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Medication

The use of medication improves smoking cessation success and helps reduce withdrawal symptoms.

The odds that your patients will quit smoking for good further increase when you prescribe combination smoking cessation medications.

Evidence shows that the use of long + short acting Nicotine Replacement Therapy (NRT) more than triples quitting success rates!

There are currently seven FDA-approved pharmacotherapies, including five nicotine replacement therapies (gum, patch, lozenge, inhaler, and nasal spray) and two other medications (bupropion and varenicline).

Not all smokers are able to quit with single-drug therapy. In fact, most smokers benefit from combination therapy to help further reduce withdrawal symptoms. Medications may be used simultaneously such as:

  • Combination NRT
    • May provide therapeutic advantage by increasing nicotine concentrations to help prevent the onset of severe withdrawal symptoms.
    • Provides a stable baseline nicotine level from the sustained release NRT, such as the nicotine patch, with immediate release NRT such as the nicotine gum, lozenge, inhaler or nasal spray.
  • Dual use of medications with different mechanisms of action (e.g., NRT and bupropion).

The FDA has determined that there are no significant safety concerns if smokers use nicotine replacement products in combination with another product, for example, a long-acting skin patch with a short-acting gum or if they do not stop smoking completely before beginning to use such products.

According to the U.S. Department of Veterans Affairs Pharmacy Benefits Management Services, Medical Advisory Panel report , effective combinations of medications are:

  • Long-term (>14 weeks) nicotine patch (18-24 weeks in trials) + other NRT (gum, lozenge, spray) as needed for a minimum of 26 weeks (up to 52 weeks in trials). Use beyond 52 weeks should be reviewed on a case-by-case basis.
  • Nicotine patch (10 weeks) + nicotine inhaler (12-26 weeks)
  • Nicotine patch (10 weeks) + bupropion SR (12 weeks)

Pharmacotherapy Intervention

Estimated Abstinence Rate (95% CI)

Estimated Odds Ratio

(95% CI)

Placebo

13.8

1.0

Bupropion SR

24.2 (22.2-26.4)

2.0 (1.8-2.2)

Nicotine Gum (6-14 wks)

19.0 (16.5-21.9)

1.5 (1.2-1.7)

Nicotine Gum (>14 wks)

26.1 (19.7-33.6)

2.2 (1.5-3.2)

Nicotine Lozenge (2mg)

24.2*

2.0 (1.4-2.8)

Nicotine Patch (6-14 wks)

23.4 (21.3-25.8)

1.9 (1.7-2.2)

Varenicline (1mg)

25.4 (19.6-33.6)

2.1 (1.5-3.0)

Varenicline (2mg)

33.2 (28.9-37.8)

3.1 (2.5-3.8)

Nicotine Patch (18-24 wks) + pm NRT (gum, lozenge, spray x 26-52 wks)

36.5 (28.6-45.3)

3.6 (2.5-5.2)

Nicotine Patch + Bupropion SR

28.9 (23.5-35.1)

2.5 (1.9-3.4)

Nicotine Patch + Nortriptyline

27.3 (17.2-40.4)

2.3 (1.3-4.2)

Nicotine Patch + Nicotine Inhaler

25.8 (17.4-36.5)

2.2 (1.3-3.6)

Effectiveness and Abstinence Rates for Tobacco Use Cessation Therapies at 6 months (Comparison to placebo)

*One qualifying randomized trial; 95% CI not reported

Information on recommended levels of combination nicotine replacement therapy can be found at the U.S. Department of Veterans Affairs website as follows: http://www.publichealth.va.gov/smoking/professionals/treatment/comboNRT-infographic.asp

More information can be found regarding combination therapy in Combination Pharmacotherapy for Stopping Smoking: What Advantages Does it Offer?

Smoking Cessation Medications’ Dosage & Duration

                       Nicotine Patch Nicotine Gum
(piece every hour)
Nicotine Lozenge
(piece every 1-2 hours)
Nicotine Nasal Spray
(in each nostril)
Nicotine Inhaler
(10mg/cartridge)
(Buproprion)
Zyban®
(start 1 week before quit date)
(Varenicline)
Chantix™
(start 1 week before quit date)
Dosage & Duration (Taken 2-3 months)

-21mg, 14mg, 7mg.

-Choice of 16 or 24-hour dosage.

-Cut down slowly (21mg 4 weeks, 14mg 2 weeks, 7mg 2 weeks) from 4 weeks to every 2 weeks.

-4mg – (25+ cigarettes/day).

-2mg – (under 25 cigarettes/day).

-Max. 24 pieces a day for up to 12 weeks.

-Not to be chewed like bubble gum.

-4mg – If tobacco is used within 30 minutes of waking.

-2mg – If tobacco is used after 30 minutes of waking.

-Max. 20 lozenges a day for up to 12 weeks.

-1-2 doses per hour as prescribed.

-Do not use more than 40 doses/day for 3-6 months.

-Use 6-16 cartridges per day for up to 6 months.

-Day 1-3: One 150mg tablet each morning.

-Day 4+ : One 150mg tablet each morning and evening. 

-Taken 3-6 months.

-Day 1-3: 0.5mg tablet per day.

-Day 4-7: 0.5mg tablet each morning and evening.

-Day 8-28: 1mg tablet each morning and evening. 

-Taken 3-6 months (or longer depending on prescription).

Please refer to this chart for dosing and precautions when discussing and prescribing these medications with your patients: http://www.nysmokefree.com/SpecialPages/rViewpdf1.ashx?No=2048

Recommendations for Use of Combination Therapy in Tobacco Use Cessation, April 2009, U.S. Department of Veterans Affairs Pharmacy Benefits Management Services, Medical Advisory report

http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm198176.htm