Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published July 27, 2022


What medications are most effective as first-line treatment for persons wanting to quit smoking?

Cigarette smoke contains approximately 7000 chemicals, including 60 to 70 known human carcinogens. Although nicotine primarily drives the addiction to cigarettes, the byproducts of combustion drive tobacco-related disease and death. Read the NEJM Clinical Practice Article here.

Clinical Pearls

Q: What factors increase the risk of a person becoming a smoker?

A: The risk factors for the onset of smoking and subsequent tobacco addiction are both genetic and environmental. The age that a person starts smoking, the number of cigarettes smoked per day, and cessation have been associated with 566 genetic variants in 406 loci. Parental smoking, peer influence, and personality traits related to impulsivity and risk-taking and sensation-seeking behaviors are associated with the initiation of and experimentation with smoking. Furthermore, adverse childhood experiences are associated with twice the risk of a person becoming an adult smoker.

Q: What percentage of smokers achieve long-term abstinence with current evidence-based treatments?

A: A person who smokes may make 30 or more attempts to quit before having permanent remission. Only 3 to 5% of smokers will be abstinent 6 to 12 months after a given quit attempt, with most relapses occurring within the first 8 days after quitting, owing to acute withdrawal symptoms. The incidence of relapse is as high as 10% in the year after 1 year of abstinence, decreasing to 2 to 4% after 2 years. Late relapses may occur, often caused by a stressful life event, and smoking even a single cigarette can lead to a full relapse. However, with evidence-based treatments, 10 to 30% of smokers have long-term abstinence.

Morning Report Questions 

Q: How effective are counseling and behavioral approaches for those who wish to quit smoking?

A: Brief behavioral interventions, such as encouraging a smoker to set a quit date within 30 days, increase cessation rates. In addition, there is a clear dose–response relationship between the intensity of the intervention and its effectiveness in sustaining abstinence from smoking, especially in persons who are not using cessation medications. Depending on the available resources, counseling may be provided by trained counselors in person or by means of state or national telephone quitlines. As compared with minimal support or as an addition to other forms of support, text-messaging programs also have been shown, with moderate-certainty evidence, to improve quit rates. Financial incentives to stop smoking also increase the odds of quitting as compared with minimal intervention. 

Q: What medications are most effective as first-line treatment for persons wanting to quit smoking?

A: The Food and Drug Administration has approved several medications for smoking cessation (i.e., nicotine-replacement therapies, varenicline, and sustained-release bupropion). Each of these medications treats acute withdrawal, limits cravings, and reduces the risk of relapse more than any intensity of counseling. Both varenicline and a combination of nicotine patches with short-acting nicotine-replacement therapy are considered the most effective and safe first-line treatments for smoking cessation. Guideline-based second-line agents include nortriptyline and clonidine; however, these agents are not approved for treating smoking addiction and have less favorable safety profiles than first-line medications.

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