ATS guideline strongly recommends varenicline for smoking cessation

Of three controller medications for tobacco dependence, the available evidence shows varenicline to be the best, according to a new clinical practice guideline from the American Thoracic Society (ATS).

A panel of individuals with expertise and training in tobacco-dependence counseling and/or treatment addressed several pharmacotherapy-initiation questions that routinely confront clinicians caring for adults with tobacco dependence. After reviewing the available evidence, the panel formulated five strong recommendations and two conditional recommendations. The guideline was funded by the ATS, which did not influence its content, and will be re-evaluated in roughly five years. It was published online on July 15 by the American Journal of Respiratory and Critical Care Medicine.

Strong recommendations included using varenicline rather than a nicotine patch; using varenicline rather than bupropion; using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition; initiating varenicline in adults, even if they are unready to quit; and using controller therapy for an extended treatment duration of more than 12 weeks rather than the standard duration of six to 12 weeks. To promote adherence to pharmacologic therapy, clinicians should be prepared to counsel patients about the relative safety and efficacy of varenicline treatment compared with a nicotine patch, the guideline said.

Conditional recommendations were to combine a nicotine patch with varenicline rather than using varenicline alone and to use varenicline rather than electronic cigarettes. The panel noted that after their evidence synthesis was completed, new evidence emerged regarding serious adverse effects of e-cigarettes. If these adverse effects continue to be reported with e-cigarettes, the strength of that recommendation should be re-evaluated, the guideline said.

The main limitation of the guideline is the small number of recommendations included, the authors noted. “Because our objective was to identify a functional, evidence-based pharmacotherapy pathway, we began the process by identifying an optimal controller medication on which to build additional clinical recommendations,” they wrote. “By necessity, our guideline could not address all possible pharmacotherapy options.”

Future guidelines should consider optimal controller strategies for patients who have declined varenicline or who have not been able to stop smoking while taking it, the authors noted.