Transdermal nicotine patches with low-intensity support to aid smoking cessation in outpatients in a general hospital. A placebo-controlled trial

Reply to Commentary on "Adult Smokers' Complete Switching Away from Cigarettes at 6, 9, and 12 Months After Initially Purchasing a JUUL e-Cigarette" and the Adult JUUL Switching and Smoking Trajectories (ADJUSST) Study

BACKGROUND

This is authors' reply to the Commentary on our publication entitled "Adult smokers' Complete Switching Away from Cigarettes at 6, 9, and 12 Months after Initially Purchasing a JUUL e-Cigarette."

METHODS AND RESULTS

Analyses addressed questions about follow-up rates and missed responses in the Adult JUUL Switching and Smoking Trajectories (ADJUSST) Study. Results demonstrate limited potential for selection bias, as participants who missed surveys were similar to those with complete data, and re-contact of participants who missed a follow-up indicated almost half were not smoking. Imputing smoking behavior for missing data would likely introduce bias and is not appropriate. The study demonstrated that JUUL products can facilitate high rates of complete switching away from cigarettes as suggested in previous experimental and observational studies. The ADJUSST cohort, including baseline nonsmokers, demonstrates a net reduction in smoking prevalence. Moreover, population modeling considering both benefits and harms demonstrated a net population benefit.

CONCLUSION

While the ADJUSST Study is not without limitations, the findings are consistent with multiple streams of real-world evidence that indicate that ENDS can facilitate switching among adults who smoke, and provide population benefits.

Switching away from smoking at 12 months among adult JUUL users varying in recent history of quit attempts made with and without smoking cessation medication

Some smokers switch away from smoking using e-cigarettes, but guidelines recommend trying approved medications first. We analyzed switching in adult smokers using JUUL by their recent history of quit attempts and use of smoking cessation medications. Participants were 8511 adult (21+) established smokers (at baseline), in which 50.3% are daily smokers, in a longitudinal observational study who completed a survey 12 months after first purchasing a JUUL Starter Kit. At baseline, participants reported attempts to quit smoking in the prior year and use of pharmacotherapy (nicotine replacement therapy [NRT] or prescription medication) in their most recent attempt. The outcomes were switching (self-reported no past-30-day smoking) and 50%+ reductions in cigarette consumption. Multivariable analyses were adjusted for baseline covariates. Two thirds of the participants had made a quit attempt in the year before purchasing JUUL. Overall, 59% [58%, 60%] had switched at 12 months. Switching was more likely in those who had used NRT and who attempted quitting without medication versus those who used prescription medications or made no quit attempt. In adjusted multivariable analyses, only making a past-year quit attempt (vs. not) was associated with higher odds of switching (OR = 1.15 [1.04, 1.28]). Over 60% of dual users reduced cigarette consumption by ≥50%. These associations were largely similar in daily smokers. Twelve months after purchasing JUUL, almost all smokers reported either switching or reducing their smoking by 50%+, including those who had recently failed to quit smoking with approved pharmacotherapies. E-cigarettes provide an alternative route to abstinence from smoking for smokers with a history of cessation and cessation treatment failure.

Study title: A systematic review of RCTs to examine the risk of adverse cardiovascular events with nicotine use

Associations between cigarette smoking and increased risk of cardiovascular disease are well established. However, it is unclear whether the association is mediated by exposure to nicotine and/or to other constituents in cigarette smoke. The objective of this systematic review and meta-analysis of randomized control trials (RCTs) was to identify any potential associations between exposure to nicotine and the risk of clinically diagnosed adverse cardiovascular events in adult current users and nonusers of tobacco products. Among 1,996 results, 42 studies, comparing nicotine and non-nicotine groups, were included and were both qualitatively and quantitatively synthesized across the outcomes of arrhythmia, nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death. The majority of studies evaluating nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death reported no events that occurred in either the nicotine or non-nicotine control groups. Among the studies that reported events, rates of adverse events were similarly low between both groups. Consistent with findings from previous systematic reviews and meta-analyses, pooled data showed that rates for arrhythmia, nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death were not significantly different between nicotine and non-nicotine groups. The overall quality of the body of evidence for each of the four outcomes of interest was graded as "moderate," limited only by the imprecision of results. The findings of this systematic review and meta-analysis indicate that, with moderate certainty, there are no significant associations between the use of nicotine and the risk of clinically diagnosed adverse cardiovascular events-specifically, arrhythmia, nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death.

Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes.

OBJECTIVES

To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes.

DESIGN

Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results.

SETTING

Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes.

PARTICIPANTS

Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes.

INTERVENTIONS

Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies.

MAIN OUTCOME MEASURES

Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events.

DATA SOURCES

Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019.

REVIEW METHODS

Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model.

RESULTS

Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard.

LIMITATIONS

Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified.

CONCLUSIONS

Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK.

FUTURE WORK

Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041302.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 59. See the NIHR Journals Library website for further project information.

A guidance was developed to identify participants with missing outcome data in randomized controlled trials

BACKGROUND AND OBJECTIVES

In order for authors of systematic reviews to address missing data in randomized controlled trials (RCTs), they need to first identify the number of trial participants with missing data. The objective of this study was to provide guidance for authors of systematic reviews on how to identify participants with missing outcome data in reports of RCTs.

METHODS

Guidance statements were informed by a review of studies addressing the topic of missing data and an iterative process of feedback and refinement, through meetings involving experts in health research methodology and authors of systematic reviews.

RESULTS

The proposed guidance includes (1) definitions of key terms, (2) 19 categories of participants described in RCT reports and who might have missing data, and (3) a flowchart on how to judge the outcome data missingness for each category. The judgment of missingness relies on how trial authors report on the categories and handle them in their analyses. Practically, for their primary analysis, systematic review authors should choose how to identify participants with missing outcome data (i.e., use either "definitely missing data" or "total possible missing data"), then select a method for handling missing data in meta-analysis. Sensitivity analyses should be undertaken to explore consistency with competing options for classifying patients as having missing data.

CONCLUSION

Adopting the proposed guidance will help promote transparency and consistency regarding how missing data are managed in systematic reviews.

Nicotine replacement therapy versus control for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.

OBJECTIVES

To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long-term smoking cessation, compared to placebo or 'no NRT' interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017.

SELECTION CRITERIA

Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow-up of less than six months, except for those in pregnancy (where less than six months, these were excluded from the main analysis). We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews.

DATA COLLECTION AND ANALYSIS

Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. A subset of six trials conducted in pregnant women found a statistically significant benefit of NRT on abstinence close to the time of delivery (RR 1.32, 95% CI 1.04 to 1.69; 2129 participants); in the four trials that followed up participants post-partum the result was no longer statistically significant (RR 1.29, 95% CI 0.90 to 1.86; 1675 participants). Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare.

AUTHORS' CONCLUSIONS

There is high-quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non-ischaemic chest pain and palpitations.

