What are the recommended treatments for smoking cessation management?

Recommended Treatments for Smoking Cessation Management

The most effective approach for smoking cessation combines pharmacotherapy (either combination nicotine replacement therapy or varenicline) with behavioral counseling, which significantly increases quit rates compared to either intervention alone or usual care. 1, 2, 3

First-Line Pharmacotherapy Options

Combination Nicotine Replacement Therapy (NRT)

• Standard dosing includes a 21 mg nicotine patch plus a short-acting NRT (lozenge, gum, inhaler, or nasal spray) for 12 weeks 2, 1
• If the 21 mg patch is not effective, consider increasing to 35 or 42 mg patch 2, 1
• Blood nicotine levels from NRT are significantly less than from smoking cigarettes, making toxicity rare even when used with smoking 2
• Combination NRT shows abstinence rates of approximately 36.5% at 6 months 1

Varenicline

• Begin varenicline one week before the planned quit date, or start medication and quit between days 8-35 of treatment 4
• Starting week: 0.5 mg once daily on days 1-3, then 0.5 mg twice daily on days 4-7 4
• Continuing weeks: 1 mg twice daily for a total of 12 weeks 4
• Shows the highest 6-month abstinence rate at approximately 21.8% compared to other monotherapies 3
• Monitor for neuropsychiatric side effects and cardiovascular symptoms 4

Bupropion SR

• Can be used with or without NRT for 7-12 weeks 1
• Shows abstinence rates of approximately 24.2% at 6 months 1
• Monitor for neuropsychiatric side effects 1

Behavioral Counseling Components

Structure and Format

• Provide at least 4 sessions during each 12-week course of pharmacotherapy 2, 1
• Session duration should be 10-30+ minutes per session 2
• First session should be within the first 2-3 weeks of treatment 2
• Individual or group therapy, delivered in-person and/or by phone 2
• Even brief advice (about 3 minutes) by healthcare providers increases quit rates 2

Content of Behavioral Therapy

• Skills training to identify smoking triggers and develop coping strategies 2
• Social support and encouragement throughout the quitting process 2
• Motivational interviewing techniques, especially for those unwilling to quit 2
• Address specific barriers to cessation and facilitators of smoking behavior change 2
• Four principles of motivational counseling: express empathy, develop discrepancy, roll with resistance, and support self-efficacy 2

Follow-up and Monitoring

• Schedule follow-up (in-person or by phone) within 2 weeks after starting pharmacotherapy 2
• Additional periodic follow-up during therapy at minimum 12-week intervals 2
• Continue follow-up after completion of therapy to monitor progress 2, 1
• For successful quitters, an additional 12 weeks of treatment is recommended to increase likelihood of long-term abstinence 4

Treatment Algorithm for Failed Quit Attempts

1. If initial quit attempt fails, try a first-line medication not previously used 1
2. If monotherapy failed, consider combination therapy 1
3. Consider longer course of treatment (6 months to 1 year) 2
4. Progressively intensify behavioral therapy with referral to specialty care (psychiatrist, psychologist) as needed 2
5. Address factors contributing to the failed attempt before another attempt 4

Special Considerations

• Nicotine withdrawal symptoms typically peak within 1-2 weeks of quitting and then subside 2
• Patients who do not quit immediately may quit later after withdrawal symptoms subside 2
• For patients with cancer or other comorbidities, smoking cessation therapy may need to be tailored to address specific challenges 2
• For patients with stroke history, the Canadian Stroke Best Practice Recommendations also support the use of NRT, varenicline, and bupropion as first-line therapy 2

Common Pitfalls to Avoid

• Providing pharmacotherapy without behavioral support significantly reduces effectiveness 1, 5
• Inadequate dosing or premature discontinuation of therapy can reduce success rates 1
• Failure to address psychiatric comorbidities that may affect cessation success 2, 1
• Not offering alternative treatments after failed quit attempts 1, 4
• Neglecting follow-up appointments, which are crucial for monitoring progress and adjusting treatment 2, 1