ATS: Guideline for Initiating Pharmacologic Treatment for Tobacco Dependence
The American Thoracic Society (ATS) has published a new guideline1 for the initiation of pharmacologic treatment among adults who are tobacco-dependent. The guideline includes 7 recommendations that address pharmacotherapy-initiation questions that treatment teams often face.
According to the authors, the guideline is an extension of the smoking cessation guidelines from the US Public Health Service (USPHS).2 While the USPHS guidelines include guidance on interventions’ efficacy, the new guideline from ATS aims to provide tailored guidance for clinical questions that can impact effectiveness.
“[This guideline] focuses on the initial pharmacotherapy of tobacco dependence, defined by problematic patterns of tobacco use leading to clinically significant impairment or distress, in adult patients, excluding pregnant and adolescent populations,” the authors wrote. “The goal is to improve patient-centered care of tobacco dependence by identifying a single evidence-based pathway that balances important outcomes, including short- and long-term tobacco abstinence and serious adverse events, while accounting for important clinical variability.”
After a systematic review, the guideline panel made the following 5 strong recommendations:
- Use varenicline over a nicotine patch among tobacco-dependent adults who are initiating tobacco treatment.
- Use varenicline over bupropion among tobacco-dependent adults who are initiating tobacco treatment.
- Begin treatment with varenicline—rather than wait until patients are ready to stop using tobacco—among tobacco-dependent adults who are not ready to discontinue tobacco use.
- Use varenicline over a nicotine patch among tobacco-dependent adults with comorbid psychiatric conditions, including substance-use disorder, depression, anxiety, schizophrenia, and/or bipolar disorder who are initiating tobacco treatment.
- Use extended-duration (>12 weeks) over standard-duration (6-–12 weeks) therapy among tobacco-dependent adults who are initiating treatment with a controller.
The panel also made the following 2 conditional recommendations:
- Use varenicline plus a nicotine patch—rather than varenicline alone—among tobacco-dependent adults who are initiating tobacco treatment.
- Use varenicline over electronic cigarettes among tobacco-dependent adults who are initiating tobacco treatment.
“The guideline addresses several limiting misconceptions, including the value of combination pharmacotherapy, the approach to patients who are reluctant to stop smoking, and the safety and efficacy of treating vulnerable behavioral health patients,” the authors concluded.
- Leone FT, Zhang Y, Evers-Casey S, et al; American Thoracic Society Assembly on Clinical Problems. Initiating pharmacologic treatment in tobacco-dependent adults. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;202(2):e5-e31. doi:10.1164/rccm.202005-1982ST
- Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care. 2008;53(9):1217-1222. http://rc.rcjournal.com/content/respcare/53/9/1217.full.pdf