Practice Guidelines

Medications for Smoking Cessation: Guidelines from the American Thoracic Society


Am Fam Physician. 2021 Mar 15;103(6):380-381.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Varenicline is more effective than nicotine patches and bupropion with similar or fewer adverse events, even with comorbid psychiatric or substance abuse conditions.

• Combining varenicline with nicotine patches appears to be more effective than using varenicline alone based on limited evidence.

• For people who smoke and are not ready to quit, prescribing varenicline increases six-month abstinence with an NNT of 6 compared with waiting for readiness.

• Extending treatment beyond 12 weeks increases abstinence, with an NNT of 19 compared with shorter treatment durations.

From the AFP Editors

Despite concerted efforts at reducing tobacco use, cigarette smoking remains the leading cause of preventable disease, disability, and death in the United States. Since 1994, the U.S. Preventive Services Task Force has recommended treatment for tobacco dependence, yet clinicians infrequently prescribe tobacco cessation therapy. Without treatment, only 3% of smokers achieve abstinence in any given year. The American Thoracic Society (ATS) published guidelines for medication initiation in tobacco-dependent adults based on a systematic review.

Medication Recommendations

The ATS recommends varenicline (Chantix) as the most effective medication for smoking cessation. Compared with nicotine patches, varenicline is more effective and better tolerated. For every 25 people treated, one additional person will remain abstinent at six months using varenicline instead of a nicotine patch (number needed to treat [NNT] = 25; 95% CI, 15 to 56). Slightly more significant adverse events occur with nicotine patches than with varenicline use. The evidence for varenicline compared with bupropion (Zyban) is similar. Abstinence at six months is more likely with varenicline than bupropion with an NNT of 13 (95% CI, 10 to 25), with similar rates of adverse events.

Combining varenicline with nicotine patches appears to be more effective compared with varenicline alone, with an NNT

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at



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