Experts Recommend Varenicline Over Nicotine Patches

A patient’s reluctance to quit has been an issue not previously tackled in any of the older ATS guidelines. The complete guideline detailing all the latest recommendations, was posted online ahead of print in the July 15th issue of the American Journal of Respiratory and Critical Care Medicine.

This latest guideline highlights that “all patients who use tobacco products should receive treatment for their dependence, rather than just be advised to stop.” It expands on the last guidance by the U.S. Public Health Service, issued in 2008 and in addition to addressing a reluctance to quit, the guideline “identifies an ‘optimal controller’ medication for clinicians to use as an initial pharmacotherapeutic choice and identifies a clinical strategy for amplifying the effectiveness of that controller,” noted Frank T. Leone, MD, MS co-chair of the ATS guideline committee.

Dr. Leone, whi is an associate professor of medicine at the University of Pennsylvania Medical Center and director of the Comprehensive Smoking Treatment Program at Penn Lung Center, believes that most adult smokers wish to quit. “At least among adults, the overwhelming majority of current smokers (including e-cigarette users) express an interest in quitting (over 70 percent) while only a very few follow through with some attempt.”

A willingness to quit is not enough

However, added Dr. Leone, a willingness to quit is not a prerequisite to achieve success. “A willingness to quit is not a pre-requisite for achieving control over the compulsion to smoke.” In line with this, the guideline suggests that administering the controller before the patients express willingness to quit may achieve the desired results. “..introducing the optimal controller to patients before they express willingness to quit results in an additional 308 patients achieving abstinence per 1000 patients treated.”

The following are the ATS recommendations formulated using the Grading of Recommendations, Assessment, Development, and Evaluation, or GRADE, approach:

• “For tobacco-dependent adults in whom treatment is being initiated, we recommend varenicline over a nicotine patch (strong recommendation, moderate certainty in the estimated effects).
• For tobacco-dependent adults in whom treatment is being initiated, we recommend varenicline over bupropion (strong recommendation, moderate certainty in the estimated effects).
• For tobacco-dependent adults in whom treatment is being initiated, we suggest varenicline plus a nicotine patch over varenicline alone (conditional recommendation, low certainty in the estimated effects).
• For tobacco-dependent adults in whom treatment is being initiated, we suggest varenicline over electronic cigarettes (conditional recommendation, very low certainty in the estimated effects).
• In tobacco-dependent adults who are not ready to discontinue tobacco use, we recommend that clinicians begin treatment with varenicline rather than waiting until they are ready to stop tobacco use (strong recommendation, moderate certainty in estimated effects).
• For tobacco-dependent adults with co-morbid psychiatric conditions, including substance use disorder, depression, anxiety, schizophrenia and/or bipolar disorder, for whom treatment is being initiated, we recommend varenicline over a nicotine patch (strong recommendation, moderate certainty in estimated effects).
• For tobacco-dependent adults for whom treatment is being initiated with a controller, we recommend using extended duration (greater than 12 weeks) over standard duration (6-12 weeks) (strong recommendation, moderate certainty in estimated effects).”

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