Smoking Cessation Regimens

General Information

Medications

Varenicline (Chantix):

  • American Thoracic Society 2020 Practice Guidelines

    • Recommended over bupropion and nicotine replacement therapy even in patients with disorder, depression, anxiety, schizophrenia, and/or bipolar disorder

    • Begin treatment rather than waiting until patients are ready to stop tobacco use (strong recommendation, moderate certainty)

    • Recommend treatment for longer than standard duration of 6-12 weeks

  • Regimen (12 weeks total)

    • Days 1 to 3: 0.5 mg qd

    • Days 4 to 7: 0.5 mg BID

    • Weeks 2-12: Quit smoking and start 1 mg BID

  • Combination with nicotine replacement therapy (NRT)

    • Traditionally recommended against combination with NRT

    • Per American Thoracic Society 2020 guidelines, there is a conditional recommendation with low certainty to combine with NRT

  • Contraindications and adverse effects

    • FDA boxed warning: May cause serious neuropsychiatric symptoms in patients, including changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide; patient should be monitored closely

    • May result in headache, nausea (dose related), insomnia, abnormal dreams, flatulence

    • May increase the risk of certain cardiovascular adverse events in patients with cardiovascular disease

    • Pregnancy category C

  • Retail price: Up to $541/month

Bupropion XL (Wellbutrin)

  • Regimen

    • Days 1-3: 150 mg

    • Days 4 to 7: 300 mg qd

    • Week two: Stop smoking and start nicotine replacement therapy (see below)

  • May combine with nicotine replacement therapy

  • Adverse effects

    • Contraindications

      • History of seizure disorder, eating disorder

      • MAO use (e.g. selegiline) within previous 14 days

    • FDA boxed warning: May increase suicidality in patients with depression

    • May result in insomnia, dry mouth

    • Pregnancy category C

  • Retail price: As low as $12/month with GoodRx Coupon

Nicotine Replacement Therapy

Nicotine patch (transdermal): Start on quit date and combine with PRN nicotine replacement

  • > 10 cigarettes/day: 21 mg/day patch x 6 weeks, 14 mg/day patch x 6 weeks, 7 mg/day patch until ready to stop

  • ≤ 10 cigarettes/day: 14 mg/day patch x 6 weeks, 7 mg/day patch until ready to stop

PRN nicotine therapy

  • Dosage for gum and lozenge based on time of first cigarette after awakening

    • < 30 minutes: 4 mg/unit x 6 weeks, 2 mg/unit until ready to stop

    • > 30 minutes: 2 mg/unit until ready to stop

  • Gum

    • Common flavors include mint, cinnamon, and mixed fruit

    • Chew gum until nicotine taste appears and then hold gum against buccal mucosa until it disappears

    • Maximum daily dose: 24 pieces

  • Lozenges

    • Common flavors include mint and cherry

    • Maximum daily dose: 20 lozenges

  • For patients using patch, total nicotine intake with PRN therapy should not exceed amount received via smoking (e.g. 1 pack/day smoker previously receiving up to 40 mg/day via smoking on 21 mg/day patch should try not to use more than 5 pieces of 4 mg/piece gum per day)

Counseling and Alternative Therapies

  • Exercise, acupuncture, hypnotherapy are ineffective for smoking cessation

  • Address behavior change, especially activities associated with smoking

  • Counsel patient about nicotine withdrawal symptoms, depression, and weight gain

  • Follow-up shortly before quit date

Resources