What is the recommended approach for smoking cessation?

Recommended Approach for Smoking Cessation

Combine pharmacotherapy with behavioral counseling—this dual approach is the most effective strategy for smoking cessation, with combination nicotine replacement therapy (NRT) or varenicline as first-line medications alongside at least 4 counseling sessions over 12 weeks. 1, 2

Initial Assessment and Documentation

Use the 5 A's Framework at every patient encounter: 2, 3

• Ask about tobacco use at every visit and document smoking status as a vital sign 1
• Advise all tobacco users to quit with clear, personalized messages 1, 2
• Assess willingness to make a quit attempt 1, 2
• Assist with evidence-based pharmacotherapy and counseling 1, 2
• Arrange follow-up contact within 2-3 weeks of starting treatment 2, 4

Document smoking status, quit attempts, and interventions used in the health record at regular intervals. 1

First-Line Pharmacotherapy Selection

Choose between two equally effective primary options: 1, 4

Option 1: Combination Nicotine Replacement Therapy (Preferred)

• Long-acting NRT (nicotine patch 21 mg daily) PLUS short-acting NRT (gum, lozenge, nasal spray, or inhaler) 4
• This combination is more effective than single NRT products 5
• Duration: minimum 12 weeks, consider extending to 6-12 months 4

Option 2: Varenicline (Preferred for Long-Term Abstinence)

• Dosing per FDA label: 6
  • Days 1-3: 0.5 mg once daily
  • Days 4-7: 0.5 mg twice daily
  • Week 2 onwards: 1 mg twice daily
• Start 1-2 weeks before quit date 4, 6
• Duration: 12 weeks initially, then additional 12 weeks for successful quitters 4, 6
• Varenicline shows superior long-term abstinence rates compared to bupropion (OR 1.60,95% CI: 1.22-2.12 at 52 weeks) 4

Option 3: Bupropion SR (Second-Line)

• Consider for patients who failed or cannot use preferred therapies 4
• Dosing: 150 mg once daily for days 1-3, then 150 mg twice daily for 12 weeks 4

Important contraindications to screen for: 4, 6

• Varenicline: history of seizures, brain metastases 4
• Bupropion: seizure disorders, MAO inhibitor use, concurrent tamoxifen 4
• Both medications are safe in patients with psychiatric disorders based on large trials 4

Behavioral Counseling Requirements

Provide intensive behavioral therapy with a dose-response relationship—more sessions yield better outcomes: 1, 2

Minimum Effective Counseling

• At least 4 sessions within 12 weeks 1, 2
• Each session lasting 10-30+ minutes (typically 30 minutes or longer) 1
• Can be delivered in-person (individual or group), by telephone, or through quitlines 1, 2

Essential Counseling Components

• Problem-solving and skills training for identifying triggers and high-risk situations 1, 2
• Coping strategies for nicotine withdrawal symptoms (which peak at 1-2 weeks then subside) 1, 4
• Social support and motivational interviewing techniques 1, 2
• Prepare patients that withdrawal symptoms typically peak within several days to 2 weeks before gradually subsiding 1

Even brief counseling (<3 minutes) provides benefit if intensive therapy is not feasible, though less effective than longer interventions. 1

Follow-Up Schedule

Schedule follow-up within 2-3 weeks after starting pharmacotherapy to assess efficacy and manage side effects 2, 4

Continue follow-up at minimum 12-week intervals during therapy 2, 4

Consider extending behavioral therapy for 6 months or more for relapse prevention 1

Managing Treatment Failure

Relapse and brief slips are common and expected—they do not necessarily indicate need for alternative intervention. 1

If initial therapy fails: 4

• Switch to the other primary therapy option (if started on combination NRT, switch to varenicline, or vice versa)
• Progressively intensify behavioral therapy with referral to specialty care (psychiatrist, psychologist) as indicated 1
• Multiple quit attempts with the same therapy may be necessary 1
• Screen for depression, anxiety, and stress—common causes of relapse 2

Critical Pitfalls to Avoid

Do not provide pharmacotherapy without counseling—the combination is significantly more effective than either alone (15.2% vs 8.6% quit rate at 6 months). 7, 5

Do not provide insufficient follow-up—lack of scheduled contact within 2-3 weeks reduces success rates. 2

Do not use single-session counseling approaches—at least 4 sessions are needed for optimal outcomes. 1, 2

Do not ignore comorbid psychiatric conditions—these are major relapse triggers requiring specialized referral. 2

Do not stop treatment prematurely—minimum 12 weeks of pharmacotherapy is essential, with consideration for 6-12 month extension. 4

Special Populations

For severe renal impairment (CrCl <30 mL/min) on varenicline: 6

• Start 0.5 mg once daily, titrate to 0.5 mg twice daily
• For end-stage renal disease on hemodialysis: maximum 0.5 mg daily if tolerated

For patients unable or unwilling to quit abruptly: 6

• Consider gradual reduction approach with varenicline
• Reduce smoking by 50% within first 4 weeks, another 50% in next 4 weeks
• Goal of complete abstinence by 12 weeks, then continue treatment for additional 12 weeks (total 24 weeks)

For cancer patients: 1

• Smoking cessation benefits occur regardless of stage or prognosis
• Continue interventions throughout oncology care continuum, including end-of-life care
• Cancer diagnosis represents a "teachable moment" for cessation