What are the recommended medication options for smoking cessation?

Medication Options for Smoking Cessation

For smoking cessation, combination nicotine replacement therapy (NRT) using a nicotine patch plus a short-acting form or varenicline are the most effective first-line pharmacotherapies, to be prescribed for a minimum of 12 weeks along with behavioral counseling. 1

First-Line Pharmacotherapy Options

1. Combination Nicotine Replacement Therapy (NRT)

• Standard regimen: 21 mg nicotine patch (continuous) plus short-acting NRT (gum, lozenge, inhaler, or nasal spray) for breakthrough cravings 1
• Minimum duration of 12 weeks, may extend to 6-12 months for continued cessation 1
• Increases abstinence rates by 50-70% compared to placebo 2
• Different forms of NRT show varying effectiveness:
  • Nicotine gum: RR 1.49 3
  • Nicotine patch: RR 1.64 3
  • Oral tablets/lozenges: RR 1.95 3
  • Nicotine inhaler: RR 1.90 3
  • Nicotine nasal spray: RR 2.02 3
• Combination NRT is as effective as varenicline 1

2. Varenicline

• Partial agonist at α4β2 nicotinic receptors 1
• Reduces withdrawal symptoms while blocking rewarding effects of nicotine 1
• Increases abstinence rates from approximately 12% (placebo) to 28% 1
• High-certainty evidence shows varenicline helps more people quit than placebo (RR 2.32) 4
• More effective than single-form NRT (RR 1.25) 4
• Similar efficacy to combination NRT 4
• Standard course: 12 weeks 5
• Dosing adjustment needed for renal impairment 1, 6

3. Bupropion SR

• Second-line option 1
• Increases cessation rates from 11% to 19% 1
• Less effective than varenicline (RR 1.36 favoring varenicline) 4
• Carries risk of seizures (1/1000 to 1/1500) 2

Treatment Algorithm

1. Initial Assessment:

   • Determine level of nicotine dependence
   • Assess for contraindications to specific medications
   • Check for comorbidities (cardiovascular disease, psychiatric conditions) 1

2. First-Line Treatment (choose one):

   • Combination NRT: Nicotine patch + short-acting NRT for 12 weeks minimum 5, 1
   • Varenicline: 12-week course 5, 1

3. If First-Line Treatment Fails:

   • If combination NRT failed: Try varenicline + behavioral therapy 5
   • If varenicline failed: Try combination NRT + behavioral therapy 5
   • Consider adding bupropion to combination NRT (Category 2B recommendation) 5

4. Behavioral Support (essential component):

   • Minimum of four sessions during each 12-week course 1
   • Session duration of 10-30+ minutes per session 1
   • Include skills training, social support, and motivational interviewing 1

5. Follow-up and Monitoring:

   • Assess smoking status and medication side effects within 2-3 weeks of starting therapy 5, 1
   • Continue follow-up at minimum 12-week intervals during therapy 1
   • Additional follow-up at 6 and 12 months after successful quitting 1

Special Considerations

• Cardiovascular disease: NRT can be used without increased risk of serious cardiovascular events 1
• Renal impairment: Adjust varenicline dosing (0.5 mg once daily, titrating to 0.5 mg twice daily in severe renal impairment) 1, 6
• Psychiatric conditions: May require specialized treatment centers 1
• Pregnancy: Limited data, but NRT may benefit mother and fetus if it leads to cessation 5

Common Pitfalls to Avoid

• Inadequate duration of treatment (should be minimum 12 weeks)
• Using monotherapy instead of combination therapy
• Insufficient behavioral support
• Failure to adjust dosing when needed
• Premature discontinuation due to minor side effects
• Not preparing patients for withdrawal symptoms (typically peak within 1-2 weeks of quitting) 1

Remember that smoking cessation pharmacotherapy is highly effective when used correctly and combined with appropriate behavioral support. The goal is to reduce morbidity and mortality while improving quality of life through successful long-term abstinence from smoking.