Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
behavioural support
Treatment recommended for ALL patients in selected patient group
There is high-certainty evidence to suggest that behavioural support by a trained cessation specialist initiated during the admission to hospital and continued for more than 1 month after discharge is effective in increasing stopping rates regardless of the admitting diagnosis.[169]
[ 
]
Behavioural support provided only in hospital, without post-discharge support, may have a modest impact on stopping rates, but the evidence is less certain.[169] Therefore, active smokers should be connected with outpatient behavioural support resources at discharge, where possible.[170]
Cochrane reviews determined that group-based interventions appear to be more promising than individual-based interventions.[110][161]
brief or comprehensive intervention for smoking cessation
The initial approach to smoking cessation varies according to location of practice. Two commonly used models are: i) very brief advice for smoking, based on an 'Ask, Advise, Assist' structure, which encourages clinicians to ask patients about tobacco use, advise them to stop, and assist them by signposting them to specialist smoking cessation services offering pharmacotherapy and behavioural support; ii) a more comprehensive intervention for smoking cessation, which can be provided using the '5 A's' structure: 1) ask about tobacco use; 2) advise to stop through clear, personalised messages; 3) assess willingness to stop; 4) assist in stopping; and 5) arrange follow-up and support.[71]
Evidence directly comparing smoking cessation models is limited. It suggests that both brief and comprehensive models can be effective, but that effectiveness may vary depending on the individual and on the clinical setting.[1] Clinicians may choose to prioritise for comprehensive interventions those with greater nicotine dependence, or previous unsuccessful stopping attempts.
Following the initial clinical contact, clinicians should offer a menu of cessation resources (medicines and behavioural support) to those who are ready to stop. Overall, the combination of behavioural support plus an evidence-based medication for smoking cessation has the best evidence for smoking cessation.[2][96]
[ ]
Some people may choose to attempt smoking cessation with behavioural support alone.
behavioural support
Treatment recommended for ALL patients in selected patient group
Behavioural support has consistently shown benefit for smoking cessation, compared with receiving minimal support, or receiving pharmacotherapy alone.[111][112] Cochrane review evidence suggests that increasing the amount of behavioural support available increases the chance of success by about 10% to 20%.[98] Another Cochrane review determined that group-based interventions in adults appear to be more promising than self-help and other less intensive interventions. There was not enough evidence to evaluate whether groups are more effective than intensive individual behavioural support.[110] There is moderate-certainty evidence that the provision of adjunctive behavioural support by a health professional other than the physician (e.g., nurse, smoking cessation specialist, smoking quitline) increases smoking cessation rates in primary care.[113]
Internet-based interventions are available that increase the likelihood of cessation and help patients avoid relapse.[114][115]
[ ]
Text messaging interventions have been shown to have a beneficial impact on 6-month cessation outcomes.[116][117]
[ ]
Financial-incentive programmes have been shown to improve tobacco cessation rates in both low- and high-income groups.[118][119][120]
Reward-based programmes are more commonly accepted than deposit-based programmes and have led to higher smoking cessation rates.[121]
nicotine replacement therapy (NRT) and/or varenicline
Additional treatment recommended for SOME patients in selected patient group
Two types of medicine have amassed the greatest volume of data demonstrating safety and efficacy for smoking cessation: NRT with a combination of short-acting and long-acting NRT (patches, gum, lozenges, and nasal spray), and varenicline.[122][123][124][125] Both are considered first-line treatments and produce significantly higher stop rates for 6 months or more than does placebo alone.[63][76]
NRTs attenuate withdrawal symptoms and can provide a coping strategy for the behavioural aspects of withdrawal, such as oral (gum, lozenge) and hand-to-mouth (inhaler) stimulation. There is strong evidence that adding a short-acting 'on-demand' form of NRT (e.g., gum, lozenge) to a long-acting nicotine patch increases success rates, and so this strategy is preferred over monotherapy where possible.[53][63][122][124][126] Evidence from one Cochrane review suggests that lower-dose nicotine patches and gum may be less effective than higher-dose products.[53]
The choice of nicotine delivery method is guided by patient preferences, prior experience, and availability. In most countries, the patch, gum, and lozenges are available without a prescription. The nasal spray generally requires a prescription. An inhaler and nicotine mouth spray may be available in some countries, but they are not currently available in the US.[76] Product literature should be consulted for further guidance on dosage of specific brands of NRT products. NRT should be started at the same time as the planned stop date.
