Carolyn Vachani, MSN, RN, AOCN & Anil Vachani, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: December 22, 2014
This article will review the available treatments, both pharmacologic (drug) and non-pharmacologic, to aid in successful smoking cessation. Please see the article Smoking Cessation. Where do I Start? for tips to help you quit.
Unfortunately, only 5-10% of smokers who attempt to quit cold turkey are successful long term. The U.S. Department of Health and Human Services recommend that, unless contraindicated, people who smoke 10 or more cigarettes a day should use a drug therapy in every attempt to quit. There are a number of pharmacologic agents that can help you quit, and there are also non-pharmacologic aids that may be helpful.
The need to smoke is driven by an addiction to nicotine and the behavior a person associates with smoking (i.e. driving the car, after a meal, etc.). The addiction to nicotine is powerful and for reasons that are not clear, quitting can be more difficult for some smokers compared to others. Nicotine binds to receptors in the brain, increasing the activity of dopamine, a chemical that causes a sense of well-being. Nicotine remains in the body for a short time, so strong cravings can start within hours of quitting. There is risk of depression after quitting, particularly for those with a history of depression. For these reasons, pharmacologic treatments are important to achieving successful smoking cessation. Pharmacologic treatments are both safe and effective in a variety of patient populations, including those with heart disease or cancer.
Seven first-line medications reliably increase long-term smoking abstinence rates and include bupropion, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. Patients should discuss past quit attempts with their provider. By identifying what worked and what did not during previous quit experiences can assist in choosing pharmacotherapy for future attempts. The choice of which therapy to use should be based on an individual's medical and psychological history, the side effects of the drug and any patient preference for the method of administration. Some therapies are available over the counter, but this should not diminish the importance of discussing your plan to quit with your healthcare provider, who can provide guidance based on your specific situation. This is particularly important for pregnant women because of potential risks to the fetus.
Nicotine replacement therapy (NRT) is currently marketed in 6 formulations: a patch, gum, lozenge, nasal spray, vapor inhaler and sublingual tablets (that are dissolved under the tongue). Because the sublingual formulation is not currently available in the U.S, it will not be discussed here.
The nicotine patch delivers a continuous level of nicotine over 24 hours. The remaining forms of NRT are considered "short acting", delivering their nicotine faster and for much shorter duration. This allows the patch to be used in conjunction with the other NRT options, which can be used for break through cravings. Studies have found that NRT doubles the chance of quitting successfully, regardless of which formulation is used.
NRT works by partially replacing the nicotine that had been received through smoking, in turn reducing the severity of withdrawal symptoms and cravings. It is important to recognize that NRT does not completely eliminate withdrawal symptoms or cravings. Some people find it helpful to use the patch in conjunction with a short acting formulation that can be used to tame cravings. Common misconceptions that smoking while wearing the patch will cause serious side effects or that you will become addicted to the NRT are not true.
All forms of NRT contain warnings about their use in patients who have had a recent heart attack, those with angina (chest pain from coronary artery disease) and serious abnormal heart rhythms (arrhythmias). Despite this, experts agree that in a person who will continue to smoke, the benefits of NRT likely outweigh the risks. In fact, the blood concentration of nicotine from cigarettes is far greater than with NRT (6-10 times higher in the arterial blood). If you have one of these medical conditions noted above, be sure to discuss your plans to quit with your healthcare provider. Some experts believe NRT may be less effective for women, however this has not been proven.
The nicotine patch should be worn 24 hours a day, but can be removed at night for individuals who develop insomnia as a side-effect. Patches are available in different doses, allowing the patient to titrate down the dose before ultimately coming off altogether. People who smoke more than 10 cigarettes a day are advised to start with a 21mg patch for 6-8 weeks, decrease to a 14mg patch for 2-4 weeks, and then a 7mg patch for an additional 2-4 weeks. Some patients may benefits from a longer course of NRT therapy – this should be discussed with your health care provider. Those who smoke more than 40 cigarettes a day (2 packs), less than 10 cigarettes a day or have not been successful in previous attempts using the patch should discuss dosing with their healthcare provider. The most common side effect is skin irritation at the site of the patch. Rotating the location of the patch may help decrease this.
Nicotine gum is a short acting NRT that comes in 2 and 4 mg strengths. Those smoking 25 or more cigarettes a day should use the higher dose. When used without other NRT, one piece of gum should be taken every 1-2 hours for the first week, followed by 1 piece every 2-4 hours for weeks 7 through 9, and then 1 piece every 4-8 hours for weeks 10 through 12. At least 10 pieces a day are recommended, with a maximum of 20-30 pieces per day. When used in combination with the patch, a 2mg piece can be taken every 1-2 hours as needed for cravings.
