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Principles of Therapy

  • Choice of therapy should be based on patient’s past experience, preference, medical conditions, and potential side effects


First-Line Medications

Nicotine Replacement Therapies (NRT)

  • Involves the use of a product that contains nicotine to replace the nicotine previously provided by smoking

    • Helps patients unwilling or unable to stop smoking to lessen their cigarette consumption

  • Should be given to patients for 8-12 weeks and gradually reduced with maximum duration of 12 months

    • Generally started when patient stops smoking to prevent adverse effects resulting from higher than usual nicotine concentrations

  • Safe and can be used in all groups of smokers including adolescents; use with caution in patients with unstable cardiovascular disease

    • It is well tolerated and toxicity is rare and short lived; blood nicotine levels from NRT are less than those from cigarette smoking

  • Behavioral support may be added to increase overall success rates but it is not required for NRT to be effective
  • Available in different forms (such as gum, inhaler, lozenge, nasal spray and patch)

    • There is no difference in efficacy among the various forms of NRT
    • All NRT forms can increase abstinence rate by 50-70%

  • Long-term use of some forms of NRT may help some people to remain abstinent
  • Considerations in providing NRT

    • Dose should be based on cigarette consumption prior to smoking cessation
    • Types of NRT to be used will be based on patient’s preference, side effects, and previous attempts
    • Replacement or adaptation doses available
    • NRT may be safely used in patients with stable cardiovascular disease
    • Contraindicated in patients who have recently suffered a cardiovascular event or have poorly controlled disease
    • Instead of longer-acting patches, oral NRTs are recommended


  • A partial neuronal α4 β2 nicotinic receptor agonist that is developed specifically for smoking cessation that targets the nicotinic acetylcholine receptor
  • Helps in alleviating symptoms of craving and withdrawal, and prevents inhaled nicotine from activating the α4 β2 receptor to cause the pleasure and reward response
  • Should be given to patients for at least 12 weeks and continued until 12 months
  • Patient should be advised to stop smoking within 1-2 weeks after starting the treatment
  • May be used in patients with stable cardiovascular disease, monitor for neuropsychiatric side effects

    • Avoid in patients with seizure risk, ie brain metastases

  • Based on a number of studies, Varenicline was found to be superior to NRT and Bupropion in achieving continuous abstinence but efficacy diminishes after 6 months, thus have limited role in relapse prevention

Bupropion HCl

  • An oral non-nicotine preparation that has been shown to be effective in treating nicotine withdrawal in cigarette smokers wishing to quit through inhibition of dopamine-norepinephrine reuptake
  • Should be given to patients 1-2 weeks prior to and up to 3-6 months after quit date
  • Patient should be advised to stop smoking in the second week of treatment
  • May be an option for patients who are not pregnant, with no current or history of seizures or closed-angle glaucoma, and not on monoamine oxidase inhibitors (MAOI) or Tamoxifen
  • Safe to use in patients with stable cardiovascular disease, monitor for neuropsychiatric side effects
  • Has lower effectivity than Varenicline as shown by clinical trials and is likely to be the 1st-line therapeutic option in cases where Varenicline is inappropriate or for smokers with depression or schizophrenia
  • Bupropion may have a limited role in relapse prevention

Combination of Pharmacotherapies

  • Indicated for patients with:

    • Failed attempt with monotherapy
    • Nicotine withdrawal
    • Breakthrough cravings
    • High level of dependence
    • Multiple failed attempts

  • Two forms of NRT

    • Patch plus another form of NRT (eg patch + spray, patch + lozenge)
    • Combination may be used safely and effectively than a single form of NRT

  • Varenicline plus NRT

    • May improve smoking abstinence rates at 6 months

  • Bupropion plus NRT

    • Combination of Bupropion and NRT has not shown significant increase in quit rates compared to NRT alone

  • Bupropion plus Varenicline

    • A randomized trial showed higher rates of abstinence with Bupropion and Varenicline combination therapy compared with Varenicline monotherapy and combination was well tolerated

Second-Line Medications

  • Eg Nortriptyline, Cytisine, Clonidine
  • Should be considered only if 1st-line medications have failed or are contraindicated

    • Evaluate for correct medication usage if initial therapy failed

  • Patients should be assessed for specific contraindications, precautions and side effects

    • May try lowering dose or switching to an alternative agent if with intolerable side effects

Other Medications

  • There were no significant effects found on the following antidepressants: Fluoxetine, Paroxetine, Sertraline, Moclobemide, or Venlafaxine
  • Antinicotine vaccines are currently undergoing clinical studies, with varying results

Non-Pharmacological Therapy

Quit Plan

  • Help the patient with a quit plan

    • Set a quit date, which is ideally within 2 weeks

  • In lower-resource settings, quitlines may also be used as an adjunctive therapy 
  • Family, friends and co-workers should be informed about plans of quitting, and understanding and support should be requested
  • Anticipate challenges in the quit plan especially during the first few weeks, such as nicotine withdrawal symptoms, weight gain
  • Remove tobacco products from environment
  • Prior to quitting, avoid smoking in places where much time is spent