 8-12 weeks) alongside a short-acting form like gum, lozenge, or inhaler for breakthrough cravings
• Considering varenicline, which works by partially activating nicotine receptors while blocking nicotine binding, as a first-line pharmacotherapy option
• Providing motivational counseling and support to encourage continued smoking cessation attempts, as smoking relapse and brief slips are common 1.

It's also important to note that smoking cessation should be offered as part of oncology treatment and continued throughout the entire oncology care continuum, including during end-of-life care, with an emphasis on patient preferences and values 1. Additionally, referral to specialized smoking cessation programs or behavior therapists with expertise in treating comorbid substance dependence and mental health disorders may be beneficial for patients with cancer or other complex needs 1. Overall, a comprehensive and multi-faceted approach to smoking cessation is essential for achieving the best possible outcomes.

From the FDA Drug Label

The efficacy of varenicline in smoking cessation was demonstrated in six clinical trials in which a total of 3659 chronic cigarette smokers (≥10 cigarettes per day) were treated with varenicline. Forty-five percent of patients receiving varenicline 1 mg per day (0. 5 mg twice daily) and 51% of patients receiving 2 mg per day (1 mg twice daily) had CO-confirmed continuous abstinence during weeks 9 through 12 compared to 12% of patients in the placebo group

The most effective smoking cessation modality among the ones mentioned is varenicline, with a 51% success rate in achieving CO-confirmed continuous abstinence during weeks 9 through 12 at a dose of 2 mg per day 2.

From the Research

Smoking Cessation Modalities

The most effective smoking cessation modality is a combination of pharmacotherapy and behavioral interventions.

• Studies have shown that combining physiological approaches with counseling significantly increases the odds of quitting compared to either technique alone 3.
• A review of current recommendations for smoking cessation found that abstinence rates for pharmacotherapies range from approximately 16% to approximately 30% at 1-year follow-up, with efficacy odds ratios (ORs) compared with placebo of approximately 1.7 for nicotine replacement therapy (NRT), approximately 1.9 for bupropion sustained release, and approximately 3.0 for varenicline 3.
• Behaviour modification therapies have achieved quit rates of between 8% and 43% for up to 1 year, with ORs in comparison to no treatment of between approximately 1.2 and approximately 2.2 3.

Combination Therapy

Combining pharmacotherapy and behavioural support has been shown to increase smoking cessation success compared to a minimal intervention or usual care 4.

• A meta-analysis of 52 studies found high-quality evidence for a benefit of combined pharmacotherapy and behavioural treatment compared to usual care, brief advice, or less intensive behavioural support, with a risk ratio (RR) of 1.83 (95% CI 1.68 to 1.98) 4.
• The use of varenicline, a partial agonist of the alpha4beta2 nicotinic acetylcholine receptor, has been shown to be effective in smoking cessation, with a higher success rate compared to other pharmacotherapies such as NRT and bupropion 5, 6.

Comparison of Modalities

Comparing the effectiveness of different smoking cessation modalities,

• Varenicline has been shown to be more effective than NRT, with a 50% higher success rate compared to nicotine patch and 70% higher success rate compared to nicotine gum 5.
• A combination of NRT patch and oral nicotine forms has been shown to be as effective as varenicline 5.
• Behavioural counselling, such as motivational interviewing and cognitive behaviour therapy, has also been shown to be effective in smoking cessation, although access to these treatments may be limited 5, 6.