Pharmacotherapy General Points

Disclaimer: The comprehensive guidance on this web page and in the attached PDF is intended to support your counselling of patients undergoing nicotine replacement therapy (NRT). Please tailor recommendations based on individual patient needs and consult with health-care practitioners as necessary.

Optimizing efficacy

• Extension of NRT duration to 24 weeks improves cessation rates. Standard NRT therapy duration is 8–12 weeks.
• First-line options for non-NRT include bupropion and varenicline. Patient preference and absence of contraindications guide medication choice.

Combination therapy

• Initially, monotherapy is preferred, but combination therapy (e.g., scheduled NRT [patch] + short-acting NRT or scheduled NRT + bupropion) may be appropriate for certain patients, such as those with severe nicotine addiction or who have failed monotherapy.
• Combining NRT products enhances effectiveness.
• Cost considerations may limit combination therapy.
• The combination of varenicline and bupropion showed promise in an open label trial.¹
• 40 weeks of maintenance therapy with varenicline + cognitive behavioural therapy (CBT) is effective in prolonging abstinence.

Comparing agents

• Varenicline has higher quit rates compared to bupropion and single forms of NRT.
  1. Ebbert JO, Croghan IT, Sood A et al. Varenicline and bupropion sustained-release combination therapy for smoking cessation. Nicotine Tob Res 2009;11(3):234-9.

Monitoring considerations

• Managing pharmacotherapy during slips: Encourage continuation of medication for at least 4 weeks after a slip.
• Mental health: Monitor mental health during and after quitting; watch for severe agitation, low mood and depression. Alert family/caregivers to watch for these changes or symptoms. Closer monitoring by health-care practitioners is needed for those with pre-existing psychiatric disorders.
• Serious adverse events: If hypertension, nicotine toxicity, mood changes or seizures occur, consider reducing dose, discontinuing medication and/or switching to an alternate therapy.
• Drug interactions: Smoking affects hepatic metabolism via CYP1A2 induction, potentially requiring dose adjustments for certain medications. This includes caffeine—advise patients that caffeine intake should be reduced by 50% starting on quit date and opt for alternative beverages like caffeine-free tea, hot chocolate, juice or ice water
• Weight gain: The risks of continuing smoking outweigh the risks of weight gain.
  • Pharmacotherapy is associated with less weight gain than behavioural methods alone.
  • Post cessation weight gain typically occurs in the first 3 months, with an increase of 4–5 kg at 12 months. Approximately 16% of patients who quit smoking lose weight, while only 13% gain more than 10 kg.
  • Encourage low-calorie snacks, sugar-free candy/gum and physical activity to manage food cravings.

Smoking Cessation Pharmacotherapy Options