Combination Varenicline/Bupropion Treatment Benefits Highly Dependent Smokers in an Adaptive Smoking Cessation Paradigm

Introduction

This study replicated and extended results of a previous trial, which found that combination varenicline/bupropion treatment increased smoking abstinence in smokers who were male, highly dependent, and who did not respond to prequit nicotine patch treatment with a >50% reduction in expired-air carbon monoxide in the first week.

Methods

One hundred and twenty-two male nicotine patch nonresponders and 52 responders were identified. Smokers in each group were randomized to receive 12 weeks of varenicline plus bupropion treatment versus varenicline plus placebo. The primary outcome was continuous smoking abstinence at weeks 8–11 after the target quit date.

Results

For smokers with a high level of dependence, judged by having a baseline Fagerstrom Test for Nicotine Dependence (FTND) score ≥ 6 and cigarette consumption ≥ 20/d, combination varenicline/bupropion treatment increased the abstinence rate relative to varenicline alone: 71.0% versus 43.8% (odds ratio = 3.14; 95% confidence interval = 1.11–8.92, p [one tailed] = .016). In contrast, less dependent smokers did not show a benefit of combination treatment relative to varenicline (abstinence rates of 32.1% vs. 45.6%, respectively); there was a significant interaction of treatment and dependence level. Patch nonresponders tended to benefit the most from combination treatment, which was well tolerated overall.

Conclusions

Combination varenicline/bupropion treatment proved significantly more efficacious than varenicline alone among highly dependent male smokers. These results, together with prior studies, support an adaptive treatment paradigm that assigns smoking cessation treatment according to baseline smoker characteristics and initial response to nicotine patch treatment.

Implications

This study replicated, in a prospective manner, an important and surprising retrospective finding from a previous clinical trial, which showed that a specific subpopulation of smokers benefited substantially from receiving a combination treatment of varenicline plus bupropion, relative to varenicline plus placebo. Specifically, male smokers having high baseline nicotine dependence (FTND score ≥ 6 and cigarette consumption ≥ 20/d), showed a marked increase in smoking abstinence rate on combination pharmacotherapy. The present study likewise found an enhancement in end-of-treatment abstinence rate in this subgroup, from 43.8% to 71.0%. The adaptive treatment paradigm, which classifies smokers based on initial dependence level and response to prequit nicotine patch treatment, may be used to identify target populations of smokers whose success can be enhanced by intervening with combination pharmacotherapy before the quit-smoking date.

Trial Registration

ClinicalTrials.gov identifier: NCT01806779.

Varenicline for Smoking Cessation in Light Smokers

INTRODUCTION

As the prevalence of cigarette smoking has declined, the proportion of smokers who smoke less than 10 cigarettes/day (cpd) has increased. Varenicline may provide an effective pharmacotherapeutic treatment option for increasing smoking abstinence rates among light smokers.

METHODS

We conducted a randomized, placebo-controlled clinical trial evaluating the efficacy of varenicline for increasing smoking abstinence rates among light smokers (5-10 cpd). Participants received varenicline or placebo for 12 weeks. Outcomes were assessed at 3 and 6 months.

RESULTS

Ninety-three participants were randomized. Fifty-two percent of participants terminated the study early. At end-of-treatment (3 months), the point prevalence smoking abstinence rate was 53.3% in the varenicline group compared to 14.5% in placebo (odds ratio [OR]: 6.69, 95% confidence interval [CI]: 2.48-18.06, P < .001), and the prolonged smoking abstinence rate was 40.0% and 8.3%, respectively (OR: 7.33, 95% CI: 2.24-23.98, P = .001). At end-of-study (6 months), the point prevalence smoking abstinence rate was 40.0% in the varenicline group compared to 20.8% in placebo (OR: 2.53, 95% CI: 1.01-6.34, P = .047), and the prolonged smoking abstinence rate was 31.1% and 8.3%, respectively (OR: 4.97, 95% CI: 1.49-16.53, P = .009). The estimated magnitude of the treatment effect remained consistent across the various missing data assumptions and in analyses that adjusted for gender. Nausea and sleep disturbance were more commonly reported in the varenicline group.

CONCLUSIONS

Varenicline was safe and effective for increasing long-term smoking abstinence rates in a population of predominantly White light cigarette smoker. The efficacy of varenicline in this study was comparable to that observed in heavier smokers.

IMPLICATIONS

Our findings demonstrate that varenicline is effective for increasing smoking cessation in light smokers. Our findings have implications for advancing the treatment of light smokers in clinical practice.

The development and testing of new nicotine replacement treatments: from 'nicotine replacement' to 'smoking replacement'

Griffith Edwards, unusually in the 1970s, saw tobacco use as falling within the remit of addiction research, and brought Michael Russell to the Addiction Research Unit [ARU] to initiate research into smoking. The work of the tobacco section of ARU paved the way to a better understanding of tobacco dependence and to developing nicotine replacement treatments. Michael Russell pioneered the idea of attractive nicotine replacement products with an acceptable safety profile replacing cigarettes on the open market and ending the tobacco epidemic, envisaging a transition from medicinal and temporary 'nicotine replacement' to recreational and potentially permanent 'smoking replacement'. Mike's prediction that the pharmaceutical industry would develop such devices did not materialize. Instead, two such products were generated by the tobacco industry (snus) and independent developers (electronic cigarettes). Another of Mike's hopes was that regulators would adopt rational policies, and that tobacco control activists would become supportive of smoking replacement once they thought through the implications. Until now, the 'smoking replacement' idea has been met with vigorous opposition from some tobacco control activists. The voices of researchers with historical links to ARU are prominent in arguing in favour of harm reduction and e-cigarettes. The most important debate ever to occur in tobacco control is under way and it carries the signature of Griffith Edwards' ARU.

A general method for handling missing binary outcome data in randomized controlled trials

AIMS

The analysis of randomized controlled trials with incomplete binary outcome data is challenging. We develop a general method for exploring the impact of missing data in such trials, with a focus on abstinence outcomes.

DESIGN

We propose a sensitivity analysis where standard analyses, which could include 'missing = smoking' and 'last observation carried forward', are embedded in a wider class of models.

SETTING

We apply our general method to data from two smoking cessation trials.

PARTICIPANTS

A total of 489 and 1758 participants from two smoking cessation trials.

MEASUREMENTS

The abstinence outcomes were obtained using telephone interviews.

FINDINGS

The estimated intervention effects from both trials depend on the sensitivity parameters used. The findings differ considerably in magnitude and statistical significance under quite extreme assumptions about the missing data, but are reasonably consistent under more moderate assumptions.

CONCLUSIONS

A new method for undertaking sensitivity analyses when handling missing data in trials with binary outcomes allows a wide range of assumptions about the missing data to be assessed. In two smoking cessation trials the results were insensitive to all but extreme assumptions.

Combination treatment with varenicline and bupropion in an adaptive smoking cessation paradigm

OBJECTIVE

The authors assessed the efficacy and safety of combination treatment with varenicline and sustained-release bupropion for smokers who, based on an assessment of initial smoking reduction prior to the quit date, were deemed unlikely to achieve abstinence using nicotine patch treatment.

