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