Which drug to be used in smoking cessation?

There are 3 first-line medications for smoking cessation i.e. nicotine replacement therapy (NRT), varenicline (a partial nicotine receptor agonist) and slow-release (SR) bupropion. All 3 agents approximately double 1-year quit rates when used for 3 months, although varenicline seems to be a little more efficacious than bupropion SR. An un-blinded study comparing varenicline with nicotine patches are analysed in details and it is concluded that the validity of that study is low regarding the relative efficacy of varenicline versus NRT. Depression and suicidal attempts have been reported with varenicline use but it is probably not induced by varenicline but by the quitting process per se. It is recommended that the first agent to be used in smoking cessation should be NRT as it is the best documented product with mild side effects. It might be optimal to combine the patch with either gum, inhaler, sublingual tablets or nasal spray. In subjects that have failed with NRT, varinicline should be the choice. Bupropion SR is preferred to subjects with depression or smokers who have failed with the previous two agents, due to the many contra-indications and side effects of bupropion SR. With one of the 3 agents combined with follow-up visits with counselling, one can expect a 1-year quit rate around 20-25%.