|Outpatient With Stable CVD||Inpatient With ACS|
|1st line||Varenicline OR combination NRT∗||In-hospital to relieve nicotine withdrawal: Nicotine patch OR combination NRT∗|
At discharge: Combination NRT or varenicline†
|2nd line||Bupropion OR single NRT product||At discharge: Single NRT product|
|If single agent is insufficient to achieve abstinence||Combine categories of FDA-approved drugs:|
Varenicline + NRT (single agent)
Varenicline + bupropion
Bupropion + NRT (single agent)
ACS = acute coronary syndromes; CVD = cardiovascular disease; FDA = U.S. Food and Drug Administration; MI = myocardial infarction; NRT = nicotine replacement therapy.
↵∗ Combination NRT comprises a nicotine patch plus the patient’s choice of nicotine gum or lozenge or inhaler or spray.
↵† Some committee members planning to use varenicline would start it in-hospital; others would not start until discharge. Regardless, continue nicotine patch or short-acting form for 1 week to manage nicotine withdrawal symptoms during up-titration of varenicline dose.
↵‡ Nortriptyline is not FDA-approved for smoking cessation indication and there are few data on use in patients with CVD.
↵§ Bupropion is listed as 3rd line because of no evidence of efficacy when started during hospitalization for acute ACS or acute MI. However, there are no special safety concerns for bupropion in this setting.