Varenicline attenuates withdrawal symptoms and blocks the reinforcing effects of nicotine. It has been shown to increase the chances of successful long-term smoking cessation by 2-3 times compared with placebo.[127] More people stop successfully with varenicline than with bupropion or with a single form of NRT. Varenicline may be as effective as or more effective than dual-form NRT.[127][128]
[ ]
[ ]
Guidance from the American Thoracic Society (ATS) and a statement from the American College of Cardiology both recommend varenicline over bupropion or NRT.[89][129] Varenicline combined with behavioural support increases abstinence more than other pharmacotherapy with behavioural support combinations.[130] Early reports of possible links of varenicline to cardiovascular and psychiatric events have not been confirmed by current research.[90][128][131] There is evidence from one Cochrane review that people taking varenicline may be at increased risk of adverse cardiac events, but at decreased risk of neuropsychiatric adverse events, although the evidence was equivocal and compatible with both benefit and harm.[127] Physicians should consider warning patients of the potential for these effects and advising them to seek medical help if the patient (or their family or carer) observes any mood or behavioural changes.[196] Varenicline is relatively slow-acting, and so should be started 1-2 weeks in advance of the stopping date.[63] To prevent nausea, varenicline can be taken after meals with a full glass of water, dosage can be increased slowly, or dose can be reduced.
Most tobacco cessation monotherapies and combination therapies are more effective than placebo at helping participants to achieve sustained abstinence.[133] Combining drugs with different mechanisms of action may increase stopping rates more than single agents.[76] One network meta-analysis showed a high probability that the combination of varenicline and NRT is more likely to achieve sustained abstinence than NRT or bupropion as monotherapies.[133] However, one randomised controlled trial showed no significant difference in abstinence among those treated with combined varenicline plus nicotine patch therapy versus varenicline monotherapy.[134] Combining varenicline with NRT agents has been associated with higher rates of adverse effects (e.g., nausea, headaches).[2]
In some locations, nicotine e-cigarettes may be considered in certain circumstances as an alternative to conventional NRT. Unlike conventional NRT, nicotine e-cigarettes are not licensed medicines, and their regulation and quality control varies across different countries and regions. Their use for smoking cessation is a topic of ongoing debate and research. There is a mounting body of evidence demonstrating that nicotine e-cigarettes are an effective method of nicotine delivery and can be used as NRT.[63][125][135][136][137]
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While they are generally considered to be less harmful than combustible cigarettes, their use as tobacco cessation aids remains controversial due to limited evidence on current devices, and uncertainty about possible health risks of long-term use.[137] Many countries (including the US) currently take a precautionary approach, and recommend against the use of e-cigarettes for smoking cessation.[1][71][72] In the UK, recommendations on nicotine e-cigarette use for smoking cessation are more supportive. A number of UK professional bodies including the National Institute for Health and Care Excellence (NICE) and the Royal College of Physicians (RCP) support the use of nicotine e-cigarettes as a smoking cessation tool in adults in certain circumstances: for example, when licensed treatments are not sufficient.[63][148][149]
Primary options
nicotine transdermal: 21 mg once daily for 6 weeks initially, followed by 14 mg once daily for 2 weeks, followed by 7 mg once daily for 2 weeks
Moreor
nicotine lozenge: 2-4 mg lozenge every 1-2 hours for 6 weeks, then taper gradually over 6 weeks, maximum 5 lozenges/6 hours or 20 lozenges/day
or
nicotine gum: 2-4 mg gum every 1-2 hours for 6 weeks, then taper gradually over 6 weeks, maximum 24 gum pieces/day
or
nicotine nasal: 0.5 mg (1 spray) in each nostril once or twice an hour initially, adjust dose according to response, maximum 10 sprays/hour or 80 sprays/day
-- AND / OR --
varenicline: 0.5 mg orally once daily for 3 days initially, followed by 0.5 mg twice daily for 4 days, followed by 1 mg twice daily for 12-24 weeks
brief or comprehensive intervention for smoking cessation
The initial approach to smoking cessation varies according to location of practice. Two commonly used models are: i) very brief advice for smoking, based on an 'Ask, Advise, Assist' structure, which encourages clinicians to ask patients about tobacco use, advise them to stop, and assist them by signposting them to specialist smoking cessation services offering pharmacotherapy and behavioural support; ii) a more comprehensive intervention for smoking cessation, which can be provided using the '5 A's' structure: 1) ask about tobacco use; 2) advise to stop through clear, personalised messages; 3) assess willingness to stop; 4) assist in stopping; and 5) arrange follow-up and support.[71]
Evidence directly comparing smoking cessation models is limited. It suggests that both brief and comprehensive models can be effective, but that effectiveness may vary depending on the individual and on the clinical setting.[1] Clinicians may choose to prioritise for comprehensive interventions those with greater nicotine dependence, or previous unsuccessful stopping attempts.
