What are the recommended treatments for smoking cessation?

Recommended Treatments for Smoking Cessation

The most effective approach for smoking cessation combines behavioral counseling with pharmacotherapy, specifically combination nicotine replacement therapy (NRT) or varenicline, as this approach has been proven most effective in achieving long-term abstinence. 1

First-Line Pharmacotherapy Options

Nicotine Replacement Therapy (NRT)

• Combination NRT (using two types) is more effective than single NRT
  • Long-acting form (patch) plus short-acting form (gum, lozenge, inhaler, or nasal spray)
  • Increases abstinence rates from 10% to 17% compared to placebo 1
  • Safe for patients with cardiovascular disease 1

Varenicline

• Most effective single agent
• Increases abstinence rates from 12% to 28% compared to placebo 1
• Dosing:
  • Starting week: 0.5 mg once daily (days 1-3), then 0.5 mg twice daily (days 4-7)
  • Continuing weeks: 1 mg twice daily for 12 weeks
  • Additional 12 weeks recommended for successful quitters 2
  • For severe renal impairment: 0.5 mg once daily, titrate to 0.5 mg twice daily 2

Bupropion SR

• Second-line option
• Increases abstinence rates from 11% to 19% compared to placebo 1

Behavioral Interventions

Counseling Components

• Minimum of four sessions during each 12-week treatment course 3
• Session duration: 10-30+ minutes per session 1
• Total contact time: 90-300 minutes 3
• Most effective when providing 8 or more sessions 3

Counseling Strategies

1. Coping with nicotine withdrawal symptoms (peak within 1-2 weeks after quitting)
2. Identifying smoking triggers
3. Coping with stressful situations where smoking is likely
4. Avoiding high-risk situations
5. Addressing patient-specific barriers to quitting 3

Counseling Approaches

• Individual counseling with cessation specialist
• Group behavioral interventions
• Telephone counseling (minimum 3 calls)
• Mobile phone-based interventions 3
• Motivational counseling using four principles:
  1. Express empathy
  2. Develop discrepancy
  3. Roll with resistance
  4. Support self-efficacy 3

Implementation Algorithm

1. Assessment

   • Document smoking status at every visit
   • Assess level of nicotine dependence
   • Check for contraindications to specific medications
   • Assess for comorbidities (cardiovascular disease, psychiatric conditions)

2. Treatment Planning

   • Set a quit date (ideally within 2 weeks)
   • Prescribe first-line pharmacotherapy:
     • Combination NRT or varenicline (preferred)
     • Consider bupropion SR if contraindications to first-line options
   • Arrange behavioral counseling (minimum 4 sessions)

3. Follow-up

   • Schedule follow-up within 2-3 weeks of starting therapy
   • Long-term follow-up at 6 and 12 months after successful quitting
   • Monitor for relapse and provide ongoing support

Treatment Duration

• Minimum 12 weeks of pharmacotherapy
• Consider extending to 24 weeks for successful quitters to increase long-term abstinence 1, 2
• Longer-term patch use (>14 weeks) is more effective than standard duration 1

Common Pitfalls to Avoid

1. Inadequate treatment duration (extend beyond 12 weeks for better outcomes)
2. Using monotherapy instead of combination therapy
3. Insufficient behavioral support
4. Premature discontinuation due to minor side effects
5. Failing to address smoking relapse, which is common 1

Special Considerations

• For patients with psychiatric conditions: May require specialized treatment centers 3
• For pregnant persons: Behavioral counseling is the primary intervention, with more intensive counseling being more effective 3
• For surgical patients: Encourage quitting as soon as possible before surgery 3

By combining pharmacotherapy with behavioral counseling, smoking cessation rates can increase from 8% to 14% compared to usual care alone 1, significantly improving morbidity, mortality, and quality of life outcomes.