New strategies help smokers quit when nicotine replacement alone doesn’t work

Howard LeWine, M.D.

Chief Medical Editor, Harvard Health Publishing

If you’ve ever smoked and tried to quit, you know how hard it can be. Nicotine is so addictive that smoking, or using tobacco in other forms, may be the toughest unhealthy habit to break. But it’s possible to quit. Just ask the millions of ex-smokers, who now outnumber smokers in the United States.

There are two main obstacles to quitting: the physical withdrawal from nicotine, and the mental and emotional withdrawal from a habit that had become a soothing part of daily routine.

Nicotine replacement, in the form of nicotine patches, gum, sprays, inhalers, and lozenges, can help overcome the physical addiction. Medications such as varenicline (Chantix) and bupropion (Zyban) can also help. They can help reduce the cravings for a cigarette, and may also make smoking less pleasurable.

Two new studies of these medications offer good news to smokers who want to quit but haven’t been able to do it with just nicotine replacement.

Two Duke University researchers asked 222 smokers who weren’t able to kick the habit with just nicotine replacement to take varenicline alone or varenicline plus bupropion while continuing to use a nicotine patch. After 12 weeks, 40% of those taking both medications were no longer smoking, compared to 25% of those taking only varenicline. The results were published online in the American Journal of Psychiatry.

Writing in this week’s JAMA, a South African team compared varenicline plus nicotine replacement with varenicline alone. The combination worked better, with 49% of the 446 participants no longer smoking at 24 weeks, compared to 33% of those using just a nicotine patch.

These results don’t suggest smokers take varenicline and bupropion as a first step in smoking cessation. Both drugs must carry a “black box” warning on their labels to highlight an increased risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts. And the South African study found that smokers taking varenicline along with nicotine replacement experienced more quitting-related side effects, including nausea, sleep problems, constipation, and depression. But when nicotine replacement alone hasn’t helped, adding varenicline with or without bupropion may lead to success.

Plan ahead

If you want to quit, you can help yourself become a non-smoker with proper planning. One model commonly used to help people break addictions is called “stages of change.” According to this model, behavior change rarely occurs at one particular moment in time. Instead, you are more likely to journey through several distinct stages before attaining your goal.

  1. In this phase, you may be thinking of changing now or in the future, but not seriously. You might know that smoking can cause health problems. But you don’t really believe smoking is a problem for you.
  2. You recognize that quitting is probably right thing to do. But you still are uncertain if you want or need to quit.
  3. You’ve accepted the idea of quitting and start looking for ways to accomplish it.
  4. You take one or more definite steps. Maybe you set a quit date, or sign up for a stop-smoking group. And you quit smoking—at least for a while.
  5. You are tempted to return to smoking. This is true for any type of behavior change. Understand that this is expected. Therefore, you need to develop strategies ahead of time to address it, even if you smoke one or two cigarettes.

Don’t give up

If you succeed on your first attempt to quit smoking, congratulations! If not, try again when you are ready. The average person makes several attempts before quitting for good.

Using nicotine replacement is a good way to deal with nicotine withdrawal symptoms. If it doesn’t work, ask your doctor about the possibility of adding varenicline or bupropion. Cognitive behavioral therapy and support groups can help break the mental and emotional attachment to cigarettes.

However long it takes, quitting is beneficial. In a study published in the Archives of Internal Medicine, researchers from the German Cancer Research Center in Heidelberg showed that quitting smoking reduces the risk of dying—even in people who quit in their 80s.

Related Information: How to Quit Smoking


  1. Monika

    Great stuff thanks for sharing this information.This will definitely helpful for smoker.

  2. Melissa

    Me e-cig with decreasing nicotine has helped me tremendously!! Down from 1 1/2 packs a day to 3-4 cigs. And I’m not a raving bitch!!!

  3. Iamme

    Ive bn smokin 4 23years n im gona try quit cold turkey. The thing is wen I dont hav a smoke I become a terrible person. I am gona do it this time round n I wil do it as I wil lean on Jehovah (“GODS name) not medicine.

  4. Guia Saúde Fácil

    I believe what you said Alaistar, but only if nicotine addiction is the only problem a person is going trough.

    You see, too much stuff gets solved in that level (mind/belief), sometimes the amount of problems a person has solve, forbids her to make a move in the right direction, in the right time.

    Please visit my website:

    • Andre Loxas

      You are very right, I could only stop smoking when I was close to retirement, and it was not the best move for me.

      Too many years smoking have caused a series of damages to my lungs and pancreas, but I could not have done in any other way as my entire life I had a lot to deal with.

      Some believe that only because someone can quit smoking by will alone, that those that can quit are losers or have a very weak character or will, when in my case was quite the opposite.

  5. Alaistar Jenkins

    I have always felt that if someone wanted to stop smoking, they would stop. Addiction in my opinion is a weakness as opposed to an illness and can be treated in pure belief etc.

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