Smoking Cessation
The single most impactful preventive intervention in medicine. Smoking cessation reduces all-cause mortality more than any drug you will ever prescribe. Ask every patient, every visit. Combination NRT + varenicline has the highest quit rate.
🚭 Pharmacotherapy
5 A's Framework
- Ask -about tobacco use at every visit
- Advise -to quit in a clear, personalized way ("Quitting is the single best thing you can do for your health")
- Assess -willingness to make a quit attempt
- Assist -offer medication + counseling (combination is most effective)
- Arrange -follow-up within 1 week of quit date
| Agent | Dose | Quit Rate | Notes |
|---|---|---|---|
| Varenicline (Chantix) MOST EFFECTIVE | 0.5 mg daily × 3 days → 0.5 mg BID × 4 days → 1 mg BID × 12 weeks. Can extend to 24 weeks. | ~30% at 1 year | Partial nicotine receptor agonist (reduces craving + blocks reward from smoking). FDA removed black box warning for neuropsych events EAGLES, 2016 -safe even in psychiatric patients. Start 1 week before quit date. GI side effects (nausea -take with food). Can combine with NRT for even higher efficacy. |
| NRT -patch | 21 mg/day × 6 wks → 14 mg × 2 wks → 7 mg × 2 wks (if > 10 cig/day). 14 mg start if < 10/day. | ~15–20% alone, ~25–30% combined | Apply to clean, hairless skin, rotate sites. Combine patch (sustained) + lozenge or gum (acute cravings) for best results -combination NRT is as effective as varenicline. |
| NRT -gum/lozenge | 2 mg or 4 mg (if first cigarette within 30 min of waking → 4 mg). Use q1–2h PRN. | ~15–20% | Best as add-on to patch for breakthrough cravings. Gum: "park and chew" technique. Lozenge: dissolve in mouth, don't chew. |
| Bupropion SR (Zyban) | 150 mg daily × 3 days → 150 mg BID × 12 weeks. Start 1–2 weeks before quit date. | ~20% | Also treats depression. Contraindicated in seizure disorders, eating disorders, MAOI use. Weight-neutral (unlike most cessation -patients often gain 5–10 lbs). Can combine with NRT. |
Highest quit rates: Varenicline + NRT patch (~35%), Varenicline alone (~30%), Combination NRT (patch + gum/lozenge, ~28%), Bupropion + NRT (~25%). All superior to counseling alone (~5–10%). Always combine pharmacotherapy with behavioral counseling (quitline: 1-800-QUIT-NOW).
📋 On Rounds
Pimp Questions
A patient says 'I've tried quitting before and it didn't work.' How do you respond?
This is actually encouraging, not discouraging. Most successful quitters have tried 6–8 times before finally quitting permanently. Each attempt teaches the patient about their triggers, cravings, and what strategies work or don't work for them. The response: 'That's actually great -it means you've been working at this. Most people need several attempts. Let's figure out what happened last time and try a different approach.' Then assess
Why is varenicline more effective than NRT alone?
Varenicline (Chantix) is a partial agonist at the α4β2 nicotinic acetylcholine receptor -the same receptor that nicotine binds. It works through a dual mechanism: (1) Agonist effect (~50% activation): provides a low level of dopamine release in the nucleus accumbens → reduces craving and withdrawal symptoms (similar to NRT but via the same receptor)
What is the evidence for combining varenicline with NRT patch?
Combination therapy (varenicline + NRT patch) is the most effective smoking cessation strategy. A meta-analysis and the VARNIC trial showed ~35-40% quit rates at 12 weeks (vs ~25% for varenicline alone, ~20% for NRT alone, ~5-10% for counseling alone).
What does the USPSTF say about e-cigarettes/vaping for smoking cessation?
USPSTF has NOT endorsed e-cigarettes for cessation -evidence is insufficient. While some studies show higher quit rates with e-cigs vs NRT (particularly the UK NIHR trial), concerns remain: (1) Dual use: many smokers vape AND smoke → no net benefit. (2) Long-term safety unknown: EVALI outbreak (2019) raised concerns, though most cases were linked to THC/vitamin E acetate, not nicotine e-cigs
Clinical Examples
📋 Case 1, Varenicline + Behavioral Counseling
Patient: 54M, 35-pack-year smoker, COPD, HTN. Failed NRT patch × 2 prior attempts. Motivated to quit (Prochaska: preparation stage). No history of seizures or psychiatric illness.
Key findings: High nicotine dependence (Fagerström score 7/10), multiple prior failures with NRT alone. Combination pharmacotherapy + counseling has highest quit rates.