METHOD

In a randomized, double-blind, parallel-group adaptive treatment trial, the authors identified 222 cigarette smokers who failed to show a reduction of more than 50% in smoking after 1 week of nicotine patch treatment. Smokers were randomly assigned to receive 12 weeks of varenicline plus bupropion or varenicline plus placebo. The primary outcome measure was continuous smoking abstinence at weeks 8-11 after the target quit date.

RESULTS

Both treatments were well tolerated. Participants who received the combination treatment had a significantly higher abstinence rate than those who received varenicline plus placebo (39.8% compared with 25.9%; odds ratio=1.89; 95% CI=1.07, 3.35). Combination treatment had a significantly greater effect on abstinence rate in male smokers (odds ratio=4.26; 95% CI=1.73, 10.49) than in female smokers (odds ratio=0.94; 95% CI=0.43, 2.05). It also had a significantly greater effect in highly nicotine-dependent smokers (odds ratio=3.51, 95% CI=1.64, 7.51) than in smokers with lower levels of dependence (odds ratio=0.71, 95% CI=0.28, 1.80).

CONCLUSIONS

Among smokers who did not show a sufficient initial response to prequit nicotine patch treatment, combination treatment with varenicline and bupropion proved more efficacious than varenicline alone for male smokers and for smokers with a high degree of nicotine dependence.

Combination varenicline and bupropion SR for tobacco-dependence treatment in cigarette smokers: a randomized trial

IMPORTANCE

Combining pharmacotherapies for tobacco-dependence treatment may increase smoking abstinence.

OBJECTIVE

To determine efficacy and safety of varenicline and bupropion sustained-release (SR; combination therapy) compared with varenicline (monotherapy) in cigarette smokers.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, blinded, placebo-controlled multicenter clinical trial with a 12-week treatment period and follow-up through week 52 conducted between October 2009 and April 2013 at 3 midwestern clinical research sites. Five hundred six adult (≥18 years) cigarette smokers were randomly assigned and 315 (62%) completed the study.

INTERVENTIONS

Twelve weeks of varenicline and bupropion SR or varenicline and placebo.

MAIN OUTCOMES AND MEASURES

Primary outcome was abstinence rates at week 12, defined as prolonged (no smoking from 2 weeks after the target quit date) abstinence and 7-day point-prevalence (no smoking past 7 days) abstinence. Secondary outcomes were prolonged and point-prevalence smoking abstinence rates at weeks 26 and 52. Outcomes were biochemically confirmed.

RESULTS

At 12 weeks, 53.0% of the combination therapy group achieved prolonged smoking abstinence and 56.2% achieved 7-day point-prevalence smoking abstinence compared with 43.2% and 48.6% in varenicline monotherapy (odds ratio [OR], 1.49; 95% CI, 1.05-2.12; P = .03 and OR, 1.36; 95% CI, 0.95-1.93; P = .09, respectively). At 26 weeks, 36.6% of the combination therapy group achieved prolonged and 38.2% achieved 7-day point-prevalence smoking abstinence compared with 27.6% and 31.9% in varenicline monotherapy (OR, 1.52; 95% CI, 1.04-2.22; P = .03 and OR, 1.32; 95% CI, 0.91-1.91; P = .14, respectively). At 52 weeks, 30.9% of the combination therapy group achieved prolonged and 36.6% achieved 7-day point-prevalence smoking abstinence compared with 24.5% and 29.2% in varenicline monotherapy (OR, 1.39; 95% CI, 0.93-2.07; P = .11 and OR, 1.40; 95% CI, 0.96-2.05; P = .08, respectively). Participants receiving combination therapy reported more anxiety (7.2% vs 3.1%; P = .04) and depressive symptoms (3.6% vs 0.8%; P = .03).

CONCLUSIONS AND RELEVANCE

Among cigarette smokers, combined use of varenicline and bupropion, compared with varenicline alone, increased prolonged abstinence but not 7-day point prevalence at 12 and 26 weeks. Neither outcome was significantly different at 52 weeks. Further research is required to determine the role of combination therapy in smoking cessation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: http://clinicaltrials.gov/show/NCT00935818.

Randomized trial of nicotine replacement therapy (NRT), bupropion and NRT plus bupropion for smoking cessation: effectiveness in clinical practice

BACKGROUND AND AIMS

Bupropion was introduced for smoking cessation following a pivotal trial showing that it gave improved efficacy over the nicotine patch and also suggesting combination treatment was beneficial. We tested in clinical practice for an effectiveness difference between bupropion and nicotine replacement therapy (NRT), whether the combination improves effectiveness and whether either treatment might be more beneficial for certain subgroups of smokers.

DESIGN

Open-label randomized controlled trial with 6-month follow-up.

SETTING

Four UK National Health Service (NHS) smoking cessation clinics.

PARTICIPANTS

Smokers (n = 1071) received seven weekly behavioural support sessions and were randomized to an NRT product of their choice (n = 418), bupropion (n = 409) or NRT plus bupropion (n = 244).

MEASURES

The primary outcome was self-reported cessation over 6 months, with biochemical verification at 1 and 6 months. Also measured were baseline demographics, health history, smoking characteristics and unwanted events during treatment.

FINDINGS

Abstinence rates for bupropion (27.9%) and NRT (24.2%) were not significantly different (odds ratio = 1.21, 95% confidence interval = 0.883-1.67), and the combination rate (24.2%) was similar to that for either treatment alone. There was some evidence that the relative effectiveness of bupropion and NRT differed according to depression (χ(2) = 2.86, P = 0.091), with bupropion appearing more beneficial than NRT in those with a history of depression (29.8 versus 18.5%). Several unwanted symptoms were more common with bupropion.

CONCLUSION

There is no difference in smoking cessation effectiveness among bupropion, nicotine replacement therapy and their combination when used with behavioural support in clinical practice. There is some evidence that bupropion is more beneficial than nicotine replacement therapy for smokers with a history of depression.

A randomised controlled trial of a theory-based interactive internet-based smoking cessation intervention (‘StopAdvisor’): Study protocol

Background: Internet-based interventions can help smokers to quit compared with brief written materials or no intervention. However, they are not widely used, particularly by more disadvantaged smokers, and there is significant variation in their effectiveness. A new smoking cessation website (‘StopAdvisor’) has been systematically developed on the basis of PRIME theory, empirical evidence, web-design expertise and user-testing with socio-economically disadvantaged smokers. This paper reports the protocol of a randomised controlled trial to evaluate the efficacy of StopAdvisor and determine whether it translates across the social spectrum.

