Recommended Management for Smoking Cessation Using Medications
The recommended first-line pharmacotherapy for smoking cessation is either combination nicotine replacement therapy (NRT) or varenicline for a minimum of 12 weeks, with varenicline showing superior efficacy for maintaining long-term abstinence. 1, 2
First-Line Pharmacotherapy Options
Combination Nicotine Replacement Therapy (NRT)
- Standard dosing includes a 21 mg nicotine patch (long-acting) plus a short-acting NRT (lozenge, gum, inhaler, or nasal spray) for 12 weeks 2
- The nicotine patch provides steady background nicotine levels while short-acting NRT addresses breakthrough cravings 1
- Higher-dose nicotine patch therapy (>25 mg/day) may provide incremental benefit for heavy smokers 2
Varenicline
- Initiate 1-2 weeks before quit date with dose titration: 0.5 mg once daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily 1, 3
- Acts as a partial agonist/antagonist at α4β2 nicotinic acetylcholine receptors, reducing cravings and smoking satisfaction 4
- Most common side effect is nausea (28.8%), which can be minimized through dose titration 4
Comparative Efficacy
- Varenicline demonstrates significantly higher abstinence rates compared to bupropion and nicotine monotherapy 1, 4
- Combination NRT is comparable in efficacy to varenicline when properly used 5
- In a direct comparison, varenicline showed higher continuous abstinence rates at 52 weeks compared to bupropion (23.0% vs 14.6%) 4
Second-Line Options
- Bupropion (if combination NRT and varenicline have been tried): 150 mg once daily for days 1-3, then 150 mg twice daily for 12 weeks 1
- Bupropion should be avoided in patients with seizure risk (including those with brain metastases) 2
- Recent evidence suggests that combining varenicline with NRT lozenges may improve self-reported abstinence rates without compromising safety 6
Treatment Duration and Follow-up
- Minimum recommended duration for pharmacotherapy is 12 weeks 2
- Consider extending therapy to 6 months-1 year to promote continued cessation 2
- Follow-up is recommended within 2-3 weeks of starting therapy, then at 12-week intervals during treatment 2
- For patients who remain smoke-free, additional follow-up at 6 and 12 months is recommended 2
Behavioral Support
- Always combine pharmacotherapy with behavioral counseling for optimal results 2, 1
- Provide 4 or more counseling sessions during each 12-week course of pharmacotherapy 2
- Session duration should be 10-30+ minutes; longer, more frequent sessions are linked to higher success rates 2
- Counseling should include skills training, social support, and motivational interviewing 2
Managing Relapse
- For patients who continue to smoke or experience relapse, either continue the initial pharmacotherapy or switch to the alternate first-line option 2
- Both preferred primary therapy approaches (combination NRT and varenicline) should be tried before proceeding to second-line options 2
- Track smoking reduction attempts; if reduction efforts stall or complete abstinence seems unlikely, consider switching to an alternative pharmacotherapy 2
- Additional or more intensive behavioral therapy should be considered for those who relapse 2
Special Considerations
- Nicotine withdrawal symptoms typically peak within 1-2 weeks of quitting and then subside 2
- Encourage continued therapy through brief slips, as patients who don't quit immediately may quit later after withdrawal symptoms subside 2
- For patients with psychiatric disorders, both varenicline and bupropion have been shown to be safe in large clinical trials 1
- Combination therapy of varenicline plus bupropion may be considered for smokers with inadequate response to frontline treatments 2
By following this evidence-based approach to smoking cessation pharmacotherapy, healthcare providers can significantly improve patients' chances of successfully quitting smoking and reducing their risk of smoking-related morbidity and mortality.