A Review of Evidence and an Algorithm for Use of Psychopharmacology in the Treatment of Tobacco Use Disorder in Behavioral Health Settings.

Background: Tobacco use poses a large public health problem, particularly among those with mental illness, but behavioral health providers often do not prioritize management of this disorder.

Methods: This is a new algorithm from the Psychopharmacology Algorithm Project at the Harvard South Shore Program for the treatment of tobacco use disorder, taking into account pertinent findings in articles, meta-analyses, reviews, and other published algorithms.

Results: Once patients are prepared to try medications, we first consider exceptions to the main algorithm when there is comorbid major depressive disorder, bipolar disorder, other serious mental illnesses, posttraumatic stress disorders, alcohol use disorder, cardiovascular morbidity, seizure disorders, or weight gain that could affect the choice of pharmacological agents. In patients with depression, bupropion could be considered as initial treatment, while bupropion should usually be avoided in patients with bipolar disorder and is relatively contraindicated in those with a seizure disorder. In the main algorithm, for patients who smoke cigarettes, varenicline has been convincingly established as the most effective treatment, with combined nicotine replacement therapy as a potential second-choice consideration. In the event of unsatisfactory response to varenicline after an adequate trial (described in detail), augmentation with bupropion may be considered; the role of combination therapy (eg, varenicline + NRT) is less well established and is discussed in the context of limited evidence. For users of smokeless tobacco, the evidence is also in favor of using varenicline first-line. Management of the side effects of these medications is discussed.

Conclusions: The algorithm concludes with a discussion of other options with less support but with potential future promise.