Gerontology, Palliative Care & Prevention · Topic 11 of 13

Tobacco Cessation

Prevention · tobacco dependence treatment

Tobacco Cessation

Treat tobacco dependence like a chronic disease: counsel and prescribe — varenicline or combination therapy — starting in the hospital and continuing after discharge.

Key numbers

Start in hospital; support ≥ 1 month≥ 1 month after discharge

Titrate varenicline to 1 mg twice daily1 mg twice daily

Reduce varenicline when CrCl < 30 mL/minCrCl < 30 mL/min

Patch 21 mg/day if > 10 cigarettes/day21 mg/day

01 · GiveVarenicline is first-line

Varenicline is the most effective single agent; when starting treatment, ATS strongly recommends varenicline over the nicotine patch and over bupropion — including in patients with psychiatric illness or substance use disorder.

02 · GiveCombination therapy beats monotherapy

Combine therapies: varenicline plus a nicotine patch (ATS suggestion), or a nicotine patch plus short-acting NRT (gum, lozenge or nasal spray) — combination NRT outperforms any single NRT and is comparable to varenicline.

03 · The ruleStart in hospital; support ≥ 1 month

In hospitalized smokers, start intensive counseling and pharmacotherapy during the stay and continue supportive contact for at least 1 month after discharge; lower-intensity or shorter interventions showed no benefit.

The rules

Know these

Extend therapy beyond 12 weeksTreat for at least 12 weeks; ATS recommends extended courses (> 12 weeks) over 6–12 weeks, and starting varenicline even in smokers not yet ready to quit rather than waiting.

Pregnancy: behavioral counseling, not routine drugsOffer pregnant patients behavioral counseling (USPSTF A); evidence for pharmacotherapy in pregnancy is insufficient, and medications are not routinely recommended for adolescents, nondaily smokers or smokeless tobacco users.

E-cigarettes are not a recommended cessation aidUSPSTF finds insufficient evidence for e-cigarettes as a cessation tool and ATS prefers varenicline over e-cigarettes; direct patients to proven counseling and medication instead.

Management

Orders

Ask, advise and treat every tobacco user must knowAsk every adult about tobacco use, advise quitting, and offer behavioral counseling plus FDA-approved pharmacotherapy to all nonpregnant adults who smoke (USPSTF grade A); combining the two works better than either alone.

Titrate varenicline to 1 mg twice dailyVarenicline: 0.5 mg daily on days 1–3, 0.5 mg twice daily on days 4–7, then 1 mg twice daily; start 1 week before the quit date, or quit between days 8 and 35.

Reduce varenicline when CrCl < 30 mL/minIn severe renal impairment (CrCl < 30 mL/min) start varenicline 0.5 mg daily and titrate to at most 0.5 mg twice daily; on hemodialysis, at most 0.5 mg daily. Nausea is the commonest side effect.

Patch 21 mg/day if > 10 cigarettes/dayNicotine patch: start 21 mg/day for > 10 cigarettes/day or 14 mg/day for ≤ 10, tapering over about 8–10 weeks; add gum or lozenges for breakthrough cravings.

Red flags & don'ts

Avoid harm

NRT is safe in stable heart disease avoidNRT is safe for most patients with cardiovascular disease; use it cautiously only within 2 weeks of MI, with serious arrhythmias or with serious angina. Avoid the patch with severe skin sensitization.

Bupropion: no seizures, eating disorders, MAOIs avoidBupropion SR (150 mg twice daily) is contraindicated with a seizure history, an eating disorder, or MAOI use within 2 weeks; insomnia and dry mouth are its common side effects.

Varenicline or bupropion?

Commonly confused

Mechanism	Partial agonist at α4β2 nicotinic receptors
Efficacy	Most effective single agent; preferred by ATS
Key caution	Dose-reduce if CrCl < 30 mL/min
Main side effect	Nausea
Neuropsychiatric safety	No excess events in EAGLES

Teach & follow up

Patient education

Use the 5 A'sStructure counseling with the 5 A's: Ask about use at every visit, Advise quitting clearly, Assess readiness, Assist with counseling and medication, and Arrange follow-up.

More detail

Reference

Show 5 reference facts

The most effective combined behavioral-plus-pharmacotherapy programs use at least 4 counseling sessions with 90–300 minutes of total contact; telephone quitlines count as effective counseling.

Varenicline is a partial agonist at the α4β2 nicotinic receptor: it eases withdrawal and blocks the reward of a cigarette after a lapse. Bupropion raises brain norepinephrine and dopamine.

In hospital trials, adding NRT to intensive counseling raised quit rates (RR 1.54); evidence that adding varenicline or bupropion to inpatient counseling adds benefit was inconclusive.

Some patients feel stronger alcohol effects on varenicline — advise drinking less until the response is known; avoiding varenicline with active suicidal risk is reasonable.

In EAGLES, varenicline produced higher abstinence than placebo (OR 3.61), nicotine patch (OR 1.68) and bupropion (OR 1.75); nausea affected 25% of varenicline users.

Pearl

Combination wins: varenicline plus a patch, or a patch plus a short-acting nicotine product.

Sources · Merck Manual Professional — Smoking Cessation (updated Apr 2025) · USPSTF — Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions (2021) · Leone FT et al. Initiating Pharmacologic Treatment in Tobacco-Dependent Adults: An Official ATS Clinical Practice Guideline. Am J Respir Crit Care Med 2020;202:e5–e31 · Anthenelli RM et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch (EAGLES). Lancet 2016;387:2507–2520 · Rigotti NA et al. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2012;CD001837 (abstract via Europe PMC) · Varenicline tablets prescribing information (Apotex) — DailyMed · Nicotine transdermal system Step 1–3 drug facts — DailyMed · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).