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Primary Care
CMECNE

American Thoracic Society: Initiating Pharmacologic Treatment in Tobacco-Dependent Adults

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the major change in the American Thoracic Society’s recommendation for first line medication for smoking cessation
2. Describe when to initiate varenicline in a patient who is not ready to stop smoking

Estimated time to complete activity: 0.25 hours

Faculty:

Ashley Comfort, MD, FACOG is the Director of Medical Content, ObG Project.

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.


The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Ashley Comfort, MD, has a financial interest in Pfizer and has no other conflicts of interest to disclose.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 3/31/2021 through 3/31/2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.25 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

All patients who use tobacco should be provided with treatment to help them quit. The American Thoracic Society (ATS) has released guidance on pharmacotherapy for tobacco cessation and state that simply advising patients to quit is insufficient. ATS is the first organization to recommend varenicline (Chantix) as first-line therapy for cessation. The guidelines also address combination pharmacotherapy, starting medication for patients who are not yet ready to quit, and treating tobacco users with comorbid psychiatric disease.

ATS Smoking Cessation Recommendations

Varenicline over other pharmacotherapy (bupropion) or nicotine replacement therapy (nicotine patch)

  • Varenicline superior for achieving long-term abstinence
    • Generally assessed by patient self-report +/- exhaled carbon monoxide testing
  • Varenicline associated with fewer serious adverse events (SAEs) vs nicotine patch
    • No difference in SAEs compared to bupropion

Varenicline plus a nicotine patch over varenicline alone (conditional recommendation)

  • Combination therapy significantly increases abstinence
  • Conditional recommendation based on
    • Anticipated issues with patient adherence | Cost | Possible increased incidence of SAEs

Start varenicline even for patients who are not yet ready to quit tobacco

  • Significant effect on abstinence even in active smokers
  • “Pharmacotherapy is no longer contingent on readiness to quit but is instead a therapeutic intervention aimed at improving readiness to stop smoking”

Start varenicline even for patients with comorbid psychiatric disease (substance use disorder, depression/anxiety, schizophrenia, bipolar disorder)

  • Stigma around varenicline use in this population due to former boxed warning regarding possible neuropsychiatric events (based on case reports, not supported by RCTs)

Extended duration (>12 weeks) therapy over standard duration (6-12 weeks) for any cessation aid (varenicline, bupropion or nicotine patch)

  • Extended therapy results in increased abstinence with less relapse

Dosing Varenicline 

Initial: Days 1 to 3: 0.5 mg once daily | Days 4 to 7: 0.5 mg twice daily 

Maintenance (day 8 and later): 1 mg twice daily continued for at least 11 weeks 

Note: Dosing should be adjusted for renal function, see references below 

References:

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

Varenicline Drug Information 

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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