Okay, everyone knows smoking is bad for you, the number one cause of preventable death in the US and the world, a direct cause of lung and heart disease and cancer… et cetera. So let’s get right down to the nitty-gritty: quitting smoking is tough. What can people do to quit?

To answer this question, I spoke with my colleague Nancy Rigotti, MD. Dr. Rigotti is director of the Massachusetts General Hospital Tobacco Research and Treatment Center. She has extensively researched nicotine and tobacco, evaluated public policies on tobacco, contributed to US Surgeon General’s Reports, and authored clinical guidelines on smoking cessation.

“It’s never too late nor too early to quit,” she emphasizes. Research shows that even people who quit after age 65 can enjoy a longer, healthier life span.

Two-pronged approach is best

Behavioral strategies can help, medicines can also help, but what’s best is a combination of both. Behavior strategies can include counseling from a healthcare provider, self-help from websites or text message services, and/or social support. If someone has an underlying psychological issue like depression, anxiety, alcohol, or another substance use disorder, addressing those issues at the same time makes it more likely they can successfully quit smoking. As far as hypnosis or acupuncture, there is not a lot of evidence showing that they work.

Medicines that can help people quit include nicotine replacement therapy and the oral medications varenicline (Chantix) and bupropion (Zyban, Wellbutrin). Each is recommended for about 12 weeks.

Nicotine replacement (“the patch” and others)

Forms of nicotine replacement therapy (NRT) include patches, gum, lozenges, inhaler, and nasal spray. Dr. Rigotti points out that it’s safe to use more than one type of NRT at the same time. Combination NRT is a patch (which is long-acting) plus a short-acting agent (like gum, lozenges, inhaler, or nasal spray), and is more effective than a single form of NRT alone. “In addition, smokers are able to adjust nicotine intake to avoid both nicotine withdrawal and nicotine overdose, as they have done this throughout their years as cigarette smokers.”

When considering NRT, smokers need to consider what dose of each product they may need. For example:

Using nicotine patches. For the long-acting patch, someone who is smoking more than 10 cigarettes per day should start with the highest-dose patch (21 mg/day) for at least six weeks. However, those who smoke less than 10 cigarettes per day or weigh under 99 pounds should start with the medium-dose patch (14 mg/day) for six weeks, followed by 7 mg/day for two weeks.

How one applies the patch is also important. Change the patch site daily to avoid skin irritation, a common side effect. If leaving the patch on overnight causes insomnia and vivid dreams, take it off and replace it the next morning (smoking quit rates are the same whether the patch is left on for 24 hours or taken off at night). If the patch is removed at night and morning nicotine cravings occur, use the gum or lozenges while waiting for the new nicotine patch to take effect.

Using gum and the lozenges. For the nicotine gum, someone who is smoking more than 25 cigarettes per day should use the 4-mg dose. Those who smoke less than that should use the 2-mg dose. Chew one piece of gum whenever there is an urge to smoke (up to 24 pieces of gum per day) for at least six weeks, then taper off.

For best results, Dr. Rigotti recommends the “chew and park” method: “Chew the gum until the nicotine taste appears, then “park” the gum between your teeth and inner cheek until the taste disappears, then chew a few more times to release more nicotine. Repeat this for 30 minutes, then discard the gum, because by that time all nicotine has been released.”

Smokers with dental issues or who use dentures may do better with the nicotine lozenge. Smokers who smoke within 30 minutes of awakening should use the 4-mg dose, while smokers who wait more than 30 minutes after awakening to smoke should use the 2-mg dose. Place a lozenge in the mouth for 30 minutes. Let it melt, no need to chew. Use up to one lozenge every hour or two for six weeks, with no more than five lozenges every six hours or 20 lozenges per day, and then gradually taper.

Medications that can help you quit

Many studies have shown that 12 weeks of the prescription medications varenicline and bupropion are effective and safe in patients who want to quit smoking. A recent, large, high-quality study helped alleviate concerns about varenicline and psychiatric or cardiovascular side effects; the FDA removed that black box warning in December of 2016. Although one 2017 study suggests a risk, the methods have been called into question. Smokers are at significantly increased risk for CV events as it is, and it is difficult to correct for this using the methods this most recent study used. Dr. Rigotti emphasizes that varenicline “is our most effective agent and no riskier than any other agent, even in patients with psychiatric issues. This message needs to get out to patients and doctors.”

She explains that NRT can be used with either varenicline or bupropion. One other medication worth mentioning is nortriptyline, an older antidepressant that is also used for chronic pain. It is modestly effective, but is associated with side effects such as dry mouth, constipation, and weight gain. As with any medication, doctors and patients need to consider medical history, current medications, and personal preferences.

To increase your chances of success, Dr. Rigotti suggests taking the medication for at least one week before you even try to quit. In fact, for people who want to quit but are not ready to set a quit date, varenicline or NRT can help them smoke less, and can actually improve their chances of quitting successfully. “Encouraging smokers who are not ready to quit to try meds anyway is a new idea with increasing data,” she points out.

I asked Dr. Rigotti about e-cigarettes. While these are not FDA-approved for smoking cessation, experts agree that, for smokers unwilling or unable to attempt to quit, they are almost certainly safer than continuing to smoke cigarettes. However, anyone switching from cigarettes to e-cigarettes must do so completely. You should not use both together.

If you are even casually considering the idea of quitting, there are a ton of free resources available through 800-QUIT-NOW. Free text messaging and other supports and resources are available at www.smokefree.gov.

Resources

Primary Care Office InSite: Tobacco Treatment. Wynne Armand, MD, Nancy Rigotti, MD, and Susan Moran, MD.

UpToDate: Pharmacotherapy for Smoking Cessation in Adults. Nancy A. Rigotti, MD, along with section editors: James K. Stoller, MD, MS; Mark D. Aronson, MD; Deputy Editor: Judith A. Melin, MA, MD, FACP.

21st-century hazards of smoking and benefits of cessation in the United States. New England Journal of Medicine, January 2013.

Nicotine replacement therapy for smoking cessation. The Cochrane Database for Systematic Reviews, 2002.

Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet, June 2016.

Efficacy and safety of varenicline for smoking cessation in patients with cardiovascular disease: a randomized trial. Circulation, January 2010.

Efficacy and Safety of Smoking Cessation Interventions in Patients with Cardiovascular Disease: A Network Meta-Analysis of Randomized Controlled Trials. Circulation: Cardiovascular Quality and Outcomes, January 2017.

Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. The American Journal of Cardiology, April 2005.

Combination varenicline and bupropion SR for tobacco-dependence treatment in cigarette smokers: a randomized trial. JAMA, January 2014.

Effect of varenicline on smoking cessation through smoking reduction: a randomized clinical trial. JAMA, February 2015.

Is a combination of varenicline and nicotine patch more effective in helping smokers quit than varenicline alone? A randomised controlled trial. BMC Medicine, May 2013.

In the clinic. Smoking cessation. Annals of Internal Medicine, March 2016.

Clinical practice. Treatment of tobacco use and dependence. New England Journal of Medicine, February 2002.

Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet, November 2013.