Table 2:
| Characteristics | Nicotine replacement | Bupropion sustained-release (SR) (Zyban®) | Varenicline (Chantix®) |
|---|---|---|---|
| Mechanism of action | Full agonist that binds to nicotinic cholinergic receptors | Mechanism incompletely understood; modulates dopaminergic transmission in the brain | Partial agonist that binds to nicotinic cholinergic receptors |
| Age considerationsb | All ages | Approved for adults ≥18; off-label use for youth under 18 | Adolescents and adults ≥17 |
| Typical administration |
Combined therapy with a nicotine patch and a short-acting nicotine product for breakthrough cravings is recommended. Nicotine patch (for maintenance dose): Apply nicotine patch to skin every 24 hours (change site daily).c Dose according to number of nicotine cartridges used per day: <1/2 cartridge/day (=0–25 mg of nicotine salts): 7 mg patch 1/2 to 1 cartridge/day (=25–50 mg of nicotine salts): 14 mg patch 1–2 cartridges/day (= 50–100mg of nicotine salts): 21 mg patch Administer patch for 4–6 weeks, then administer the next lowest dose patch for 2–4 weeks, and continue wean until patient tolerates no nicotine. Short-acting nicotined (for breakthrough cravings): Gum: Use one piece (2 or 4 mg) every 1 to 2 hours. (After chewing into piece and tasting nicotine, gum should be ‘parked’ between oral gums and cheek for best absorption.) Lozenge: Use one lozenge (1, 2 or 4 mg) every 1 to 2 hours. In adults smoking cigarettes, 4 mg gum and lozenges have typically been recommended for patients whose first cigarette is within 30 minutes of waking; otherwise, 2 mg gum or lozenges are recommended. How these recommendations might apply to youth who vape is unclear. In general, treatment should begin with more frequent use of short-acting nicotine products, and then attempts should be made to increase interval between doses as cessation continues (e.g., 1 piece/lozenge every 1–2 hours for weeks 1–6, then every 2–4 hours for weeks 7–9, and every 4–8 hours for weeks 10–12). |
Begin treatment at least one week before target quit date. Bupropion SR 150 mg by mouth once daily for 3 days, then increase to 150 mg by mouth twice daily. After 2–3 months, may consider discontinuing medication; however, continued treatment with bupropion may support ongoing cessation for up to a year, and some patients may choose to remain on the medication even longer. |
Begin treatment at least one week before target quit date. Varenicline 0.5 mg by mouth once daily for days 1–3, then increase to 0.5 mg by mouth twice daily for days 4–7, then increase to 1 mg by mouth twice daily. Continue for a total of 12 weeks of treatment; a second 12-week course of treatment may support ongoing cessation. |
| Other considerations | In some countries nicotine replacement therapy is available over-the-counter for adults. Data suggest that for adults, cessation is most likely following combination therapy of nicotine replacement with varenicline (preferred), or of nicotine replacement with bupropion [5,39,40,45,46]. | May be beneficial in patients with underlying depression. Due to elevated risk for seizure, contraindicated in individuals with a seizure disorder or eating disorder, or who have abruptly discontinued alcohol, benzodiazepines, or anti-epileptic drugs. | Previously had a black-box warning in the United States due to concern for risk of increased suicidality and agitation; warning was dropped in 2016 after clinical trial data showed that varenicline did not significantly increase these risks [42,47]. If patients experience these symptoms, the medication should be discontinued, and the patient closely monitored. |
a.
Listed medications have been studied for smoking cessation; their use among youth who vape has not been extensively studied
b.
Based on US Food & Drug Administration recommendations and available clinical trial data; use of medications in younger ages than those listed here can be considered
c.
Patches can be worn during the daytime only or overnight; wearing the patch overnight may help reduce morning cravings
d.
Short-acting nicotine inhalers and nicotine oral/nasal sprays are also available; their use in youth is discouraged due to concerns regarding potential misuse and reinforcing effect [38]