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July 22, 2020

Smokers should begin cessation drugs, then decide when to quit

New treatment guidelines also advise varenicline over the patch

Addiction Smoking
Smoking cessation guidelines Gerd Altmann/Pixabay

Research shows that the drug varenicline is an effective first line of therapy to help smokers quit using cigarettes.

New guidelines for treating tobacco dependence could significantly change the way clinicians help patients quit smoking cigarettes. 

Prior treatment approaches called for patients to stop smoking before receiving treatments like varenicline, a drug that aids cessation. Now, experts say smokers just need to be willing to begin treatment.

The new guidelines, issued by the American Thoracic Society, were published in the American Journal of Respiratory and Critical Care Medicine.

"The old paradigm in the field is people have to want to quit before starting treatment, but this leaves a lot of potential people off the table," Dr. Frank T. Leone, director of comprehensive smoking treatment programs at Penn Medicine and co-chair of the American Thoracic Society subcommittee responsible for the new guidelines, told PhillyVoice.

Smokers are 2.5 times more likely to successfully quit under the new approach, even if they are still smoking when they begin treatment, Leone said. That equates to an extra 300 people per every 1,000 smokers who will quit if they are started on treatment immediately. 

That's a big deal, Leone said.

Essentially, the new guidelines call for clinicians to stop directing patients to start taking a medication a few days before quitting. Instead, they should instruct patients to begin the medication and then have a followup conversation when the patient feels ready to quit. That removes the threat of an official stop date, Leone said. 

Research shows that more patients are willing to take the medicine as long as their doctor is not pushing a specific day to quit smoking, according to Leone. The new guidelines do not take autonomy away from the patients. Rather, they recognize the patient needs to be at the center of the decision-making process. 

"Earlier guidelines emphasized that clinicians have a responsibility to treat because treatment works, but they didn't outline a specific clinical pathway to follow," Leone said. "This is the first one to offer a universal clinical pathway for the majority of patients."

The new guidelines include five strong recommendations and two conditional ones regarding drug therapy choices for smoking cessation. A panel of experts came together to identify the questions important to clinicians and then voted on the best possible outcomes.

Most of the recommendations focused on the preference of the drug varenicline as the first line of therapy. 

After conducting a systematic literature review, the panel found that varenicline is more effective than nicotine patches and the drug bupropion at increasing abstinence. The drug also slightly decreases the risk of serous adverse events among most tobacco-dependent adults when compared to the use of a nicotine patch and bupropion.

Plus, smokers with underlying mental health issues, like substance-use disorder, depression, anxiety, schizophrenia and bipolar disorder, respond favorably to varenicline. People with psychiatric or substance-use disorders account for almost 40% of cigarette consumption in the U.S.

"Varenicline, brand name Chantix, has gotten a reputation for causing mood changes, anger and depression, leading to concern about treating people with underlying mental health issues with it," Leone said. "Research however shows that it is safe to use even in people experiencing depression or anxiety.

"A huge portion of smoking population turned away from varencline because of rumors. Smoking causes side effects, not the therapy."

The recommendations also call for using a controller therapy for more than 12 weeks instead of the standard 6 to 12 weeks. Controller therapy reduces the frequency and intensity of the craving to smoke, Leone said. But reliever medications are meant to be used during a craving episode. 

The 2018 American College of Cardiology tobacco-cessation clinical pathway recommends at least 3 months of therapy with nicotine and 3 to 6 months of therapy when using varenicline or bupropion.

The conditional recommendations – which the panel acknowledges need more research – found that varenicline is superior to electric cigarettes as a treatment option, and that the combination of varenicline and a nicotine patch is more effective than using the drug alone. 

Leon emphasized that these guidelines are just a first step and don't cover all therapeutic approaches to smoking cessation.

"We just wanted to write down one pathway that the average clinician could use for a majority of their patients," he said.

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