What are the recommended treatments for smoking cessation?

Recommended Treatments for Smoking Cessation

Combine pharmacotherapy with behavioral counseling—specifically, use either combination nicotine replacement therapy (NRT) or varenicline as first-line medication alongside at least 4 counseling sessions over 12 weeks. 1, 2

First-Line Pharmacotherapy

Combination NRT (nicotine patch + short-acting NRT) and varenicline are the two preferred primary therapies, with varenicline demonstrating superior long-term abstinence rates. 1, 2

Combination Nicotine Replacement Therapy

• Start with 21 mg nicotine patch daily plus a short-acting NRT (lozenge, gum, inhaler, or nasal spray) for breakthrough cravings 1, 2
• If 21 mg patch is inadequate, increase to 35-42 mg patch 3
• Continue for minimum 12 weeks, with extension to 6-12 months for successful quitters to prevent relapse 1, 2
• Combination NRT achieves 36.5% abstinence at 6 months, significantly outperforming single-agent NRT 3
• Blood nicotine levels from NRT are substantially lower than from smoking, making toxicity rare even with concurrent smoking 1

Varenicline

• Initiate 1-2 weeks before quit date with dose titration: 0.5 mg once daily for days 1-3, then 0.5 mg twice daily for days 4-7, then 1 mg twice daily 2, 4
• Achieves 33.2% abstinence at 6 months, the highest rate among monotherapies 3
• Demonstrates odds ratio of 1.60 (95% CI: 1.22-2.12) versus bupropion at 52 weeks 2
• Continue for 12 weeks minimum, with additional 12 weeks recommended for successful quitters 1, 4

Common pitfall: Varenicline is contraindicated in patients with brain metastases due to seizure risk 2, 3, 4

Second-Line Pharmacotherapy

Bupropion SR

• Reserve for patients who failed or cannot tolerate first-line therapies 2
• Dosing: 150 mg once daily for days 1-3, then 150 mg twice daily for 7-12 weeks 2, 3
• Achieves 24.2% abstinence at 6 months 3
• Contraindicated in patients with seizure risk, those taking MAO inhibitors, and patients on tamoxifen 2

Behavioral Counseling (Essential Component)

Pharmacotherapy alone without counseling may not exceed unaided cessation rates—the combination is critical. 1

Intensity and Structure

• Provide minimum 4 sessions during the 12-week pharmacotherapy course, with first session within 2-3 weeks of starting medication 1, 2, 3
• Each session should last 10-30+ minutes; longer and more frequent sessions correlate with higher success rates 1
• Eight or more sessions show the largest effect, though differences between session numbers are not statistically significant 1
• Combined behavioral and pharmacotherapy interventions increase cessation rates from 8% to 14% versus usual care 2

Delivery Methods

• Individual or group therapy, in-person or by telephone 1
• Refer to smoking cessation quitlines (1-800-QUIT-NOW in US) if face-to-face intervention unavailable 1
• Mobile phone-based interventions are effective alternatives 1
• Brief physician advice alone (3 minutes) produces small but important increases in quit rates 1

Content Requirements

• Skills training for coping with withdrawal symptoms (which peak at 1-2 weeks then subside) 1, 3
• Identifying and managing smoking triggers 1
• Social support and motivational interviewing using four principles: express empathy, develop discrepancy, roll with resistance, support self-efficacy 1
• Tailored print or web-based educational materials 1

Follow-Up Protocol

• Initial follow-up within 2 weeks of starting pharmacotherapy (can extend to 3 weeks if coordinating with scheduled appointments) 1, 3
• Additional follow-up at minimum 12-week intervals during therapy and after completion 1, 3
• Track smoking reduction attempts; if progress stalls, switch pharmacotherapy 1, 3

Management of Treatment Failure

If initial therapy fails, switch to the alternative first-line option (combination NRT to varenicline or vice versa) before trying second-line agents. 2, 3

• Consider dose adjustments based on side effects and efficacy 1, 3
• Progressively intensify behavioral therapy with each failed attempt, including referral to specialty care (psychiatrist, psychologist) as needed 1, 3
• Slips and relapses are expected—they do not necessarily indicate need to switch methods; continued attempts with same therapy can succeed 1, 3

Special Populations

Pregnant Persons

• Behavioral counseling is first-line treatment; more intensive counseling with tailored materials about maternal-fetal effects is most effective 1
• NRT may benefit mother and fetus if it leads to cessation, as it is safer than continued smoking 2
• Oral NRT forms (gum, lozenge) are preferable to patches due to more rapid nicotine clearance if problems arise 2

Cardiovascular Disease

• NRT is safe in cardiovascular disease patients, with no significant adverse effects in studies 2
• Use with physician agreement if disease is acute or poorly controlled 2
• Benefits of smoking cessation outweigh potential medication risks 4

Psychiatric Disorders

• Both varenicline and bupropion are safe in large clinical trials of patients with psychiatric conditions 2
• Monitor for neuropsychiatric adverse events including mood changes, depression, anxiety, suicidal ideation 4
• Instruct patients to discontinue and contact provider if such symptoms occur 4

Renal Impairment

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

Critical Safety Warnings

Varenicline

• Common side effect: nausea 2
• Monitor for seizures, somnambulism (sleepwalking with potential harmful behavior), accidental injuries 4
• Instruct patients to use caution with driving/machinery until effects known 4
• Reduce alcohol consumption until interaction effects are known 4

Bupropion

• Side effects include disturbed sleep, dry mouth, headaches, nausea 2
• Absolute contraindications: seizure disorders, concurrent MAO inhibitor use, tamoxifen therapy 2

Treatment Duration

• Minimum 12 weeks for initial quit attempt with combination NRT or varenicline 1, 2
• Extend to 6-12 months for successful quitters to maximize long-term abstinence 1, 2
• Avoid extending beyond 1 year if possible 1

Gradual Cessation Approach

For patients unable or unwilling to quit abruptly:

• Begin varenicline and reduce smoking by 50% within first 4 weeks 4
• Reduce by additional 50% in next 4 weeks 4
• Achieve complete abstinence by 12 weeks, then continue treatment for additional 12 weeks (total 24 weeks) 4