What are the recommended treatments for nicotine dependency?

Recommended Treatment for Nicotine Dependency

All patients with nicotine dependence should receive combination therapy consisting of pharmacotherapy plus behavioral counseling, as this approach is superior to either intervention alone and can achieve quit rates of approximately 15-22% at 6 months. 1, 2

Initial Assessment and Engagement

• Ask about tobacco use at every clinical visit and document it as a vital sign 1, 3
• Advise all tobacco users to quit in a clear, strong, and personalized manner, emphasizing personally relevant health risks and benefits 1
• Assess willingness to make a quit attempt at the current visit 1
• For patients unwilling to quit now, offer motivational interviewing to elicit their personal motivations and resources, then arrange follow-up for when they are ready 1

First-Line Pharmacotherapy Options

Preferred Initial Approach: Combination Nicotine Replacement Therapy (NRT)

• Use a long-acting nicotine patch PLUS a short-acting NRT product (gum, lozenge, inhaler, or nasal spray) for breakthrough cravings 3
• This combination is more effective than NRT monotherapy 1
• All NRT products are available and effective; selection should be guided by patient preference and contraindications 1

Alternative First-Line Option: Varenicline

• Varenicline 1 mg twice daily for minimum 12 weeks is highly effective, achieving 21.8% quit rates at 6 months in head-to-head trials 4, 2
• Dosing schedule: Start 1 week before quit date with 0.5 mg once daily for days 1-3, then 0.5 mg twice daily for days 4-7, then 1 mg twice daily 4
• Varenicline was superior to bupropion (16.2% quit rate) and nicotine patch monotherapy (15.7% quit rate) in the EAGLES trial 2
• Nausea is the most common adverse effect and may require dose adjustment 1, 4
• Consider dose reduction to 0.5 mg twice daily if adverse effects are not tolerated 4

Alternative First-Line Option: Bupropion SR

• Bupropion SR 150 mg twice daily can be used as monotherapy or combined with nicotine patch 1
• Bupropion plus nicotine patch is superior to bupropion alone 1

Behavioral Counseling Components

• Provide at least brief counseling (minimum 3 minutes) focusing on two key questions: "Are you willing to quit now?" and "What worked or didn't work when you tried before?" 1, 3
• There is a dose-response relationship: more intensive counseling (≥10 minutes) yields better outcomes 1
• Effective counseling includes practical problem-solving skills, social support within treatment, and arranging social support outside treatment 1, 5
• Refer to telephone quitlines (1-800-QUIT-NOW), which provide free evidence-based counseling 1, 3

Treatment Duration and Follow-Up

• Minimum 12 weeks of pharmacotherapy for initial quit attempt 1, 4
• An additional 12 weeks of treatment is recommended for successful quitters to increase likelihood of long-term abstinence 4
• Extended treatment beyond 14 weeks promotes continued cessation 1, 3
• Arrange follow-up within 2-3 weeks of initiating therapy to assess abstinence status and medication tolerability 3
• Continue follow-up at regular intervals to provide ongoing support 1

Management of Treatment Failure or Relapse

When patients fail to achieve abstinence or relapse despite appropriate treatment, use one of these three strategies: 1

1. Try a Different First-Line Medication

• If NRT failed, switch to varenicline 1 mg twice daily 1
• If varenicline or bupropion failed, try combination NRT 1

2. Use Combination Pharmacotherapy

• Combine nicotine patch with another NRT product (gum, lozenge, nasal spray, or inhaler) 1
• Combine bupropion SR with nicotine patch 1
• Consider combining varenicline with NRT, which has shown increased quit rates in some studies 2

3. Extend Treatment Duration

• Occasional patients benefit from treatment courses longer than the standard 8-12 weeks 1
• Consider 24 weeks of total treatment for patients using gradual reduction approaches 4

Special Populations and Considerations

Adolescents

• Pharmacotherapy can be considered for moderate to severely tobacco-dependent adolescents who want to stop smoking 1
• Behaviorally based programs work best for those with minimal to mild dependence 1
• Use the adapted 5 As model and refer to teen-specific resources like teen.smokefree.gov 1

Patients with Contraindications

• Avoid bupropion and varenicline in patients with brain metastases due to increased seizure risk 3
• For severe renal impairment (creatinine clearance <30 mL/min): start varenicline at 0.5 mg once daily, titrate to 0.5 mg twice daily maximum 4
• For end-stage renal disease on hemodialysis: maximum 0.5 mg daily if tolerated 4

Critical Implementation Points

• Combining counseling with pharmacotherapy is superior to either alone—this is the most important evidence-based finding 1, 2
• The combination of brief physician advice plus assistance to obtain treatment is effective across virtually all healthcare settings 2, 5
• Tobacco dependence is a chronic condition requiring repeated intervention; the average smoker makes approximately 6 quit attempts before achieving long-term abstinence 2, 5
• All seven FDA-approved medications (varenicline, bupropion SR, and five NRT formulations) are effective and should be recommended unless contraindicated 1