What medications are recommended for smoking cessation?

Recommended Medications for Smoking Cessation

The most effective medications for smoking cessation are combination nicotine replacement therapy (NRT) and varenicline, which should be used alongside behavioral therapy for all smokers attempting to quit. 1

First-Line Pharmacotherapy Options

1. Combination Nicotine Replacement Therapy (NRT)

• Combines a long-acting nicotine patch with a short-acting NRT product (lozenges, gum, inhaler)
• Increases abstinence rates from 10% to 31.5% compared to placebo 1, 2
• Dosing recommendations:
  • Standard dose nicotine patch: 21mg/24hr for smokers of >10 cigarettes/day
  • Apply patch once daily to clean, dry, hairless skin, rotating sites
  • Add short-acting NRT (lozenges) as needed for breakthrough cravings (limit to 20 lozenges/day)
  • Consider removing 24-hour patches at bedtime if sleep disturbances occur 1

2. Varenicline (Chantix)

• Increases abstinence rates from 12% to 28% compared to placebo 1, 2
• More effective than single NRT products or bupropion alone
• Dosing considerations:
  • Requires dose adjustment in patients with renal impairment 1, 3
  • Typically used for minimum 12 weeks, may extend to 6 months 1

3. Bupropion SR

• Increases abstinence rates from 11% to 19% compared to placebo 1
• Second-line option when combination NRT or varenicline are not suitable
• Contraindicated in patients with seizure disorders or brain metastases 1

Behavioral Therapy Components

Pharmacotherapy should always be combined with behavioral therapy for best results:

• Minimum of 4 sessions during each 12-week treatment course
• Total contact time of 90-300 minutes 1
• Components should include:
  • Coping strategies for nicotine withdrawal symptoms
  • Identifying smoking triggers
  • Developing strategies for high-risk situations
  • Addressing patient-specific barriers to quitting 1

Treatment Algorithm

1. Assessment: Determine current smoking status and history 4, 1
2. First-line therapy: Prescribe either combination NRT or varenicline 4, 1
3. Behavioral support: Provide counseling (individual, group, or telephone-based) 4, 1
4. Set quit date: Within 1-2 weeks of starting therapy 1
5. Follow-up: Assess within 2-3 weeks of starting therapy, then throughout the minimum 12-week treatment period 1
6. Extended support: Consider longer treatment (up to 6 months or 1 year) for those needing continued support 1

Special Considerations

• Highly dependent smokers: Combination therapy particularly beneficial 1
• Cardiovascular disease: NRT can be used without increased risk of serious cardiovascular events 1
• Psychiatric conditions: Specialized treatment centers recommended; NRT is well-tolerated 1
• Pre-surgical patients: Encourage quitting as soon as possible before surgery 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Minimum 12 weeks recommended 1
2. Using monotherapy instead of combination therapy: Combination approaches are more effective 1
3. Insufficient behavioral support: Counseling significantly improves success rates 4, 1
4. Premature discontinuation due to minor side effects: Most side effects are manageable 1
5. Failing to address smoking relapse: Relapse is common and should be anticipated with strategies in place 4, 1

Smoking cessation medications, when combined with behavioral therapy, significantly improve quit rates and reduce mortality and morbidity related to smoking. The NCCN and other guidelines strongly recommend this combined approach for all smokers attempting to quit 4, 1.