What are the treatments for nicotine dependence?

From the Guidelines

The most effective treatment for nicotine addiction is a combination of medication and behavioral support, with first-line medications including nicotine replacement therapy (NRT) and non-nicotine prescription medications such as varenicline and bupropion. The most successful approach typically combines medication with behavioral support, including counseling, support groups, or quit lines. First-line medications include nicotine replacement therapy (NRT) in various forms: patches, gum, lozenges, inhalers, and nasal sprays. Non-nicotine prescription medications are also effective, including varenicline (Chantix) and bupropion (Zyban) 1. These medications work by either replacing nicotine to reduce withdrawal symptoms or by affecting brain receptors to decrease cravings and block nicotine's pleasurable effects.

Key Treatment Options

• Nicotine replacement therapy (NRT) in various forms: patches, gum, lozenges, inhalers, and nasal sprays
• Non-nicotine prescription medications: varenicline (Chantix) and bupropion (Zyban)
• Behavioral support through counseling, support groups, or quit lines
• Mobile apps and text message programs can provide additional support

Recommended Approach

Combining NRT products, such as using a combination of short-acting and long-acting forms of NRT, has been found to be more effective than using a single form of NRT. Varenicline appears to be more effective than NRT or bupropion SR 1. Information on dosing regimens is available in the package inserts of individual medications or in the 2020 Surgeon General Report on Smoking Cessation.

Important Considerations

• The physical addiction to nicotine causes withdrawal symptoms when quitting, while psychological dependence creates habitual behaviors, making a comprehensive approach addressing both aspects most effective for long-term success
• Behavioral support through counseling, support groups, or quit lines significantly increases success rates when combined with medication
• Mobile apps and text message programs can provide additional support

From the FDA Drug Label

As shown in Table 17 Continuous Abstinence (95% confidence interval), Study in Patients with or without a History of Psychiatric Disorder Varenicline1 mg BID BupropionSR150 mg BID NRT 21mg/daywithtaper Placebo Weeks 9 through 12 Non-38%26%26%14% Psychiatric(35%, 41%)(23%, 29%)(24%, 29%)(12%, 16%) Cohort Psychiatric29%19%20%11% Cohort(26%, 32%)(17%, 22%)(18%, 23%)(10%, 14%) Weeks 9 through 24 Non-25%19%18%11% Psychiatric(23%, 28%)(16%, 21%)(16%, 21%)(9%, 13%) Cohort Psychiatric18%14%13%8% Cohort(16%, 21%)(12%, 16%)(11%, 15%)(7%, 10%)

The treatments for nicotine addiction are:

• Varenicline: a medication that can help patients quit smoking
• Bupropion: an antidepressant that can aid in smoking cessation
• NRT (Nicotine Replacement Therapy): a treatment that delivers nicotine to the body in a controlled manner to reduce withdrawal symptoms
• Placebo: a dummy treatment used for comparison in clinical trials 2

From the Research

Treatments for Nicotine Addiction

• Nicotine replacement therapy (NRT) is a common treatment for nicotine addiction, which can be administered in various forms such as gum, lozenge, transdermal patch, nasal spray, and inhaler 3
• Bupropion, an inhibitor of the neuronal uptake of noradrenaline and dopamine, is also effective for smoking cessation and its effectiveness is improved by a moderate level of counselling 3
• Varenicline, a partial agonist at nicotinic alpha4beta2 receptors, has been shown to be at least as effective as bupropion for smoking cessation and probably more effective than bupropion 3

Comparison of Treatments

• Combination NRT (fast-acting form + patch) results in higher long-term quit rates than single form NRT 4
• High-dose NRT and combination NRT do not demonstrate consistent effects over other interventions, except for varenicline which has been shown to be more effective than other options 5
• Bupropion and NRT have similar effectiveness for smoking cessation, but bupropion may be more beneficial for smokers with a history of depression 6
• Varenicline combined with bupropion has been shown to have the best effect on smoking cessation compared to other interventions, including varenicline combined with NRT and monotherapies 7

Forms and Doses of NRT

• 21 mg patches result in higher quit rates than 14 mg (24-hour) patches, and using 25 mg patches results in higher quit rates than using 15 mg (16-hour) patches 4
• 4 mg gum is more effective than 2 mg gum, but only for smokers who are highly dependent 4
• Using NRT prior to quitting may improve quit rates compared to using it from quit date only, but further research is needed to confirm this finding 4