What are the recommended treatments for smoking cessation?

Smoking Cessation Treatment Recommendations

Combination nicotine replacement therapy (NRT) using a nicotine patch plus a short-acting form (lozenge, gum, inhaler, or nasal spray) OR varenicline are the most effective first-line pharmacotherapies for smoking cessation and should be prescribed for a minimum of 12 weeks, along with behavioral counseling. 1

First-Line Pharmacotherapy Options

Option 1: Combination NRT

• Standard regimen: 21 mg patch (continuous) plus short-acting NRT for breakthrough cravings 2
• Duration: Minimum 12 weeks, may extend to 6-12 months for continued cessation 2
• Effectiveness: Nearly 3 times more effective than placebo (OR 2.73) and 34% more effective than single NRT forms 1
• Safety: Blood nicotine levels from NRT are significantly lower than from cigarettes; NRT is well-tolerated with rare nicotine toxicity 2

Option 2: Varenicline (Chantix)

• Standard regimen: Start with 0.5 mg once daily (days 1-3), then 0.5 mg twice daily (days 4-7), then 1 mg twice daily 3
• Duration: Minimum 12 weeks; additional 12 weeks recommended for successful quitters 3
• Mechanism: Partial agonist at α4β2 nicotinic receptors - reduces withdrawal symptoms while blocking rewarding effects of nicotine 4
• Effectiveness: Increases abstinence rates from approximately 12% (placebo) to 28% 2

Behavioral Support Components

Behavioral support should be combined with pharmacotherapy for optimal results:

• Session frequency: Four or more sessions during each 12-week course 2
• Session duration: 10-30+ minutes per session 2
• Content: Skills training, social support, motivational interviewing 2
• Delivery options: Individual or group therapy, in-person and/or by phone 2
• Provider: Tobacco treatment specialist or trained staff member 2
• Minimum intervention: Brief advice (3 minutes) by healthcare providers 2

Follow-up Protocol

• First follow-up: Within 2-3 weeks after starting pharmacotherapy 2
• Subsequent follow-ups: At minimum 12-week intervals during therapy 1
• Assessment: Smoking status, medication side effects, withdrawal symptoms 2
• Long-term follow-up: At 6 and 12 months after successful quitting 1

Treatment Algorithm

1. Initial assessment:

   • Determine nicotine dependence level
   • Assess for contraindications to medications
   • Check for comorbidities (cardiovascular disease, psychiatric conditions)

2. First-line treatment:

   • Prescribe combination NRT or varenicline
   • Provide behavioral counseling (minimum 4 sessions)
   • Set quit date (1 week after starting varenicline or immediately with NRT)

3. For persistent smoking or relapse:

   • Continue initial therapy OR switch to alternative first-line option 2
   • Consider dose adjustments as clinically indicated 2
   • Intensify behavioral support 2

4. Second-line options (if first-line fails):

   • Bupropion SR (increases cessation rates from 11% to 19%) 2
   • Extended duration of pharmacotherapy 2
   • More intensive behavioral therapy 2

Common Pitfalls to Avoid

• Inadequate treatment duration: Minimum 12 weeks required; premature discontinuation reduces success
• Monotherapy instead of combination: Combination approaches are more effective
• Insufficient behavioral support: Adding counseling to NRT nearly triples success rates 1
• Failure to adjust dosing: Consider dose adjustments for side effects or inadequate response
• Not preparing for withdrawal: Symptoms typically peak within 1-2 weeks of quitting 2
• Premature discontinuation due to minor side effects: Most side effects are transient

Special Considerations

• Cardiovascular disease: NRT is not linked to increased serious cardiovascular events 1
• Psychiatric conditions: Specialized treatment centers may be needed for patients with comorbid mental health disorders 2
• Renal impairment: For varenicline, begin with 0.5 mg once daily and titrate to 0.5 mg twice daily in severe renal impairment 3

By combining appropriate pharmacotherapy with behavioral support and providing adequate follow-up, smoking cessation rates can be significantly improved, leading to substantial reductions in morbidity and mortality.