The gum should not be used like bubble gum, but briefly chewed until a peppery taste develops, and then the gum should be placed between the teeth and gums to allow the nicotine to be absorbed through the gum tissue. If the gum is just chewed, the nicotine is released into the mouth and swallowed, rendering the nicotine unabsorbable and possibly leading to nausea. Other possible side effects include jaw pain, mouth soreness, upset stomach and hiccups.
The nicotine lozenge, which also comes in 2 and 4 mg strengths, is a good alternative for those who cannot tolerate the gum. People who smoke their first cigarette within 30 minutes of awakening should use the 4mg strength, others the 2mg strength. The dosing schedule for the lozenge is the same as the gum schedule described above. Possible side effects are similar and include mouth and throat irritation and hiccups.
The nicotine inhaler is designed to look and feel like a cigarette, helping users to appease the habitual nature of smoking. The inhaler is placed in the mouth and "puffs" are taken from it to quickly deliver the nicotine to the mouth and back of the throat. It can be used alone or in combination with the other NRTs. The dose is 6-16 cartridges a day for 12 weeks, then taper the amount used over the next 6-12 weeks. Each cartridge contains 10mg of nicotine or 400 "puffs". It would take about 80 puffs to get as much nicotine as is delivered by one cigarette. Possible side effects include mouth and throat irritation and cough. Currently, this formulation is only available with a prescription.
Nicotine nasal spray is used similar to nasal sprays for nasal congestion. This method of delivery sends higher doses of nicotine to the brain faster than other formulations and may be helpful for heavy smokers. Users should take 1 or 2 sprays (0.5mg per spray) in each nostril, every hour, for 3 to 6 months, then taper the dose over 4-6 weeks. Possible side effects include runny nose, throat irritation and cough, though these typically subside after 3 days of use. This formulation is currently only available with a prescription.
Bupropion (Wellbutrin®, Zyban®) was the first non-nicotine agent approved by the U.S. Food and Drug Administration for smoking cessation. It is an anti-depressant, but works equally well in people with and without a history of depression. How the drug works to break a smoking addiction is not fully understood. Clinical trials have found that it doubles the chances of successful quitting when compared to placebo, and is most effective when used in combination with 1 or more NRTs and counseling.
People should begin taking the 150mg sustained release tablets twice a day, at least 7 to 10 days before their quit date and continue for 2-3 months. People with a history of a seizure disorder, eating disorder or those taking a medication from the MAO inhibitors class of drugs (used to treat depression and Parkinson 's disease) should not take this drug. Users must understand that the drug does not effect mood (unless they are also depressed), nor does it make smoking unpleasant or break the habitual nature of smoking. The drug does, however, reduce the stress associated with quitting and the associated withdrawal symptoms and may improve the will to quit. Users may not notice this effect, but experts say it is the absence of distressing symptoms that indicate the drug is working.
Possible side effects include insomnia, dry mouth, headache, tremors, nausea and anxiety. Buproprion is only available with a prescription. One positive effect seen with this drug is that it suppresses the weight gain often seen with quitting.
Varenicline is a prescription medication designed specifically for treating tobacco addiction. The drug works by stimulating the release of dopamine, which mimics the effect of nicotine, leading to a reduction in cravings and withdrawal symptoms. In addition, the drug blocks nicotine's ability to bind to receptors in the brain, making smoking less satisfying for those who lapse and smoke after their quit date. Research has found that the odds of quitting using varenicline are 2 and a half times that of placebo. Recent evidence suggests that the combination of varenicline and NRT may be more effective than varenicline alone, however more studies are needed on long term smoking rates.
The drug is started at 0.5 mg once a day for 3 days, then 0.5 mg twice a day on days 4 through 7, then 1 mg twice a day for 12 weeks. If the user is not smoking at 12 weeks, an additional 12 weeks is recommended to prevent relapse. Possible side effects include nausea (seen in 30% of users), insomnia, abnormal or vivid dreams and headache. Only 3% of users discontinued the drug due to the nausea, which can be lessened by taking the drug with food and a full glass of water. In 2008, the FDA issued a warning regarding the association of varenicline therapy with changes in behavior, agitation, depressed mood and thoughts of or attempted suicide. Patients and their family members should report any of these symptoms immediately to their healthcare provider.