Methods: The trial has two arms with participants randomised to the offer of the interactive ‘StopAdvisor’ website (intervention condition) or a non-interactive, static website (control condition). Participants are adults from the UK, who smoke every day and are willing to make a serious quit attempt within a month of enrolment. At least 4260 participants will be recruited with a minimum of 2130 in each of two socio-economic sub-groups. The intervention comprises a structured quit plan and a variety of theory- and evidence-based behaviour change techniques for smoking cessation. Tailored support is offered in the form of a series of tunnelled sessions and a variety of interactive menus for use up to a month before, and then for one month after quitting (http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The control is a static website that presents brief and standard advice on smoking cessation. Assessments are at baseline and 2-, 4- and 7-months post-enrolment. The primary outcome measure will be Russell Standard 6-months sustained abstinence, defined as self-reported continuous abstinence verified by saliva cotinine or anabasine at 7-month follow-up. Secondary outcome measures will include 7-day point-prevalence abstinence at 7-month follow-up, self-reported abstinence at 2- and 4-month follow-ups, satisfaction ratings of the website and quantitative indices of website interaction. All analyses will be by intention to treat and the main analysis will compare the two conditions on the primary outcome measure using a logistic regression model, adjusted for baseline characteristics. The efficacy of the intervention across the social spectrum will be assessed by a logistic regression focusing on the interaction between condition and socio-economic disadvantage.

Trial registration: ISRCTN99820519.

Nicotine replacement therapy for smoking cessation

BACKGROUND

The aim of nicotine replacement therapy (NRT) is to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.

OBJECTIVES

The aims of this review were: To determine the effect of NRT compared to placebo in aiding smoking cessation, and to consider whether there is a difference in effect for the different forms of NRT (chewing gum, transdermal patches, oral and nasal sprays, inhalers and tablets/lozenges) in achieving abstinence from cigarettes. To determine whether the effect is influenced by the dosage, form and timing of use of NRT; the intensity of additional advice and support offered to the smoker; or the clinical setting in which the smoker is recruited and treated. To determine whether combinations of NRT are more likely to lead to successful quitting than one type alone. To determine whether NRT is more or less likely to lead to successful quitting compared to other pharmacotherapies.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search July 2012.

SELECTION CRITERIA

Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 150 trials; 117 with over 50,000 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The risk ratio (RR) of abstinence for any form of NRT relative to control was 1.60 (95% confidence interval [CI] 1.53 to 1.68). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 55 trials) for nicotine gum; 1.64 (95% CI 1.52 to 1.78, 43 trials) for nicotine patch; 1.95 (95% CI 1.61 to 2.36, 6 trials) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials) for nicotine inhaler; and 2.02 (95% CI 1.49 to 2.73, 4 trials) for nicotine nasal spray. One trial of oral spray had an RR of 2.48 (95% CI 1.24 to 4.94). The effects were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. The effect was similar in a small group of studies that aimed to assess use of NRT obtained without a prescription. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum, but weaker evidence of a benefit from higher doses of patch. There was evidence that combining a nicotine patch with a rapid delivery form of NRT was more effective than a single type of NRT (RR 1.34, 95% CI 1.18 to 1.51, 9 trials). The RR for NRT used for a short period prior to the quit date was 1.18 (95% CI 0.98 to 1.40, 8 trials), just missing statistical significance, though the efficacy increased when we pooled only patch trials and when we removed one trial in which confounding was likely. Five studies directly compared NRT to a non-nicotine pharmacotherapy, bupropion; there was no evidence of a difference in efficacy (RR 1.01; 95% CI 0.87 to 1.18). A combination of NRT and bupropion was more effective than bupropion alone (RR 1.24; 95% CI 1.06 to 1.45, 4 trials). Adverse effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks.

AUTHORS' CONCLUSIONS

All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50 to 70%, regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT.

An exploration of the missing data mechanism in an Internet based smoking cessation trial

Background

Missing outcome data are very common in smoking cessation trials. It is often assumed that all such missing data are from participants who have been unsuccessful in giving up smoking (“missing=smoking”). Here we use data from a recent Internet based smoking cessation trial in order to investigate which of a set of a priori chosen baseline variables are predictive of missingness, and the evidence for and against the “missing=smoking” assumption.

Methods

We use a selection model, which models the probability that the outcome is observed given the outcome and other variables. The selection model includes a parameter for which zero indicates that the data are Missing at Random (MAR) and large values indicate “missing=smoking”. We examine the evidence for the predictive power of baseline variables in the context of a sensitivity analysis. We use data on the number and type of attempts made to obtain outcome data in order to estimate the association between smoking status and the missing data indicator.

Results

We apply our methods to the iQuit smoking cessation trial data. From the sensitivity analysis, we obtain strong evidence that older participants are more likely to provide outcome data. The model for the number and type of attempts to obtain outcome data confirms that age is a good predictor of missing data. There is weak evidence from this model that participants who have successfully given up smoking are more likely to provide outcome data but this evidence does not support the “missing=smoking” assumption. The probability that participants with missing outcome data are not smoking at the end of the trial is estimated to be between 0.14 and 0.19.

Conclusions

Those conducting smoking cessation trials, and wishing to perform an analysis that assumes the data are MAR, should collect and incorporate baseline variables into their models that are thought to be good predictors of missing data in order to make this assumption more plausible. However they should also consider the possibility of Missing Not at Random (MNAR) models that make or allow for less extreme assumptions than “missing=smoking”.

Smoking characteristics and comorbidities in the power to quit randomized clinical trial for homeless smokers

INTRODUCTION

Smoking prevalence in homeless populations is strikingly high (∼70%); yet, little is known about effective smoking cessation interventions for this population. We conducted a community-based clinical trial, Power To Quit (PTQ), to assess the effects of motivational interviewing (MI) and nicotine patch (nicotine replacement therapy [NRT]) on smoking cessation among homeless smokers. This paper describes the smoking characteristics and comorbidities of smokers in the study.

METHODS

Four hundred and thirty homeless adult smokers were randomized to either the intervention arm (NRT + MI) or the control arm (NRT + Brief Advice). Baseline assessment included demographic information, shelter status, smoking history, motivation to quit smoking, alcohol/other substance abuse, and psychiatric comorbidities.

RESULTS

Of the 849 individuals who completed the eligibility survey, 578 (68.1%) were eligible and 430 (74.4% of eligibles) were enrolled. Participants were predominantly Black, male, and had mean age of 44.4 years (S D = 9.9), and the majority were unemployed (90.5%). Most participants reported sleeping in emergency shelters; nearly half had been homeless for more than a year. Nearly all the participants were daily smokers who smoked an average of 20 cigarettes/day. Nearly 40% had patient health questionnaire-9 depression scores in the moderate or worse range, and more than 80% screened positive for lifetime history of drug abuse or dependence.

CONCLUSIONS

This study demonstrates the feasibility of enrolling a diverse sample of homeless smokers into a smoking cessation clinical trial. The uniqueness of the study sample enables investigators to examine the influence of nicotine dependence as well as psychiatric and substance abuse comorbidities on smoking cessation outcomes.

Treating heavy smokers in primary care with the nicotine nasal spray: randomized placebo-controlled trial

AIMS

Of six established nicotine replacement therapy (NRT) formulations, only the gum and patch have been tested without specialist clinic support in placebo-controlled trials. We aimed to broaden the evidence base by examining if the nicotine nasal spray (NNS) could be effective with only brief support in general practice.

