In 2025, the NCCN updated its recommendations for smoking cessation in oncology patients. They now include positions on electronic cigarettes, smokeless nicotine products and the harm reduction strategy, while emphasising an individualised approach and a focus on behavioural support.
Updated NCCN recommendations for smoking cessation in oncology patients
The American professional society NCCN (National Comprehensive Cancer Network) published updated recommendations in May 2025 concerning smoking cessation in oncology patients. They now include positions on smokeless nicotine products, a mention of the role of electronic cigarettes in the cessation process and a separate section devoted to the harm reduction strategy. The recommendations are included in category 2A, which means that they are supported by a lower level of evidence, but there is more than 85% agreement among the NCCN panel regarding their appropriateness.
Basic principles of the recommendations
The NCCN emphasises that all oncology patients should be informed about the negative impact of smoking on treatment outcomes and the risk of complications. Patients should be advised to stop smoking, and those who are ready to do so should have an individualised cessation plan created.
For patients who are not ready to stop smoking, it is recommended to identify barriers and concerns. These patients may be offered pharmacotherapy with the aim of reducing cigarette consumption and setting a realistic date for quitting smoking in the near future. The patient’s readiness to stop smoking should be assessed at every visit.
General approach to the treatment of tobacco dependence
Primarily, a combination of nicotine replacement therapy (NRT) and behavioural treatment for 12 weeks is recommended, or alternatively varenicline in combination with behavioural treatment for the same period (category 1). The efficacy and tolerability of therapy should be assessed within three weeks of initiation, ideally after one week, and subsequently after 12 weeks.
Patients who successfully stop smoking should be motivated to maintain abstinence. Pharmacotherapy may be extended if necessary. In patients who relapse or fail to stop smoking, it is recommended to assess motivation, the efficacy of primary therapy and adherence. It is possible to continue the original treatment with strengthened adherence and behavioural support, or to switch to an alternative primary therapy. Efficacy should again be assessed within three weeks and subsequently after 12 weeks.
Patients should be informed that relapses are common and that achieving long-term abstinence may require multiple attempts.
Patients before surgery
Patients who undergo surgery are advised to stop smoking as soon as possible. A longer period of abstinence improves surgical outcomes, but should not lead to postponement of the operation. Initial treatment with NRT or varenicline in combination with behavioural therapy is recommended. NRT is not a contraindication to surgery.
Alternative approaches to smoking treatment
All patients should be offered motivational and behavioural support regardless of the chosen cessation method.
Electronic cigarettes
Electronic cigarettes deliver nicotine through a heated aerosol. Randomised clinical studies and systematic reviews show that they may be effective in smoking cessation. However, they contain addictive substances and harmful chemicals, while the long-term effects of vaping are not yet known. Aerosols from electronic cigarettes contain significantly lower concentrations of toxic substances than smoke from combustible cigarettes.
Patients who have stopped smoking thanks to vaping should be supported in maintaining abstinence. Once they are confident that they can maintain long-term non-smoking, cessation of vaping may be recommended, but not at the cost of risking a return to smoking. Optimal procedures for stopping vaping are not known, therefore it is recommended to follow general guidance for smoking cessation.
The FDA may authorise the sale of certain electronic cigarettes, but none of them is approved as a therapeutic device for smoking cessation.
Cases of EVALI have been associated with products contaminated with vitamin E acetate in illegal e-liquids, not with commercial products approved by the FDA. Vitamin E acetate has largely been removed from U.S. vaping products.
Harm reduction and alternative nicotine products
A wide range of alternative nicotine products is available on the market, for example snus or nicotine pouches. Some of them have received MRTP (Modified Risk Tobacco Products) status from the FDA, meaning products with modified risk. These products are not approved as treatment for tobacco dependence, but a complete switch from smoking to MRTP may reduce the incidence of malignancies and other smoking-related diseases.
Dual use of cigarettes and alternative products may be more harmful than smoking alone, and patients should be discouraged from it. If a patient uses smokeless alternatives as support for cessation, it is necessary to focus on achieving complete and long-term abstinence from smoking.