Management:
- Varenicline 0.5 mg daily × 3 days → 0.5 mg BID × 4 days → 1 mg BID × 12 weeks (most effective single agent, 33% quit rate vs 14% placebo)
- Set quit date 1-2 weeks after starting (allows drug to reach steady state)
- Behavioral counseling: 1-800-QUIT-NOW (quitline doubles quit rates when combined with meds)
- Consider combo: varenicline + nicotine patch (JAMA 2014: combo superior to varenicline alone)
- Warn: nausea (most common side effect, take with food). Vivid dreams. Psychiatric monitoring
Teaching point: Varenicline is the most effective single cessation agent. The old FDA black box warning for psychiatric events was REMOVED in 2016 after the EAGLES trial showed no increased risk. Do not withhold from patients with psychiatric history.
📋 Case 2, Inpatient Smoking Cessation After ACS
Patient: 48M admitted for NSTEMI, underwent PCI. 25-pack-year smoker. Currently nicotine-deprived and motivated. Asking about quitting.
Key findings: Hospitalization for ACS is a "teachable moment", quit rates are highest when cessation is initiated during admission. Continued smoking post-ACS doubles the risk of recurrent MI and death.
Management:
- Start NRT in hospital: nicotine patch 21 mg/day + nicotine lozenge 2 mg PRN (combo NRT during admission)
- Add varenicline before discharge if no contraindication (start during admission → continue outpatient)
- Brief motivational interviewing: "How important is quitting to you on a scale of 1-10? What would make it higher?"
- Arrange follow-up: smoking cessation clinic or quitline within 1 week of discharge
- Document smoking status and cessation plan in discharge summary
Teaching point: Every admission is an opportunity. The 5 A's: Ask (smoking status), Advise (quit), Assess (readiness), Assist (meds + counseling), Arrange (follow-up). NRT is safe in ACS, nicotine from patches causes far less cardiovascular harm than nicotine from cigarettes.
📋 Case 3, Pregnant Smoker
Patient: 28F, 10-pack-year smoker, newly pregnant (8 weeks). Smoking 10 cigarettes/day. Concerned about harm to baby but unable to quit cold turkey.
Key findings: Smoking during pregnancy: risk of preterm birth (2×), low birth weight, placental abruption, SIDS, and childhood asthma. Behavioral counseling is first-line in pregnancy. Pharmacotherapy options are limited.
Management:
- Behavioral counseling FIRST, pregnancy-specific counseling programs achieve 5-10% quit rates (doubles with intensive support)
- If counseling alone fails: nicotine patch (lowest effective dose), benefits of quitting likely outweigh NRT risks, but discuss shared decision-making
- Varenicline and bupropion are NOT recommended in pregnancy (insufficient safety data)
- Motivational framing: "Quitting before 15 weeks eliminates most of the excess risk to your baby"
- Postpartum relapse prevention, 70% of women who quit during pregnancy relapse within 6 months postpartum
Teaching point: Behavioral counseling is first-line for pregnant smokers. NRT can be used if counseling fails, the risk of continued smoking far outweighs NRT risk. The critical window is quitting before 15 weeks, which nearly eliminates the excess risk of preterm birth and low birth weight.
📣 Sample Presentation
One-Liner
"Ms. Davis is a 52-year-old with 30-pack-year smoking history, COPD, and HTN. She wants to quit but has tried cold turkey twice and relapsed within 2 weeks both times. Ready to try medication."
Key Points to Cover on Rounds
Pack-year: 30. Prior quit attempts: 2 (cold turkey -no pharmacotherapy). Stage of change: preparation (ready to set quit date). Pharmacotherapy plan: varenicline 0.5 mg daily × 3 days → 0.5 mg BID × 4 days → 1 mg BID (start 1 week before quit date, continue × 12 weeks). Added NRT patch 21 mg/day for combination therapy (varenicline + NRT = highest quit rate ~35%). Quit date set: 2 weeks from today. Behavioral counseling: quitline referral (1-800-QUIT-NOW), trigger avoidance strategies discussed. LDCT lung cancer screening: eligible (50-80 yo, ≥20 pack-years) -ordered. Plan: follow-up call at 1 week post-quit date, office visit at 4 weeks.
🔍 Overview
Overview
See the tabs above for the complete smoking cessation reference: Workup, Management, Medications, Rounds, Summary, and One Pager.
🧪 Workup
Workup
See the Overview and Management tabs for the smoking cessation assessment framework (5 A's, Ask, Advise, Assess, Assist, Arrange; pack-year history; readiness-to-quit stages; triggers; co-morbid psychiatric/substance use).
⚡ Management
Management
See the Management tab for the full stepwise smoking cessation algorithm, behavioral counseling + pharmacotherapy combinations, follow-up timing, and relapse management.
💊 Medications
Medications
Medication details (varenicline, bupropion, NRT combinations, patch + gum/lozenge) with evidence-based dosing and trial citations are in the Management tab.
