Smoking Cessation Medications Compatible with Continued Smoking
Varenicline and bupropion are the two medications that can be initiated while the patient continues to smoke, as both allow for flexible quit dates after treatment initiation.
Varenicline: Primary Option for Gradual Cessation
- Varenicline can be started one week before the quit date, or alternatively, the patient can begin dosing and then quit smoking between days 8 and 35 of treatment 1.
- For patients unwilling to quit abruptly, varenicline supports a gradual approach where smoking is reduced by 50% within the first four weeks, another 50% in the next four weeks, with complete abstinence by 12 weeks 1.
- The standard dosing is 0.5 mg once daily for days 1-3, then 0.5 mg twice daily for days 4-7, followed by 1 mg twice daily from day 8 through end of treatment 1.
- Varenicline achieves approximately 28% six-month abstinence versus 12% with placebo (relative risk 2.27) and is superior to bupropion (OR 0.68 favoring varenicline; 95% CI 0.56-0.83) 2.
Bupropion: Alternative Option
- Bupropion can be prescribed as abstinent-contingent treatment where the smoker makes a commitment to stop on a particular date, but the medication is started before that date 2.
- Bupropion aids long-term smoking cessation with efficacy similar to NRT, yielding approximately 20% six-month abstinence versus 12% with placebo (RR 1.62; 95% CI 1.49-1.76) 2.
- The medication should be started before the quit date to allow therapeutic levels to build 3, 4.
Why Nicotine Replacement Therapy Is NOT Appropriate
- NRT (including patches and nasal spray) should be prescribed as part of abstinent-contingent treatment, requiring the smoker to commit to stopping on a particular quit date 2.
- All forms of NRT are designed to replace nicotine from cigarettes after cessation, not to be used concurrently with smoking 5.
- Using NRT while continuing to smoke can lead to nicotine excess and potential cardiovascular effects, as blood nicotine levels would be additive 2, 6.
- The NCCN guidelines specify that combination NRT should begin after the patient has committed to a quit date, not during active smoking 2.
Critical Implementation Points
- Both varenicline and bupropion must be combined with behavioral counseling for optimal outcomes, with at least 4 sessions totaling 91-300 minutes of contact recommended 2.
- Follow-up should occur within 2-3 weeks after starting pharmacotherapy to assess adherence and manage side effects 2.
- Nausea is the most common side effect of varenicline (occurring in 24-31% of patients) and may require dose adjustment 2.
- Bupropion is contraindicated in patients with seizure history, while varenicline should be avoided in patients with brain metastases due to seizure risk 2, 7.