Following the initial clinical contact, clinicians should offer a menu of cessation resources (medicines and behavioural support) to those who are ready to stop. Overall, the combination of behavioural support plus an evidence-based medication for smoking cessation has the best evidence for smoking cessation.[2][96]
[ ]
Some people may choose to attempt smoking cessation with behavioural support alone.
behavioural support
Treatment recommended for ALL patients in selected patient group
Behavioural support has consistently shown benefit for smoking cessation, compared with receiving minimal support, or receiving pharmacotherapy alone.[111][112] Cochrane review evidence suggests that increasing the amount of behavioural support available increases the chance of success by about 10% to 20%.[98] Another Cochrane review determined that group-based interventions in adults appear to be more promising than self-help and other less intensive interventions. There was not enough evidence to evaluate whether groups are more effective than intensive individual behavioural support.[110] There is moderate-certainty evidence that the provision of adjunctive behavioural support by a health professional other than the physician (e.g., nurse, smoking cessation specialist, smoking quitline) increases smoking cessation rates in primary care.[113]
Internet-based interventions are available that increase the likelihood of cessation and help patients avoid relapse.[114][115]
[ ]
Text messaging interventions have been shown to have a beneficial impact on 6-month cessation outcomes.[116][117]
[ ]
Financial-incentive programmes have been shown to improve tobacco cessation rates in both low- and high-income groups.[118][119][120]
Reward-based programmes are more commonly accepted than deposit-based programmes and have led to higher smoking cessation rates.[121]
brief or comprehensive intervention for smoking cessation
Smoking in pregnancy and smoking in adolescents represent special circumstances with additional considerations.
As in the general adult population, the initial approach to smoking cessation varies according to location of practice. Two commonly used models are: i) very brief advice for smoking, based on an 'Ask, Advise, Assist' structure, which encourages clinicians to ask patients about tobacco use, advise them to stop, and assist them by signposting them to specialist smoking cessation services offering pharmacotherapy and behavioural support; ii) a more comprehensive intervention for smoking cessation, which can be provided using the '5 A's' structure: 1) ask about tobacco use; 2) advise to stop through clear, personalised messages; 3) assess willingness to stop; 4) assist in stopping; and 5) arrange follow-up and support.[71]
Smoking during pregnancy is a well-established risk factor for adverse pregnancy outcomes including preterm deliveries, low birth weight, and preterm-related deaths, and it is still prevalent to varying degrees globally.[7][156] All pregnant women who smoke should be advised on the adverse effects of smoking on their fetus (low birth weight, preterm birth) and offered access to smoking cessation interventions.[157] Likewise, all adolescents who smoke should be advised to stop smoking, and offered evidence-based interventions.[63] Data on efficacy of cessation treatments in adolescents are limited.[62][161]
[ ]
This is due, in part, to challenges in conducting studies in this population. In addition, the experience of smoking and smoking cessation may differ between this age group and adults. For instance, levels of nicotine dependence may not be equal to those of adult smokers.
behavioural support
Treatment recommended for ALL patients in selected patient group
In pregnancy, behavioural and psychological interventions are considered first-line treatments in some locations, including the US.[71][157]
The American Academy of Pediatrics (AAP) recommends that for adolescents who smoke and who wish to stop using tobacco, clinicians offer referral for a behavioural intervention for smoking cessation.[60]
In the UK, the National Institute for Health and Care Excellence (NICE) recommends behavioural support as one of a range of treatment options (both pharmacological and non-pharmacological) for smoking cessation in pregnant women and adolescents.[63]
Behavioural support interventions to prevent tobacco use in children and adolescents are effective, but the data on efficacy of cessation treatments in adolescents are limited.[62][161]
[ ]
One Cochrane review found evidence to suggest that behavioural support delivered via a group setting is effective in increasing smoking cessation among adolescents.[161]
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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