What are the treatment options for smoking cessation?

From the Guidelines

The most effective approach to smoking cessation is a combination of medication and behavioral support, with first-line medications including nicotine replacement therapy (NRT) and varenicline, as recommended by the US Preventive Services Task Force in 2021 1. The treatment options for smoking cessation are varied and can be tailored to individual patient needs.

• Medications such as NRT, bupropion, and varenicline have been shown to increase quit rates, with varenicline being the most effective 1.
• Behavioral support, including individual or group counseling, quitlines, mobile apps, and text message programs, can also significantly increase success rates 1.
• A minimum of 12 weeks of combination NRT or varenicline is recommended for the initial quit attempt, with therapy potentially extended to promote continued cessation 1.
• Follow-up is crucial, with recommendations for in-person or phone follow-up within 2 weeks after starting pharmacotherapy and periodic follow-up during and after therapy 1.
• Nicotine withdrawal symptoms typically peak within 1-2 weeks of quitting and then subside, and patients should be encouraged to continue therapy through brief slips 1.
• Combining pharmacologic therapy and behavior therapy is the most effective approach and leads to the best results for smoking cessation, as stated in the NCCN clinical practice guidelines in oncology 1.
• High-intensity behavior therapy with multiple counseling sessions is most effective, but at least a minimum of brief counseling is highly recommended 1.
• 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.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Begin varenicline tablets dosing one week before the date set by the patient to stop smoking. Alternatively, the patient can begin varenicline tablets dosing and then quit smoking between days 8 and 35 of treatment. Consider a gradual approach to quitting smoking with varenicline tablets for patients who are sure that they are not able or willing to quit abruptly. Another attempt at treatment is recommended for those who fail to stop smoking or relapse when factors contributing to the failed attempt have been addressed. Provide patients with appropriate educational materials and counseling to support the quit attempt.

The treatment options for smoking cessation with varenicline include:

• Abrupt quitting: Start varenicline tablets one week before quitting smoking
• Gradual quitting: Reduce smoking by 50% from baseline within the first four weeks, by an additional 50% in the next four weeks, and continue reducing with the goal of reaching complete abstinence by 12 weeks
• Counseling and education: Provide patients with appropriate educational materials and counseling to support the quit attempt
• Repeat treatment: Another attempt at treatment is recommended for those who fail to stop smoking or relapse when factors contributing to the failed attempt have been addressed 2

From the Research

Treatment Options for Smoking Cessation

The treatment options for smoking cessation include a range of pharmacological and behavioral interventions.

• First-line pharmacotherapies:
  • Nicotine replacement therapy (NRT) in various formulations, such as transdermal patch, gum, nasal spray, inhaler, and lozenge 3, 4, 5, 6
  • Bupropion, an atypical antidepressant 3, 4, 5, 6
  • Varenicline, a partial agonist of the alpha(4)beta(2) nicotinic acetylcholine receptor 3, 4, 5, 6
• Second-line pharmacotherapies:
  • Nortriptyline, a tricyclic antidepressant agent 3, 4, 6
  • Clonidine, an antihypertensive drug 3, 4, 6
• Other treatment options:
  • Cytisine and naltrexone, which have shown potential in recent evidence 5
  • Nicotine vaccines, which are under investigation and offer promise, especially for relapse prevention 3, 4, 6

Selection of Pharmacologic Agent

The selection of a pharmacologic agent for smoking cessation should be based on the patient's comorbidities and preferences, as well as on the agent's adverse event profile 4, 5, 7.

• Factors to consider in prescribing pharmacotherapy: evidence, patient preference, patient experience 7
• Combinations of pharmacotherapies, such as two or more forms of NRT or bupropion + form of NRT, may be considered for patients with failed attempts with monotherapy or breakthrough cravings 7
• Specific combinations, such as patch + gum or bupropion + patch, may be recommended based on patient needs and preferences 7

Behavioral Support

Behavioral support is an essential component of smoking cessation treatment, and healthcare providers play an important role in helping patients quit smoking 3, 5, 7.

• Comprehensive programs for tobacco control can substantially reduce the frequency of tobacco use 3
• The US Public Health Service Guideline recommends a combination of behavioral support and pharmacologic therapy for smoking cessation 3