Disclosures: Leone reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
July 27, 2020
2 min read

Varenicline recommended over patch, bupropion as initial treatment for smoking cessation

Disclosures: Leone reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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The American Thoracic Society issued a new clinical practice guideline that outlines recommendations for initiating pharmacologic treatment for smoking cessation in tobacco-dependent adults.

The new guideline, published in the American Journal of Respiratory and Critical Care Medicine, expands upon guidance issued in 2008 by the U.S. Public Health Service. The new guideline identifies varenicline (Chantix, Pfizer) as an “optimal controller” medication for clinicians to use as an initial pharmacotherapeutic and also identifies a clinical strategy to amplify effectiveness of varenicline.

Smoking Cessation
Source: Adobe Stock.

Guidance for clinicians

The clinical practice guideline acknowledges that “all patients who use tobacco should receive treatment for their dependence, and not simply be encouraged to stop.”

“At least among adults, the overwhelming majority of current smokers (including e-cigarette users) express an interest in quitting (over 70%) while only a very few follow through with some attempt,” ATS guideline committee co-chair Frank T. Leone, MD, MS, associate professor of medicine at the University of Pennsylvania Medical Center and director of the Comprehensive Smoking Treatment Program at Penn Lung Center, said in a press release issued by the ATS. “A willingness to quit is not a prerequisite for achieving control over the compulsion to smoke.”

According to the new guideline, “introducing the optimal controller to patients before they express willingness to quit results in an additional 308 patients achieving abstinence per 1,000 patients treated.”

Seven recommendations

A panel of individuals with documented expertise and training in tobacco-dependence counseling and/or treatment was created to prioritize questions and outcomes important for smoking cessation for clinicians. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to assess the estimated effects and rate the strength of possible recommendations.

The panel recommended seven recommendations for pharmacotherapy choices for smoking cessation in tobacco-dependent adults in whom treatment is being initiated:

Varenicline is recommended over a nicotine patch (strong recommendation).

Varenicline is recommended over bupropion (strong recommendation).

Clinicians can begin varenicline treatment in tobacco-dependent adults who are not ready to discontinue tobacco use rather than waiting until they are ready to stop (strong recommendation).

Varenicline is recommended over a nicotine patch in tobacco-dependent adults with comorbid psychiatric conditions, including those with anxiety, bipolar disorder, depression, schizophrenia and substance-use disorder (strong recommendation).

Extended duration (over 12 weeks) of initial treatment with a controller is recommended over standard duration (6-12 weeks) therapy (strong recommendation).

Varenicline plus a nicotine patch is recommended over varenicline only (conditional recommendation.


Varenicline is recommended over electronic cigarettes (conditional recommendation).

The full recommendation list and details are included in the clinical practice guideline.

“Traditionally, the clinical community has engaged tobacco use as the toxic antecedent to chronic disease, and so it follows that clinicians have focused on methods to increase the patient’s motivation to stop. Our 21st century perspective engages tobacco use as the cardinal manifestation of a disturbance in the brain’s molecular-learning mechanisms,” the panel wrote. “From that perspective, the treatment team’s responsibility extends beyond facilitating quitting and includes maximizing longitudinal control over the compulsion to smoke.”