Smoking Cessation Pharmacotherapy Options

Quitting is hard. Your plan doesn’t have to be. Here’s a simple, evidence-based approach that pairs combination NRT(patch + short-acting) with varenicline or bupropion when appropriate—plus dosing, side effects, and follow-up you can copy/paste into your EMR.

Why Combination NRT?

Preferred for effectiveness: a nicotine patch (steady 24-hr coverage) + gum/lozenge (for breakthroughs/urges).
You can also combine varenicline (Chantix) with a patch in selected patients (watch for nausea/vivid dreams).

Step 1 — Set the Quit Date & Choose a Base

Nicotine Patch (start on quit date)
Dose by smoking intensity; taper optional.

• >10 cig/day:

  • Step 1 21 mg daily × 6 weeks → Step 2 14 mg × 2 weeks → Step 3 7 mg × 2 weeks

• ≤10 cig/day:

  • Step 2 14 mg daily × 6 weeks → Step 3 7 mg × 2 weeks

Common issues & tips

• Skin irritation, insomnia/vivid dreams → remove at bedtime and use short-acting NRT for mornings.

• High doses can cause tachycardia, dizziness, nausea, headache.

• Use caution in: unstable angina, recent MI, uncontrolled HTN, severe esophagitis/PUD, significant renal/hepatic impairment (risk–benefit still often favors NRT vs smoking).

Step 2 — Add Short-Acting for Cravings

Gum/Lozenge (while awake & with urges)

• If smokes ≤30 min after waking → 4 mg

• If smokes >30 min after waking → 2 mg

• Typical: 1 piece every 1–2 hours (max per label).

How to use (teach this)

• Gum: Chew–park technique—chew until tingling/peppery, park between cheek & gum; repeat for ~30 minutes.

• Lozenge: Park between gum & cheek; do not chew or swallow.

• Avoid food/acidic drinks 15 minutes before/after (coffee, soda, juice) to improve absorption.

Nicotine Nasal Spray (Rx)

• Fastest relief; good for heavy/triggered cravings.

• 1 dose = 2 sprays (1 per nostril). Start 1–2 doses/hour as needed.

• Max usually 5 doses/hour (10 sprays) and 40 doses/day (80 sprays).

• Expect nasal/throat irritation early on.

Step 3 — Consider Non-NRT Medications

Varenicline (Chantix)

• MoA: partial agonist—reduces cravings, blocks reward.

• Start 1 week before quit date:

  • Day 1–3: 0.5 mg QD

  • Day 4–7: 0.5 mg BID

  • Day 8 onward: 1 mg BID for 12 weeks; may continue another 12 weeks if successful.

• Side effects: nausea, insomnia/vivid dreams (take with food and water).

• Notes: Dose-adjust in severe CKD; monitor mood/sleep. May combine with patch in selected patients.

Bupropion SR (Wellbutrin SR)

• Best for: patients worried about weight gain or with depression; generally less effective than varenicline or combo NRT but still helpful.

• Formulation: use SR (12-hour), not XL.

• Start 1 week before quit date:

  • Day 1–3: 150 mg QD

  • Then 150 mg BID (last dose ≥8 hrs after first; avoid evening dosing).

• Contraindications: seizure disorder, bulimia/anorexia, MAOI use, abrupt withdrawal from alcohol/benzos/sedatives.

• Side effects: insomnia, dry mouth, anxiety.

Putting It Together: Simple Regimens

Most patients (first-line):

• Patch (dose by cig/day) + gum/lozenge PRN

• Add varenicline if high dependence or prior NRT failure (or use varenicline alone if preferred).

High-craving/heavy smokers:

• Patch + gum/lozenge + nasal spray PRN (teach limits), or varenicline + patch (monitor dreams/nausea).

Quick Rx Examples (copy/paste)

Patch + Gum

Varenicline (with or without patch)

Bupropion SR

Follow-Up (build this into your schedule)

• 1–2 weeks after quit date, then at 3 months and 1 year.

• Normalize slips; adjust meds; extend therapy if helping.

• Offer quitline (1-800-QUIT-NOW) and text/app support.

Counseling Pearls (that actually help)

• Set a quit date and remove cigarettes/lighters the day before.

• Identify triggers (coffee, car, stress) and pair each with a replacement (gum/lozenge, nasal spray, walk, water, deep breathing).

• Morning cravings? Consider keeping the patch on overnight or remove at bedtime and use short-acting on waking.

• Weight concerns → bupropion SR helps; coach on snacks, hydration, steps.

• Sleep issues/dreams → earlier dosing of varenicline, remove patch at bedtime, or step down dose.

EMR SmartPhrase (paste & tweak)