DESIGN

Randomized placebo-controlled trial.

SETTING

Twenty-seven English general practices.

PARTICIPANTS

A total of 761 heavy smokers received brief support and 12 weeks of treatment with NNS (506) or placebo (255).

MEASUREMENTS

The primary outcome was biochemically verified complete abstinence from smoking throughout weeks 3-12.

FINDINGS

NNS compared with placebo more than doubled the number who successfully stopped smoking [15.4% versus 6.7%, odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.5-4.4]. Many participants reported minor irritant adverse symptoms. NNS was particularly effective among those who were more highly dependent on nicotine (OR = 6.17, 95% CI = 2.13-17.9). Of those who failed to stop during the first week (417, 54.8%), only one (0.2%) achieved later success.

CONCLUSIONS

NNS is effective when given in primary care. The benefit was lower than in a specialist clinic but similar to that with the nicotine patch in primary care. Unlike most other NRT formulations, bupropion or varenicline, NNS was especially helpful for more dependent smokers. Continuing treatment of those initially failing was not beneficial. An initial 1-week prescription to those more dependent on nicotine is likely to be the most cost-effective NNS treatment protocol. These results should offer support to the effectiveness of the other NRT formulations untested in this setting.

Promoting smoking cessation in Bangladeshi and Pakistani male adults: design of a pilot cluster randomised controlled trial of trained community smoking cessation workers

Background

The prevalence of smoking is higher among Pakistani and Bangladeshi males than among the general population. Smokers who receive behavioural support and medication quadruple their chances of stopping smoking, but evidence suggests that these populations do not use National Health Service run stop smoking clinics as frequently as would be expected given their high prevalence of smoking. This study aims to tackle some of the main barriers to use of stop smoking services and adherence to treatment programmes by redesigning service delivery to be more acceptable to these adult male populations. The study compares the effectiveness of trained Pakistani and Bangladeshi smoking cessation workers operating in an outreach capacity ('clinic + outreach') with standard care ('clinic only') to improve access to and success of National Health Service smoking cessation services.

Methods/design

This is a pilot cluster randomised controlled trial based in Birmingham, UK. Super output areas of Birmingham will be identified in which more than 10% of the population are of Pakistani and/or Bangladeshi origin. From these areas, 'natural geographical communities' will be identified. Sixteen aggregated agglomerations of super output areas will be identified, separating areas from each other using buffer regions in order to reduce potential contamination. These natural communities will be randomised to 'clinic + outreach' (intervention) or 'clinic only' (control) arms. The use of stop smoking services and the numbers of people quitting smoking (defined as prolonged self-reported abstinence at four weeks, three months and six months) will be assessed in each area. In addition, we will assess the impact of the intervention on adherence to smoking cessation treatments and patient satisfaction.

Trial registration

Current Controlled Trials ISRCTN 82127540.

Combination treatment with varenicline and nicotine replacement therapy

INTRODUCTION

A paucity of data exists regarding the safety and effectiveness of combination treatment with varenicline and nicotine replacement therapy (NRT).

METHODS

We reviewed the clinical experience of two groups of cigarette smokers enrolled in a residential tobacco treatment program: (a) patients receiving combination treatment with varenicline and NRT (N = 104) and (b) usual-care patients receiving treatment before the release of varenicline (N = 135).

RESULTS

Demographic characteristics were similar between the two groups. Among smokers receiving varenicline and NRT, 71% used the nicotine patch with a mean dose of 32 mg/day (SD = 14) and 73% used at least two types of NRT. Adverse events were experienced by 39% (95% CI = 31%-49%) of patients receiving varenicline and NRT and by 59% (95% CI = 51%-67%) of usual-care patients during the residential program. A total of five patients (5%) discontinued varenicline due to adverse events, compared with one patient in the usual-care group. We did not observe a significant difference in the 30-day point prevalence smoking abstinence rate at 6 months between patients treated with varenicline and NRT (54%; 95% CI = 44%-64%) and usual-care patients (59%; 95% CI = 50%-66%).

DISCUSSION

Our findings suggest that combination therapy with varenicline and NRT is safe and well tolerated among patients in a residential tobacco treatment program.

Assessing the outcomes of prolonged cessation-induction and aid-to-cessation trials: floating prolonged abstinence

INTRODUCTION

A Society for Research on Nicotine and Tobacco working group recommended outcome measures for cessation-induction trials and aid-to-cessation trials. Cessation-induction trials aim to motivate unwilling quitters to make a quit attempt. Aid-to-cessation trials give either medication or behavioral interventions to increase the rate at which willing quitters succeed in their attempts. Nicotine-assisted reduction programs combine features of both types of interventions by giving nicotine replacement to unwilling quitters. Treatment can be prolonged more than a year, quit attempts can occur and succeed early or late in the program, and renewed quit attempts are an inherent part of the program. Conventional outcome measures are tied to a fixed but arbitrary point in follow-up and cannot capture the true outcome: Prolonged cessation anchored to the point at which a person makes a successful quit attempt.

DISCUSSION

We propose that the outcome should be counted from the successful quit attempt that began during the treatment period and continues for a defined period, ideally 6 months. In particular, if a trial compared a short reduction program with a long reduction program, it would not be possible to obtain an unbiased assessment of the outcome of such a trial using a measure tied to a fixed point in follow-up. Floating prolonged abstinence could provide such an assessment and is suitable for either prolonged cessation-induction trial or combined cessation-induction and aid-to-cessation trials.

Nicotine replacement therapy for smoking cessation

BACKGROUND

The aim of nicotine replacement therapy (NRT) is temporarily to replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.

OBJECTIVES

The aims of this review were:To determine the effect of NRT compared to placebo in aiding smoking cessation, and to consider whether there is a difference in effect for the different forms of NRT (chewing gum, transdermal patches, nasal spray, inhalers and tablets/lozenges) in achieving abstinence from cigarettes. To determine whether the effect is influenced by the dosage, form and timing of use of NRT; the intensity of additional advice and support offered to the smoker; or the clinical setting in which the smoker is recruited and treated. To determine whether combinations of NRT are more likely to lead to successful quitting than one type alone. To determine whether NRT is more or less likely to lead to successful quitting compared to other pharmacotherapies.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for papers with 'nicotine' or 'NRT' in the title, abstract or keywords. Date of most recent search July 2007.

SELECTION CRITERIA

Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow up of less than six months.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 132 trials; 111 with over 40,000 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The RR of abstinence for any form of NRT relative to control was 1.58 (95% confidence interval [CI]: 1.50 to 1.66). The pooled RR for each type were 1.43 (95% CI: 1.33 to 1.53, 53 trials) for nicotine gum; 1.66 (95% CI: 1.53 to 1.81, 41 trials) for nicotine patch; 1.90 (95% CI: 1.36 to 2.67, 4 trials) for nicotine inhaler; 2.00 (95% CI: 1.63 to 2.45, 6 trials) for oral tablets/lozenges; and 2.02 (95% CI: 1.49 to 3.73, 4 trials) for nicotine nasal spray. The effects were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. The effect was similar in a small group of studies that aimed to assess use of NRT obtained without a prescription. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum, but weaker evidence of a benefit from higher doses of patch. There was evidence that combining a nicotine patch with a rapid delivery form of NRT was more effective than a single type of NRT. Only one study directly compared NRT to another pharmacotherapy. In this study quit rates with nicotine patch were lower than with the antidepressant bupropion.

