The U.S. Surgeon General released a 2020 report on smoking cessation, urging Americans to stop smoking cigarettes while reviewing their numerous health consequences. According to the report, cigarette smoking is the leading cause of preventable disease and death in the U.S. and 68 percent of smokers desire to quit.
So, if you are trying to quit, here is a synopsis of the smoking cessation medications available so that you can be equipped with the knowledge and tools to discuss with your doctor at your next visit.
Note that we do not know how effective medications are in adolescents, those who smoke five or less cigarettes a day, and those who use smokeless tobacco. Smoking cessation medications are also not FDA-approved for pregnant women. So, these people should most especially consult with their doctor, regardless of any of the medication options discussed here.
Nicotine Replacement Therapy (NRT)
NRT is used to mitigate withdrawal symptoms, while excluding all the other harmful chemicals found in cigarettes.
NRT options include:
- Patches, gum, lozenges—available over the counter (OTC) and easily accessible without requiring a visit to a doctor.
- Inhalers and nasal sprays—available only by prescription.
Combining the long-acting patch along with a short-acting gum or lozenge is a common strategy that has been shown to be more efficacious than using a single type of nicotine replacement alone.
Most common side effects include mostly gastrointestinal symptoms (like nausea, diarrhea, and abdominal pain) and headaches.
Dosing is dependent on the quantity of cigarettes a person currently smokes and is then tapered down from there. For instance, for those who opt for the patch:
- If a person smokes more than 10 cigarettes/day and weighs more than 45 kg, the highest dose patch—21 mg/day—is recommended for an initial 6 weeks, tapering down to 14 mg/day for 2 weeks, then 7 mg/day for 2 weeks.
- If a person smokes less than or equal to 10 cigarettes/day or weighs less than 45 kg, initiation is recommended at 14 mg/day for 6 weeks, then 7 mg/day for 2 weeks.
These regimens are flexible, however, and can be stretched out over a longer time span if necessary to achieve successful cessation.
Bupropion
A prescription medication that reduces cigarette cravings and withdrawals, bupropion is also prescribed as an antidepressant which may be an added benefit for those who suffer from depression.
Bupropion is a generic drug, and perhaps less costly and more affordable than brand drugs used to assist with smoking cessation. It is available in two doses, so you can initiate at the lower dose and then increase if needed. Ideally, it should be initiated approximately 2 weeks prior to the desired quit date and continued for a minimum of 12 weeks. Abruptly quitting seems to be a more effective method of stopping cigarette smoking, but gradually reducing smoking is still acceptable during treatment.
The most common side effects of bupropion include insomnia—as bupropion tends to be activating and energizing, it may more ideal for those who are generally low energy and fatigued—and appetite suppression, so it may help in those who are worried about weight gain as a complication of smoking cessation. However, it is contraindicated in those with a history of seizure disorder as it can lower the threshold for seizures in these susceptible people.
Varenicline
Varenicline is another prescription medication used to aid with smoking cessation, but this one is available only as brand at this time and is therefore costlier than the other options. However, it may be considered after attempting some of the other options.
This medication blocks the effect of nicotine receptors in the reward center of the brain and therefore decreases the craving effect of nicotine that leads to dependence. It also helps to decrease withdrawal symptoms.
The recommendation is to initiate varenicline 1-4 weeks prior to the desired quit date and to take it for a full 12-week course, but it can be continued for an additional 12 weeks in order to reduce relapse risk if needed.
The most common side effects of varenicline include vivid dreams, insomnia, and nausea. There were also initial concerns about an increased risk of depression and suicidal thoughts with this drug, but the FDA removed that black box warning in 2016 after a large study referred to as the “EAGLES” trial (see references below) researched 8,000 smokers who revealed similar rates of psychiatric events with varenicline, bupropion, the patch, and a placebo.
The EAGLES study also found that varenicline provides a greater chance of successful quitting after 6 months, when compared to all the other methods and placebo. But bupropion and the patch were still more effective than placebo, and still solid options.
There are also concerns over the cardiovascular effects of varenicline, but most of the evidence has not shown an increased risk. Based on research so far, it seems less likely to present a problem for those with low risk of heart disease, but there are not enough studies to determine how safe it is for those with high risk of cardiovascular events at this time.
It is also important to note that we must weigh the risk of smoking cigarettes on heart disease itself. However, there are other solid options to consider prior to considering varenicline.
Electronic Cigarettes (E-cigarettes)
E-cigarettes sure have gained a lot of media coverage in the recent past. They are battery-operated devices that heat up nicotine into a vapor that can be inhaled. They contain many fewer toxins than cigarettes do, and likely pose less risk to most established smokers than continuing to smoke regular cigarettes. But, e-cigs are not approved by the FDA and still require further research to determine how effective they are and what their long-term risks include, as current studies are inconclusive and conflicting. We also need more studies to determine how they stack up and compare with the other cessation medication options.
However, we do know that e-cigs are not safe for adolescents, young adults, and pregnant women, in addition to adults who aren’t using any tobacco products and are simply vaping for the sake of vaping.
If you do decide to give e-cigarettes a shot in an effort to cease regular cigarette smoking, make sure to perform a 100% switch from cigarette smoking to e-cigs and not smoke and vape at the same time, which is not recommended.
Behavioral Counseling
Although not a medication, I would be doing a disservice if I did not mention the role of counseling in smoking cessation. For some, counseling alone may be sufficient for quitting without the need for medications. Behavioral counseling has shown to increase the chances of quitting—this can be in person with a doctor or group, or over the telephone via free quitting smoking hotlines. You can reach the free hotline at 1-800-QUIT-NOW.
In summary, medications may not be the right answer for everyone. However, if you are considering one of these smoking cessation tools, it is vital to understand the pros and cons of your options. Hopefully, you now have enough information to have a more meaningful and fruitful discussion with your doctor.
Just note that, regardless of what smoking cessation aid you opt for, most people require multiple attempts before they successfully quit. So if you do fall off the wagon, simply get back on again. In the words of Yoda, “Do or do not. There is no try.”
For a video version of this article, check out: @MajdMD on YouTube.com.
REFERENCES:
U.S. General Surgeon Smoking Cessation Report: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment: https://pubmed.ncbi.nlm.nih.gov/30527452/
Pharmacological Interventions for Smoking Cessation: https://pubmed.ncbi.nlm.nih.gov/23728690/
EAGLES double-blind, randomized, placebo-controlled study: https://pubmed.ncbi.nlm.nih.gov/27116918/
Risk of Neuropsychiatric Adverse Events Associated with Varenicline: Systemic Review and Meta-Analysis: https://pubmed.ncbi.nlm.nih.gov/25767129/
Risk of Cardiovascular Serious Adverse Events Associated with Varenicline Use for Tobacco Cessation: Systematic Review and Meta-Analysis: https://pubmed.ncbi.nlm.nih.gov/22563098/
