What are the recommended treatments for smoking cessation?

Recommended Treatments for Smoking Cessation

The most effective approach for smoking cessation is combining pharmacotherapy (either combination nicotine replacement therapy or varenicline) with behavioral therapy, which significantly improves cessation rates compared to either approach alone. 1

First-Line Pharmacotherapy Options

Preferred Primary Therapies:

1. Combination Nicotine Replacement Therapy (NRT)

   • Standard regimen: 21 mg patch + short-acting NRT (lozenge, gum, inhaler, or nasal spray)
   • Duration: Minimum 12 weeks
   • If 21 mg patch is insufficient, consider increasing to 35-42 mg patch
   • Blood nicotine levels from NRT are significantly lower than from cigarettes, making toxicity rare

2. Varenicline

   • Dosing schedule:
     • Days 1-3: 0.5 mg once daily
     • Days 4-7: 0.5 mg twice daily
     • Weeks 2-12: 1 mg twice daily
   • Begin 1 week before target quit date, or patient can quit between days 8-35 of treatment
   • For successful quitters, an additional 12 weeks is recommended to increase long-term abstinence
   • Cautions: Monitor for nausea (common), neuropsychiatric effects, and avoid in patients with brain metastases due to seizure risk 1, 2

Behavioral Therapy Components

• Recommended intensity: Four or more sessions during each 12-week course of pharmacotherapy
• Session duration: 10-30+ minutes per session (longer sessions linked to higher success rates)
• First session: Within first 2-3 weeks of treatment
• Format options: Individual or group therapy, in-person and/or by phone
• Provider: Tobacco treatment specialist or trained staff member
• Content: Skills training, social support, motivational interviewing, educational materials
• At minimum: Brief advice (even 3 minutes) by healthcare providers increases quit rates 1

Treatment Algorithm

1. Initial Assessment:

   • Document smoking status
   • Assess nicotine dependency:
     • Cigarettes per day
     • Time to first cigarette after waking
     • Use of other tobacco/nicotine products
   • Review history of quit attempts and previous treatments
   • Evaluate readiness to quit

2. First-Line Treatment:

   • Start either combination NRT or varenicline
   • Implement behavioral therapy concurrently
   • Schedule follow-up within 2-3 weeks

3. For Persistent Smoking or Relapse:

   • Continue initial therapy or switch to the other primary option
   • Intensify behavioral therapy
   • Consider subsequent options only after trying both primary therapies:
     • Combination NRT with bupropion
     • Bupropion alone (less effective than primary options)
     • Extended duration of pharmacotherapy

4. Follow-up Protocol:

   • Assess smoking status and medication side effects within 2-3 weeks
   • Continue follow-up at minimum 12-week intervals
   • Evaluate at 6 and 12 months for sustained abstinence

Common Pitfalls and Considerations

• Relapse management: Smoking slips and relapses are common and expected. They don't necessarily indicate need for alternative treatment - the same therapy may work with continued effort 1

• Medication adherence: Often inadequate, making behavioral therapy crucial for supporting proper medication use

• Neuropsychiatric effects: Monitor for mood changes, psychosis, hallucinations, suicidal ideation with varenicline 2, 3

• Underutilization of treatment: Most smokers attempt to quit without evidence-based treatments. Females, whites, older, more educated and wealthier smokers are more likely to use treatments 4

• Gradual approach option: For patients unwilling to quit abruptly, varenicline can be used with a gradual reduction approach (50% reduction in first 4 weeks, another 50% in next 4 weeks, complete cessation by 12 weeks) 2

• Dose adjustments: Consider for patients experiencing side effects or with renal impairment 2

• Comorbid conditions: Depression, anxiety, and stress are common in smokers and can trigger relapse, requiring specialized behavioral interventions 1

By implementing this comprehensive approach combining the most effective pharmacotherapy with appropriate behavioral support, patients have the best chance of achieving long-term smoking cessation and reducing smoking-related morbidity and mortality.