AUTHORS' CONCLUSIONS

All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50-70%, regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT.

Varenicline in the routine treatment of tobacco dependence: a pre-post comparison with nicotine replacement therapy and an evaluation in those with mental illness

AIMS

To compare the effectiveness of varenicline with nicotine replacement for smoking cessation and to evaluate the safety and effectiveness of varenicline in people with mental illness.

DESIGN

Evaluation of consecutive routine cases before and after the introduction of varenicline.

SETTING

National Health Service (NHS) tobacco dependence clinic in London, UK.

PARTICIPANTS

A total of 412 cases receiving routine care.

INTERVENTION

Seven group support sessions over 6 weeks with either nicotine replacement therapy (NRT) (n = 204) or varenicline (n = 208).

MEASUREMENTS

Verified abstinence 4 weeks after quit day, severity of withdrawal symptoms, incidence and severity of adverse drug symptoms, cost per patient treated and cost per successful short-term quitter.

FINDINGS

Short-term cessation rates were higher with varenicline than NRT (odds ratio = 1.70, 95% confidence interval = 1.09-2.67). Varenicline was equally effective in those with and without mental illness. Craving to smoke, but not adverse mood, was less severe with varenicline than NRT. The cost per quitter was similar for varenicline and NRT. There was a higher incidence of adverse drug symptoms among those taking varenicline, but these were tolerated by most smokers. There was no evidence that varenicline exacerbated mental illness.

CONCLUSIONS

In this setting and with group support varenicline appears to improve success rates over those achieved with NRT, and is equally effective and safe in those with and without a mental illness.

Transdermal nicotine for smoking cessation in postmenopausal women

This study examined the efficacy of transdermal nicotine in postmenopausal smokers, and whether a history of depression or hormone replacement therapy (HRT) moderated smoking cessation outcomes. Postmenopausal smokers (N=152) received intensive smoking cessation counseling and were randomly assigned to use either a 21-mg nicotine patch for 3 months, with a 1-month taper, or a placebo patch. The primary outcome was biochemically validated 7-day point prevalence smoking abstinence during treatment (i.e., 1, 2, 6, and 12 weeks after the quit date) and 1 year after study medication was discontinued. Subjects who received transdermal nicotine were significantly more likely than placebo-treated subjects to remain abstinent from smoking during treatment, but not at the 1-year follow-up. The majority of subjects (>50%) in both groups accurately identified their treatment assignment. History of depression was associated with a decreased likelihood to abstain from smoking throughout the study. HRT did not moderate smoking outcomes. These data indicate that transdermal nicotine may provide short-term benefits for smoking cessation in postmenopausal women. However, efforts are needed to improve long-term abstinence rates and smoking outcomes among women with a history of depression.

Developments in pharmacotherapy for tobacco dependence: past, present and future

In the mid-1970s there were no effective pharmacological treatments for tobacco dependence. The invention of nicotine gum was a major treatment advance and also greatly helped our understanding of the nature of tobacco dependence. There are now eight effective pharmacotherapies (nicotine gum, patch, nasal spray, inhaler, lozenge/tablet, bupropion, nortriptyline and clonidine) available to aid smoking cessation. Other non-nicotine agents that show promise are under investigation, including glucose, rimonabant, selegiline and varenicline. Greater knowledge of the mechanisms of action of the effective non-nicotine agents should lead to better understanding of the nature of tobacco dependence. Future research into optimal treatments should examine long-term combination pharmacotherapy combined with improved psychosocial support that is partly designed to enhance medication compliance. In addition, there is a need for studies designed to evaluate the efficacy of pharmacotherapies in populations such as youth, pregnant smokers and smokers with co-occurring mental health problems.

Outcome criteria in smoking cessation trials: proposal for a common standard

Smoking cessation treatment is now integrated into many health-care systems and a major research effort is under way to improve current success rates. Until now results from randomized clinical trials have been reported in many different ways, leading to problems of interpretation. We propose six standard criteria comprising the 'Russell Standard' (RS). These criteria are applicable to trials of cessation aids where participants have a defined target quit date and there is face-to-face contact with researchers or clinic staff, as follows. (1) Follow-up for 6 months (RS6) or 12 months (RS12) from the target quit date or the end of a predefined 'grace period'; (2) self-report of smoking abstinence over the whole follow-up period allowing up to five cigarettes in total; (3) biochemical verification of abstinence at least at the 6-month or 12-month follow-up point; (4) use of an 'intention-to-treat' approach in which data from all randomized smokers are included in the analysis unless they have died or moved to an untraceable address (participants who are included in the analysis are counted as smokers if their smoking status at the final follow-up cannot be determined); (5) following-up 'protocol violators' and using their true smoking status in the analysis; and (6) collecting follow-up data blind to smokers' allocation to trial group. We believe that these criteria provide the best compromise between practicability and surrogacy for long-term cessation and will enable meaningful comparison between studies. There may be good reasons why other outcome criteria would also be reported, and studies that involve interventions with special groups or where there is no designated target quit date or face to face contact would need to adapt these criteria accordingly.

Nicotine replacement therapy for smoking cessation

BACKGROUND

The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes.

OBJECTIVES

The aims of this review were:to determine the effectiveness of the different forms of NRT (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; to determine its effectiveness compared to other pharmacotherapies.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register in March 2004.

SELECTION CRITERIA

Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow up of less than six months.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. For each study we calculated summary odds ratios. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed effect model.

MAIN RESULTS

We identified 123 trials; 103 contributing to the primary comparison between NRT and a placebo or non-NRT control group. The odds ratio (OR) for abstinence with NRT compared to control was 1.77 (95% confidence intervals (CI): 1.66 to 1.88). The ORs for the different forms of NRT were 1.66 (95% CI: 1.52 to 1.81) for gum, 1.81 (95% CI: 1.63 to 2.02) for patches, 2.35 (95% CI: 1.63 to 3.38) for nasal spray, 2.14 (95% CI: 1.44 to 3.18) for inhaled nicotine and 2.05 (95% CI: 1.62 to 2.59) for nicotine sublingual tablet/lozenge. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum (OR 2.20, 95% CI: 1.85 to 3.25). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy. In this study quit rates with bupropion were higher than with nicotine patch or placebo.

REVIEWERS' CONCLUSIONS

All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase the odds of quitting approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT.

Clinical trial comparing nicotine replacement therapy (NRT) plus brief counselling, brief counselling alone, and minimal intervention on smoking cessation in hospital inpatients

BACKGROUND

Guidelines recommend that smoking cessation interventions are offered in all clinical settings to all smokers willing to make a quit attempt. Since the effectiveness of routine provision of behavioural counselling and nicotine replacement therapy (NRT) to smokers admitted to hospital has not been established, a randomised controlled trial of these interventions given together compared with counselling alone or minimal intervention was performed in hospital inpatients.

