By Deborah Jeanne Sergeant
Quitting smoking or other tobacco products is difficult.
Of the approximately 67.7% of U.S. adults who smoked in 2022 and who tried to quit, only 8.8% were successful, according to the Centers for Disease Control and Prevention.
Nicotine and the habit of smoking are powerfully addictive.
The good news is that using prescription medication to help in the process of quitting can help.
“Tobacco cessation medications vary in both mechanism of action and effectiveness,” said Kristen Richardson, registered nurse, certified tobacco treatment specialist and director of the CNY Regional Center for Tobacco Health Systems at St. Joseph’s Health. “The optimal standard of care relies on a combination of evidence-based behavioral counseling and FDA-approved pharmacotherapy. This dual approach significantly increases the chances of successfully quitting compared to either method alone.”
Opting for just one medication may not be as effective for many people as a two-pronged approach.
“Medical guidelines strongly recommend pairing a long-acting medication to prevent withdrawal with a short-acting medication to manage acute cravings,” Richardson said.
Prescription Varenicline (generic; formerly brand name Chantix) helps break the addiction by disrupting the uptake of nicotine to the brain. Even if the patient lights up, the cigarette won’t deliver the same effect as before.
“Widely considered the most powerful quit-smoking pill available, this prescription medication works on the brain in two key ways,” Richardson said. “It tricks the brain into releasing a steady, low level of dopamine, which takes the edge off withdrawal. It also blocks the high. It binds to the brain’s nicotine receptors, meaning if someone taking varenicline were to slip up and smoke, vape or use a pouch, they won’t get that satisfying ‘rush,’ helping break the habit loop.”
Bupropion SR (brand name Zyban) works differently. Initially approved as an antidepressant, it reduces the effects of withdrawal and irritability, two main reasons people trying to quit end up returning to tobacco use.
Richardson said that bupropion increases dopamine and norepinephrine, brain chemicals that can stimulates the ‘feel good’ effects of nicotine, “making the loss of cigarettes less severe. It also acts to block nicotine receptors, like Varenicline, acting as an antagonist, binding to nicotinic receptors in the brain, which effectively blocks nicotine from binding to them. If someone attempting to quit slips up and smokes a cigarette while taking bupropion, they won’t get the same amount of pleasure, which weakens the urge to continue. It roughly doubles the chances of successfully quitting smoking compared to using a placebo.”
Combination therapy protocol pairs a long-use prescription with a quick acting or short-acting relief medication like the nicotine replacement patch, gum or lozenge to help patients with both mood and cravings. Nicotine replacement involves gradually weaning the patient off dependence on nicotine in increments.
The combination helps by “providing the nicotine they crave to ease withdrawal symptoms, but without the tar, carbon monoxide and myriad other toxic chemicals found in cigarette smoke, smokeless chew tobacco and vape or electronic devices,” Richardson said. “This allows someone trying to quit to focus on breaking the behavioral habits.”
A new medication under research with the FDA, Cytisinicline, works similarly to Varenicline by stimulating nicotine receptors to reduce craving and withdrawal and reduce the reward form smoking.
“It acts as both an agonist, mimicking nicotine just enough to ease cravings and an antagonist, blocking nicotine from binding and rewarding the brain, to help users quit smoking and vaping, Richardson said. “While it has shown promising efficacy in clinical trials, the FDA recently delayed its approval due to facility inspection issues and incomplete labeling rather than safety or efficacy concerns.”
Some people believe that e-cigarettes or “vapes” are helpful cessation products. However, they are not FDA-approved as safe or effective in cessation and they also have their own health risks. Many vape liquids come from China and other countries with few consumer safety laws and can contain heavy metals that are heated to high temperatures to achieve the water vapor that users inhale. Widespread reports of lung problems among vape users indicate the short-term dangers. The long-term dangers are yet unknown.
“I encourage folks to understand that it’s not a matter of willpower,” said Rebecca Padilla, senior manager of nationwide health promotions with the American Lung Association. “It’s a chronic health condition. We would never advise someone with asthma if you tried harder, you could breathe better.”
She encourages smokers who want to quit to discuss a plan with their primary are provider and find a therapist for their mental health since the FDA-approved medication alone does not change the behavior that fuels nicotine addiction.
“The more we’ve researched the mechanics of substance use disorder, the more we realize that nicotine use is a symptom of underlying mental issues,” Padilla said. “A lot of times, folks end up self-medicating with nicotine because they’re anxious, depressed or having a hard time focusing. It goes hand in hand with other substances. We encourage co-treating with mental health issues because the efficacy of cotreatment is the standard we’d like to see healthcare providers uphold.”
Padilla also said that it can take six weeks minimum of working with counseling and supports such as the American Lung Association’s Freedom from Smoking program to acquire enough tools to manage quitting. This way, patients have coping mechanisms in place when they feel the urge to light up.
She encourages people who want to quit to contact resources such as their primary care provider,
New York State Quitline (1-866-NY-QUITS) and The American Lung Association (www.Lung.org, www.FreedomFromSmoking.org or 1-800-LUNG-USA).