What are effective medications for nicotine cessation?

Effective Medications for Nicotine Cessation

Start with either varenicline 1 mg twice daily for 12 weeks OR combination nicotine replacement therapy (21 mg patch plus short-acting form like gum or lozenge) for 12 weeks, as these achieve the highest quit rates at approximately 28-33%. 1, 2, 3

First-Line Treatment Algorithm

Option 1: Varenicline (Preferred for Most Patients)

Varenicline is the single most effective pharmacotherapy, increasing quit rates nearly 3-fold compared to placebo (OR 2.88; 95% CI 2.40-3.47) and achieving 21.8% abstinence at 6 months versus 9.4% with placebo. 2, 4

Dosing schedule: 5, 2, 6

• Days 1-3: 0.5 mg once daily
• Days 4-7: 0.5 mg twice daily
• Day 8 onwards: 1 mg twice daily for minimum 12 weeks
• Consider extending treatment an additional 12 weeks for patients who achieve initial abstinence 5, 1

Varenicline is superior to bupropion (OR 1.59) and single-form NRT (OR 1.57), with the EAGLES trial demonstrating 21.8% quit rates versus 16.2% for bupropion and 15.7% for nicotine patch. 2, 4

Key contraindications and cautions: 5, 1, 6

• Avoid in patients with seizure history or brain metastases
• Monitor for neuropsychiatric symptoms (mood changes, depression, suicidal ideation)
• Most common side effects are nausea (28-29%), insomnia (14%), and abnormal dreams (10-13%)
• Side effects are dose-dependent; consider dose reduction if poorly tolerated 5, 2

Option 2: Combination Nicotine Replacement Therapy

Combination NRT (nicotine patch PLUS short-acting form) achieves the highest cessation rates at 31.5%, significantly outperforming single-agent therapy. 1, 3

Recommended regimen: 1, 3

• 21 mg nicotine patch daily PLUS
• 2-4 mg nicotine gum or lozenge as needed for cravings
• Minimum duration: 12 weeks
• Consider extending to 6-12 months for sustained abstinence 1

NRT is particularly safe in patients with cardiovascular disease, including those with established coronary heart disease, as blood nicotine levels from NRT are significantly lower than from smoking. 1, 3

Second-Line Treatment: Bupropion SR

Use bupropion SR 150 mg twice daily for 7-12 weeks if varenicline or combination NRT are contraindicated or not tolerated, achieving 19% quit rates versus 11% with placebo. 5, 3

Absolute contraindication: Seizure disorder or conditions that lower seizure threshold 5, 3

Common side effects include insomnia, dry mouth, and rare but serious seizure risk. 3

Treatment Failure Algorithm

If initial therapy fails: 5, 1, 3

1. If combination NRT failed: Switch to varenicline 1 mg twice daily for 12 weeks
2. If varenicline failed: Switch to combination NRT (patch plus short-acting form) OR add bupropion to NRT
3. If single-agent therapy failed: Escalate to combination therapy before trying a different single agent

Essential Behavioral Support

All pharmacotherapy MUST be combined with behavioral counseling to maximize effectiveness, increasing cessation rates from 18% to 21%. 1, 3, 4

Minimum counseling requirement: At least 4 sessions over 12 weeks, though even brief counseling (>3 minutes) provides benefit. 5, 1

The combination of medication plus behavioral counseling achieves 15.2% quit rates over 6 months compared to 8.6% with brief advice alone. 4

Critical Pitfalls to Avoid

Inadequate treatment duration: Most patients require minimum 12 weeks of pharmacotherapy; premature discontinuation is a leading cause of failure. 5, 3

Monotherapy when combination therapy is indicated: For highly dependent smokers or those who failed previous attempts, start with combination therapy rather than single agents. 1, 3

Insufficient dosing: Heavy smokers may require higher-dose NRT or extended varenicline treatment beyond standard 12 weeks. 1, 3

Failing to combine with behavioral support: Pharmacotherapy alone has significantly lower success rates than when combined with counseling. 5, 1, 4

Premature medication discontinuation due to side effects: Most side effects (especially varenicline nausea) are dose-dependent and diminish over time; consider dose reduction rather than discontinuation. 5, 2

Special Populations

Severe renal impairment (CrCl <30 mL/min): Start varenicline at 0.5 mg once daily, titrate to maximum 0.5 mg twice daily. 5, 6

Cardiovascular disease: NRT and varenicline are both safe; the 25-50% mortality reduction from smoking cessation far outweighs any theoretical medication risks. 1, 3

Psychiatric history: While varenicline requires monitoring for neuropsychiatric symptoms, the EAGLES trial showed no significant increase in serious neuropsychiatric events compared to other cessation medications. 5, 2