New guideline strongly recommends varenicline for smoking cessation

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.

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.

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.

For the full article, please visit for the October 2020 issue of Pharmacy Today.