What is the recommended management for smoking cessation?

Management of Smoking Cessation

The most effective approach for smoking cessation is a combination of pharmacotherapy (preferably combination nicotine replacement therapy or varenicline) with behavioral therapy, which should be offered to all smokers attempting to quit. 1

First-Line Pharmacotherapy Options

Preferred Options:

1. Combination Nicotine Replacement Therapy (NRT)

   • Long-acting nicotine patch (provides steady background levels)
   • PLUS short-acting NRT (gum, lozenge, inhaler, or nasal spray) for breakthrough cravings
   • Doubles cessation rates compared to placebo (from approximately 10% to 20%) 2, 1
   • Standard dosing:
     • Patch: 21mg/24hr for smokers of >10 cigarettes/day
     • Short-acting NRT: Use as needed for cravings (up to 20 lozenges/day)

2. Varenicline (Chantix)

   • Equally effective as combination NRT 1
   • Dosing: 0.5mg once daily (days 1-3), 0.5mg twice daily (days 4-7), then 1mg twice daily 3
   • Begin 1 week before quit date; treat for 12 weeks
   • For successful quitters, additional 12 weeks recommended to increase long-term abstinence 3

3. Bupropion SR

   • Second-line option
   • Increases abstinence rates from 11% to 19% compared to placebo 1
   • Should be avoided in patients with seizure disorders or brain metastases 2

Behavioral Therapy Components

Essential Elements:

• Minimum of 4 sessions during each 12-week treatment course 1
• Session duration: 10-30+ minutes per session
• Total contact time: 90-300 minutes
• Format options: individual counseling, group therapy, telephone counseling, or mobile-based interventions 1

Behavioral Strategies:

• Coping with nicotine withdrawal symptoms
• Identifying smoking triggers
• Developing strategies for high-risk situations
• Addressing patient-specific barriers to quitting
• Motivational counseling using four principles: express empathy, develop discrepancy, roll with resistance, and support self-efficacy 1

Treatment Algorithm

1. Initial Assessment

   • Document smoking status
   • Assess readiness to quit
   • Evaluate level of nicotine dependence

2. First-Line Treatment

   • Prescribe either combination NRT or varenicline
   • Provide behavioral therapy (minimum of brief counseling)
   • Set a quit date (ideally within 1-2 weeks)

3. Follow-up

   • Assess within 2-3 weeks of starting therapy
   • Monitor for side effects and adjust medication if needed
   • Continue support through duration of therapy (minimum 12 weeks)
   • Additional follow-up at 6 and 12 months 2

4. For Persistent Smoking or Relapse

   • Continue initial therapy OR switch to alternative first-line option
   • Consider increasing behavioral support
   • For continued relapse after trying both preferred options, consider bupropion or extended duration of therapy 2

Special Considerations

• Highly dependent smokers: Combination therapy particularly beneficial; may require longer treatment duration 1
• Cardiovascular disease: NRT can be used safely 2, 1
• Pregnancy: Behavioral counseling is primary intervention; pharmacotherapy decisions should be individualized 1
• Surgery patients: Encourage quitting as soon as possible before surgery 1

Common Pitfalls to Avoid

1. Inadequate treatment duration (minimum 12 weeks recommended)
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 1

Efficacy Comparison

• Combination of medication and behavioral counseling: 15.2% quit rate over 6 months
• Brief advice or usual care alone: 8.6% quit rate 4
• Varenicline: 21.8% 6-month quit rate
• Bupropion: 16.2% 6-month quit rate
• Nicotine patch: 15.7% 6-month quit rate
• Placebo: 9.4% 6-month quit rate 4

Remember that smoking is a chronic relapsing disorder, and patients may require multiple quit attempts before achieving long-term abstinence. Slips and relapses are expected and can be managed with continued support and treatment adjustments.