How can I help a patient with stable depression and anxiety on fluoxetine (fluoxetine) quit tobacco and marijuana use?

Comprehensive Cessation Support for Tobacco and Marijuana

You should immediately initiate pharmacotherapy for tobacco cessation now rather than waiting until January, combining it with structured behavioral counseling and applying similar behavioral strategies to support marijuana cessation. Delaying pharmacotherapy reduces success rates and misses a critical window when the patient is motivated 1.

Immediate Actions for Tobacco Cessation

Start Pharmacotherapy Now

Begin first-line pharmacotherapy immediately—do not wait until January. The evidence strongly supports early intervention when patients express motivation 1.

Your best pharmacotherapy options include:

• Varenicline (1 mg twice daily after titration): Most effective single agent, increasing abstinence rates to approximately 28% vs. 12% with placebo 1
• Combination NRT: Use nicotine patch (long-acting) PLUS a rapid-delivery form (gum, lozenge, inhaler, or nasal spray)—this combination is more effective than single NRT 1
• Bupropion SR (if varenicline contraindicated): Increases abstinence to 19% vs. 11% with placebo 1

Important consideration for your patient: Fluoxetine does NOT improve smoking cessation rates and should not be relied upon for tobacco cessation, even though he's taking it for depression 2, 3. His stable mental health on fluoxetine is good, but you need dedicated smoking cessation pharmacotherapy.

Structured Behavioral Counseling

Implement the 5 A's framework at every visit 1:

• Ask: Document tobacco and marijuana use as vital signs at each visit 1
• Advise: Provide clear, strong, personalized advice to quit both substances 1
• Assess: Confirm his willingness to quit (already established—he's motivated) 1
• Assist: Provide practical counseling and pharmacotherapy 1
• Arrange: Schedule regular follow-up 1

Deliver at least 4 counseling sessions of 10-30 minutes each over the next 12 weeks 1. Schedule the first session within 2-3 weeks of starting pharmacotherapy 1.

Focus your counseling on these specific strategies 1:

• Set a firm quit date (within the next 2-4 weeks, not January) 1, 4
• Remove all tobacco products and marijuana from home and work before the quit date 1
• Identify high-risk situations: When does he typically smoke or use marijuana? (e.g., after meals, with certain friends, when stressed) 1
• Develop specific coping strategies: Deep breathing for relaxation, changing routines where smoking/marijuana use occurs, finding substitutes for hand-to-mouth behavior 1
• Problem-solve previous quit attempts: Ask "What worked or didn't work when you tried to quit before?" 1, 4

Marijuana Cessation Strategy

Apply similar behavioral approaches to marijuana cessation, as there are no FDA-approved pharmacotherapies for cannabis use disorder 4.

Use the adapted 5 A's approach for marijuana 4:

• Set a concurrent or sequential quit date for marijuana (discuss whether to quit both simultaneously or tobacco first) 4
• Identify marijuana-specific triggers: Daily use pattern, social situations, method of use (bowl/glass water vapor) 4
• Develop marijuana-specific coping strategies for the one-ounce-per-week habit 4
• Discourage alcohol or other substance use that could trigger relapse to either tobacco or marijuana 4

Follow-Up Schedule

Arrange intensive follow-up support 1:

• First follow-up within 2-3 weeks of quit date to assess abstinence and adjust treatment 1, 4
• Continue follow-up contacts (in-person or phone) at least monthly for the first 3 months 1, 4
• Assess for relapse risk factors at each visit: cravings, anxiety/depression worsening, exposure to other users, stress 1, 4
• Adjust pharmacotherapy if needed: If breakthrough cravings occur, consider combination therapy or dose adjustment 1

Special Considerations for This Patient

Depression and Anxiety Monitoring

Monitor closely for mood changes during cessation attempts 1. While his depression/anxiety is stable on fluoxetine, nicotine and marijuana withdrawal can temporarily worsen these symptoms 1.

• Continue fluoxetine as prescribed for mood stabilization 2, 3
• Coordinate with his upcoming counseling at SPRHS (starting 11/11/2025) to address any mood changes during cessation 1
• Consider referral to specialized behavioral therapy if depression/anxiety worsens, as these are common relapse triggers 1

Combination Therapy Rationale

For this patient with 5-year smoking history and daily marijuana use, combination pharmacotherapy is strongly indicated 1:

• His daily marijuana use suggests high substance dependence 5
• Combination NRT (patch + rapid-delivery) provides both steady-state nicotine levels and on-demand craving relief 1
• Combining counseling with pharmacotherapy increases success rates to approximately 24% vs. 3-5% with willpower alone 5

Common Pitfalls to Avoid

Do not delay pharmacotherapy until January—this reduces motivation and success rates when the patient is currently willing to quit 1.

Do not rely on fluoxetine for smoking cessation—it does not improve quit rates despite being an antidepressant 2, 3.

Do not provide only brief advice without follow-up—lack of continued support significantly reduces cessation success 1, 4.

Do not address only tobacco while ignoring marijuana—both substances require structured cessation plans with regular monitoring 4.

Do not underestimate the importance of behavioral counseling—pharmacotherapy alone without counseling may not be better than unaided cessation 1, 5.