Table 5 Pharmacotherapy for nicotine dependence

Medication^a:

Any patient smoking more than 10 cigarettes a day or who smoke within 30 -60 minutes of waking will suffer from withdrawal symptoms and should be offered pharmacological support once they set a quit date. Remember to offer psychological support during the first 3 months of the cessation attempt

Nicotine replacement therapy (NRT)

NRT should not be combined with smoking. Its main effect is to reduce abstinence and help the patient through the first couple of months of craving. Most patients use too low doses for too short a time. They should use a dose that takes away abstinence symptoms. Most people need a full dose for 2–3 months, then they might gradually reduce the use over some months. Added success has been shown if NRT is started 14 days prior to quit date

Dosage: It is often wise to combine two different NRTs—a patch to cover most of the day and gum or other types of NRT (e.g. spray) for craving situations during daytime

Patch: Comes in 14 mg/24 h or 10 mg/16 h for light smokers or in 21 mg/24 h—15 mg/16 h for more heavy smokers. Some patients need more than one patch a day to keep the symptoms low

Side effects: Skin rash, allergy, insomnia, wild dreams

Gum, inhalers, lozenges, sublingual tablets: To be administered every 1–2 h for relief of symptoms while awake. Since nicotine is absorbed through the mucosa in the mouth it is important to instruct the patient in the use of gum carefully. Chew a few times on the gum then “park” it in the mouth

Side effects: local-sore dry mouth, dyspepsia, nausea, headache, jaw ache. Often dose dependent

Contraindication: Pregnancy (in some countries)

Varenicline (©Champix, ©Chantix)

Varenicline is a nicotinic receptor partial agonist. In addition to blocking the receptor it also stimulates it thus reducing abstinence. It is the first drug designed for smoking cessation. Results are promising with quit rates up to 44% in some studies

Dosage: Start 1 week before quit date: 0.5 mg for 3 days, 0.5 mg bid for 4 days, then 1 mg bid from quit date for 12 weeks

Side effects: nausea and headache. There is no danger of seizures. Risk of psychiatric side effects is the same as for other smoking cessation medications

Contraindication: Pregnancy

Bupropion (©Zyban)

Bupropion is the first medication proven to reduce the craving

Dosage: twice daily starting with one tablet a day for a week two weeks prior to quit date, then regularly 150 mg bid from quit date for 7–12 weeks

Adverse effects: insomnia, headache, dry mouth, dizziness, anxiety

Contraindications: Seizures, pregnancy, major depression, schizophrenia, drugs for treating depression or schizophrenia

Other medication:

Other drugs have shown to be effective in smoking cessation but are not licenced for use. The cost of these drugs are often low and should be considered in case cost is a limiting factor

Nortryptilyn (©Noritren) is cheap and has also been shown to be effective, but adverse effects that include sedation, dry mouth, lightheadedness and risks of cardiac arrhythmia in patients with CHD limit its application. It should thus be a second line agent

Cystisine (©Tabex) has a mechanism of action like Varenicline, binding to the nicotinic receptor. It has been used for smoking cessation in eastern European countries and has received increasing interest due to its low cost. Side effects include stomach-ache, dry mouth, dyspepsia and nausea

Which drug to advice?

Previous experience, availability, cost and patient’s preference will often guide the choice of medication. In a cost-effectiveness study from a high-income country, both NRT, Varenicline and Bupropion were shown to be cost-effective compared to placebo^b. Varenicline was show to be most cost-effective