Review: Pharmacotherapy for smoking cessation

Abstract

Smoking is associated with numerous cancers and atherosclerosis. Smoking cessationhas substantial potential in reducing morbidity and mortality worldwide. The initial steps “5 A’s”(Ask, Advise, Assess, Assist, Arrange) should be applied in all patients. Behavioral counselingand pharmacotherapy are both effective, but the combination of the two is more effective thaneither alone. The first-line pharmacotherapy includes nicotine replacement, bupropion, andvarenicline. Nicotine replacement therapy (NRT) consists of long-active formulations, such asin a patch, and short-acting formulations such as in gum, lozenge, inhaler, and nasal spray. Ascompared to placebo, NRT increases the chances of quitting smoking. Nicotine replacementtherapy does not increase cardiovascular risk and is safe in patients with cardiovasculardisease. Sustained-release bupropion is more effective than nicotine patches and can becombined with nicotine patches. Buprenorphine is generally well tolerated, except that it lowersseizure threshold and is contraindicated in patients with seizure disorders. Varenicline alsosignificantly improves the success rate of smoking cessation. The latest evidence suggeststhat varenicline is not associated with an increased risk of neuropsychiatric or cardiovascularevents. In conclusion, the use of NRT (nicotine patch + nicotine gum/lozenge/inhaler/spray),bupropion (with NRT), or varenicline is strongly recommended for smoking cessation, unlessthey are contraindicated.