Smoking Cessation Guidelines

Introduction to Smoking Cessation

• The use of professional support from healthcare professionals improves overall cessation rates, according to the American Thoracic Society 1
• The American Heart Association and National Comprehensive Cancer Network recommend nicotine replacement therapy (NRT), varenicline, and bupropion as treatment options for smoking cessation 2, 3

Treatment Options

• Varenicline is the most effective first-line medication for smoking cessation, followed by combination nicotine replacement therapy, and bupropion with or without NRT as alternative options, according to the National Comprehensive Cancer Network 2
• Combination nicotine replacement therapy doubles the chance of successful smoking cessation and has a lower risk of side effects compared to varenicline and bupropion, with a recommended dosing approach of applying one patch daily and using short-acting NRT as needed for breakthrough cravings 2

Nicotine Replacement Therapy (NRT)

• The recommended starting dose of nicotine patch is 21 mg for smokers of >10 cigarettes per day, and 14 mg for smokers of ≤10 cigarettes per day, as determined by the American Heart Association and NCCN 2, 4

• Treatment with NRT should continue for at least 12 weeks for optimal effectiveness, with a step-down approach recommended for lighter smokers (≤10 cigarettes/day) and heavy smokers (>10 cigarettes/day) as follows:

  Smoker type	Week 1-6	Week 7-8
  Lighter smoker	14 mg patch	7 mg patch
  Heavy smoker	21 mg patch	14 mg patch (weeks 5-6), 7 mg patch (weeks 7-8)

  2, 5, 6

• The lozenge strength is determined by time to first cigarette, as follows:

  Time to first cigarette	Lozenge strength
  >30 minutes after waking	2 mg
  ≤30 minutes after waking	4 mg

  1, 3

Contraindications and Precautions

• Varenicline is contraindicated in patients with brain metastases due to seizure risk, and bupropion is contraindicated in patients with seizure risks, such as stroke or brain metastases, with common side effects including dry mouth, insomnia, headaches, and nausea 2
• Pregnant patients and those with recent myocardial infarction should use NRT with caution, and patients should not smoke while using nicotine patches to avoid exacerbating symptoms 7
• Patients with brain metastases should not use NRT due to seizure risk, and those with coronary heart disease can use NRT safely, without increased risk of cardiac events 2, 8

Side Effects and Monitoring

• Common side effects of NRT include local skin reactions (15.8% of users), nausea, vomiting, sweating, and sleep disturbances, which can be managed with proper patient education and monitoring 5, 6
• The risk of developing dependence on NRT products is low 6
• Monitoring for increased side effects, particularly nausea, is necessary when using varenicline or combination NRT for smoking cessation, as recommended by the National Comprehensive Cancer Network 2

Treatment Duration and Follow-up

• The standard treatment duration for all pharmacotherapies is 12 weeks, but may be extended to 6 months-1 year to promote continued abstinence, with the National Comprehensive Cancer Network recommending periodic monitoring at minimum 12-week intervals 2
• Schedule follow-up within 2-3 weeks after starting pharmacotherapy to assess efficacy and side effects, and continue periodic monitoring at minimum 12-week intervals throughout treatment 2
• Patients should be advised about expected weight gain (average 5 kg) when quitting smoking, and reminded that the health benefits of tobacco cessation far outweigh the risks from weight gain 5, 8

Administration and Patient Education

• One nicotine patch should be applied daily to clean, dry, hairless skin, at the same time each day, with a different skin site used for each new application, and may be removed for sleep if needed, as recommended by the American Heart Association 3
• The patient should use the lozenge every 1-2 hours as needed for cravings, allowing it to dissolve slowly in the mouth (about 20-30 minutes), and avoiding food and beverages 15 minutes before and after lozenge use 3
• Assessment of smoking status and medication side effects should be performed within 2-3 weeks of starting therapy and continued periodically at no more than 12-week intervals, according to the National Comprehensive Cancer Network 2