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Varenicline does not increase psychiatric adverse effects and is more effective than nicotine patch for patients with psychiatric co-morbidities&#46; The combination of varenicline and nicotine patch is more effective than varenicline alone&#46; Extended duration pharmacotherapy &#40;&#62;12 weeks&#41; is more effective than standard duration &#40;6&#8211;12 weeks&#41;&#46; Varenicline can be initiated for a patient who is ready to intiate pharmacotherapy but is not yet ready to stop smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although strong recommendations were made favoring varenicline compared to other FDA &#40;US Food and Drug Administration&#41; approved tobacco dependence treatment medications&#44; if a patient does not wish to use varenicline&#44; it is reasonable for the provider to prescribe or recommend another FDA approved tobacco dependence treatment medication such as nicotine patch and&#47;or bupropion&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The ATS guideline was developed using GRADE &#40;Grading of Recommendations Assessment&#44; Development and Evaluation&#41; methodology&#46; The methodology was developed to reduce risk for bias and develop &#8220;guidelines you can trust&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Evidence is condensed to estimates of effect size derived from pooled data from the randomized clinical trials and assessment of quality of the evidence&#46; Evidence from outside of randomized clinical trials is excluded&#46; Strong recommendations can only be made when supported by high quality evidence from randomized clinical trials&#46; When high quality evidence exists and there are not other conflicting findings&#44; that approach can work well&#46; When there is important conflicting data from laboratory and observational research&#44; that approach can be problematic&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The limitation of GRADE methodology was evident in evaluating electronic cigarettes versus varenicline&#46; The evidence synthesis included data from two open label trials comparing electronic cigarettes to nicotine patch and eleven randomized controlled clinical trials comparing varenicline to nicotine patch&#46; As the evidence was of very low quality&#44; a conditional recommendation against e-cigarettes and in favor of varenicline was made&#46; Extensive evidence from observational and laboratory studies raising concern of lack of efficacy and significant harms from electronic cigarettes was excluded from the evidence synthesis&#46; Six committee members &#40;myself included&#41; dissented from the conditional recommendation asserting that&#44; based on evidence excluded from the evidence synthesis&#44; a strong recommendation against electronic cigarettes should have been made&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Acute harms from electronic cigarettes include injuries from product explosions&#44; nicotine poisoning&#44; and severe lung diseases&#46; Electronic cigarette use is associated with increased risk for cardiovascular disease&#44; chronic obstructive lung disease&#44; and cancer&#46; There is a decreased rate of smoking cessation and an increased rate of relapse to smoking among electronic cigarette users&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> An open label clinical trial of electronic cigarettes vs&#46; nicotine patch found that 80&#37; of the subjects who stopped smoking with the electronic cigarette were not able to stop electronic cigarette use&#46; Many of the smokers who used electronic cigarettes remained dual users of combustible tobacco and electronic cigarettes&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Dual use of electronic cigarettes and combustible tobacco may be more harmful than combustible tobacco alone&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The World Health Organization advises&#44; &#8220;Unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use&#44; WHO does not endorse e-cigarettes as cessation aids&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The Ibero-Latino-American respiratory scientific societies states&#44; &#8220;Health professionals should never recommend the use of this type of device &#40;electronic nicotine delivery systems&#41;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Electronic cigarettes have substantial harms and prolong tobacco and nicotine dependence&#46; Electronic cigarettes should not be recommended by health care providers&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Founding</p><p id="par0050" class="elsevierStylePara elsevierViewall">This work has not received any type of funding&#46;</p></span>"
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Editorial
The Most Important Learnings from the new Official American Thoracic Society (ATS) Clinical Practice Guidelines: Initiating Pharmacologic Treatment in Tobacco Dependent Adults
Los aprendizajes más importantes de la nueva guía de práctica clínica de la American Thoracic Society: Inicio del tratamiento farmacológico en adultos dependientes del tabaco
Harold J. Farber1
