Smoking Cessation Treatment | MIMS Malaysia

• 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

Varenicline

• 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

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