Smoking Cessation
Loren Bonner
A new evidence-based guideline from the American Thoracic Society addresses several pharmacotherapy-initiation questions for treating tobacco use and dependence. The overall message is a recommendation in favor of varenicline over other forms of monotherapy.
The guideline includes five strong recommendations and two conditional recommendations about pharmacotherapy for smoking cessation (see sidebar).
In states where pharmacists can prescribe cessation medications, these recommendations can provide guidance for a “starting point” in the discussion about medication options with patients, said Karen Hudmon, BSPharm, DrPH, professor of pharmacy practice at Purdue University College of Pharmacy, whose primary clinical and research focus has been on tobacco cessation.
“Varenicline should be prescribed with confidence,” she said. “However, combination [nicotine replacement therapy] is a comparable alternative that was not addressed in the recommendations.”
Combination nicotine replacement therapy (NRT) involves the use of the nicotine patch plus a short-acting NRT agent. And compared to varenicline, it comes at a much lower financial cost to patients. “I recommend either varenicline or combination NRT as a starting point for discussions about treatment options because these are associated with the highest quit rates,” she said. “Between these two approaches, it will usually be a matter of patient preference.”
In states where prescriptive authority for cessation medications is not yet permitted, pharmacists can lean toward the OTC combination of the nicotine patch plus the nicotine gum and/or the nicotine lozenge. Pharmacists can also contact the patient’s primary care provider for varenicline or other prescription cessation agents, such as the nicotine inhaler or the nasal spray.
Things to consider
Hudmon was surprised to see that the expert panel’s recommendations advocated for initiating varenicline in patients who were not ready to quit, rather than waiting until patients are ready, and is skeptical about the practicality of the recommendation. “It’s not clear whether patients will be interested in this approach, especially given the current cost of varenicline,” she said. Additionally, despite ample evidence supporting the efficacy of cessation medications, most patients attempt to quit without medication.
Hudmon found the (strong) recommendation for the use of varenicline versus the nicotine patch in patients with comorbid psychiatric conditions to be an important takeaway from the report. “This guidance, which was based on data from two randomized trials, will hopefully be useful to alleviate clinicians’ discomfort with prescribing varenicline in these patient populations,” she said.
Other options
Pharmacists should be aware of the recommendations and the strong supporting evidence in favor of varenicline over other single-agent approaches.
“Combination therapy was discussed for varenicline plus the nicotine patch, but another option is to combine varenicline plus a short-acting NRT medication, like gum, lozenge, inhaler, or nasal spray,” said Hudmon. This was not addressed in the recommendations, but it provides patients with an ability to obtain some relief for situational urges when needed, she said.
As of December 2016, the boxed warnings on varenicline and bupropion SR for smoking cessation no longer exist. However, patients who are on any of the cessation medications should be monitored during the post-quit period. A follow-up contact within the first 2 weeks of quitting is advised.
Pharmacists can play an important role in helping their patients quit by recommending the most effective treatment modalities and referring patients to the tobacco quitline (1-800-QUIT NOW) for additional assistance.
Summary of recommendations
1. 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).
2. For tobacco-dependent adults in whom treatment is being initiated, we recommend varenicline over bupropion (strong recommendation, moderate certainty in the estimated effects).
3. 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).
4. 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).
5. In tobacco-dependent adults who are not ready to discontinue tobacco use, we recommend that clinicians begin treatment with varenicline rather than waiting until patients are ready to stop tobacco use (strong recommendation, moderate certainty in the estimated effects).
6. For tobacco-dependent adults with comorbid 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 the estimated effects).
7. For tobacco-dependent adults for whom treatment is being initiated with a controller, we recommend using extended-duration (>12 wk) over standard-duration (6–12 wk) therapy (strong recommendation, moderate certainty in the estimated effects).
Source: American Journal of Respiratory and Critical Care Medicine/ATS (American Thoracic Society) Journals