What are the optimal strategies for enhancing smoking cessation measures in General Practice (GP) patients?

From the Guidelines

To optimize smoking cessation measures in general practice patients, I recommend implementing a comprehensive approach combining behavioral support with pharmacotherapy, as this has been shown to increase tobacco smoking cessation rates compared with either usual care/brief cessation interventions alone or pharmacotherapy alone 1.

Key Components of the Approach

• Systematically identify all smokers through electronic medical records and brief screening at each visit
• Offer a structured intervention using the 5A's framework: Ask about tobacco use, Advise to quit, Assess willingness, Assist with quitting, and Arrange follow-up
• For pharmacotherapy, first-line medications include nicotine replacement therapy (NRT), varenicline, and bupropion
• NRT should be offered in adequate doses (e.g., 21mg/24hr patches for heavy smokers) and often works best when combined (e.g., patch plus gum or lozenge)
• Varenicline (starting at 0.5mg daily for 3 days, then 0.5mg twice daily for 4 days, then 1mg twice daily) for 12 weeks has the highest quit rates
• Bupropion SR 150mg daily for 3 days then 150mg twice daily for 7-12 weeks is another effective option
• Combine medications with regular behavioral support through in-person counseling, telephone quitlines, or digital interventions
• Schedule follow-up appointments at 1,2, and 4 weeks after quit date, then monthly as needed

Rationale

• Combining behavioral and pharmacotherapy interventions has been shown to increase tobacco smoking cessation rates compared with either usual care/brief cessation interventions alone or pharmacotherapy alone 1
• High-intensity behavior therapy with multiple counseling sessions is most effective, but at least a minimum of brief counseling is highly recommended 1
• Pharmacotherapy dose adjustments may be considered, as clinically indicated 1
• Smoking relapse and brief slips are common, and providers should discuss this and provide guidance and support to encourage continued smoking cessation attempts 1

Recent Guidelines

• The 2024 ESC guidelines for the management of chronic coronary syndromes recommend measures to promote smoking cessation, including brief advice, counselling and behavioural interventions, and pharmacological therapy 1
• The guidelines also recommend avoiding passive smoking and discouraging the use of electronic cigarettes as an alternative to conventional cigarettes 1

From the FDA Drug Label

Smoking cessation therapies are more likely to succeed for patients who are motivated to stop smoking and who are provided additional advice and support. Provide patients with appropriate educational materials and counseling to support the quit attempt. 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. Patients who are motivated to quit, and who did not succeed in stopping smoking during prior varenicline tablets therapy for reasons other than intolerability due to adverse events or who relapsed after treatment, should be encouraged to make another attempt with varenicline tablets once factors contributing to the failed attempt have been identified and addressed

The optimal strategies for enhancing smoking cessation measures in General Practice (GP) patients include:

• Motivation: ensuring patients are motivated to stop smoking
• Advice and support: providing additional advice and support to patients
• Educational materials and counseling: providing patients with appropriate educational materials and counseling to support the quit attempt
• Gradual approach: considering a gradual approach to quitting smoking for patients who are not able or willing to quit abruptly
• Repeated attempts: encouraging patients to make another attempt at quitting if they fail to stop smoking or relapse, once factors contributing to the failed attempt have been identified and addressed 2, 2, 2

From the Research

Optimal Strategies for Enhancing Smoking Cessation Measures

The optimal strategies for enhancing smoking cessation measures in General Practice (GP) patients involve a combination of behavioral counseling and pharmacotherapy.

• Behavioral counseling can be delivered in person, by telephone, text messages, or the internet, and can be brief or intensive 3.
• Pharmacotherapy options include nicotine replacement therapy (NRT), varenicline, bupropion, and cytisine, which can be used individually or in combination 4, 3, 5, 6.
• First-line therapy should include both pharmacotherapy and behavioral support, with varenicline or combination NRT as preferred initial interventions 3.
• Combination pharmacotherapy is indicated for highly nicotine-dependent smokers, patients who have failed with monotherapy, and patients with breakthrough cravings 5.

Effective Pharmacotherapeutic Options

Effective pharmacotherapeutic options for smoking cessation include:

• Nicotine gum, lozenge, patch, nasal spray, and inhaler 4
• Sustained-release bupropion and varenicline 4, 3, 5, 6
• Cytisine and naltrexone, which have shown potential in recent studies 4, 6
• Combination of NRT products, such as a nicotine patch with other NRT products, which is more effective than using a single NRT product 3

Importance of Patient Preferences and Prior Experiences

Healthcare providers should consider patient preferences and prior experiences with quitting when selecting a pharmacotherapeutic option 4.

• Providers should provide medication-specific counseling for the selected therapy and encourage adherence with the behavioral and pharmacotherapeutic treatment regimen 4.
• Customizing the smoking cessation strategy based on currently available scientific evidence and patient's preference is crucial, particularly for patients with specific cardiovascular and psychiatric comorbidities 6.