METHODS

Medical and surgical inpatients who were current smokers at the time of admission were randomised to receive either usual care (no additional advice at admission), counselling alone (20 minute intervention with written materials), or NRT plus counselling (counselling intervention with a 6 week course of NRT). Continuous and point prevalence abstinence from smoking (validated by exhaled carbon monoxide <10 ppm) was measured at discharge from hospital and at 3 and 12 months, and self-reported reduction in cigarette consumption in smokers was assessed at 3 and 12 months.

RESULTS

274 inpatient smokers were enrolled. Abstinence was higher in the NRT plus counselling group (n=91) than in the counselling alone (n=91) or usual care (n=92) groups. The difference between the groups was significant for validated point prevalence abstinence at discharge (55%, 43%, 37% respectively, p=0.045) and at 12 months (17%, 6%, 8%, p=0.03). The respective differences in continuous validated abstinence at 12 months were 11%, 4%, 8% (p=0.25). There was no significant difference between counselling alone and usual care, or in reduction in cigarette consumption between the treatment groups.

CONCLUSIONS

NRT given with brief counselling to hospital inpatients is an effective routine smoking cessation intervention.

Controlled trial of three weeks nicotine replacement treatment in hospital patients also given advice and support

BACKGROUND

Smoking is a major public health issue, estimated as causing 120 000 deaths in the UK per year. Smoking cessation is an important aspect of the treatment of many diseases. Nicotine replacement therapy (NRT) has been shown to increase cessation rates among healthy volunteers and in general practice, but it is not clear whether it has an effect in hospital patients.

METHODS

Patients referred by their hospital doctor to the smoking cessation counsellor and who agreed to participate in the study were randomised to receive either NRT given as a nicotine patch daily and a nicotine inhalator on an as needed basis plus advice and support (AS+NRT), or to receive just advice and support (AS). Claims of smoking cessation were validated at 1 week, 3 months, 6 months, and 1 year by carbon monoxide (CO) breath testing.

RESULTS

A total of 245 patients were randomised, 136 AS+NRT and 109 AS. There were no significant demographic differences between the two groups at baseline. At 1 year 35 (14%) had sustained cessation confirmed by a CO breath test, 20/136 (15%) AS+NRT and 15/109 (14%) AS, p=0.857. One hundred and ten patients gave up smoking for at least 1 week, 54% AS+NRT and 33% AS (p<0.001). By 6 months there was no significant difference between the two groups (22/136 (16%) AS+NRT and 15/109 (14%) AS).

CONCLUSION

In hospital patients NRT, given as regular daily patches plus an inhalator to be used as needed, did not add to the smoking cessation rate achieved at 1 year by regular advice and support, despite significantly increasing the cessation rate at 1 week.

Consenso sobre o tratamento da dependência de nicotina

Têm sido atribuídas à dependência de nicotina 20% das mortes nos EUA. Estudos têm mostrado que 30% a 50% das pessoas que começam a fumar escalam para um uso problemático. Nos últimos 20 anos, a educação e a persuasão não foram suficientes para promover uma mudança política, cultural e social relacionada ao comportamento de fumar. As intervenções para interromper o uso de tabaco ainda não estão integradas às rotinas dos serviços de saúde no mundo. A falta de estratégias de integração, de tempo disponível para acoplar ações assistenciais mais específicas e mesmo a percepção dos profissionais de saúde de que os tratamentos para a dependência de nicotina são pouco efetivos são algumas das barreiras apontadas. Assim, elaborar um consenso sobre a dependência de nicotina teve como objetivos: • levantar dados epidemiológicos relevantes relacionados ao uso do tabaco no mundo e no Brasil; • revisar as ações gerais e centrais da nicotina; • elaborar um protocolo de triagem mínimo para serviços de atenção primária à saúde; • recomendar diretrizes básicas de avaliação, diagnóstico e tratamento para todos os níveis de atenção à saúde em relação à dependência de nicotina; • fornecer sugestões para a abordagem de grupos especiais de pacientes: adolescentes, gestantes, idosos, pacientes em regime de internação, obesos e pacientes com comorbidades psiquiátricas, cardiovasculares e respiratórias.

Can anti-smoking television advertising affect smoking behaviour? controlled trial of the Health Education Authority for England's anti-smoking TV campaign

OBJECTIVES

To evaluate the effectiveness of the Health Education Authority for England's anti-smoking television advertising campaign in motivating smokers to give up and preventing relapse in those who had already given up.

DESIGN

A prospective, controlled trial was conducted in four TV regions in central and northern England. One region received no intervention (controls), two regions received TV anti-smoking advertising (TV media), and one region received TV anti-smoking advertising plus locally organised anti-tobacco campaigning (TV media + LTCN). The TV advertisements were screened in two phases over 18 months; during the first phase the intensity of the advertising was varied between TV regions. 5468 men and women (2997 smokers, 2471 ex-smokers) were selected by two stage random sampling and interviewed before the intervention, of whom 3610 were re-interviewed six months later, after the first phase of the campaign. Only those interviewed at six months were followed to the main end point at 18 months when 2381 subjects were re-interviewed.

MAIN OUTCOME MEASURES

Self reports of cigarette smoking at the 18 month follow up were compared between the three levels of intervention. Odds ratios for intervention effects were adjusted for pre-intervention predictors of outcome and pooled for smokers and ex-smokers using meta-analytic methods.

RESULTS

After 18 months, 9. 8% of successfully re-interviewed smokers had stopped and 4.3% of ex-smokers had relapsed. The pooled adjusted odds ratio for not smoking in the TV media only condition compared to controls was 1.53 (95% confidence intervals (CI) 1.02 to 2.29, p = 0.04), and for TV media + LTCN versus controls, 1.67 (95% CI 1.0 to 2.8, p = 0.05). There was no evidence of an extra effect of the local tobacco control network when combined with TV media (odds ratio 1.15, 95% CI 0.74 to 1.78, p = 0.55). The was also no evidence of any intervention effects after the first phase of the TV media campaign, including no effect of varying the intensity of the advertising during this initial phase. Applying these results to a typical population where 28% smoke and 28% are ex-smokers, and where there would be an equal number of quitters and relapsers over an 18 month period without the campaign, suggests that the campaign would reduce smoking prevalence by about 1.2%.

CONCLUSIONS

The Health Education Authority for England's anti-smoking TV campaign was effective in reducing smoking prevalence through encouraging smokers to stop and helping prevent relapse in those who had already stopped. The lack of an effect after the first phase of the campaign indicates that if advertising at this intensity is to have an impact, a prolonged campaign is necessary. These results support the UK governments' recent decision to fund similar campaigns, and suggests that anti-smoking TV advertising should be undertaken routinely as an essential component of any population smoking reduction strategy. Reducing smoking prevalence would make a substantial contribution to achieving the UK government's target of preventing 300 000 cancer and heart disease deaths over the next 10 years.

