General Information

The National Comprehensive Cancer Network (NCCN) guidelines recommends that smoking cessation be provided as part of oncology treatment.1

According to the guideline, the most effective strategy is to combine behavioral therapy with pharmacologic therapy. Behavioral therapy plus nicotine replacement therapy (NRT) or varenicline are recommended for 12 weeks; extended therapy beyond 6 months may be necessary. Bupropion is recommended as an alternative therapy if cessation is not achieved with NRT and varenicline.

Relapse, slips, and multiple quit attempts are common before successful cessation, and this behavior does not necessarily indicate a need to switch therapy. Health care providers should continue to provide guidance and support during relapses and slips.

Behavioral Therapy

The NCCN recommends using behavioral therapy in addition to NRT or bupropion.

A Cochrane review and meta-analysis demonstrated that intensive behavioral therapy improved smoking abstinence (risk ratio [RR], 1.17; 95% CI, 1.11-1.24). Intensive behavioral therapy was effective for increasing the odds of smoking cessation when combined with NRT (RR, 1.14; 95% 1.06-1.23) and bupropion (RR, 1.27; 95% CI, 1.10-1.46), but not varenicline (RR, 1.11; 95% CI, 0.89-1.37).2

NRT

The NCCN recommends the combined use of fast- (ie, gums, lozenges) and long-acting (ie, patch) formulations.

A Cochrane systematic review and meta-analysis conducted in 2013 demonstrated the efficacy of NRT compared with placebo (odds ratio [OR], 1.84; 95% CI, 1.71-1.99).3

Used singularly, the long-acting patch (OR, 1.91; 95% CI, 1.71-2.14), the short-acting gum (OR, 1.68; 95% CI, 1.51-1.88), and other short-acting formulations (OR, 2.04; 95% CI, 1.75-2.38) were effective in increasing the odds of quitting. Their combination, however, increased efficacy by nearly 3-fold (OR, 2.73; 95% CI, 2.07-3.65).

The large, randomized controlled EAGLES trial (ClinicalTrials.gov Identifier: NCT01456936) of 8144 patients demonstrated that NRT patch achieved higher smoking abstinence than placebo (OR, 2.15; 95% CI, 1.82-2.54).4

Common adverse events (AEs) of NRT are primarily related to the route of administration. The patch, for example, can cause skin sensitivity and irritation; gum can cause hiccups, gastrointestinal disturbances, jaw pain, and orodental problems; sublingual tablets can cause hiccups, burning in the mouth, sore throat, coughing, and dry lips.

There may be a small increase in the risk of palpitation and chest paints with NRT use. The Cochrane review found a rate of 2.5% with NRT compared with 1.4% with placebo (OR, 1.88; 95% CI, 1.37-2.57) in data from 15 trials. There is, however, insufficient evidence to suggest an increased risk of cardiovascular events or cancer.