Why treat tobacco dependence in the inpatient setting?
Initiating tobacco dependence pharmacotherapy during the inpatient stay is widely accepted, and significantly increases the likelihood that patients will go on to stop smoking.(1)
A 2016 Quality Improvement study performed at Penn-Presbyterian Hospital suggested as many as 30% of inpatients who receive treatment will go on to make a quit attempt in the month following discharge. This was significantly improved from the baseline 2% who did so without inpatient intervention.
Clinicians find computerized support of tobacco dependence treatment feasible and acceptable, adopting the recommendations at high rates.(2)
Why varenicline?
Varenicline (Chantix®) is an agonist-antagonist of the nicotinic cholinergic receptor, and is effective at reducing the impulse to smoke. Clinical practice guidelines identified varenicline as the optimal controller choice for most situations.(3)
Although varenicline has a delayed onset of peak activity, hospitalized patients started on varenicline at admission experienced a significant increase in likelihood of abstinence at one year.(4)
It's true that some insurance plans don't cover varenicline. However, an order during the inpatient stay provides an opportunity for pharmacy to identify and overcome systematic barriers well in advance of discharge.
Doesn't varenicline cause serious psychiatric side effects?
A large body of observational and experimental evidence supports a favorable safety profile for tobacco dependence medications, including varenicline. Initiating pharmacotherapy is guideline recommended in patients with a history of serious mental illness.(3)The largest prospective study of neuropsychiatric side effects was the EAGLES trial.(5)
What if the patient isn't interested in quitting?
By treating the underlying dependence, without a prerequisite current interest in quitting, clinicians can expect to help as many as 308 additional patients quit smoking per 1000 treated.(3)
For management advice, or practical tips on ways to approach resistance to quitting, consider consulting the Tobacco Treatment Service for assistance with varenicline management. Order through Epic, or contact us at 1-888-PENN-STOP.
Why order a Tobacco Treatment Service consult for varenicline management?
The service is designed to support clinician management efforts. Requesting a consult is appropriate for any patient, including those for whom varenicline is not the best choice. Consult for help with:
- Behavioral counseling
- Patient education and follow-up
- Dosing and medication choices
- Managing patient reluctance
Contraindications to using varenicline?
There are no significant drug-drug interactions; varenicline may be used in patients currently being treated with antidepressants, opioid analgesics, sedative-hypnotics, and other tobacco dependence medications. When in doubt, consider ordering a Tobacco Treatment Service consult for guidance.
Varenicline requires dose adjustment in patients with GFR <30ml/min. For specific dosing recommendations, contact the pharmacy department or Tobacco Treatment Service.
View varenicline product information sheet
- Nahhas GJ, Wilson D, Talbot V, Cartmell KB, Warren GW, Toll BA, et al. Feasibility of Implementing a Hospital-Based "Opt-Out" Tobacco-Cessation Service. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2017 Aug 1;19(8):937-43.
- Seth B, Herbst N, Oleinik K, Clark K, Helm ED, O'Donnell C, et al. Feasibility, Acceptability, and Adoption of an Inpatient Tobacco Treatment Service at a Safety-Net Hospital: A Mixed-Methods Study. Ann Am Thorac Soc. 2020 Jan;17(1):63-71.
- Leone FT, Zhang Y, Evers-Casey S, Evins AE, Eakin MN, Fathi J, et al. Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 Jul 15;202(2):e5-31.
- Windle SB, Dehghani P, Roy N, Old W, Grondin FR, Bata I, et al. Smoking abstinence 1 year after acute coronary syndrome: follow-up from a randomized controlled trial of varenicline in patients admitted to hospital. CMAJ Can Med Assoc J J Assoc Medicale Can. 2018 26;190(12):E347-54.
- Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet Lond Engl. 2016 Apr 22;