Smoking Cessation

Introduction to Smoking Cessation

Smoking is a chronic relapsing disorder, and patients may slip or relapse, which should be expected and managed with continued support and treatment adjustments as needed, according to the National Comprehensive Cancer Network 1
Smoking cessation should be offered regardless of cancer status or prognosis, as it improves cancer treatment outcomes, reduces disease recurrence, and decreases secondary cancers, as recommended by the National Comprehensive Cancer Network 1

E-cigarettes should be avoided as an alternative to conventional cigarettes, as they are not harm-free, according to the European Heart Journal 2

Current smoking status and history should be assessed as part of the smoking cessation process, and counseling should be provided as part of behavioral support for smoking cessation, with the goal of doubling the chance of successful smoking cessation, as recommended by the American Thorax Society, National Comprehensive Cancer Network (NCCN), and American Heart Association 1, 3, 4
Behavioral therapy should include a minimum of 4 sessions during each 12-week treatment course, with a total contact time of 90-300 minutes, focusing on coping strategies for nicotine withdrawal symptoms, identifying smoking triggers, and addressing patient-specific barriers to quitting, as recommended by the National Comprehensive Cancer Network 1
Brief advice (3 minutes) by healthcare providers is the minimum effective intervention, and more intensive counseling yields better results, with individual counseling providing personalized support and strategies 5, 1

Nicotine Replacement Therapy (NRT) is recommended as a first-line therapy for smoking cessation, with combination NRT increasing abstinence rates (RR 1.34, 95% CI 1.18 to 1.51) and being a recommended approach for smoking cessation 1, 6
Varenicline is more effective than single NRT products or bupropion alone, increasing abstinence rates from 12% to 28% compared to placebo, with high-certainty evidence showing it helps more people quit than placebo (RR 2.32) 5, 1
Bupropion SR increases abstinence rates from 11% to 19% compared to placebo, but should be avoided in patients with seizure disorders or brain metastases, and is a second-line option 5, 1

Pregnant persons should receive behavioral counseling as the primary intervention, with more intensive counseling being more effective for smoking cessation, as recommended by the American Medical Association 7
Surgical patients should be encouraged to quit smoking as soon as possible before surgery, and patients with renal impairment should have varenicline dosing adjusted, as recommended by the National Comprehensive Cancer Network 1
Highly dependent smokers may particularly benefit from combination therapy, and the NCCN recommends specialized treatment centers for smoking cessation in patients with psychiatric conditions, with NRT being well-tolerated 1

Follow-up assessments should be conducted within 2-3 weeks of starting therapy, with continued support through the duration of therapy (minimum 12 weeks), and additional follow-up at 6 and 12 months, as recommended by the National Comprehensive Cancer Network 1
Longer-term patch use (>14 weeks) has been shown to be more effective than standard duration, and treatment may be extended to 6 months or even 1 year for those who need continued support 8, 9, 1

Smoking increases all-cause mortality and cancer-specific mortality, increases the risk of second primary cancers, may reduce response to treatment, and increases treatment-related toxicity in patients with cancer and macrocytosis, according to the National Comprehensive Cancer Network 1
Inadequate treatment duration, using monotherapy instead of combination therapy, insufficient behavioral support, premature discontinuation due to minor side effects, and failing to address smoking relapse are common pitfalls in smoking cessation treatment, and can reduce success rates 1, 5