| 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. |
Internet Citation:
Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/prescrib.htm
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