What medications can help counteract the effects of smoking in an adult?

Medications to Counteract the Effects of Smoking

For adults who smoke, varenicline is the most effective single pharmacotherapy, increasing quit rates to 28% compared to 12% with placebo, and should be combined with behavioral counseling for optimal results. 1

First-Line Pharmacotherapy Options

The FDA has approved three categories of medications for smoking cessation, all of which significantly improve quit rates: 1

Varenicline (Most Effective)

• Varenicline demonstrates superior efficacy, increasing abstinence rates from 12% (placebo) to 28%, outperforming both bupropion and nicotine replacement therapy 1, 2
• Dosing regimen: Start 0.5 mg once daily for days 1-3, increase to 0.5 mg twice daily for days 4-7, then 1 mg twice daily from day 8 onward for 12 weeks 3
• An additional 12-week course is recommended for patients who successfully quit to further increase long-term abstinence 3
• Common side effects include nausea, insomnia, and abnormal dreams, but these are typically mild to moderate and manageable 4

Bupropion SR (Sustained-Release)

• Increases quit rates from 11% (placebo) to 19% 1
• Functions as a norepinephrine and dopamine reuptake inhibitor 4
• Effective alternative when varenicline is not tolerated or contraindicated 1

Nicotine Replacement Therapy (NRT)

• Increases abstinence rates from 10% (placebo) to 17% with any single form of NRT 1
• Available in multiple formulations: transdermal patches, lozenges, gum, inhalers, and nasal spray 1
• Combination NRT is more effective than single-product use: specifically, combining a long-acting nicotine patch with a rapid-delivery form (gum, lozenge, inhaler, or nasal spray) provides superior results 1, 2

Optimal Treatment Strategy

Combination Therapy (Highest Success Rates)

Combining pharmacotherapy with behavioral counseling increases cessation rates from 8% to 14-15%, significantly better than either intervention alone 1, 2

The most effective approach includes: 1

• Pharmacotherapy (preferably varenicline or combination NRT)
• At least 4 in-person behavioral counseling sessions 1
• Total contact time of 90-300 minutes, with interventions providing 8 or more sessions showing the largest effect 1

Behavioral Counseling Components

Effective counseling must include: 1

• Practical problem-solving skills training: helping patients recognize high-risk smoking situations and develop coping strategies
• Social support provision
• Motivational interviewing techniques
• Clear, strong, personalized advice to quit

Multiple delivery formats are effective: 1

• Individual or group counseling
• Telephone counseling (at least 3 calls)
• Mobile phone-based interventions

Treatment Algorithm

Step 1: Assessment and Initiation

• Ask about tobacco use at every clinical encounter using direct questions: "Have you smoked any tobacco product in the past 30 days, even a puff?" 1
• Provide clear, strong, compassionate advice: "The most important thing you can do for your health is to quit tobacco use. I can help." 1

Step 2: Select Pharmacotherapy

• First choice: Varenicline 1 mg twice daily (after 1-week titration) for 12 weeks, with consideration for an additional 12 weeks 3, 2
• Alternative first choice: Combination NRT (21 mg patch daily plus short-acting NRT as needed) 5, 2
• Second choice: Bupropion SR if varenicline not tolerated 1

Step 3: Add Behavioral Support

• Arrange at least 4 counseling sessions totaling 90-300 minutes 1
• Include problem-solving skills, social support, and motivational interviewing 1

Step 4: Follow-up

• Schedule follow-up within 2-3 weeks to assess efficacy and manage side effects 5
• If unsuccessful by week 4, reassess and consider switching medications 6

Enhanced Combination Strategies

For highly nicotine-dependent smokers or those who failed monotherapy: 7

• Combine varenicline with NRT (some studies show increased quit rates) 2
• Use dual NRT products (patch plus rapid-delivery form) 1
• Consider NRT plus bupropion SR (may be more effective than bupropion alone) 1

Special Populations

Pregnant Women

• Behavioral counseling is first-line treatment, increasing cessation rates from 11% to 15% 1, 8
• Counseling should include pregnancy-specific messages about maternal and fetal health effects 1, 8
• NRT may be considered only if behavioral counseling fails and only under physician supervision, as NRT is likely safer than continued smoking despite being FDA Pregnancy Category D 8
• Evidence on pharmacotherapy efficacy in pregnancy is insufficient 1, 8

Renal Impairment

• For severe renal impairment (creatinine clearance <30 mL/min): varenicline 0.5 mg once daily, may titrate to 0.5 mg twice daily 3
• For end-stage renal disease on hemodialysis: maximum 0.5 mg once daily 3

Critical Pitfalls to Avoid

Do not recommend e-cigarettes for smoking cessation - evidence is insufficient regarding their effectiveness, and they may be potentially harmful with unclear cardiovascular and pulmonary risks 1

Do not use minimal interventions alone - even brief advice (<3 minutes) has some effect, but the dose-response relationship clearly favors more intensive interventions 1

Do not fail to combine therapies - using pharmacotherapy without behavioral support, or vice versa, significantly reduces success rates 1, 2

Do not discontinue treatment prematurely - patients should complete the full 12-week course, with consideration for an additional 12 weeks for successful quitters 3

Evidence Strength Considerations

The 2021 USPSTF guidelines 1 represent the most recent high-quality evidence, confirming and updating the 2015 recommendations 1. The EAGLES trial 2, a large randomized controlled trial of 8,144 participants, provides the strongest direct comparison data showing varenicline's superiority (21.8% quit rate) over bupropion (16.2%), nicotine patch (15.7%), and placebo (9.4%) at 6 months.

The combination of varenicline with intensive behavioral counseling (at least 4 sessions totaling 90-300 minutes) represents the evidence-based standard of care for maximizing smoking cessation success and reducing tobacco-related morbidity and mortality. 1, 2