Abstract
Although concerns exist regarding a potential increased risk of cardiovascular events for smoking cessation pharmacotherapies, there is general consensus that any increased risk associated with their use would be outweighed by the benefits of smoking cessation; thus, clinical guidelines recommend that such pharmacotherapies be offered to everyone who wants to quit smoking. In the interest of minimizing risk to patients, prescribers need evidence indicating how these pharmacotherapies compare with one another in terms of cardiovascular safety. To compare the risk of major adverse cardiovascular events (MACE) among individuals initiating varenicline, nicotine replacement therapy (NRT) patches, or bupropion. This retrospective, population-based cohort study using linked pharmaceutical dispensing, hospital admissions, and death data was conducted in New South Wales, Australia. Participants included adults who were dispensed a prescription smoking cessation pharmacotherapy between 2008 and 2015 or between 2011 and 2015, depending on the availability of the pharmacotherapies being compared. Pairwise comparisons were conducted for risk of MACE among 122 932 varenicline vs 92 148 NRT initiators; 342 064 varenicline vs 10 457 bupropion initiators; and 102 817 NRT vs 6056 bupropion initiators. First course of the smoking cessation pharmacotherapy of interest. The primary outcome was MACE, defined as a composite of acute coronary syndrome, stroke, and cardiovascular death. Secondary outcomes were the individual components of MACE. Inverse probability of treatment weighting with high-dimensional propensity scores was used to account for potential confounding. Cox proportional hazards regression models with robust variance were used to estimate hazard ratios (HRs) and 95% CIs. Data were analyzed January 24, 2019, to September 1, 2021. The mean (SD) age of included individuals ranged from 41.9 (14.2) to 49.8 (14.9) years, and the proportion of women ranged from 42.8% (52 702 of 123 128) to 52.2% (53 693 of 102 913). The comparison of 122 932 varenicline initiators and 92 148 NRT patch initiators showed no difference in the risk of MACE (HR, 0.87; 95% CI, 0.72-1.07) nor in the risk of the secondary outcomes of acute coronary syndrome (HR, 0.96; 95% CI, 0.76-1.21) and stroke (HR, 0.72; 95% CI, 0.45-1.14). However, decreased risk of cardiovascular death was found among varenicline initiators (HR, 0.49; 95% CI, 0.30-0.79). The results of comparisons involving bupropion were inconclusive owing to wide confidence intervals (eg, risk of MACE: 342 064 varenicline vs 10 457 bupropion initiators, HR, 0.87 [95% CI, 0.53-1.41]; 102 817 NRT patch vs 6056 bupropion initiators, HR, 0.79 [95% CI, 0.39-1.62]). The finding of this cohort study that varenicline and NRT patch use have similar risk of MACE suggests that varenicline, the most efficacious smoking cessation pharmacotherapy, may be prescribed instead of NRT patches without increasing risk of major cardiovascular events. Further large-scale studies of the cardiovascular safety of varenicline and NRT relative to bupropion are needed.
Highlights
Smoking remains a leading preventable cause of morbidity and premature mortality, accounting for 6.4 million deaths worldwide in 2015.1 Quitting smoking substantially reduces the risk of developing cardiovascular disease, chronic obstructive pulmonary disease, and cancer, and it can extend life expectancy by up to 10 years.[2]Clinical practice guidelines from most countries recommend that adults who want to quit smoking be offered smoking cessation pharmacotherapies.[3]
The comparison of 122 932 varenicline initiators and 92 148 nicotine replacement therapy (NRT) patch initiators showed no difference in the risk of major adverse cardiovascular events (MACE) (HR, 0.87; 95% CI, 0.72-1.07) nor in the risk of the secondary outcomes of acute coronary syndrome (HR, 0.96; 95% CI, 0.76-1.21) and stroke (HR, 0.72; 95% CI, 0.45-1.14)
The results of comparisons involving bupropion were inconclusive owing to wide confidence intervals
Summary
Clinical practice guidelines from most countries recommend that adults who want to quit smoking be offered smoking cessation pharmacotherapies.[3] The efficacy of these medicines, which include bupropion, varenicline, and nicotine replacement therapy (NRT), is well established, with varenicline having the highest efficacy.[4] For all 3 smoking cessation pharmacotherapies, concerns exist regarding possible adverse cardiovascular effects. These concerns were prompted by the nonstatistically significant increased risks of major adverse cardiovascular events (MACE) observed in some clinical trials and meta-analyses.[5,6,7,8,9,10] Other meta-analyses have not found an increased risk.[4,11,12,13] Because the pooled incidence is low even in those studies giving rise to concerns (Յ1% in all treatment groups),[6,9] there is a general consensus that any increased risk associated with the use of these pharmacotherapies would be small and outweighed by the benefits of smoking cessation.[14,15] in the interest of minimizing risk to patients, prescribers need evidence on how these medicines compare with each other in terms of cardiovascular safety
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