Smoking Cessation: First-Line Medical Therapies

Healthcare professionals can help you or your family members in smoking cessation, by using an appropriate framework and asking the right questions. Some ways of helping you or your family members quit smoking is through behavioural management, or through the use of medications. The use of medication, or pharmacotherapy, has shown to be hugely effective in helping patients to quit smoking.

World No Tobacco Day happens on 31 May every year. This year, in conjunction with World No Tobacco Day, we explore the options available for healthcare professionals to help you or your family members quit smoking in this article.

Why do you need medical therapy for smoking cessation?

Smoking is expensive. It is estimated that smoking costs an average smoker SGD4,928 a year. It also costs an estimated seven million people their lives around the world annually. Asia contains half of the world’s male tobacco smokers. They predominantly come from three countries: China, India, and Indonesia. Asia is not just the world’s biggest consumer of tobacco, it is also the largest manufacturer of it.

While this continent is still in the early ages of a tobacco epidemic, it is not too late to rectify this burgeoning problem. Smokers will need help to quit smoking because it goes without saying that this is very challenging. The smoker will need to get accustomed to two things:

1. The absence of nicotine circulating the brain, leading to withdrawal symptoms
2. Smoke-free daily schedule. 

The success rate of quitting smoking without intervention is a dismal 3-5%. Smokers can thus consider medical therapies to increase their chances of overcoming this seemingly insurmountable task.

What are the medical therapies for smoking cessation?

This article will go through a few common first-line medications: treatments that aim to reduce nicotine withdrawal symptoms.

Nicotine replacement therapy (NRT)

Tobacco contains nicotine as the main component. It is the chemical responsible for making smoking so addictive as it triggers a dopamine release with each puff. NRT exerts its effects through its safe and sustained delivery of nicotine to the body over a prolonged period while simultaneously replacing tobacco as a source of nicotine. This reduces cravings, paving the way to smoking cessation. 

NRT may be delivered in three ways: patches, gum, and lozenges. Choosing between these options depends on different needs, such as the level of dependency one has on smoking. The various strengths and doses cater to an assortment of habits, health conditions and lifestyles. However, smoking and NRT cannot exist together. When done in tandem, it instead raises nicotine levels in the body, thereby reducing the efficacy of NRT. 

Common side effects of NRT include: 

• Sleep disturbance (insomnia and abnormal dreams)
• Headache
• Nausea and/or vomiting
• Dizziness
• Gastrointestinal complaints
• Palpitations

Varenicline

This medication has been approved for the treatment of tobacco use and dependency in more than 80 countries. Belonging to a class of medications known as smoking cessation aids, varenicline acts as a partial agonist and antagonist of nicotine. Simply put, as an agonist, varenicline binds to nicotine receptors to produce a similar effect to that of nicotine. However, being a partial agonist, the effect this medication produces will not be as pronounced as that of nicotine. This helps to stave off withdrawal symptoms and diminish cravings.

Secondly, because varenicline is a nicotine antagonist, it binds to the receptors for nicotine, preventing the binding of the actual nicotine from tobacco. This reduces the rewarding sensations achieved through smoking.

Varenicline is commonly taken as an oral tablet and is safe for patients with chronic obstructive pulmonary disorder as aid for smoking cessation.

Commonly reported side effects include:

• Nausea
• Insomnia
• Abnormal (vivid, unusual, or strange) dreams

Bupropion

You may have heard of this medication as an antidepressant. However, apart from treating depression, it can also be used for smoking cessation. 

There are thought to be many ways bupropion helps in smoking cessation. Nicotine in tobacco stimulates the receptors, which releases a chemical called dopamine. Dopamine is responsible for the good feelings experienced when you smoke. 

• One way bupropion works is by delaying the re-uptake of dopamine from the synaptic cleft. This diminishes nicotine’s stimulative effect on the postsynaptic membrane. Hence, the effects of smoking withdrawal are reduced, thus making smoking less rewarding for the smoker.
• Another way bupropion is thought to work is by antagonising the effects of nicotine at the receptors.

Bupropion, like some antidepressant medications, lowers the threshold for seizures. Hence, seizure-prone smokers may want to take precautions with this medication or completely avoid it. On the contrary, bupropion is safe for use in COPD patients. This medication can be taken as a tablet, with a sustained-release version available.

Synergistic Therapies

The therapies listed above can be applied synergistically to obtain the best customised treatment plan for anyone looking to kick the habit. Smokers can even consider supplementing with behavioural support. For heavy smokers, synergistic therapy may be necessary as recommended doses for these medications may be insufficient to attain the desired abstinence rates and lessen withdrawal symptoms. Useful combination therapy regimens include:

1. Various forms of NRTs
2. Bupropion with NRT
3. Varenicline with NRT

What if these medical therapies do not help in smoking cessation?

Your healthcare provider may consider using second-line medications. However, some treatments may not have obtained approval from the relevant governing authorities yet. Also, some treatments may have lowered or an undetermined efficacy when compared against these first-line medications. 

Summary

There are health benefits abound for quitting smoking: heart rate and blood pressure drop after 20 minutes; coughing and breathlessness lessen after a few months. In a year, a quitter’s risk of coronary heart disease is roughly about half that of a smoker. Before starting on any of these treatments, it is advisable to seek professional medical advice.

Article is written in conjunction with World No Tobacco Day 2021, held on 31 May.