What are the recommended medications for smoking cessation?

Recommended Medications for Smoking Cessation

The first-line medications for smoking cessation are combination nicotine replacement therapy (NRT) and varenicline, with varenicline showing superior efficacy for long-term abstinence compared to other options. 1

First-Line Pharmacotherapy Options

1. Varenicline (Chantix)

• Mechanism: Partial agonist at α4β2 nicotinic acetylcholine receptors
• Dosing:
  • Start 1-2 weeks before quit date
  • Days 1-3: 0.5 mg once daily
  • Days 4-7: 0.5 mg twice daily
  • Week 2-12: 1 mg twice daily (if tolerated)
• Efficacy: Highest abstinence rates among all medications (33.2% at 6 months vs 11.5% for placebo) 1
• Duration: Minimum 12 weeks; may extend to 6 months-1 year for continued cessation 1

2. Combination Nicotine Replacement Therapy (NRT)

• Components: Long-acting nicotine patch + short-acting NRT (gum, lozenge, inhaler, or nasal spray)
• Dosing:
  • 21 mg patch daily + short-acting NRT as needed for breakthrough cravings
  • For insufficient response, consider increasing to 35 or 42 mg patch 1
• Duration: Minimum 12 weeks 1

3. Bupropion SR

• Mechanism: Norepinephrine and dopamine reuptake inhibitor
• Dosing:
  • Start 1-2 weeks before quit date
  • 150 mg once daily for 3 days, then 150 mg twice daily
• Duration: 7-12 weeks 1
• Efficacy: Increases cessation rates compared to placebo (19.7% vs 11.5% at 6+ months) 1, 2

Comparative Efficacy

1. Varenicline vs. Bupropion:

   • Varenicline is significantly more effective than bupropion for smoking cessation
   • Continuous abstinence rates at 9-12 weeks: OR = 1.79 (CI: 1.59-2.02) 2
   • Long-term abstinence at 52 weeks: OR = 1.60 (CI: 1.22-2.12) 2

2. Combination NRT vs. Single NRT:

   • Combination NRT is more effective than single NRT products 1

3. Bupropion + NRT:

   • More effective than bupropion alone (RR 1.24, CI 1.06-1.45) 3

Treatment Algorithm

1. Initial Treatment Choice:

   • Start with either varenicline OR combination NRT based on:
     • Patient preference
     • Contraindications
     • Previous cessation attempts
     • Comorbidities

2. If First Treatment Fails:

   • Try the other first-line option not previously used
   • Consider combination therapy (bupropion + NRT)
   • Consider extended treatment duration
   • Consider higher doses of NRT 1

Special Considerations

Contraindications and Precautions

1. Varenicline:

   • Monitor for neuropsychiatric symptoms, especially in patients <24 years
   • Contraindicated in patients with brain metastases due to seizure risk 1
   • Common side effect: nausea (may need management, especially in cancer patients) 1

2. Bupropion:

   • Contraindicated in patients with seizure disorders or conditions lowering seizure threshold
   • Contraindicated with brain metastases, MAO inhibitors, and closed-angle glaucoma 3
   • Monitor for neuropsychiatric symptoms

3. NRT:

   • Generally well-tolerated even when used with continued smoking
   • Blood nicotine levels from NRT are significantly less than from smoking cigarettes 1

Behavioral Support

All pharmacotherapy should be paired with behavioral counseling:

• Four or more sessions during each 12-week course of pharmacotherapy
• First session within 2-3 weeks of starting
• Session duration: 10-30+ minutes (longer sessions linked to higher success rates)
• Individual or group therapy, in-person and/or by phone 1

Follow-up Recommendations

• Assessment within 2-3 weeks of initiating therapy
• Periodic follow-up during therapy (at minimum 12-week intervals)
• Follow-up after completion of therapy
• Monitor for withdrawal symptoms (typically peak within 1-2 weeks of quitting)
• Encourage continued therapy through brief slips 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Minimum 12 weeks recommended; consider extended treatment for those at high risk of relapse
2. Failure to combine pharmacotherapy with behavioral support: Combined approach is more effective than either alone
3. Inadequate dosing: Consider dose adjustments if initial response is insufficient
4. Premature discontinuation: Encourage patients to continue therapy despite brief slips
5. Ignoring comorbidities: Patients with psychiatric conditions may need specialized approaches

By following this evidence-based approach to smoking cessation pharmacotherapy, clinicians can significantly improve patients' chances of successfully quitting smoking and reducing their risk of smoking-related morbidity and mortality.