⚡ Summary
Summary
The Highest-Yield Intervention You Have
Smoking cessation reduces all-cause mortality more than any drug you will prescribe. Ask every patient at every visit: brief advice from a clinician measurably raises quit rates, and a hospital admission is one of the most effective teachable moments there is.
Use the 5 A's
Ask, Advise, Assess, Assist, Arrange. The step that gets skipped is Arrange, and follow-up contact is what converts an intention into a quit. Set a quit date, remove tobacco from the home, and plan for triggers and for the first difficult week.
Combination Therapy Beats Monotherapy
Varenicline plus a nicotine patch gives the highest quit rates, around 35%. Varenicline alone about 30%, combination NRT (patch plus gum or lozenge) about 28%, bupropion plus NRT about 25%. All are far superior to counseling alone, at 5 to 10%. Always pair pharmacotherapy with behavioral support: each roughly doubles the effect of the other.
Combine Long-Acting and Short-Acting NRT
The patch provides a steady baseline; gum, lozenge or inhaler covers breakthrough cravings. Using the patch alone under-treats, because cravings are episodic and a steady-state delivery cannot answer them. Dose the patch by cigarettes per day and start it on the quit date.
Varenicline Is Safer Than Its Reputation
EAGLES found no significant increase in neuropsychiatric events compared with placebo or the other agents, and the FDA boxed warning was removed. Start it 1 week before the quit date and continue for 12 weeks, with nausea and vivid dreams as the usual side effects and dose reduction in renal impairment.
Know When Not to Use Bupropion
Contraindicated with a seizure disorder, an eating disorder, or in a patient at risk of alcohol or benzodiazepine withdrawal, because it lowers the seizure threshold. It is a reasonable choice when depression coexists, and it reduces the post-cessation weight gain that puts some patients off.
Reframe Relapse as Data
Most successful quitters make several attempts. Treat a relapse as information about the trigger rather than as a failure, and re-engage rather than waiting for the patient to raise it again. Ask what worked and for how long, and change the regimen accordingly.
Adjust the Other Medications After They Quit
Tobacco smoke induces CYP1A2, so stopping raises levels of clozapine, olanzapine, theophylline and caffeine, sometimes to toxicity within days. Reduce those doses at cessation rather than waiting for symptoms. Also share the concrete benefits: risk of myocardial infarction falls within a year, and lung cancer risk falls substantially over a decade, which motivates more than a general warning does.
📄 One Pager
Text version
AMBULATORY · One Pager
Smoking Cessation
The single most impactful preventive intervention in medicine: ask every patient every visit, and pair pharmacotherapy with counseling because either one alone leaves most of the benefit on the table.
The 5 A's (takes 3 minutes)
- Ask about tobacco use at every visit, because status changes and a documented ask is what triggers the rest of the pathway.
- Advise to quit in a clear, personalized way: "Quitting is the single best thing you can do for your health."
- Assess willingness to make a quit attempt, since this decides whether you set a quit date today or do motivational work instead.
- Assist with medication plus counseling, because the combination substantially outperforms either alone.
- Arrange follow-up within 1 week of the quit date, which is when relapse risk peaks.
- A prior failed attempt is a good sign, not a bad one. Most successful quitters try 6-8 times first; each attempt teaches the patient their triggers and what does not work.
Quit Rates, Highest First
- Varenicline + NRT patch: ~35%. The most effective strategy, so this is the default offer unless something contraindicates it.
- Varenicline alone: ~30% at 1 year, the most effective single agent.
- Combination NRT (patch + gum or lozenge): ~28%, which is roughly as effective as varenicline and matters when varenicline is unavailable or refused.
- Bupropion + NRT: ~25%.
- Bupropion alone: ~20%; NRT patch alone: ~15-20%.
- Counseling alone: ~5-10%. Every pharmacotherapy option beats it, which is the argument for always offering a drug.
Assist, Step by Step
1
Pick the agent: varenicline plus NRT patch if no contraindication, since it has the highest quit rate. Bupropion is the alternative when depression coexists, and combination NRT when varenicline is not an option.
2
Start the drug BEFORE the quit date: varenicline 1 week ahead, bupropion 1-2 weeks ahead. Both need time to reach steady state so cravings are already blunted on day one.
3
Set an explicit quit date and titrate through it, so the plan has a fixed target rather than an open-ended intention.
4
Add behavioral counseling: quitline 1-800-QUIT-NOW, trigger-avoidance strategies. Counseling roughly doubles quit rates when combined with medication.
5
Arrange follow-up within 1 week of the quit date (relapse risk is highest early), then an office visit at about 4 weeks to check adherence, side effects, and whether to extend therapy.
