What are the recommended medications for smoking cessation?

Recommended Medications for Smoking Cessation

For smokers of 10 or more cigarettes per day, first-line pharmacotherapy should be either combination nicotine replacement therapy (NRT) or varenicline, with varenicline demonstrating superior long-term abstinence rates, and bupropion reserved as an alternative for patients who cannot use or have failed the preferred therapies. 1

First-Line Pharmacotherapy Options

Combination Nicotine Replacement Therapy (NRT)

• Combination NRT (long-acting patch plus short-acting form) is more effective than single-agent NRT and represents a preferred primary therapy. 1
• Standard dosing consists of a 21 mg nicotine patch plus a short-acting NRT form (gum, lozenge, or inhaler) for 12 weeks. 1
• There is no scientific basis for recommending one form of NRT over another, and combining different forms is both safe and potentially beneficial. 2
• NRT doubles the chance of successful cessation when used correctly. 1

Varenicline

• Varenicline shows superior efficacy compared to bupropion, with an odds ratio of 1.60 (95% CI: 1.22-2.12) for continuous abstinence at 52 weeks. 1
• Initiate 1-2 weeks before the quit date with dose titration: 0.5 mg once daily initially, increasing to 1 mg twice daily if tolerated. 1
• Common side effects include nausea; varenicline is contraindicated in patients with brain metastases due to seizure risk. 1

Bupropion

• Bupropion should be considered for patients who have failed or cannot use the preferred therapies (combination NRT or varenicline). 1
• Dosing regimen: 150 mg once daily for days 1-3, then 150 mg twice daily for days 4 through 12 weeks. 1
• Contraindications include seizure risk, concurrent MAO inhibitor use, and patients taking tamoxifen. 1
• Side effects include disturbed sleep, dry mouth, headaches, and nausea. 1

Treatment Duration and Monitoring

• The minimum recommended duration for combination NRT or varenicline is 12 weeks, with possible extension to 6 months-1 year to promote continued cessation. 1
• Both NRT and bupropion should be prescribed for relatively short durations initially, with prescriptions repeated only if the quit attempt is continuing. 2
• Follow-up within 2-3 weeks of starting therapy is recommended to assess efficacy and manage side effects, with additional follow-up at minimum 12-week intervals. 1

Critical Implementation Principles

Behavioral Support Integration

• Pharmacotherapy must always be combined with behavioral counseling for optimal results. 1
• At least 4 in-person counseling sessions should be provided, with cessation rates plateauing after approximately 90 minutes of total counseling contact time. 1
• The combination of behavioral and pharmacotherapy interventions increases cessation rates from approximately 8% to 14% compared to usual care. 1

Treatment Algorithm

• If initial therapy fails, switch to the other primary therapy option (from combination NRT to varenicline or vice versa) before trying subsequent options. 1
• For highly nicotine-dependent smokers or those with breakthrough cravings, combination pharmacotherapy is indicated. 3
• Higher-dose nicotine patch therapy (>25 mg/day) may provide incremental benefit for heavy smokers. 1

Special Population Considerations

Cardiovascular Disease

• NRT can be recommended for patients with cardiovascular disease, but only with the agreement of the patient's physician if the disease is acute or poorly controlled. 2
• NRT appears safe when given to smokers with cardiovascular disease, with studies not revealing significant adverse effects. 2

Pregnancy

• Use of NRT by pregnant smokers may benefit the mother and fetus if it leads to cessation of smoking, as NRT is almost certainly safer than continued smoking. 2
• Oral dosing forms may be preferable to transdermal patches because nicotine levels can be reduced more rapidly in the event of problems. 2

Psychiatric Disorders

• Both varenicline and bupropion have been shown to be safe in patients with psychiatric disorders in large clinical trials. 1

Common Pitfalls to Avoid

• Do not prescribe the full course upfront: A high proportion of smokers fail to quit or relapse within the first few weeks, making it wasteful to supply the full course initially. 2
• Do not use monotherapy in highly dependent smokers: Combination therapy is more effective for patients who are heavily nicotine-dependent or who have failed monotherapy. 3
• Do not delay follow-up: Early assessment within 2-3 weeks is critical to manage side effects and reinforce the quit attempt. 1
• Do not ignore contraindications: Specific contraindications exist for both bupropion (seizure risk, MAO inhibitors) and varenicline (brain metastases), and these must be respected. 1