What are the recommended treatments for smoking cessation?

Recommended Treatments for Smoking Cessation

The most effective treatment for smoking cessation combines behavioral counseling with pharmacotherapy, with varenicline or combination nicotine replacement therapy (NRT) as the preferred first-line interventions. 1, 2

Assessment and Initial Approach

• Assess current smoking status and history
• Provide brief advice (minimum 3 minutes) as the initial intervention
• Explain that smoking is a chronic relapsing disorder, and relapses should be expected and managed with continued support 1

First-Line Pharmacotherapy Options

1. Varenicline (Preferred Option)

• Dosing schedule: 3
  • 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
  • Begin one week before quit date or start medication and quit between days 8-35
  • An additional 12 weeks recommended for successful quitters
• More effective than single NRT or bupropion (21.8% vs 15.7% and 16.2% quit rates at 6 months) 2
• Caution: Monitor for neuropsychiatric adverse events, seizures, and interactions with alcohol 3
• Dose adjustment: For severe renal impairment (CrCl <30 mL/min), begin with 0.5 mg once daily and titrate to 0.5 mg twice daily 3

2. Nicotine Replacement Therapy (NRT)

• Combination NRT (preferred over single NRT):
  • Increases abstinence rates (RR 1.34,95% CI 1.18 to 1.51) 1
  • Typically combines long-acting (patch) with short-acting (gum, lozenge, inhaler) forms
• Longer-term patch use (>14 weeks) is more effective than standard duration 1

3. Bupropion SR

• Increases abstinence rates from 11% to 19% compared to placebo 1
• Contraindicated in patients with seizure disorders or brain metastases 1
• Consider as second-line option or for patients who cannot use varenicline or NRT

Behavioral Support (Essential Component)

• Minimum of 4 sessions during each 12-week treatment course
• Total contact time of 90-300 minutes
• Focus on:
  • Coping strategies for nicotine withdrawal symptoms
  • Identifying smoking triggers
  • Addressing patient-specific barriers to quitting 1
• Can be delivered in-person, by telephone, text messages, or internet 2

Treatment Algorithm

1. First attempt: Varenicline + behavioral counseling

   • Alternative: Combination NRT + behavioral counseling

2. If unsuccessful or contraindicated:

   • Switch from varenicline to combination NRT or vice versa
   • Consider bupropion as an alternative

3. For highly dependent smokers:

   • Consider combination therapy approaches
   • Refer to specialized treatment centers, particularly for patients with psychiatric conditions 1

4. For patients unable/unwilling to quit abruptly:

   • Consider gradual approach with varenicline
   • Reduce smoking by 50% within first four weeks
   • Reduce by additional 50% in next four weeks
   • Goal of complete abstinence by 12 weeks
   • Continue treatment for additional 12 weeks (24 weeks total) 3

Follow-up and Relapse Prevention

• Conduct follow-up assessments within 2-3 weeks of starting therapy
• Continue support through duration of therapy (minimum 12 weeks)
• Additional follow-up at 6 and 12 months 1
• For relapse: Recommend another treatment attempt after addressing factors contributing to the failed attempt 3

Special Populations

• Pregnant persons: Prioritize behavioral counseling as primary intervention 1
• Surgical patients: Encourage quitting as soon as possible before surgery 1
• Renal impairment: Adjust varenicline dosing as noted above 3
• Cancer patients: Offer cessation regardless of cancer status or prognosis 1

Common Pitfalls to Avoid

• Inadequate treatment duration (should be minimum 12 weeks)
• Using monotherapy instead of combination therapy
• Insufficient behavioral support
• Premature discontinuation due to minor side effects
• Failing to address smoking relapse 1
• Using e-cigarettes as an alternative (not recommended, not harm-free) 1