First-line pharmacologic options for tobacco cessation
| Drug, available doses | Dosing | Administrationa | Common side effects | Comments |
|---|---|---|---|---|
| Nicotine patch (7 mg, 14 mg, 21 mg) | ≤ 10 cigarettes/day: start with nicotine patch 14 mg/day > 10 cigarettes/day: start with nicotine patch 21 mg/day | Apply one patch each morning to any non-hairy, clean, dry skin on upper body or outer arm. Rotate the site daily to avoid skin irritation. After 6 weeks, taper to lower doses for 2-4 weeks. | Skin irritation Insomnia Vivid dreams | Consider removing patch at bedtime in case of insomnia and vivid dreams. |
| Nicotine gum (2 mg, 4 mg) | Smokers wait > 30 min after waking to smoke: use 2 mg Smokers smoke within 30 min of waking: use 4 mg | "Chew and park" is recommended: chew until tingling sensations occurs, then "park" until tingling disappears. Then chew again to repeat. Chew one piece of gum every 1-2 hours or whenever there is an urge to smoke. Use up to 24 pieces of gum/day per day for 6 weeks. Gradually reduce use over a second 6 weeks, for a total duration of 3 months. | Mouth irritation Esophageal and gastric irritation Hiccups Jaw pain Nausea/vomiting Excess salivation Headache Palpitations | Avoid acidic beverages (eg, coffee, carbonated drinks) 15 minutes before and during gum use, as they reduce nicotine absorption. |
| Nicotine lozenge (2 mg, 4 mg) | Smokers wait > 30 min after waking to smoke: use 2 mg Smokers smoke within 30 min of waking: use 4 mg | Place lozenge in the mouth and allow it to dissolve for 30 minutes. Use 1 lozenge every 1-2 hours for 6 weeks. Maximum five lozenges every six hours or 20 lozenges per day. Gradually reduce number of lozenges used per day over a second 6 weeks. | Mouth irritation Mouth ulcers Abdominal pain Hiccups Nausea/vomiting Diarrhea Headache Palpitations | Do not chew lozenge. Avoid acidic beverages (eg, coffee, carbonated drinks) 15 minutes before and during gum use, as they reduce nicotine absorption. |
| Nicotine inhaler (10 mg/cartridge) | Puff into mouth as needed; use 6-16 cartridges per day (at least 6 cartridges per day for the first 3-6 weeks) for up to 12 weeks | Inhale deeply into back of throat or puff in short breaths. Maximum 16 cartridges per day. Gradually reduce dose over 6-12 weeks | Mouth irritation Throat irritation Cough | Required frequent use. Each cartridge lasts about 20 minutes if continuously puffing. Inhaled nicotine may cause bronchospasm. |
| Nicotine nasal spray (10 mg/mL) | Use 1 spray in each nostril 1-2 times per hour | Maximum of 10 sprays per hour or 80 spray per day. Adjust dose as needed based in response. Gradually reduce dose after 12 weeks. | Side effects are common (headache, throat irritation, cough, rhinitis). Nasal irritation may be a reason to stop. | Provides a more rapid rise in plasma nicotine concentration than that produced by agents absorbed via the oral mucosa. |
| Bupropion SR (sustained release) (150 mg) | 150 mg once daily for 3 days, then increase to 150 mg twice daily | Begin at least 1-2 weeks before target quit date. May use longer than 12 weeks if needed for maintenance. Consider combination therapy, discontinuation, or alternative agent if no progress is made by seventh week. | Insomnia Headache Dizziness Diaphoresis Weight loss Xerostomia Nausea/vomiting | Consider lowering dose to 150 mg daily if full dose not tolerated. Decreases seizure threshold. |
| Varenicline (0.5 mg, 1 mg) | Days 1-3: 0.5mg once daily Days 4-7: 0.5 mg twice daily Day 8 and later: 1 mg twice daily | Treatment should be continued for 12 weeks but can be extended. Consider dose reduction if usual dose is not tolerated. | Insomnia Nausea/vomiting Abnormal dreams Headache Nasopharyngitis Xerostomia | Varenicline does not increase the risk of depression, suicidal ideation, or cardiovascular disease. |
↵a Nicotine replacement therapy is recommended for 2 to 3 months after smoking cessation. However, it may be used through the period when the patient is at high risk for relapse. Some smokers may need to use nicotine replacement products indefinitely.