Smoking Cessation Medications

First-Line Pharmacotherapies

• The American College of Physicians recommends nicotine replacement therapy (NRT), bupropion SR, and varenicline as first-line smoking cessation medications, with combination NRT and varenicline showing the highest cessation rates 1, 2
• NRT is available in multiple forms, including patches, gum, lozenges, inhalers, and nasal spray, and works by providing nicotine to reduce withdrawal symptoms while eliminating exposure to other harmful chemicals in tobacco 1, 3
• Using combination NRT (particularly a nicotine patch plus a rapid-delivery form like gum or lozenge) is more effective than single NRT products, with a cessation rate of approximately 31.5% 1, 2
• The American Heart Association recommends long-term nicotine patch therapy (>14 weeks) for smoking cessation, as it appears superior to shorter-term treatment 3
• Common side effects of NRT include local irritation at the application site and epistaxis with nasal spray 4, 5
• Varenicline is a partial agonist at α4β2 nicotinic acetylcholine receptors that reduces cravings and blocks rewarding effects of smoking, with a recommended dosing of 1 mg twice daily for 12 weeks 3, 6
• The National Comprehensive Cancer Network recommends varenicline as a first-line medication for smoking cessation, with a cessation rate of approximately 28% compared to 12% with placebo 3, 6
• Common side effects of varenicline include nausea, and requires monitoring for neuropsychiatric symptoms 6, 2
• Bupropion SR is an atypical antidepressant that inhibits norepinephrine and dopamine reuptake, with a recommended dosing of 150 mg twice daily for 7-12 weeks 6
• The European Society of Cardiology recommends bupropion SR as a first-line medication for smoking cessation, with a cessation rate of approximately 19% compared to 11% with placebo 6, 7
• Common side effects of bupropion SR include insomnia, dry mouth, and a rare but serious risk of seizures 6, 7

Combination Therapies

• The American College of Physicians recommends combining behavioral support with pharmacotherapy to increase cessation rates, with an increase from 18% to 21% 1
• Combination NRT (patch plus short-acting form) has shown the highest cessation rates, with a rate of approximately 31.5% 1, 3
• Bupropion plus nicotine patch appears superior to bupropion alone, with a cessation rate of approximately 25% 1, 3

Common Pitfalls and Caveats

• Inadequate duration of therapy is a common pitfall, with most pharmacotherapies requiring at least 8-12 weeks of treatment 1, 2
• Insufficient dosing is another common pitfall, with higher-dose NRT may be needed for heavy smokers 3
• Failure to combine behavioral counseling with pharmacotherapy is a common caveat, with combined approaches significantly increasing success rates 1, 2
• Premature discontinuation due to side effects is a common pitfall, with most side effects being mild and diminishing over time 6
• Not considering combination therapy for patients who fail monotherapy is a common caveat, with combination therapy increasing cessation rates 3
• Overlooking the need for extended treatment in some patients to prevent relapse is a common pitfall, with extended treatment increasing cessation rates 3

Selection Algorithm

• For most patients, the National Comprehensive Cancer Network recommends starting with varenicline or combination NRT (patch plus short-acting form) as these have the highest success rates 6, 2
• For patients with psychiatric history or concerns about varenicline, the American College of Physicians recommends considering combination NRT or bupropion 6, 2
• For patients with seizure risk, the European Society of Cardiology recommends avoiding bupropion and using NRT or varenicline instead 6
• For patients who failed previous quit attempts with one medication, the American Heart Association recommends trying an alternative first-line medication or combination therapy 3
• For patients with high nicotine dependence, the National Comprehensive Cancer Network recommends considering combination therapy from the start 3, 2