The only Vare against nicotine addiction

The patient’s struggle with self and nicotine addiction continues to challenge both sufferers and treatment providers. What options are effective for staying “clean” in the long run? American scientists have addressed this question and developed a guideline.

Traditionally, tobacco use has been viewed primarily as a toxic precursor to chronic disease. Physicians have therefore often focused on therapeutic methods designed to increase patient motivation to discontinue. This approach seems outdated these days in that tobacco use is now considered a cardinal manifestation of a disruption in the brain’s molecular learning mechanisms, write Frank T. Leone, M.D., of the Comprehensive Smoking Treatment Program at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues. From this perspective, the responsibility of the treatment team goes beyond facilitating cessation to include maximizing long-term control over the urge to smoke.

The authors focused on initial pharmacotherapy for tobacco dependence that causes clinically significant impairment or suffering in adult patients (excluding pregnant women and adolescents). The goal was to improve patient-centered care for tobacco dependence by identifying an evidence-based pathway that aligns key outcomes, including short- and long-term tobacco abstinence and serious adverse events, while accounting for important clinical variation. However, some aspects such as communication and counseling methods, health system design, disease control guidelines, and second-line therapy had to be omitted by the researchers in their assessment because, according to them, each of these topics is “robust enough to warrant its own guideline” [1]. The guideline was created under the assumption that accepted principles of tobacco dependence treatment are already in practice (box).

Varenicline beats plaster

The guideline panel made a total of seven recommendations, which represent simple changes in practice but are likely to increase the effectiveness of pharmacotherapy for tobacco dependence. In doing so, the researchers formulated five strong recommendations and two conditional recommendations regarding the choice of pharmacotherapy.

For tobacco dependent adults where treatment is initiated, it is recommended:

Varenicline versus a nicotine patch (strong recommendation, moderate certainty in estimated effects).
Varenicline versus bupropion (strong recommendation, moderate certainty in estimated effects).
Varenicline plus a nicotine patch versus varenicline alone (conditional recommendation, low certainty in estimated effects).

For tobacco dependent adults where treatment is initiated, it is recommended:

Varenicline versus electronic cigarettes (conditional recommendation, very low certainty in estimated effects). The authors note that new evidence has now emerged regarding serious adverse effects of electronic cigarettes. If these continue to be reported, the strength of the recommendation should be reevaluated.

For tobacco-dependent adults who are not ready to quit tobacco use, it is recommended:

Start treatment with varenicline rather than waiting until patients are ready to quit tobacco use (strong recommendation, moderate certainty in estimated effects)

For tobacco-dependent adults with comorbid psychiatric conditions, including substance use disorder, depression, anxiety, schizophrenia, and/or bipolar disorder, for whom treatment is initiated is recommended:

Varenicline over a nicotine patch (strong recommendation, moderate certainty in estimated effects).

For tobacco-dependent adults, starting treatment with a controller is recommended:

Use of long-term therapy (>12 weeks) versus standard therapy (6-12 weeks) (strong recommendation, moderate certainty in estimated effects).

The main limitation of the guideline was the limited number of recommendations included, as the authors themselves acknowledge. Because the goal was to find a functional, evidence-based pathway for pharmacotherapy, they would have begun the process by identifying an optimal control drug on which to build additional clinical recommendations. Therefore, their study could not consider all possible pharmacotherapeutic options. Future guidelines should consider optimal control strategies for patients in whom varenicline has previously failed or who have previously refused this treatment, write Dr. Leone et al.

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