From the Guidelines
Smoking cessation treatment should include a combination of behavioral support and medication therapy, with first-line medications being nicotine replacement therapy (NRT), varenicline (Chantix), and bupropion (Zyban), as evidenced by the most recent and highest quality study 1.
Key Components of Smoking Cessation Treatment
- Behavioral support: setting a quit date, identifying triggers, developing coping strategies, and regular follow-up
- Medication therapy: NRT, varenicline, and bupropion
- Combining medications, particularly different forms of NRT, can increase success rates
- Treatment should continue for at least 8-12 weeks, with longer durations improving long-term abstinence rates
Medication Options
- NRT: patches (21mg, 14mg, or 7mg for 24-hour use), gum (2mg or 4mg), lozenges (2mg or 4mg), nasal spray, and inhalers
- Varenicline: started at 0.5mg once daily for 3 days, then 0.5mg twice daily for 4 days, followed by 1mg twice daily for 12-24 weeks
- Bupropion SR: taken at 150mg daily for 3 days, then 150mg twice daily for 7-12 weeks
Importance of Behavioral Support
- High-intensity behavior therapy with multiple counseling sessions is most effective, but at least a minimum of brief counseling is highly recommended 1
- Behavioral counseling involving several sessions (≥4) with planned total contact time usually ranging from 90 to 300 minutes can increase tobacco smoking cessation rates 1
Considerations for Treatment
- Patient preferences and values should be taken into account when considering the best approach to fostering smoking cessation 1
- The choice of appropriate pharmacotherapy should take into account the patient’s medical stability, clinical needs, other medical factors, and patient preferences 1
- Relapse is common and should be viewed as a learning opportunity rather than failure, with renewed attempts encouraged 1
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Begin varenicline tablets dosing one week before the date set by the patient to stop smoking. Alternatively, the patient can begin varenicline tablets dosing and then quit smoking between days 8 and 35 of treatment. INDICATIONS AND USAGE NICOTROL Inhaler is indicated as an aid to smoking cessation for the relief of nicotine withdrawal symptoms. The smoking cessation treatment options include:
- Varenicline (PO): Begin dosing one week before the date set by the patient to stop smoking, or start dosing and quit smoking between days 8 and 35 of treatment 2.
- Nicotine (INH): Used as part of a comprehensive behavioral smoking cessation program 3. It is recommended to provide patients with appropriate educational materials and counseling to support the quit attempt 2. Dose reduction may be helpful for patients who cannot tolerate adverse effects, and another attempt at treatment is recommended for those who fail to stop smoking or relapse when factors contributing to the failed attempt have been addressed 2.
From the Research
Smoking Cessation Treatment Options
- Combined behavioral and pharmacological therapies appear to be the best approach for treating tobacco dependence 4
- Nicotine replacement therapies (NRT) combined with supportive counseling are the most widely used and intensively researched treatment methods 4
- Pharmacologic smoking cessation aids, such as NRT, bupropion SR, and varenicline, are recommended for all smokers who are trying to quit, unless contraindicated 5
Effectiveness of Smoking Cessation Treatments
- The rate of successful smoking cessation at 1 year is 3% to 5% when the patient simply tries to stop, 7% to 16% if the smoker undergoes behavioral intervention, and up to 24% when receiving pharmacological treatment and behavioral support 5
- Varenicline is as least as good as and probably more effective than bupropion for smoking cessation 6
- Extended use (greater than 12 weeks) of a controller therapy (varenicline, bupropion, or nicotine patch) is associated with significantly higher sustained quit rates and lower relapse rates than standard use (six to 12 weeks) 7
Recommendations for Smoking Cessation
- All patients, including school-aged children and adolescents, should be asked if they smoke and offered evidence-based treatments for smoking cessation 7
- Use of the 5 A's framework (ask, advise, assess, assist, arrange) can help clinicians promote smoking cessation 7
- Current standard for smoking cessation is a combined psychological and pharmacological treatment 8