Initiating Pharmacologic Treatment in Tobacco-Dependent Adults
Publication Date: July 15, 2020
Last Updated: January 19, 2024
Recommendations
Treatment
For tobacco-dependent adults in whom treatment is being initiated, we recommend varenicline over a nicotine patch. (S, M)
Remarks: To promote adherence to pharmacologic therapy, providers should be prepared to counsel patients about the relative safety and efficacy of varenicline treatment compared with a nicotine patch.
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For tobacco-dependent adults in whom treatment is being initiated, we recommend varenicline over bupropion. (S, M)
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For tobacco-dependent adults in whom treatment is being initiated, we suggest varenicline plus a nicotine patch over varenicline alone. (C, L)
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For tobacco-dependent adults in whom treatment is being initiated, we suggest varenicline over electronic cigarettes. (C, VL)
Remarks: The recommendation’s strength reflects very low certainty in the effects used to derive the recommendation. After our evidence synthesis, new evidence emerged regarding serious adverse effects of electronic cigarettes. If these serious adverse effects continue to be reported, the strength of the recommendation should be reevaluated. Note that this recommendation is intended for treatment of tobacco dependence under the supervision of a clinician; it should not be extrapolated to unsupervised treatment or recreational use.
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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. (S, M)
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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. (S, M)
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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. (S, M)
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Recommendation Grading
Overview
Title
Initiating Pharmacologic Treatment in Tobacco-Dependent Adults
Tobacco-Dependent Adults in Whom Treatment Is Being Initiated
Target Provider Population
Physicians, other clinicians, nurses, and policy makers who inform patient decision-making, clinical practice, and health-policy decisions.
PICO Questions
For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline or a Nicotine Patch?
For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline or Bupropion?
For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline plus Nicotine-Replacement Therapy or Varenicline Alone?
For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated, Should Treatment Be Started with Varenicline or an Electronic Cigarette?
In Tobacco-Dependent Adults Who Are Not Ready to Discontinue Tobacco Use, Should Clinicians Begin Treatment with the Optimal Controller or Wait Until They Are Ready to Stop Tobacco Use?
In Tobacco-Dependent Adults with Comorbid Psychiatric Conditions, Including Substance-Use Disorder, Depression, Anxiety, Schizophrenia, and/or Bipolar Disorder, for Whom Treatment Is Being Initiated, Should Clinicians Start with the Optimal Controller Identified for Patients without Psychiatric Conditions or Use a Nicotine Patch?
In Tobacco-Dependent Adults for Whom Treatment Is Being Initiated with a Controller, Should They Be Treated with an Extended-Duration (>12 wk) or Standard-Duration (6–12 wk) Regimen?
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Specialties Involved
Family Medicine, Internal Medicine General, Obstetrics And Gynecology, Preventive Medicine, Pulmonology, Addiction Medicine, Preventive Medicine
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List of Questions
Refer to Data Supplement
Description of Study Criteria
Refer To Data Supplement
Description of Search Strategy
A systematic review of the medical literature is conducted. ATS staff use the information entered into the plan, including the clinical questions, inclusion/exclusion criteria for qualified studies, search terms/phrases, and range of study dates, to perform the systematic review. Literature searches of selected databases, including The Cochrane Library and Medline (via PubMed) are performed. Working with the Expert Panel, ATS staff complete screening of the abstracts and full text articles to determine eligibility for inclusion in the systematic review of the evidence.
Description of Study Selection
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Description of Evidence Analysis Methods
ATS uses RevMan to combine results of multiple studies. ATS uses GradePro software to combine the summary of findings and quality assessment tables into a single table.
Description of Evidence Grading
ATS uses the Evidence to Recommendations (EtR) framework.
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect.
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Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect.
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Description of Recommendation Grading
ATS uses a formal consensus methodology based on the modified Delphi technique in clinically important areas where there is limited evidence or a lack of high‐quality evidence to inform clinical guidance recommendations.
GRADE rates the certainty (also known as quality or confidence) in effect estimates for benefits and harms as high, moderate, low or very low, and the overall certainty is based on the lowest confidence of the outcomes critical for decision making. Recommendations are classified as strong (desirable consequences clearly do or do not outweigh undesirable consequences) or conditional (the balance of desirable and undesirable consequences is less certain).P Alternative designations are conditional, discretionary, or contingent recommendations.
A strong recommendation was made for an intervention when, following deliberations, the panel was certain that the desirable consequences of the intervention outweigh the undesirable consequences, likewise a strong recommendation would have been made against a proposed intervention if the panel was certain that the undesirable consequences of the intervention outweigh the desirable consequences. A strong recommendation indicates that almost all well-informed patients would choose to have or not to have the intervention.
A conditional recommendation was made for an intervention when the panel was uncertain whether the desirable consequences of the intervention outweigh the undesirable consequences, likewise a conditional recommendation would have been made against a proposed intervention if the panel was uncertain that the undesirable consequences of the intervention outweigh the desirable consequences. Reasons for a conditional recommendation and thus uncertainty included low or very low quality of evidence, or the desirable and undesirable consequences being finely balanced, with underlying values and preferences playing an important role.
Description of Funding Source
ATS provides funding for Guideline Development.
Company/Author Disclosures
ATS Conflict of Interest Policy complies with the CMSS Code for Interactions with Companies. ATS requires no COI with Tobacco entity (includes manufacturer/dissemination of e-cigarettes).