American Thoracic Society guideline for initiating medications for smoking cessation

Reference

Leone FT, Zhang Y, Evers-Casey S, et al. 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.

Synopsis

The ATS convened a guideline development panel composed of a methodology team and a team of experts. Although the co-chairs of the teams and at least 50% of the panel members had to be free of conflicts of interest, most of the panel members also (refreshingly!) reported no ties to industry. The panel used explicit approaches to identify key clinical questions, conduct systematic reviews, assess the risk of bias of included studies, construct evidence tables, and assess the safety and effectiveness of interventions. The included studies used a variety of markers of smoking cessation (eg, self-report, exhaled carbon monoxide, etc.) at varying intervals (eg, 7 days, 10 to 12 weeks, 6 months, 12 months, etc.). The first 2 questions dealt with binary choices of initiating treatment with varenicline versus either nicotine patches or bupropion (Zyban). The team identified 14 randomized trials (n = 7362 participants) that compared varenicline with nicotine patches and 7 trials (n unknown) that compared varenicline with bupropion. For each of these comparisons, the data were pretty solid that varenicline was modestly more effective than nicotine patches in several measures of effectiveness (relative risks ranged from 1.2 to 1.4) and more effective than bupropion (relative risks ranged from 1.3 to 1.4). From the studies that reported adverse effects, varenicline had fewer than the comparators. The panel found 3 trials that compared varenicline monotherapy versus varenicline plus nicotine patches (they found no studies that used other forms of nicotine replacement) that showed the combination was more effective, but at a slight increase in adverse events. Based on this, the ATS made a conditional recommendation in favor of the combination treatment. The panel identified 4 trials of precontemplative smokers and found that early treatment with varenicline was twice as effective in achieving abstinence than waiting for patients to become ready. This came at a cost of increased side effects. The panel identified 2 trials that compared varenicline with nicotine patches in 2194 patients with comorbid mental illness and found that varenicline was modestly more effective and had fewer adverse effects than nicotine replacement, but with uncertain effects on substance use or exacerbations of the underlying psychiatric conditions. Finally, the authors identified 12 studies that evaluated standard duration (6 weeks - 12 weeks) controller therapy with varenicline, bupropion, or nicotine with longer duration (more than 12 weeks) therapy and found that longer duration was modestly more effective than standard duration with a slight increase in adverse effects.