Step by Step Guide to Smoking Cessation Pharmacotherapy

1. Assess willingness to quit smoking. Provide motivation

2. Suggest accessing and 800-QUIT-NOW (800-784-8669)

3. Assess previous attempts to quit. Depending on previous pharmacotherapy, can consider alternative pharmacotherapy

4. As a first line, use combined nicotine replacement therapy

a. 14 mg /day (for >10 cigarettes/day, use 21 mg/day) 7 mg used when tapering

b. Nicotine gum for cravings despite use of nicotine patch

5. Varenicline can be safely used as a first choice in absence of severe depression, history of a suicidal attempt, suicidal ideation or bipolar disorder. Dose adjustment required in renal dysfunction.

  • Start one to two weeks before quit date
  • 0.5 mg/day for three days followed by
  • 0.5 mg twice a day for four days followed by
  • 1 mg twice a day

6. Bupropion is a second line medicine alternative

  • 150 mg/day for three days followed by 150 mg twice a day
  • Avoid bupropion in patients with history of seizures or at risk of seizure

7. Consider referral for group therapy

8. Continue pharmacotherapy for at least 12 weeks

9. In case of relapse but with continued willingness and desire to quit, can continue pharmacotherapy with more attempts to quit

10. Cautious nicotine replacement therapy can be initiated during hospitalization (Ref PMID: 15820167)

11. Reasonable to use nicotine replacement therapy, varenicline or bupropion in patients at high risk of cardiovascular disease. Although there were concerns about increased risk of cardiovascular diseases related to varenicline in one of the trials, other trials have not found a similar association (Ref).