American Thoracic Society: Initiating Pharmacologic Treatment in Tobacco-Dependent Adults
SUMMARY:
All patients who use tobacco should be provided with treatment to help them quit. The American Thoracic Society (ATS) has released guidance on pharmacotherapy for tobacco cessation and state that simply advising patients to quit is insufficient. ATS is the first organization to recommend varenicline as first-line therapy for cessation. The guidelines also address combination pharmacotherapy, starting medication for patients who are not yet ready to quit, and treating tobacco users with comorbid psychiatric disease.
ATS Smoking Cessation Recommendations
Varenicline over other pharmacotherapy (bupropion) or nicotine replacement therapy (nicotine patch)
- Varenicline superior for achieving long-term abstinence
- Generally assessed by patient self-report +/- exhaled carbon monoxide testing
- Varenicline associated with fewer serious adverse events (SAEs) vs nicotine patch
- No difference in SAEs compared to bupropion
Varenicline plus a nicotine patch over varenicline alone (conditional recommendation)
- Combination therapy significantly increases abstinence
- Conditional recommendation based on
- Anticipated issues with patient adherence | Cost | Possible increased incidence of SAEs
Start varenicline even for patients who are not yet ready to quit tobacco
- Significant effect on abstinence even in active smokers
- “Pharmacotherapy is no longer contingent on readiness to quit but is instead a therapeutic intervention aimed at improving readiness to stop smoking”
Start varenicline even for patients with comorbid psychiatric disease (substance use disorder, depression/anxiety, schizophrenia, bipolar disorder)
- Stigma around varenicline use in this population due to former boxed warning regarding possible neuropsychiatric events (based on case reports, not supported by RCTs)
Extended duration (>12 weeks) therapy over standard duration (6-12 weeks) for any cessation aid (varenicline, bupropion or nicotine patch)
- Extended therapy results in increased abstinence with less relapse
Dosing Varenicline
Initial: Days 1 to 3: 0.5 mg once daily | Days 4 to 7: 0.5 mg twice daily
Maintenance (day 8 and later): 1 mg twice daily continued for at least 11 weeks
Note: Dosing should be adjusted for renal function, see references below
References:
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