What are the recommended medications and therapies for smoking cessation in individuals with anxiety?

Medications and Therapies for Smoking Cessation in Individuals with Anxiety

For individuals with anxiety who want to quit smoking, the most effective approach is combination therapy with behavioral interventions plus pharmacotherapy, specifically varenicline or combination nicotine replacement therapy (NRT), along with appropriate management of the underlying anxiety disorder.

First-Line Pharmacotherapy Options

1. Varenicline (Chantix)

• Dosing: Begin 1 week before quit date with titration schedule:
  • Days 1-3: 0.5 mg once daily
  • Days 4-7: 0.5 mg twice daily
  • Day 8-end of treatment: 1 mg twice daily 1
• Duration: 12 weeks standard; additional 12 weeks if successful to increase long-term abstinence
• Efficacy: Highest cessation rates among monotherapies (approximately 28% vs 12% with placebo) 2, 3
• Special considerations for anxiety patients:
  • Monitor for worsening anxiety or mood changes
  • Reports of treatment-emergent agitation, depressed mood, and behavioral changes require immediate discontinuation 2
  • Consider lower starting dose in patients with severe anxiety

2. Combination NRT

• Components: Long-acting form (patch) + short-acting form (gum/lozenge/inhaler/nasal spray)
• Efficacy: Very high cessation rates (approximately 31.5% vs 10.6% with placebo) 3
• Advantage for anxiety patients: More gradual nicotine reduction may help manage withdrawal symptoms that could exacerbate anxiety

3. Bupropion SR

• Dosing: Begin 1-2 weeks before quit date
• Efficacy: Moderate (approximately 19.1% vs 10.6% with placebo) 3
• Caution: May increase anxiety in some patients; has FDA boxed warning regarding suicidal behavior 4

Behavioral Interventions (Essential Component)

Behavioral therapy significantly enhances medication effectiveness and should always be included 2:

1. Cognitive-Behavioral Therapy (CBT)

• Particularly effective for anxiety patients
• Key components:
  • Identifying smoking triggers
  • Developing coping skills for stress and anxiety
  • Problem-solving for high-risk situations
  • Addressing anxiety-specific barriers to quitting 2

2. Counseling Structure

• Intensity: Four or more sessions during 12-week pharmacotherapy
• Duration: 10-30+ minutes per session
• First session: Within 2-3 weeks of starting medication 2
• Format options: Individual or group counseling, in-person or telephone

3. Motivational Interviewing Techniques

• Particularly helpful for anxiety patients:
  • Express empathy
  • Develop discrepancy between smoking behavior and goals
  • Roll with resistance
  • Support self-efficacy 2

Algorithm for Patients with Anxiety

1. Assessment:

   • Evaluate severity of nicotine dependence
   • Assess anxiety symptoms and current treatment
   • Screen for depression and other mental health conditions
   • Review prior quit attempts

2. Treatment Selection:

   • First choice: Varenicline + CBT (if no history of severe anxiety exacerbation with varenicline)
   • Alternative first choice: Combination NRT + CBT (if concerned about varenicline side effects)
   • Second choice: Bupropion + CBT (if varenicline and NRT contraindicated or unsuccessful)

3. Anxiety Management During Cessation:

   • Ensure anxiety disorder is adequately treated before quit attempt
   • Consider referral to mental health specialist for concurrent anxiety treatment
   • For patients with elevated anxiety/depression, specialized smoking cessation programs with staff trained in mental health disorders are optimal 2

4. Monitoring and Follow-up:

   • Assess within 2-3 weeks after starting therapy
   • Regular follow-up at 12-week intervals
   • Monitor for nicotine withdrawal symptoms (peak within 1-2 weeks)
   • Evaluate for anxiety exacerbation or mood changes

Special Considerations for Anxiety Patients

• Higher relapse risk: Anxiety is a known risk factor for smoking relapse 2
• Withdrawal symptoms: May mimic or exacerbate anxiety (irritability, restlessness, difficulty concentrating)
• Medication adjustments: May need lower starting doses or more gradual titration
• Additional support: More frequent counseling sessions may be beneficial

Common Pitfalls to Avoid

1. Undertreating anxiety: Ensure underlying anxiety disorder is adequately treated before or concurrent with smoking cessation
2. Ignoring medication interactions: Some anxiety medications may interact with smoking cessation pharmacotherapy
3. Insufficient behavioral support: Relying solely on medications without adequate counseling reduces success rates 2
4. Premature discontinuation: Nicotine withdrawal symptoms peak within 1-2 weeks; encourage continued therapy through brief slips 2
5. Missing relapse risk factors: Regularly assess for risk factors including elevated anxiety, stress, depression, and exposure to smokers 2

By implementing this comprehensive approach that addresses both smoking cessation and anxiety management, patients have the best chance of successfully quitting smoking while maintaining their mental health.