6
Treat the full 12 weeks, extending varenicline to 24 weeks in patients who need it, because stopping at the first sign of success is a common relapse trigger.
Key Drugs
Varenicline (Chantix)0.5 mg daily × 3 days → 0.5 mg BID × 4 days → 1 mg BID × 12 weeks, extendable to 24 weeks. Start 1 week before the quit date. Partial nicotine receptor agonist: it reduces craving and blocks the reward from smoking. Nausea is the main side effect, so take with food.
NRT patch21 mg/day × 6 wks → 14 mg × 2 wks → 7 mg × 2 wks if > 10 cig/day; start at 14 mg if < 10/day. Apply to clean hairless skin and rotate sites. Provides the sustained baseline level, not breakthrough coverage.
NRT gum / lozenge2 mg, or 4 mg if the first cigarette is within 30 min of waking (a marker of higher dependence). Use q1-2h PRN. Best as the add-on to the patch for breakthrough cravings. Gum uses "park and chew"; lozenge dissolves and is not chewed.
Bupropion SR (Zyban)150 mg daily × 3 days → 150 mg BID × 12 weeks, starting 1-2 weeks before the quit date. Also treats depression and is weight-neutral, which matters because quitters often gain 5-10 lbs. Can be combined with NRT.
Screening & Follow-Up
- Annual LDCT lung cancer screening: age 50-80, ≥ 20 pack-years, and currently smoking or quit within 15 years (USPSTF 2021). It reduces lung cancer mortality 20% (NLST), so eligibility should be checked at the same visit you address cessation.
- Follow-up call at 1 week post-quit date, office visit at 4 weeks: early relapse is the dominant failure mode and is often fixable by adding a short-acting NRT or adjusting the dose.
- Document pack-years, prior quit attempts, and stage of change, because the number of prior attempts and what failed last time drives the next regimen choice.
- Counsel on weight gain (typically 5-10 lbs) up front, so it does not become an unspoken reason to relapse. Bupropion is the weight-neutral option.
- Warn about varenicline side effects: nausea (take with food) and vivid dreams, both of which patients stop the drug over if they are not forewarned.
Pitfalls
- Withholding varenicline from patients with psychiatric illness. The FDA removed the neuropsychiatric black box warning in 2016 after EAGLES, 2016 showed no increased risk. These are exactly the patients who need the most effective drug.
- Bupropion in a patient with a seizure disorder, eating disorder, or on an MAOI. All are contraindications.
- Using the patch alone and calling it maximal therapy. The patch covers baseline; add a gum or lozenge for acute cravings, which lifts the quit rate from ~15-20% to ~25-30%.
- Starting the drug on the quit date. Varenicline needs a week and bupropion 1-2 weeks to reach steady state first.
- Treating a prior failed attempt as evidence the patient cannot quit. Reframe it: most quitters need several attempts, and the useful question is what happened last time.
- Recommending e-cigarettes as cessation therapy. USPSTF has NOT endorsed them, evidence is insufficient, dual use means many patients get no net benefit, and long-term safety is unknown.
Special Populations
- Pregnancy: behavioral counseling is first-line (pregnancy-specific programs achieve 5-10% quit rates, which doubles with intensive support). Varenicline and bupropion are NOT recommended given insufficient safety data. If counseling fails, nicotine patch at the lowest effective dose with shared decision-making, since continued smoking carries clearly greater risk.
- Pregnancy, the framing that motivates: quitting before 15 weeks eliminates most of the excess risk to the baby (preterm birth 2×, low birth weight, placental abruption, SIDS, childhood asthma). Plan postpartum relapse prevention, because 70% of women who quit in pregnancy relapse within 6 months.
- Inpatient after ACS: admission is a teachable moment with the highest quit rates. Start combination NRT in hospital (patch 21 mg/day plus lozenge 2 mg PRN) and add varenicline before discharge. NRT is safe in ACS: nicotine from a patch causes far less cardiovascular harm than nicotine from cigarettes, and continued smoking post-ACS doubles the risk of recurrent MI and death.
- Any hospitalization: document smoking status and the cessation plan in the discharge summary, and arrange quitline or cessation clinic follow-up within 1 week of discharge.
Key Evidence
- EAGLES, 2016: no excess neuropsychiatric events with varenicline or bupropion, including in psychiatric patients. This is why the FDA black box came off and why you should not withhold the drug.
- NLST: annual LDCT reduced lung cancer mortality 20%, the basis for the USPSTF 2021 screening criteria (age 50-80, ≥ 20 pack-years, current or quit within 15 years).
- Combination beats monotherapy: varenicline plus NRT patch reaches ~35%, versus ~30% varenicline alone and ~5-10% for counseling alone, which is the practical case for always layering drug plus counseling.
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