What are the recommended treatments for smoking cessation?

Smoking Cessation Treatment

The most effective approach to smoking cessation combines pharmacotherapy (either combination nicotine replacement therapy or varenicline as first-line agents) with behavioral counseling, which increases quit rates to approximately 15-22% compared to 8-9% with minimal intervention alone. 1, 2

Recommended Pharmacotherapy

First-Line Agents (Choose One)

Combination Nicotine Replacement Therapy (NRT):

• 21 mg nicotine patch daily PLUS a short-acting NRT (gum, lozenge, inhaler, or nasal spray) for breakthrough cravings 1, 3
• If 21 mg patch is inadequate, increase to 35-42 mg patch 1
• Duration: minimum 12 weeks, can extend to 6-12 months 1, 3
• NRT is safe and well-tolerated; blood nicotine levels from combination NRT remain significantly lower than from smoking 1

Varenicline (Alternative First-Line):

• Days 1-3: 0.5 mg once daily 1, 4
• Days 4-7: 0.5 mg twice daily 1, 4
• Week 2-12: 1 mg twice daily if tolerated 1, 4
• Start 1-2 weeks before quit date 1, 4
• Duration: 12 weeks minimum, consider additional 12 weeks for successful quitters 1, 3
• Varenicline demonstrates superior efficacy compared to bupropion (OR 1.60) and appears more effective than single-agent NRT 3, 2

Second-Line Agent

Bupropion SR:

• Use only if first-line agents fail or are contraindicated 3
• Days 1-3: 150 mg once daily 1
• Days 4 through 7-12 weeks: 150 mg twice daily 1
• Contraindicated in patients with seizure risk, those taking MAO inhibitors, and patients on tamoxifen 3

Comparative Efficacy Data

• Varenicline: 21.8% quit rate at 6 months 2
• Bupropion: 16.2% quit rate at 6 months 2
• Nicotine patch: 15.7% quit rate at 6 months 2
• Placebo: 9.4% quit rate at 6 months 2

Required Behavioral Support

Pharmacotherapy alone without counseling may not be better than unaided cessation 1

Minimum Counseling Requirements

• At least 4 counseling sessions during the 12-week pharmacotherapy course 1
• First session within 2-3 weeks of starting treatment 1
• Each session: 10-30+ minutes (longer sessions yield higher success rates) 1
• Even brief physician advice of 3 minutes increases quit rates 1

Counseling Content Must Include

• Coping strategies for nicotine withdrawal (peaks at 1-2 weeks, then subsides) 1
• Identifying and avoiding smoking triggers 1
• Problem-solving skills for high-risk situations 1
• Motivational interviewing using four principles: express empathy, develop discrepancy, roll with resistance, support self-efficacy 1

Delivery Methods (All Effective)

• Individual counseling with cessation specialist 1
• Group behavioral therapy 1
• Telephone counseling/quitlines 1
• Mobile phone-based interventions 1

Follow-Up Schedule

• Initial follow-up within 2 weeks of starting pharmacotherapy (can extend to 3 weeks if coordinating with other appointments) 1, 3
• Additional follow-up at minimum 12-week intervals during therapy 1
• Continue follow-up after completing therapy 1

Management of Treatment Failure

• If reduction efforts stall or abstinence seems unlikely, switch to the alternative first-line agent (NRT to varenicline or vice versa) 1
• Consider dose adjustments as clinically indicated 1
• Progressively intensify behavioral therapy with each treatment line, referring to specialty care (psychiatrist, psychologist) as needed 1
• Encourage continued therapy through brief slips; patients may quit later after withdrawal symptoms subside 1

Critical Safety Warnings

Varenicline

• Nausea is common; manage carefully in patients receiving chemotherapy 1, 3
• Absolutely contraindicated in patients with brain metastases due to seizure risk 1, 3
• Monitor for neuropsychiatric symptoms (depression, suicidal ideation, hostility) though uncommon 1, 4
• Cases of somnambulism reported; discontinue if occurs 4
• Instruct patients about potential accidental injury risk until they know how varenicline affects them 4

Bupropion

• Contraindicated with seizure disorders, MAO inhibitors, and tamoxifen use 3
• Monitor for neuropsychiatric symptoms 1
• Common side effects: disturbed sleep, dry mouth, headaches, nausea 3

Special Populations

Pregnant Persons:

• Behavioral counseling is the primary intervention 1
• More intensive counseling with tailored materials about maternal and fetal health effects 1
• Pharmacotherapy decisions require careful risk-benefit assessment 1

Patients with Psychiatric Disorders:

• Both varenicline and bupropion shown safe in large trials 3
• High incidence of depression, anxiety, and stress in smokers increases relapse risk 1
• Consider referral to specialized programs with mental health expertise 1

Perioperative Patients:

• Encourage quitting as soon as possible, but do not delay cancer surgery for smoking cessation 1
• Elective reconstructive procedures may benefit from 60-90 day cessation period 1

Dose Adjustments for Renal Impairment

Severe renal impairment (CrCl <30 mL/min) on varenicline:

• Start 0.5 mg once daily, titrate to 0.5 mg twice daily 4
• End-stage renal disease on hemodialysis: maximum 0.5 mg daily if tolerated 4

Common Pitfalls to Avoid

• Never prescribe pharmacotherapy without arranging behavioral support 1, 5
• Do not use single-agent NRT when combination NRT is available and appropriate 3, 2
• Do not abandon patients after initial failure; average of 6 quit attempts needed for long-term abstinence 2
• Do not overlook brief physician advice—even 3 minutes is effective 1