What are the recommended treatments for smoking cessation?

Recommended Treatments for Smoking Cessation

The most effective approach to smoking cessation combines behavioral counseling with pharmacotherapy, specifically either combination nicotine replacement therapy (nicotine patch plus a short-acting NRT) or varenicline, for at least 12 weeks. 1, 2

First-Line Pharmacotherapy Options

Combination Nicotine Replacement Therapy (NRT)

• Standard regimen: 21 mg patch plus short-acting NRT (lozenge, gum, inhaler, or nasal spray) for 12 weeks 1, 2
• Consider increasing to 35 or 42 mg patch if 21 mg is ineffective 1
• Blood nicotine levels from NRT are significantly lower than from cigarettes, making toxicity rare 1, 2
• Using two types of NRT is more effective than using a single form 1, 3

Varenicline

• Dosing: 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 remainder of treatment 4
• Begin 1-2 weeks before quit date or have patient quit between days 8-35 of treatment 4
• Standard duration: 12 weeks, with additional 12 weeks recommended for successful quitters 4
• Shows higher 6-month abstinence rates (21.8%) compared to bupropion (16.2%) and nicotine patch (15.7%) 3
• Contraindicated in patients with brain metastases due to seizure risk 1, 2
• Monitor for neuropsychiatric side effects and nausea (common side effect) 1, 4

Behavioral Counseling Components

Structure and Format

• Provide at least 4 sessions during each 12-week course of pharmacotherapy 1, 2
• Session duration: 10-30+ minutes; longer, more frequent sessions linked to higher success rates 1
• First session should occur within 2-3 weeks of starting treatment 1
• Can be delivered individually or in groups, in-person or by phone 1
• Even brief advice (3 minutes) from healthcare providers increases quit rates 1

Content of Counseling

• Provide problem-solving skills and coping strategies for:
  • Managing nicotine withdrawal symptoms (peak within 1-2 weeks) 1, 2
  • Identifying smoking triggers 1
  • Coping with stressful situations where smoking is likely 1
• Include motivational interviewing techniques:
  • Express empathy 1
  • Develop discrepancy 1
  • Roll with resistance 1
  • Support self-efficacy 1
• Provide social support and practical training 1

Follow-Up and Monitoring

• Assess smoking status and medication side effects within 2-3 weeks of starting therapy 1
• Continue follow-up at minimum 12-week intervals during treatment 1
• Conduct follow-up after completion of therapy to monitor progress 1
• Encourage continued therapy through brief slips 1
• Consider dose adjustments if side effects occur 1

For Failed Quit Attempts

• If initial quit attempt fails, try the alternative first-line medication not previously used 1, 2
• Consider extending therapy to 6 months or 1 year to promote continued cessation 1
• Progressively intensify behavioral therapy with referral to specialty care as needed 1
• Another treatment attempt is recommended when factors contributing to the failed attempt have been addressed 4

Common Pitfalls to Avoid

• Providing pharmacotherapy without behavioral support significantly reduces effectiveness 1, 2
• Inadequate dosing or premature discontinuation of therapy 2, 3
• Failure to address psychiatric comorbidities (depression, anxiety) that may affect cessation success 1
• Not offering alternative treatments after failed quit attempts 2, 5
• Neglecting follow-up, which is crucial for monitoring progress and adjusting treatment 1, 2

Additional Treatment Options

• Bupropion SR: Alternative option for 7-12 weeks, showing 6-month abstinence rates of 24.2% 2, 3
• Telephone counseling: Provide at least 3 telephone calls for effective support 1
• Self-help materials: Tailored materials are more effective than generic information 1