What are the recommended treatments for smoking cessation?

Recommended Treatments for Smoking Cessation

The most effective approach for smoking cessation combines pharmacotherapy (either combination nicotine replacement therapy or varenicline) with behavioral counseling, as this multimodal strategy significantly increases quit rates compared to either intervention alone. 1, 2

First-Line Pharmacotherapy Options

Combination Nicotine Replacement Therapy (NRT)

• Standard regimen: 21 mg nicotine patch plus a short-acting NRT (lozenge, gum, inhaler, or nasal spray) for 12 weeks 1
• If 21 mg patch is ineffective, consider increasing to 35 or 42 mg patch 2
• Blood nicotine levels from NRT are significantly less than from smoking cigarettes, making toxicity rare even when used with smoking 1

Varenicline

• Dosing: Start with 0.5 mg once daily on days 1-3, then 0.5 mg twice daily on days 4-7, then 1 mg twice daily for a total of 12 weeks 3
• Begin varenicline 1 week before the target quit date, or start medication and quit between days 8-35 of treatment 3
• An additional 12 weeks of treatment is recommended for successful quitters to increase likelihood of long-term abstinence 3
• Contraindicated in patients with brain metastases due to seizure risk 1, 2
• Monitor for neuropsychiatric side effects 3

Comparative Effectiveness

• Varenicline shows higher 6-month abstinence rates (21.8%) compared to bupropion (16.2%) and nicotine patch (15.7%) 4
• Combination NRT shows abstinence rates of 36.5% at 6 months 2

Behavioral Counseling Components

• Provide at least 4 sessions during each 12-week course of pharmacotherapy 1, 2
• Session duration: 10-30+ minutes; longer sessions are linked to higher success rates 1
• First session should occur within 2-3 weeks of starting pharmacotherapy 1
• Include skills training, social support, and motivational interviewing 1, 2
• Address specific strategies for:
  • Coping with nicotine withdrawal symptoms (peak within 1-2 weeks after quitting) 1, 2
  • Identifying smoking triggers 1
  • Developing coping skills for high-risk situations 1
  • Addressing barriers to cessation 1

Implementation Approach

Initial Assessment

• Use the 5 A's framework: Ask about tobacco use, Advise to quit, Assess willingness to quit, Assist with quitting, Arrange follow-up 1, 5
• Even brief advice (3 minutes) from healthcare providers increases quit rates 1, 6

Follow-up Protocol

• Assess smoking status and medication side effects within 2-3 weeks of initiating therapy 1
• Continue periodic follow-up during therapy at minimum 12-week intervals 1
• Follow-up after completion of therapy is crucial for monitoring progress 1, 2

Treatment for Persistent Smoking or Relapse

• If initial quit attempt fails, try the alternative first-line therapy option (switch from combination NRT to varenicline or vice versa) 1
• Consider extending therapy to 6 months-1 year to promote continued cessation 1
• Progressively intensify behavioral therapy with referral to specialty care as needed 1
• Recognize that slips and relapses are common; encourage continued attempts 1

Special Considerations

Perioperative Setting

• Encourage smokers with planned cancer surgery to quit as soon as possible 1
• Smoking increases risk of pulmonary complications, surgical site infection, and poor wound healing 1
• Access to cancer surgery should not be restricted for smokers 1
• For elective procedures like plastic surgery reconstruction, consider delaying surgery for 60-90 days after smoking cessation 1

Common Pitfalls to Avoid

• Providing pharmacotherapy without behavioral support significantly reduces effectiveness 1, 2
• Inadequate dosing or premature discontinuation of therapy 2
• Failure to address psychiatric comorbidities that may affect cessation success 1, 2
• Not offering alternative treatments after failed quit attempts 2
• Neglecting follow-up monitoring and adjustment of treatment 1, 2