What are the recommendations for when you should take medication in order to quit smoking?

The general recommendation is that all smokers trying to quit should be offered medication. There is compelling evidence that medication aids in abstinence. The evidence is even stronger that medication and counseling are more effective than either alone. For that reason, medication is strongly encouraged. All seven of the FDA-approved medications for treating tobacco use are recommended, including bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. Additionally, the use of these medications for up to six months does not present a known health risk, and developing dependence on these medications is rare. The higher-dose preparations have been shown to be effective in highly dependent smokers. NRT combinations are especially helpful for highly dependent smokers or those with a history of severe withdrawal. Combining the nicotine patch long-term with nicotine gum, nicotine nasal spray, nicotine inhaler, or bupropion SR, also increases long-term abstinence rates relative to placebo treatments. However, combining varenicline with NRT agents has been associated with higher rates of side effects (such as nausea and headaches). Unfortunately, there are no well-accepted algorithms to guide optimal selection among the first-line medications. Data show that bupropion SR and nicotine replacement therapies, in particular the 4-mg nicotine gum and 4-mg nicotine lozenge, bupropion SR, and nortriptyline appear to be especially effective in treating tobacco-dependent patients diagnosed with depression, but nicotine replacement medications also appear to help individuals with a past history of depression.

That being said, there are some exceptions to that general recommendation. These exceptions are:

Women: Evidence is mixed as to whether NRT is less effective in women than men. The clinician should consider the use of another type of medication with women, such as bupropion or varenicline.

Pregnant women: These smokers should be encouraged to quit without medication. The studies of medication use are far too small. Bupropion has not been found to be effective at all in pregnant smokers. That being said, one may still recommend medication to this group if, in the clinician's opinion, the benefits outweigh the risks. In pregnant women, for example, the risks of nicotine alone on the mother and the fetus must be weighed against the risks of nicotine, tar and carbon monoxide should the pregnant woman be unable to stop smoking without the benefit of an NRT.

Cardiac patients: NRT should be used with caution among particular cardiovascular patient groups: those who have had a heart attack within two weeks, those with serious arrhythmias[1], and those with unstable angina pectoris[2].

Light smokers, smokeless tobacco users, and adolescents: Few studies have been done on these populations to conclude any significant benefit, nor suggest any potential risk. Again, the clinician should weigh the risks against the benefits when considering medications in these populations.

What are the success rates of the five nicotine replacement therapies alone and in combination with other forms?

The success rates are listed in Table 10.

Table 10 success Rates of NRT Medications

success Rates of NRT Medications

Recent studies have examined the combination of some of the nicotine replacement products and the smoking cessation aids. The FDA has not approved these medications in combination because of the limited number of efficacy and safety studies. Nevertheless, it is frequently done in practice. Using the patch alone, there is an estimated abstinence rate of 17.4%. By combining the nicotine gum or nicotine lozenge with the patch, the abstinence rate can increase to 28.6%. Therefore, combining the patch with other self-titrating nicotine replacement therapies may be more effective than just using the nicotine patch alone. There is less evidence to support doubling the nicotine patch. In fact, there are warnings against doing so. Combining medications is one of the recommended treatments for those heavy smokers who have difficulty quitting with just the patch and who are being closely monitored by a physician. Table 11 shows the success rates of NTRs used in combination.

Table 11 success Rate of NTRs When used in combination


success rate



Patch + ad lib NRT


Patch + Bupropion


Patch + Inhaler


Patch + Nortriptyline


Varenicline 2 mg/d


  • [1] Abnormal heart rhythm.
  • [2] (Also known as angina.) Severe chest pain due to a blockage of blood flow in the arteries of the heart. It is a symptom of an impending heart attack.
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