Treatment Options

Most smokers benefit from using counseling, medications and social support to help quit. To find out if a particular health insurance covers smoking cessation, call the plan administrator. National guidelines provide recommendations about the kinds of benefits that should be covered. Health insurance plans should cover the treatment options noted below:

• Counseling: Telephone-based counseling should be offered to all plan participants. Free counseling is available at 1-800-QUIT-NOW. Health plans can also contract with commercial services;

• Medications: Health plans should provide full coverage for the medications listed below, which should be offered to all smokers who want to quit, unless medically counter-indicated (e.g., special precautions for pregnant women).

Treatment Options

The treatments listed below are the most common ones used to help smokers quit. They include several different kinds of counseling and medications. Some medications are available over the counter, and others need a prescription. The table shows the likelihood of success for someone who tries to quit. As a patient, your doctor may recommend a combination of different types of treatments. It is important to understand that nicotine is not the ingredient in tobacco smoke that causes cancer. So, it is safe to use nicotine replacement. Don't be discouraged if you are not able to quit on the first attempt. Most smokers require a number of attempts (as many as 8 to 10) before they are able to stop smoking. The good news is that there are now more ex-smokers than current smokers.

Self-Help - Quit Rate 9-12%

There are many types of self-help interventions available to smokers (e.g., pamphlets/booklets/mailings/manuals, videotapes, audiotapes, referrals to 12-step programs, reactive telephone hotlines, help lines, computer programs/Internet, and community programs) but they have not been found to be very effective.

Counseling - Quit Rate13-17%

Two types of counseling and behavioral therapies result in higher quit rates: (1) providing smokers with practical counseling (problem solving skills/skills training), and (2) providing support and encouragement as part of treatment. These types of counseling should be included in smoking cessation interventions. Telephone quit lines, which may include call-back counseling and proactive interventions by quit line counselors, are the most common form of counseling. 1-800-QUIT-NOW is a free national counseling service that any smoker can call.

Bupropion SR (Zyban) - Quit Rate 24%

Bupropion SR was the first non-nicotine medication shown to be effective for smoking cessation and was approved by the FDA for that use in 1997. It acts on chemicals in the brain that are related to nicotine craving. It can be used alone or together with nicotine replacement.. It is contraindicated in patients with a seizure disorder, a current or prior diagnosis of bulimia or anorexia nervosa, use of a monoamine oxidase (MAO) inhibitor within the previous 14 days, or in patients taking another medication that contains bupropion. Bupropion SR can be used in combination with nicotine replacement therapies. It is available only with a prescription.

Nicotine Replacement Therapy - Quit Rate 19-26%

Nicotine replacement therapy (NRT) medications deliver nicotine with the intent to replace, at least partially, the nicotine obtained from cigarettes and to reduce the severity of nicotine withdrawal symptoms. Different forms of NRT (such as gum and patch) may be used in combination, and NRT may also be used in combination with Bupropion SR. NRT should not be used by pregnant women who try to quit.

Nicotine gum is an effective NRT smoking cessation treatment that patients should be encouraged to use. Highly dependent smokers should use 4mg instead of 2 mg. Nicotine gum when chewed delivers nicotine to the blood and then to the brain in minutes. Long-term use (more than 14 weeks) increases the likelihood of quitting. It is available only over the counter.

The nicotine inhaler is an effective NRT smoking cessation treatment that patients should be encouraged to use. Nicotine inhalers are a thin plastic tube with nicotine cartridge inside. When you puff on the inhaler, the cartridge releases a nicotine vapor. In terms of behavior, the inhaler is the closest thing to smoking a cigarette, which some smokers find helpful. It is only available by prescription. Quit Rate: 25%

The nicotine lozenge is an effective NRT smoking cessation treatment that patients should be encouraged to use. The lozenge is a tablet that dissolves in the mouth and releases nicotine. It is available only over the counter. Quit Rate: 24%

Nicotine nasal spray is an effective NRT smoking cessation treatment that patients should be encouraged to use. The nasal spray delivers nicotine to the bloodstream as it is quickly absorbed through the nose. It is available only by prescription. Quite Rate: 27%

The nicotine patch is an effective NRT smoking cessation treatment that patients should be encouraged to use. Nicotine patches deliver nicotine through the skin. The nicotine dose is gradually decreased by switching to lower nicotine dose patches over the course of a few weeks. Use of high dose (greater than 25 mg) patches increases likelihood of quitting. Patches are available both with and without a prescription. Quit Rate: 23-27%

Varenicline (Chantix) - Quit Rate 33%

Varenicline is sold under the name of Chantix in the US and Champix in other countries. It is an effective smoking cessation treatment that patients should be encouraged to use. It is a non-nicotine medication that was approved by the FDA for the treatment of tobacco dependence in 2006. Its mechanism of action is presumed to be due to its partial nicotine receptor agonist and antagonist effects. It is well tolerated in most patients. In February and May 2008 , the FDA added warnings regarding the use of Chantix. Specifically, it noted that (1) the most common side effects reported among Chantix users include nausea (30%), sleep disturbance, constipation, gas, and/or vomiting; (2) depressed mood, agitation, changes in behavior, suicidal ideation, and suicide have been reported in patients attempting to quit smoking while using Chantix; (3) some Chantix users report vivid, unusual or strange dreams. The FDA recommends (1) if a patient who is taking Chantix, or their family or caregivers, notice agitation, depressed mood, or changes in behavior that are not typical, or if the patient develops suicidal thoughts or actions, they should stop taking Chantix and call their doctor right away, (2) that patients tell their health care provider about any history of psychiatric illness prior to starting Chantix; and (3) Patients should use caution driving or operating machinery until they know how quitting smoking with CHANTIX may affect them; and (4) that clinicians monitor patients for changes in mood and behavior when prescribing Chantix. In light of these FDA recommendations, clinicians should consider eliciting information on their patients' psychiatric history. It should be used with caution in patients with severe renal dysfunction. Chantix is not recommended for use in combination with nicotine replacement therapy (NRT). It is available only with a prescription. The quit rate presented here is for 2mg/day dose; a lower dose also has a lower quit rate.

Medication Combinations - Quit Rate 26-36%

Evidence exists that combining the nicotine patch long-term (> 14 weeks) with either nicotine gum or nicotine nasal spray, the nicotine patch with the nicotine inhaler, or the nicotine patch with bupropion SR, increases long-term quit rates.

Counseling and Medication Combinations - Quit Rate 26-32%

The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. There is a strong relation between the number of sessions of counseling, when it is combined with medication, and the likelihood of successful smoking cessation.


Source: Fiore MC, Jaen, CR, Baker, TB, et al. Treating Tobacco Use and Dependence: 2008 Update . Clinical Practice Guideline. Rockville , MD : U.S. Department of Health and Human Services. Public Health Service. May 2008.