Electronic Cigarettes (E-cigarettes)
Electronic cigarettes, also known as e-cigarettes, are battery operated devices designed to deliver nicotine with tobacco smoke by heating a nicotine containing solution. E-cigarettes became available in Europe and the United States in 2006, and have gained popularity among smokers wishing to reduce or quit traditional cigarette smoking. There are very few studies that have evaluated the use of e-cigarettes for smoking cessation. There appears to be a small beneficial effect of e-cigarette use on short-term cigarette smoking rates. There are, however, many concerns regarding the use of e-cigarettes as smoking cessation aids, including the lack of standardized manufacturing of these devices and the risk of impurities and contamination of the nicotine liquid with toxic chemicals (e.g. metal particles, etc.). There is also concern that e-cigarettes have the potential to increase cigarette use by reducing the motivation of smokers to quit completely, and by providing a gateway to smoking for non-smokers, particularly among adolescents.
The previously discussed therapies are considered first line options for the treatment of tobacco addiction. There are two agents, nortriptyline and clonidine, that are not FDA approved for use as tobacco addiction treatments, but are recommended by current guidelines for those who cannot tolerate or have failed the first line therapies. You can discuss these options with your healthcare provider if you have previously tried the first line options.
There are several non-pharmacologic therapies that are promoted for use in treating tobacco addiction. Some are more effective than others, so let's review the most commonly used therapies.
Telephone counseling is a popular method of smoking cessation support, which is most commonly initiated by the patient calling a help line, but can include a counselor contacting a patient. Telephone support has been shown to improve cessation success when 3 or more calls were made or received. Recent studies have shown this support to improve quit rates over those with NRT alone. Similarly, online support has become a common support tool for smoking cessation, but this method has not yet been shown to have an advantage in clinical studies. This may be due to the variability in the quality of the websites available. This method of counseling may also be more effective in certain demographic groups (i.e. teens, young adults).
Cognitive behavioral approaches involve teaching the patient to reduce and cope better with the negative mood or cravings associated with withdrawal, change habits associated with smoking and improve their motivation to quit. This intervention can be done through individual or group counseling. Studies have found a strong positive correlation between the total minutes of counseling and successful quitting.
Programs using supervised exercise programs have shown some benefit to quitting success, particularly in women. Further research is needed to further define its role in smoking cessation programs. Quit programs and contests run in the community or workplace have been shown to increase the number of people attempting to quit, but this has not necessarily led to increased quit rates.
Hypnotherapy has been promoted as an effective aid to smoking cessation. It is proposed to work by either lessening the desire to smoke, improve the will to quit and/or help the person concentrate on a quit program. Clinical trials have not yet shown an advantage of hypnosis for smoking cessation, but may be effective for some individuals. Further studies are needed to better define its role.
Acupuncture, acupressure, laser therapy and electro stimulation are all non-pharmacologic therapies promoted to aid in smoking cessation by reducing withdrawal symptoms. A review of studies comparing these therapies to sham forms of the therapies (the equivalent to placebo in studies), did not find evidence that these therapies increased the number of people who successfully quit smoking. However, due to the poor design of many studies, there is not enough evidence to dismiss the possibility that they may have some effect and may be better than no therapy for some patients.
With all the available therapies for treating tobacco addiction, it is important to discuss them with your healthcare provider for guidance on which methods are best for your specific situation. Combine these therapies with our "Smoking Cessation. Where do I Start" article to develop your plan to quit.
Abbot NC, Stead LF, White AR & Barnes J. Hypnotherapy for smoking cessation. Cochrane Database of Systematic Reviews 1998, Issue 2. Reported up to date in 2005.
A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. American Journal of Preventive Medicine 35:158-76, 2008.
Hajek P, Etter JF, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction. 2014;109(11):1801-10.
Koegelenberg CF, Noor F, Bateman ED, van Zyl-Smit RN, Bruning A, O'Brien JA, et al. Efficacy of varenicline combined with nicotine replacement therapy vs varenicline alone for smoking cessation: a randomized clinical trial. Jama. 2014;312(2):155-61.
Niaura, R. Nonpharmacologic therapy for smoking cessation: Characteristics and efficacy of current approaches. The American Journal of Medicine (2008) 121:4A, S11-S19.
Nides, M. Update on pharmacologic options for smoking cessation treatment. The American Journal of Medicine (2008) 121:4A, S20-S31.
White AR, Rampes H & Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews 2006, Issue 1.