The current state of tobacco cessation treatment

Humberto K. Choi; Jorge Ataucuri-Vargas; Charlie Lin; Amanda Singrey

doi:10.3949/ccjm.88a.20099

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TABLE 1

The Heaviness of Smoking Index

How many cigarettes do you smoke a day?
	Score
10 or fewer	0
11–20	1
21–30	2
31 or more	3
How soon after waking up do you smoke your first cigarette of the day?
	Score
60 minutes	0
31–60 minutes	1
6–30 minutes	2
Within 5 minutes	3
Level of nicotine dependence by total score:
0–2 = low
3–4 = moderate
5–6 = high

Based on information in reference 4.

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TABLE 2

Suggested messages to use when giving advice on tobacco cessation

Brief advice:

“Quitting is the best way to improve your health.”

Develop discrepancy:

“How do you think your smoking is affecting your loved ones?”

Express empathy:

“Many people worry about managing without cigarettes.”

Manage resistance:

“You are worried about how you would manage withdrawal symptoms.”

Personalized messages:

“The best way to prevent lung cancer is to quit smoking.”

“The best way to prevent another heart attack is to quit smoking.”

Connect to resources:

“There are many effective options. I can help you find the best effective treatment for you.”

Support self-efficacy:

“Would you like information about the benefits and strategies of quitting?”

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TABLE 3

First-line pharmacologic options for tobacco cessation

Drug, available doses	Dosing	Administration^{^a}	Common side effects	Comments
Nicotine patch (7 mg, 14 mg, 21 mg)	≤ 10 cigarettes/day: start with nicotine patch 14 mg/day > 10 cigarettes/day: start with nicotine patch 21 mg/day	Apply one patch each morning to any non-hairy, clean, dry skin on upper body or outer arm. Rotate the site daily to avoid skin irritation. After 6 weeks, taper to lower doses for 2-4 weeks.	Skin irritation Insomnia Vivid dreams	Consider removing patch at bedtime in case of insomnia and vivid dreams.
Nicotine gum (2 mg, 4 mg)	Smokers wait > 30 min after waking to smoke: use 2 mg Smokers smoke within 30 min of waking: use 4 mg	"Chew and park" is recommended: chew until tingling sensations occurs, then "park" until tingling disappears. Then chew again to repeat. Chew one piece of gum every 1-2 hours or whenever there is an urge to smoke. Use up to 24 pieces of gum/day per day for 6 weeks. Gradually reduce use over a second 6 weeks, for a total duration of 3 months.	Mouth irritation Esophageal and gastric irritation Hiccups Jaw pain Nausea/vomiting Excess salivation Headache Palpitations	Avoid acidic beverages (eg, coffee, carbonated drinks) 15 minutes before and during gum use, as they reduce nicotine absorption.
Nicotine lozenge (2 mg, 4 mg)	Smokers wait > 30 min after waking to smoke: use 2 mg Smokers smoke within 30 min of waking: use 4 mg	Place lozenge in the mouth and allow it to dissolve for 30 minutes. Use 1 lozenge every 1-2 hours for 6 weeks. Maximum five lozenges every six hours or 20 lozenges per day. Gradually reduce number of lozenges used per day over a second 6 weeks.	Mouth irritation Mouth ulcers Abdominal pain Hiccups Nausea/vomiting Diarrhea Headache Palpitations	Do not chew lozenge. Avoid acidic beverages (eg, coffee, carbonated drinks) 15 minutes before and during gum use, as they reduce nicotine absorption.
Nicotine inhaler (10 mg/cartridge)	Puff into mouth as needed; use 6-16 cartridges per day (at least 6 cartridges per day for the first 3-6 weeks) for up to 12 weeks	Inhale deeply into back of throat or puff in short breaths. Maximum 16 cartridges per day. Gradually reduce dose over 6-12 weeks	Mouth irritation Throat irritation Cough	Required frequent use. Each cartridge lasts about 20 minutes if continuously puffing. Inhaled nicotine may cause bronchospasm.
Nicotine nasal spray (10 mg/mL)	Use 1 spray in each nostril 1-2 times per hour	Maximum of 10 sprays per hour or 80 spray per day. Adjust dose as needed based in response. Gradually reduce dose after 12 weeks.	Side effects are common (headache, throat irritation, cough, rhinitis). Nasal irritation may be a reason to stop.	Provides a more rapid rise in plasma nicotine concentration than that produced by agents absorbed via the oral mucosa.
Bupropion SR (sustained release) (150 mg)	150 mg once daily for 3 days, then increase to 150 mg twice daily	Begin at least 1-2 weeks before target quit date. May use longer than 12 weeks if needed for maintenance. Consider combination therapy, discontinuation, or alternative agent if no progress is made by seventh week.	Insomnia Headache Dizziness Diaphoresis Weight loss Xerostomia Nausea/vomiting	Consider lowering dose to 150 mg daily if full dose not tolerated. Decreases seizure threshold.
Varenicline (0.5 mg, 1 mg)	Days 1-3: 0.5mg once daily Days 4-7: 0.5 mg twice daily Day 8 and later: 1 mg twice daily	Treatment should be continued for 12 weeks but can be extended. Consider dose reduction if usual dose is not tolerated.	Insomnia Nausea/vomiting Abnormal dreams Headache Nasopharyngitis Xerostomia	Varenicline does not increase the risk of depression, suicidal ideation, or cardiovascular disease.

↵a Nicotine replacement therapy is recommended for 2 to 3 months after smoking cessation. However, it may be used through the period when the patient is at high risk for relapse. Some smokers may need to use nicotine replacement products indefinitely.

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TABLE 4

Drug interactions to consider in tobacco cessation treatment

Agent	Potential drug interactions
Nicotine replacement therapies	Adenosine, cimetidine, varenicline
Varenicline	Alcohol, nicotine, OCT2 inhibitors (eg, histamine-2-receptor blockers, quinolones, tafenoquine, trimethoprim)
Bupropion	Drugs that lower seizure threshold (eg, alcohol, selective serotonin reuptake inhibitors, tricyclic antidepressants, systemic steroids)
	CYP2D6 substrates (eg, aripiprazole, atomoxetine, brexpiprazole, clozapine, codeine, duloxetine, fesoterodine, galantamine, hydrocodone, iloperidone, metoprolol, metoclopramide, nebivolol, pimozide, primaquine, selective serotonin reuptake inhibitors, tamoxifen, tamsulosin, thioridazine, tramadol, tricyclic antidepressants, valbenazine, vortioxetine)
	Dopaminergic medications (eg, amantadine, levodopa)
	CYP2B6 inducers (eg, carbamazepine, efavirenz, nelfinavir, nevirapine, phenobarbital, phenytoin, primidone, rifampin, ritonavir)
	CYP2B6 inhibitors (eg, clopidogrel, mifepristone; ticlopidine)
	Digoxin, monoamine oxidase inhibitors
Cigarette smoke	CYP1A2 substrates (eg, clozapine, fluvoxamine, olanzapine, tacrine, theophylline)