What medications are helpful for a patient seeking to quit smoking?

Medications for Smoking Cessation

Varenicline 1 mg twice daily for 12 weeks combined with behavioral counseling is the most effective treatment for smoking cessation, nearly tripling quit rates compared to placebo and outperforming all other single medications. 1, 2, 3, 4

First-Line Pharmacotherapy Options

Varenicline (Preferred)

• Varenicline achieves the highest quit rates among single medications: 21.8-28% at 6 months versus 9.4% with placebo 3, 4
• Superior to bupropion (16.2% quit rate) and nicotine patch (15.7% quit rate) in head-to-head comparison 4
• Increases odds of quitting almost 3-fold compared to placebo (RR 2.24,95% CI 2.06-2.43) 1, 3

Dosing regimen: 1, 3, 5

• Days 1-3: 0.5 mg once daily
• Days 4-7: 0.5 mg twice daily
• Weeks 2-12: 1 mg twice daily
• Begin 1-2 weeks before quit date 1, 3
• For successful quitters, extend treatment an additional 12 weeks (total 24 weeks) to maximize long-term abstinence 1, 3

Common side effects and management: 1

• Nausea (28-40%): typically peaks in weeks 1-2 and diminishes over time; may require careful management in cancer patients on chemotherapy
• Insomnia (14%) and abnormal dreams (10-13%)
• Monitor for neuropsychiatric symptoms (depression, agitation, suicidal ideation), though large trials found no increased risk versus placebo 1, 5

Contraindications: 1, 2

• Absolute: history of serious hypersensitivity to varenicline
• Avoid in patients with brain metastases due to seizure risk
• Safe in stable cardiovascular disease 3, 5

Combination Nicotine Replacement Therapy (Alternative First-Line)

• Nicotine patch plus short-acting NRT (gum, lozenge, inhaler, or nasal spray) achieves 36.5% abstinence at 6 months—the highest among NRT combinations 3
• More effective than single NRT products 4, 6
• Recommended duration: minimum 12 weeks, can extend to 6-12 months 7, 3
• Safe even in patients with cardiovascular disease 3

Bupropion SR (Second-Line)

• Quit rate: 19% versus 11% with placebo 3
• Dosing: 150 mg once daily for 3 days, then 150 mg twice daily for 12 weeks 7, 1
• Absolute contraindication: any history of seizure disorder, even if remote and no longer requiring medication 2, 3
• Less effective than varenicline (RR 1.39 favoring varenicline, 95% CI 1.25-1.54) 1

Essential Behavioral Counseling Component

All pharmacotherapy must be combined with behavioral counseling—medication alone significantly reduces efficacy 2, 3, 4, 8

Minimum counseling requirements: 7, 1, 3

• At least 4 sessions during 12-week pharmacotherapy course
• Each session 10-30+ minutes (longer sessions = higher success rates)
• First session within 2-3 weeks of starting medication

Counseling content must include: 2, 3

• Skills training for recognizing high-risk situations
• Social support strategies
• Motivational interviewing techniques
• Practical problem-solving for triggers and coping strategies
• Development of quit plan with specific quit date

Evidence for combined approach:

• Pharmacotherapy plus behavioral counseling achieves 15.2% quit rate versus 8.6% with brief advice alone 2, 4
• Combined treatment increases success 83% compared to minimal intervention (RR 1.83,95% CI 1.68-1.98) 8

Follow-Up Schedule

Critical monitoring intervals: 7, 1, 3

• First follow-up: within 2-3 weeks after starting medication
• Assess smoking status and medication side effects
• Additional follow-up at 12 weeks and therapy completion
• Minimum intervals every 12 weeks during treatment

Management of Treatment Failure

If patient fails first attempt or relapses: 7, 1, 3

1. Continue or resume initial pharmacotherapy with intensified behavioral therapy (first option)
2. Switch to different first-line medication:
   • If failed varenicline → switch to combination NRT
   • If failed combination NRT → switch to varenicline
3. Consider combination pharmacotherapy:
   • Combination NRT + bupropion
   • Varenicline + NRT (some evidence supports this)
4. Progressively intensify behavioral therapy with specialty referral as indicated

Before restarting treatment, identify and address factors contributing to failure: 1

• Frequent/intense cravings
• Elevated anxiety, stress, or depression
• Living/working with smokers
• Drug or alcohol use/abuse
• Inadequate behavioral therapy support

Critical Pitfalls to Avoid

2, 3

• Never provide varenicline without behavioral counseling—this dramatically reduces efficacy
• Do not use inadequate counseling duration (<10 minutes per session)
• Do not discontinue therapy prematurely (minimum 12 weeks required)
• Do not delay treatment initiation
• Never use bupropion in patients with any seizure history
• Do not fail to arrange follow-up within 2-3 weeks

Special Populations

• Pregnant women: behavioral interventions are first-line; insufficient evidence for pharmacotherapy 3
• Severe renal impairment (CrCl <30 mL/min): start varenicline at 0.5 mg once daily, titrate to 0.5 mg twice daily if tolerated 3
• Psychiatric history: varenicline can be safely used; large trials showed no increased neuropsychiatric events versus placebo in over 4,000 patients with diagnosed psychiatric disorders 1, 5

Practical Implementation Algorithm

1. Assess tobacco use at every visit (document as vital sign) 7
2. Advise all smokers to quit with clear, strong, personalized message 7
3. Assess willingness to quit now 7
4. If willing:
   • Set quit date 7, 3
   • Prescribe varenicline 1 mg twice daily × 12 weeks (preferred) OR combination NRT 3, 4
   • Arrange minimum 4 counseling sessions of 10-30+ minutes each 3
   • Schedule follow-up within 2-3 weeks 1, 3
5. If not willing: offer motivational discussion and support when ready 7