Smoking Cessation Pharmacotherapy

Introduction to Smoking Cessation

The American College of Cardiology and other guideline societies recommend combination nicotine replacement therapy (NRT) and varenicline as first-line medications for smoking cessation, with varenicline showing superior efficacy for long-term abstinence compared to other options 1, 2

Varenicline is a partial agonist at α4β2 nicotinic acetylcholine receptors, with a dosing regimen of 0.5 mg once daily for days 1-3, 0.5 mg twice daily for days 4-7, and 1 mg twice daily for weeks 2-12, and has the highest abstinence rates among all medications (33.2% at 6 months vs 11.5% for placebo) 2
Combination NRT consists of a long-acting nicotine patch and short-acting NRT, with a dosing regimen of 21 mg patch daily and short-acting NRT as needed, and has a minimum treatment duration of 12 weeks 1
Bupropion is a norepinephrine and dopamine reuptake inhibitor, with a dosing regimen of 150 mg once daily for 3 days and then 150 mg twice daily, and increases cessation rates compared to placebo (19.7% vs 11.5% at 6+ months) 2

Varenicline is significantly more effective than bupropion for smoking cessation, although the provided odds ratios are from an ignored reference, combination NRT is more effective than single NRT products 2
Bupropion + NRT is more effective than bupropion alone (RR 1.24, CI 1.06-1.45), according to Praxis Medical Insights, but this fact is from a less preferred source 3

The initial treatment choice should be either varenicline or combination NRT, based on patient preference, contraindications, previous cessation attempts, and comorbidities 1, 2
If the first treatment fails, the other first-line option not previously used should be tried, or combination therapy (bupropion + NRT) should be considered, along with extended treatment duration and higher doses of NRT 2

Varenicline requires monitoring for neuropsychiatric symptoms, especially in patients <24 years, and is contraindicated in patients with brain metastases due to seizure risk, with common side effects including nausea 1
Bupropion is contraindicated in patients with seizure disorders or conditions lowering seizure threshold, and requires monitoring for neuropsychiatric symptoms 3
NRT is generally well-tolerated, even when used with continued smoking, and blood nicotine levels from NRT are significantly less than from smoking cigarettes 1

All pharmacotherapy should be paired with behavioral counseling, consisting of four or more sessions during each 12-week course of pharmacotherapy, with the first session within 2-3 weeks of starting, and session duration of 10-30+ minutes 1

Assessment should be done within 2-3 weeks of initiating therapy, with periodic follow-up during therapy and after completion, monitoring for withdrawal symptoms and encouraging continued therapy through brief slips 1

Inadequate treatment duration, failure to combine pharmacotherapy with behavioral support, inadequate dosing, premature discontinuation, and ignoring comorbidities are common pitfalls in smoking cessation treatment 1