What are some pharmacological options for smoking cessation?

Pharmacological Options for Smoking Cessation

The most effective pharmacological options for smoking cessation are combination nicotine replacement therapy (NRT) or varenicline, which should be used as first-line treatments for at least 12 weeks in combination with behavioral therapy. 1, 2

First-Line Pharmacotherapy Options

Combination Nicotine Replacement Therapy (NRT)

• Combines long-acting nicotine patch with short-acting NRT (gum, lozenge, inhaler, or nasal spray) 1, 2
• Standard dosing: 21 mg patch plus short-acting NRT for cravings for 12 weeks 1
• For patients with higher nicotine dependence, consider increasing to 35 or 42 mg patch 1
• Increases abstinence rates from approximately 10% (placebo) to 17% (NRT) 1
• Combination NRT is more effective than single forms of NRT 1, 3
• NRT is well-tolerated with rare and transient nicotine toxicity 1

Varenicline

• Partial nicotine receptor agonist that reduces withdrawal symptoms 1, 2
• Dosing: Start 1-2 weeks before quit date with titration schedule 1, 2
  • Days 1-3: 0.5 mg once daily
  • Days 4-7: 0.5 mg twice daily
  • Weeks 2-12: 1 mg twice daily (if tolerated)
• Increases abstinence rates from approximately 12% (placebo) to 28% 1, 4
• More effective than bupropion with an odds ratio of 1.60 (95% CI: 1.22-2.12) at 52 weeks 2
• Common side effect: nausea (may need management especially during cancer treatment) 1
• Contraindicated in patients with brain metastases due to seizure risk 1, 2
• Monitor for neuropsychiatric symptoms (depression, suicidal ideation/behavior) 1

Second-Line Pharmacotherapy Option

Bupropion

• Atypical antidepressant that reduces nicotine withdrawal symptoms 1, 2
• Can be used alone or in combination with NRT 1
• Increases abstinence rates from approximately 11% (placebo) to 19% 1
• Some studies suggest NRT in combination with bupropion may be more effective than bupropion alone 1
• Contraindicated in patients with seizure risk, those taking MAO inhibitors, and patients taking tamoxifen 2
• Side effects include disturbed sleep, dry mouth, headaches, and nausea 2

Treatment Duration and Follow-up

• Minimum recommended duration for combination NRT or varenicline is 12 weeks 1, 2
• Therapy may be extended to 6 months-1 year to promote continued cessation 1
• Follow-up recommended within 2-3 weeks of starting therapy 1
• Additional follow-up at minimum 12-week intervals during therapy 1
• Nicotine withdrawal symptoms typically peak within 1-2 weeks of quitting and then subside 1

Comparative Efficacy

• Varenicline (27.6%) and combination NRT (31.5%) have the highest cessation rates 4
• Single forms of NRT (17.6%) and bupropion (19.1%) have similar efficacy 4
• All forms of NRT (gum, patch, nasal spray, inhaler, sublingual tablets/lozenges) are effective compared to placebo 3

Important Clinical Considerations

• Pharmacotherapy should always be combined with behavioral therapy for optimal results 1
• If initial therapy fails, consider switching to the other primary therapy option before trying subsequent options 1
• Smoking relapse and brief slips are common; continue therapy through brief slips 1
• Multiple quit attempts with the same therapy may be necessary to achieve long-term cessation 1
• For patients with cancer, smoking cessation is particularly important for improving treatment outcomes 1
• When using varenicline, avoid co-administration with NRT due to increased adverse events (nausea, headache, vomiting, dizziness) 5

Special Populations

• For patients with psychiatric disorders, both varenicline and bupropion have been shown to be safe in large clinical trials 2
• For perioperative patients, smoking cessation should occur as far in advance as feasible 2
• For pregnant women, behavioral interventions are recommended as first-line treatment 1

By using these evidence-based pharmacological options in combination with behavioral therapy, patients have the best chance of successfully quitting smoking and maintaining long-term abstinence.