Factors affecting choice of drug therapy for tobacco smoking and nicotine dependence

The most effective drug therapy is the nicotine receptor agonist varenicline, closely followed by combination nicotine replacement therapy (combination NRT)Cahill, 2016Davies, 2020. Each of these is more effective than NRT monotherapy or bupropionThe Royal Australian College of General Practitioners (RACGP), 2021.

The most widely available and best tolerated form of drug therapy is NRT. It is less likely to cause adverse effects and drug interactions than varenicline and bupropionThe Royal Australian College of General Practitioners (RACGP), 2021. Medium- or fast-acting NRT can be added to treatment with varenicline or bupropion if required to control cue-driven cravings.

Bupropion is an option when combination NRT and varenicline are not suitable, though it is less effective. Bupropion is contraindicated in patients with a history of seizures, eating disorders and those taking irreversible monoamine oxidase inhibitors.

Nortriptyline is an option when first-line drug therapies (NRT, varenicline and bupropion) are not suitable or were not effective after an adequate trial. Nortriptyline is a second-line choice, mainly due to adverse effects and drug interactions. Nortriptyline has similar efficacy to bupropion but is not approved by the Therapeutic Goods Administration (TGA) for the management of tobacco smoking.

Nicotine vaping products are an alternative for use when first-line drug therapies (NRT, varenicline and bupropion) are not suitable or were not effective after an adequate trial. However, evidence for efficacy is evolving and long-term safety is not certainHartmann-Boyce, 2021. There are no TGA-approved nicotine vaping products.

Other factors affecting choice of drug therapy include:

• the patient’s previous experience of treatments
• cost—though all options are significantly cheaper than smoking
• convenience—some patients prefer taking once or twice daily tablets; others value the wider availability of combination NRT (available at most supermarkets, pharmacies and online)
• the patient’s preferred form of therapy (tablets [varenicline or bupropion], gum, lozenges, patches, inhalators, sprays)—for patients choosing NRT, see Correct use of nicotine replacement therapy—patient information for a comparison of the available formulationsThe Royal Australian College of General Practitioners (RACGP), 2021.

Only NRT, varenicline and bupropion are registered by the Australian Therapeutic Goods Administration (TGA) for the management of tobacco smoking.