A quick thread on the comparative efficacy and safety of tobacco cessation pharmacotherapy.

Tobacco use is associated with a a horrific number of cancers, CV events, pulmonary problems, and harms pretty much every part of the body. Also, it's not cool anymore/

Despite all these health risks it is one of the most difficult substances to quit using. Tobacco is a remarkably addictive substance, this is due to the chemical nicotine, this is present in large amounts in the plant as protection from predators.

When tobacco is consumed by humans it results in a mild euphoria, stimulation, and enhanced cognitive function. This is mainly due to nicotine acting as an agonist at nicotinic acetylcholine receptors (ionotropic; sodium and potassium).

The effects are rapid and of short duration, leading the need to administer again through a day or night as withdrawal symptoms manifest repeatedly and worsen with longer duration. This is a bio-medical issue; morals and "willpower" are not the cause or a solution

As with other SUDs, shaming and stigmatization will only hurt the individual and decrease the chances of cessation. As most people, even many HCWs take this approach with substance users their is often a sense of abandonment and even self-blame. Demonstrating empathy is

the first step towards treatment, if this doesn't occur there's little point in prescribing anything.

When it's time to prescribe there are three options: Nicotine replacement therapy(NRI), gum and patches are common; bupropion; an antidepressant with a unique mechanism;

and finally varenicline, a nicotine partial agonist with targeted action at the a4b2 NaChRs.
Varenicline is the most effective with an NNT btw 8-10 for 6 mo abstinence. Bupropion and NRT are similar with NNT btw 13-15. (NNTs are rough averages across lit for this thread)

Safety: Varenicline carries a black box warning for SI, but large studies post-approval have shown it does not carry a significant risk, an FDA advisory board stated this in 2016 but it remains despite this evidence.
according to one large retrospective analysis ...

varenicline compared to NRT had 1yr RR reductions of 10% for CV hospitalizations 20% for neuropsych hospitalization , and 19% mortality.

Bupropion and NRT did not differ substantially.

Varenicline by the numbers is a the safest and effective and concerns about suicidal ideations by many to be far too high. However, the decision of which to use should be based around the Pt and their desires. It is important they feel heard as multiple attempts are the norm.

Primary sources: https://pubmed.ncbi.nlm.nih.gov/33523610/ 
https://jamanetwork.com/journals/jama/fullarticle/2775286
https://academic.oup.com/ntr/article-abstract/23/2/302/5850393?redirectedFrom=fulltext
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464943/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488024/
https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-description-mental-health-side-effects-stop-smoking