Smoking Cessation Therapies
SMOKING CESSATION THERAPIES

Smoking cessation pharmacotherapy should be used with a comprehensive behavioral smoking cessation program. Nicotine replacement therapy used in conjunction with a frequent, intensive, high-quality smoking cessation program is more successful than either used alone. Every smoker should be offered smoking cessation therapy at every office visit. Make first follow-up contact preferably during the first week of anticipated quit date, second contact within the first month, and additional follow-up as needed. Intensive interventions are more effective.

Patients must stop smoking before starting a nicotine replacement regimen. Concomitant drugs may need adjustment in dose when smoking is stopped.

Pregnant or breastfeeding smokers should first be encouraged to attempt to quit smoking without pharmacologic therapy. They should be offered intensive counseling treatment. Nicotine replacement should be used during pregnancy only if the increased likelihood of quitting smoking (and its benefits) outweighs the risks of nicotine replacement therapy.

Pediatric and adolescent patients should be provided with counseling interventions to aid with smoking cessation. Counseling has been shown to be effective in treatment of adolescent smokers. Nicotine replacement therapy and bupropion SR are not recommended as a component of pediatric tobacco use interventions. Although shown to be safe in adolescents, these medications have shown little evidence to be effective in promoting long-term smoking abstinence. Small amounts of nicotine may be toxic to children and animals; these products should be stored in a safe place away from children and pets (including used patches).

Local skin reactions may occur with nicotine patches. Treatment with a mild steroid cream may be helpful.

Concerns about weight gain should be addressed by informing the patient about its likelihood and preparing for its occurrence. Clinicians should neither deny the likelihood of weight gain nor minimize its significance to the patient. During the quit attempt, patients should be offered help addressing weight gain by encouraging to adopt a healthy lifestyle (eg, diet consisting of fruits and vegetables, limit alcohol consumption, exercise). For smokers with great concerns about weight gain, bupropion SR or nicotine replacement therapy (esp. nicotine gum and lozenge) is recommended, which have been shown to delay weight gain after quitting.

Generic Brand Strength Adult Dose Notes
TRANSDERMAL
nicotine Habitrol OTC 21mg/24hr, 14mg/24hr, 7mg/24hr >10cigarettes/day:
21mg patch daily for 4wks; then 14mg patch daily for 2wks, then 7mg patch daily for 2wks, then stop
≤10cigarettes/day:
14mg patch daily for 6wks then 7mg patch daily for 2wks, then stop
Apply to clean, dry, nonhairy site on trunk or upper outer arm. Rotate sites. Do not cut patch. Remove patch after 24hrs; if vivid dreams or other sleep disturbances occur, remove at bedtime and reapply in AM.
Nicoderm CQ OTC 21mg/
 
24hr,
14mg/
 
24hr,
7mg/
 
24hr
>10cigarettes/day:
21mg patch daily for 6wks; then 14mg patch daily for 2wks; then 7mg patch daily for 2wks; then stop
≤10cigarettes/day:
14mg patch daily for 6wks; then 7mg patch daily for 2wks; then stop
Apply to clean, dry, nonhairy site on trunk or upper outer arm. Rotate sites. Remove after 16−24hrs; if vivid dreams or other sleep disturbances occur, remove at bedtime and reapply in AM.
CHEWING GUM
nicotine polacrilex Nicorette OTC 2mg, 4mg Use 1 piece every 1−2hrs for 6wks (at least 9 pieces/day), then every 2−4hrs for 3wks, then every 4−8hrs for 3wks, then stop; max 24 pieces/day. If strong or frequent cravings, may use 2nd piece within the hour; avoid continuous use. Use 2mg if patient smoked 1st cigarette >30mins after waking up; use 4mg if patient smoked 1st cigarette within 30mins of waking up. Do not eat or drink for 15min before and during use.
NASAL SPRAY
nicotine Nicotrol NS Rx 0.5mg/
 
spray
Individualize. Usually 1−2 doses/hr; max 5 doses/hr, 40 doses/day for up to 3mos; may discontinue abruptly or taper. Do not sniff, swallow, or inhale spray. Nasal vasoconstrictors may delay absorption.
INHALER
nicotine inhalation system Nicotrol Inhaler Rx 10mg/
 
cartridge (4mg delivered)
Individualize. Use at least 6 cartridges/day for 1st 3−6wks; max 16 cartridges/day for 1st 12wks, then reduce gradually over 12 more weeks. Each cartridge lasts about 20min with frequent continuous puffing and provides nicotine equivalent to about 2 cigarettes.
LOZENGES
nicotine polacrilex Nicorette Lozenge OTC 2mg, 4mg 1 lozenge every 1−2hrs (at least 9 lozenges/day) for 6wks, then every 2−4hrs for 3wks, then every 4−8hrs for 3wks, then stop; max 5 lozenges/6hrs (20 lozenges/day). Use 2mg if patient smoked 1st cigarette >30mins after waking up; use 4mg if patient smoked 1st cigarette within 30mins of waking up. Dissolve slowly in mouth; minimize swallowing. Do not eat or drink for 15min before and during use.
Nicorette Mini Lozenge OTC
TABLETS
varenicline tartrate Chantix Rx 0.5mg, 1mg Initially 0.5mg once daily for 3 days, then 0.5mg twice daily for 4 days, then 1mg twice daily. Treat for 12wks; may continue 12 more weeks if patient successfully stops smoking to further increase the likelihood of abstinence. Reduce dose in renal impairment. Begin therapy 1wk before target quit date. Alternatively, may begin therapy and then quit smoking between Days 8 and 35 of treatment. Take after eating with a glass of water. May reduce dose if intolerable nausea or other adverse effects occur.
bupropion 
HCl
Zyban Rx 150mg Initially 150mg once daily for 3 days, then 150mg twice daily at least 8hrs apart; max 300mg/day in divided doses. Treat for 7–12wks. Swallow whole. Avoid bedtime dosing. Set a target quit date within the first 2wks of treatment. Reassess treatment plan if attempt is unsuccessful. May consider ongoing therapy if patient does not feel ready to discontinue treatment after 12wks.
REFERENCES

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

Not an inclusive list of medications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.

(Rev. 1/2019)