Predictors and timing of adverse experiences during trandsdermal nicotine therapy

OBJECTIVES

Difficulty sleeping is a recognised tobacco withdrawal symptom, but sleep problems, like application site reactions, are commonly reported as adverse reactions to transdermal nicotine therapy. However, no studies have examined potential predictive factors associated with the occurrence of expected adverse experiences during transdermal nicotine therapy. The subject of skin tolerability among patients with a history of eczema, psoriasis or other skin disorders is of particular interest, as are the relationships between plasma concentrations of nicotine, concurrent smoking, sleep problems and nausea.

METHODS

The cohort study involving 1392 participants was designed to assess the timing, severity and predictive factors of adverse experiences reported during 24-hour transdermal nicotine therapy. Data were collected on patients aged 18 to 70 years old who were smokers and who had expressed a strong desire to stop smoking. The intervention consisted of brief behavioural counselling, a booklet containing smoking cessation advice and instructions for use of the patches, and a 12-week course of decreasing transdermal nicotine doses.

RESULTS

Follow-up was available on 1392 out of 1481 study participants. The majority of adverse experiences were mild. Sleep problems occurred in 669 out of 1392 (48%) participants and most often commenced on the day of smoking cessation. Application site reactions occurred in 478 out of 1392 (34%) participants and most often occurred after 6 days of therapy. No predictor had an adjusted hazard ratio above 2. Statistically significant (p < 0.05) predictors of sleep problems were successfully quitting smoking and female gender. Predictors of application site reactions were psoriasis or eczema, other skin conditions, age <40 years, female gender, place of birth outside Australasia, and trade or university education level. Substantially increased nicotine intake during therapy compared with baseline smoking occurred in 8% of participants who smoked concurrently, and 4% of participants who did not (p = 0.1). Increased nicotine intake was associated with a modest increase in the overall rate of adverse experiences (89% vs 63%, p = 0.04) and dizziness/lightheadedness (17% vs 3%, p = 0.03), but not with sleep problems or cardiovascular events.

CONCLUSIONS

Transdermal nicotine therapy appears to be well tolerated, even if the user smokes concurrently. Sleep disturbance during therapy appeared to be primarily associated with tobacco withdrawal rather than with nicotine excess from treatment with transdermal nicotine. Study participants with pre-existing skin disorders were somewhat more likely to report mild application site reactions than other participants.

A meta-analysis to assess the incidence of adverse effects associated with the transdermal nicotine patch

To estimate the frequency of adverse effects associated with the use of the transdermal nicotine patch, we abstracted and analysed data from 47 reports of 35 clinical trials. The meta-analysis presented here represents a synthesis of data from 41 groups of nicotine patch recipients totalling 5501 patients, and 33 groups of placebo recipients totalling 3752 patients. Smoking abstinence was the primary outcome in 32 of the trials, and relief of colitis symptoms was the primary outcome in 2 of the trials; 1 study of contact sensitisation was included in the skin irritation analysis. The patch was clearly effective as an aid to smoking abstinence. Despite the large number of patients in the analysis, few adverse cardiovascular outcomes (myocardial infarction, stroke, tachycardia, arrhythmia, angina) were reported, and no excess of these outcomes was detected among patients assigned to nicotine-patch use. The incidences of several minor adverse effects were clearly elevated among the nicotine-patch groups, especially sleep disturbances, nausea or vomiting, localised skin irritation and respiratory symptoms, but the background rates and risk ratios varied considerably across studies. The incidence of nausea or vomiting appeared to be lowest when the patch dose was tapered. The results of this meta-analysis indicate that very large studies would be needed to assess the effect of the patch, if any, on serious, rare outcomes. These results also suggest that the rate of minor adverse effects might be lowered by modifying patch-use protocols.

Effects of three doses of transdermal nicotine on post-cessation eating, hunger and weight

Smokers were randomly assigned to 0, 7, 14 or 21 mg doses of transdermal nicotine and had their eating and weight followed for 6 weeks. Among the 66 subjects who were abstinent for all 6 weeks, caloric, carbohydrate and fat intake, hunger, and weight increased in those on placebo, but alcohol, caffeine and protein intake did not. Nicotine patch decreased caloric, carbohydrate and fat intake in a dose-related manner, showed a trend for weight and showed no effect for hunger. Neither abstinence from smoking nor nicotine therapy shifted the percent of calories from sweets or carbohydrates. We conclude nicotine replacement reduces post-cessation increases in eating but does not have a specific effect on sweet intake.

Transdermal nicotine plus support in patients attending hospital with smoking-related diseases: a placebo-controlled study

BACKGROUND

Cessation rates in smokers attending special clinics or their General Practitioners can be increased by transdermal nicotine (TNS). This study assesses the efficacy of TNS as an adjunct to advice and support in helping patients attending hospital with smoking-related diseases to stop smoking.

METHODS

In a double-blind, placebo-controlled, randomized manner, 234 inpatients and outpatients with smoking-related respiratory or cardiovascular disease, aged 18-75 years, who were willing to try to stop smoking, were advised by their hospital doctor to stop smoking. This was reinforced by repeated advice and encouragement from the Smoking Cessation Counsellor initially and at 2, 4, 8 and 12 weeks, supplemented by a 24 h patch in adjusted doses over that period. Those not smoking at 12 weeks were followed up at 26 and 52 weeks. Self-reported complete abstinence from 12 to 52 weeks was validated by expired air carbon monoxide measurement at 12, 26 and 52 weeks.

RESULTS

Twenty-four (21%) of 115 TNS patients were verified as non-smokers at 12, 26 and 52 weeks and claimed continued abstinence, compared with 17 (14%) of 119 in the placebo (P) group (P = 0 center dot 15) -5% confidence limits for odds ratio of abstinence on TNS compared to P: 0 center dot 83, 3 center dot 37. Cessation was related to increasing age (P = 0 center dot 02) and lower Fagerstrom score (P = 0 center dot 05). Minor skin reactions were more frequent in the TNS group (47% TNS; 34% P), as was nausea (12% TNS; 3% P). Severe skin reactions were rare (5% TNS; 4% P).

CONCLUSION

The suggestion that TNS produces an increase of 50% in relative terms (7% absolute increase) in smoking cessation over placebo in this population of hospital patients is sufficiently strong to warrant a further study large enough to answer whether or not this result was due to chance.

Pharmacology of nicotine and its therapeutic use in smoking cessation and neurodegenerative disorders

During the last decade, nicotine has been used increasingly as an aid to smoking cessation and has been found to be a safe and efficacious treatment for the symptoms of nicotine withdrawal. This period has also seen significant advances in our understanding of the mechanisms underlying the psychopharmacological responses to nicotine, including, particularly, those that have been implicated in nicotine addiction. This paper reviews this decade of progress in the specific context of the therapeutic application of nicotine to the treatment of smoking cessation. Other putative future applications, particularly in the treatment of neurodegenerative disorders, are also reviewed.