Pulmonary Section, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tobacco dependence is one of the most important non-infectious causes of premature death and disability&#46; Although commonly viewed as a bad habit&#44; it is now known to be a severe treatable chronic illness&#46; Nicotine withdrawal can lead to a variety of neuropsychiatric symptoms which can be severe&#44; including anger&#44; irritability&#44; depression&#44; difficulty feeling pleasure&#44; and difficulty concentrating in addition to the cravings of compulsion to use nicotine&#46; Pharmacotherapy of tobacco dependence focuses on treating these withdrawal symptoms so that the patient can feel normal when not using tobacco products&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The American Thoracic Society &#40;ATS&#41; Clinical Practice Guideline for Initiating Pharmacologic Treatment in Tobacco-Dependent Adults documents that varenicline is more effective than nicotine patch or bupropion for pharmacotherapy of tobacco dependence&#46; Varenicline does not increase psychiatric adverse effects and is more effective than nicotine patch for patients with psychiatric co-morbidities&#46; The combination of varenicline and nicotine patch is more effective than varenicline alone&#46; Extended duration pharmacotherapy &#40;&#62;12 weeks&#41; is more effective than standard duration &#40;6&#8211;12 weeks&#41;&#46; Varenicline can be initiated for a patient who is ready to intiate pharmacotherapy but is not yet ready to stop smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although strong recommendations were made favoring varenicline compared to other FDA &#40;US Food and Drug Administration&#41; approved tobacco dependence treatment medications&#44; if a patient does not wish to use varenicline&#44; it is reasonable for the provider to prescribe or recommend another FDA approved tobacco dependence treatment medication such as nicotine patch and&#47;or bupropion&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The ATS guideline was developed using GRADE &#40;Grading of Recommendations Assessment&#44; Development and Evaluation&#41; methodology&#46; The methodology was developed to reduce risk for bias and develop &#8220;guidelines you can trust&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Evidence is condensed to estimates of effect size derived from pooled data from the randomized clinical trials and assessment of quality of the evidence&#46; Evidence from outside of randomized clinical trials is excluded&#46; Strong recommendations can only be made when supported by high quality evidence from randomized clinical trials&#46; When high quality evidence exists and there are not other conflicting findings&#44; that approach can work well&#46; When there is important conflicting data from laboratory and observational research&#44; that approach can be problematic&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The limitation of GRADE methodology was evident in evaluating electronic cigarettes versus varenicline&#46; The evidence synthesis included data from two open label trials comparing electronic cigarettes to nicotine patch and eleven randomized controlled clinical trials comparing varenicline to nicotine patch&#46; As the evidence was of very low quality&#44; a conditional recommendation against e-cigarettes and in favor of varenicline was made&#46; Extensive evidence from observational and laboratory studies raising concern of lack of efficacy and significant harms from electronic cigarettes was excluded from the evidence synthesis&#46; Six committee members &#40;myself included&#41; dissented from the conditional recommendation asserting that&#44; based on evidence excluded from the evidence synthesis&#44; a strong recommendation against electronic cigarettes should have been made&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Acute harms from electronic cigarettes include injuries from product explosions&#44; nicotine poisoning&#44; and severe lung diseases&#46; Electronic cigarette use is associated with increased risk for cardiovascular disease&#44; chronic obstructive lung disease&#44; and cancer&#46; There is a decreased rate of smoking cessation and an increased rate of relapse to smoking among electronic cigarette users&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> An open label clinical trial of electronic cigarettes vs&#46; nicotine patch found that 80&#37; of the subjects who stopped smoking with the electronic cigarette were not able to stop electronic cigarette use&#46; Many of the smokers who used electronic cigarettes remained dual users of combustible tobacco and electronic cigarettes&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Dual use of electronic cigarettes and combustible tobacco may be more harmful than combustible tobacco alone&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The World Health Organization advises&#44; &#8220;Unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use&#44; WHO does not endorse e-cigarettes as cessation aids&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The Ibero-Latino-American respiratory scientific societies states&#44; &#8220;Health professionals should never recommend the use of this type of device &#40;electronic nicotine delivery systems&#41;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Electronic cigarettes have substantial harms and prolong tobacco and nicotine dependence&#46; Electronic cigarettes should not be recommended by health care providers&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Founding</p><p id="par0050" class="elsevierStylePara elsevierViewall">This work has not received any type of funding&#46;</p></span>"
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Article information
ISSN: 03002896
Original language: English
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