From the Guidelines
The first line treatment for smoking cessation is a combination of behavioral counseling and pharmacotherapy, with varenicline being the most effective pharmacotherapy option, as evidenced by the most recent study 1.
Key Components of Treatment
- Behavioral counseling: provides support, encouragement, and strategies to manage triggers and withdrawal symptoms
- Pharmacotherapy: options include nicotine replacement therapy (NRT), varenicline, and bupropion SR
Pharmacotherapy Options
- Varenicline: starting at 0.5mg daily for 3 days, then 0.5mg twice daily for 4 days, then 1mg twice daily for 12 weeks
- NRT: available in various forms, including patches, gum, lozenges, inhalers, or nasal spray
- Bupropion SR: 150mg daily for 3 days, then 150mg twice daily for 7-12 weeks
Combination Therapy
- Using a combination of NRT products, such as combining short-acting plus long-acting forms of NRT, has been found to be more effective than using a single form of NRT 1
- Varenicline appears to be more effective than NRT or bupropion SR, based on a smaller number of studies 1
Important Considerations
- Patient preference, medical history, and previous quit attempts should be taken into account when choosing a treatment option
- Treatment should be accompanied by a structured quit plan, regular follow-up, and strategies to manage triggers and withdrawal symptoms
- Behavioral counseling and pharmacotherapy should be used in combination to increase cessation rates, as evidenced by studies 1
From the FDA Drug Label
Varenicline was evaluated in a double-blind, placebo-controlled trial where patients were instructed to select a target quit date between Day 8 and Day 35 of treatment.
Varenicline was evaluated in a 52-week double-blind placebo-controlled study of 1,510 subjects who were not able or willing to quit smoking within four weeks, but were willing to gradually reduce their smoking over a 12 week period before quitting
Varenicline was evaluated in a double-blind, placebo-controlled trial of patients who had made a previous attempt to quit smoking with varenicline, and either did not succeed in quitting or relapsed after treatment. The first line treatment for smoking cessation is varenicline.
- Key points:
- Varenicline had a superior rate of CO-confirmed abstinence during weeks 9 through 12 and from weeks 9 through 52 compared to placebo in multiple studies 2.
- Varenicline was effective in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular disease.
- Dosage: Varenicline 1 mg twice daily. The evidence supports the use of varenicline as a first line treatment for smoking cessation 2.
From the Research
First-Line Treatment for Smoking Cessation
- The first-line treatment for smoking cessation should include both pharmacotherapy and behavioral support, with varenicline or combination nicotine replacement therapy (NRT) as preferred initial interventions 3.
- Combining medication and behavioral counseling is associated with a higher quit rate compared to brief advice or usual care, with a quit rate of 15.2% over 6 months 3.
- Varenicline has been shown to have a significantly higher 6-month quit rate (21.8%) compared to bupropion (16.2%) and the nicotine patch (15.7%) 3.
Pharmacotherapy Options
- Nicotine replacement therapy (NRT), bupropion, and varenicline are approved by the U.S. Food and Drug Administration as first-line treatments for smoking cessation 4, 5.
- Combination NRT and varenicline have been shown to have the greatest smoking cessation rates 5.
- Clonidine and nortriptyline are second-line treatments used when first-line treatments fail or are contraindicated, or by patient preference 5.
Behavioral Interventions
- Behavioral interventions, such as counseling, can increase quit rates, but effectiveness varies depending on the characteristics of the support provided 6.
- There is high-certainty evidence of benefit for the provision of counseling and guaranteed financial incentives 6.
- Evidence suggests possible benefit for individual tailoring, delivery via text message, email, and audio recording, and intervention content with motivational components and a focus on how to quit, but further studies are needed to evaluate these components 6.