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Provide pharmacological treatment for individuals who wish to stop smoking and have not achieved cessation without pharmacological agents or who prefer to use such agents.

  • The five NRTs (i.e., patch, gum, lozenge, nasal spray, inhaler) and bupropion are first-line treatment approaches that are equally effective in alleviating withdrawal symptoms and reducing smoking.

  • Choice of first-line treatments is based on patient preference, route of administration, and side-effect profile (Table 6).

  • Significant adverse events of NRTs, including dependence, are rare.

  • Using a combination of these first-line treatments may improve outcome (e.g., two NRTs or an NRT plus bupropion).

  • If withdrawal contributes to relapse, additional NRT (e.g., increased dose or number of NRTs, different formulation that yields higher nicotine levels) should be considered.

  • Combined psychosocial and pharmacological therapy produces the best outcomes.

  • Nortriptyline and clonidine have utility as second-line agents but appear to have more side effects (Table 6).

  • Other medications and acupuncture have not been proven to be effective.

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Table 6. Pharmacological Treatments for Nicotine Dependence

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Table Reference Number
Table 6. Pharmacological Treatments for Nicotine Dependence

Provide psychosocial treatments as essential components of a comprehensive treatment program as well as for individuals who prefer these approaches.

  • Such treatments are typically provided in a multimodal package that includes advising the patient to stop smoking, helping the patient decide on the timing of a quit attempt, advising against caffeine and alcohol use, helping the patient learn skills to avoid relapse, and helping the patient select a quit date (with abrupt cessation preferred over gradual cessation).

  • Treatment outcome is improved by follow-up visits 1–3 days after cessation.

  • If relapse is not due to withdrawal, alter psychosocial therapy type or intensity.

  • When delivered in individual, group, telephone, or self-help (written, video, Internet) formats, potentially helpful psychosocial treatments include the following:

    • Brief interventions. Include behavioral supportive cessation counseling with aspects of motivational enhancement therapy (MET).

    • Behavioral therapies. Include contingency management, cue exposure, and "rapid smoking" aversion approaches.

    • Cognitive-behavioral therapies. Address cognitive coping skills, such as identifying maladaptive thoughts, challenging them, and substituting more effective thought patterns to prevent a slip from becoming a relapse (e.g., not viewing the slip as a catastrophe), and behavioral coping skills, such as removing oneself from the situation, substituting other behaviors (walking, exercising), and using skills to manage triggers (assertiveness, refusal skills, time management).

    • Social support. Appears to be beneficial as a specific intervention or with support provided by a spouse.

  • Psychosocial treatments that have not been proven effective include inpatient treatment, hypnosis, and 12-step-oriented groups.

Table Reference Number
Table 6. Pharmacological Treatments for Nicotine Dependence

References

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