Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation

Who should receive pharmacotherapy for smoking cessation?All smokers trying to quit except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations: those with medical contraindications, those smoking less than 10 cigarettes/day, pregnant, and adolescent smokers.
What are the first-line pharma-cotherapies recommended in this guideline?All five of the FDA-approved pharmacotherapies for smoking cessation are recommended including bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch.
What factors should a clinician consider when choosing among the five first-line pharmacotherapies?Because of the lack of sufficient data to rank-order these five medications, choice of a specific first-line pharmacotherapy must be guided by factors such as clinician familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain).
Are pharmacotherapeutic treatments appropriate for lighter smokers (e.g., 10-15 cigarettes/day)?If pharmacotherapy is used with lighter smokers, clinicians should consider reducing the dose of first-line pharmacotherapies.
What second-line pharmacotherapies are recommended in this guideline?Clonidine and nortriptyline.
When should second-line agents be used for treating tobacco dependence?Consider prescribing second-line agents for patients unable to use first-line medications because of contraindications or for patients for whom first-line medications are not helpful. Monitor patients for the known side effects of second-line agents.
Which pharmacotherapies should be considered with patients particularly concerned about weight gain?Bupropion SR and nicotine replacement therapies (NRTs), in particular nicotine gum, have been shown to delay, but not prevent, weight gain.
Which pharmacotherapies should be considered with patients with a history of depression?Bupropion SR and nortriptyline appear to be effective with this population.
Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease?No. Nicotine replacement therapies are safe and have not been shown to cause adverse cardiovascular effects. However, the safety of these products has not been established for the immediate post-MI period or in patients with severe or unstable angina.
May tobacco dependence pharmacotherapies be used long-term (e.g., 6 months or more)?Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms during the course of pharmacotherapy or who desire long-term therapy. A minority of individuals who successfully quit smoking use ad libitum NRT medications (gum, nasal spray, inhaler) long-term. The use of these medications long-term does not present a known health risk. Additionally, the FDA has approved the use of bupropion SR for a long-term maintenance indication.
May nicotine replacement pharmacotherapies ever be combined?Yes. There is evidence that combining the nicotine patch with either nicotine gum or nicotine nasal spray increases long-term abstinence rates over those produced by a single form of NRT.
Current as of December 2012
Internet Citation: Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. December 2012. Agency for Healthcare Research and Quality, Rockville, MD.