Nicotine patch therapy prior to quitting smoking: a meta-analysis

Current Pharmacotherapies for Smoking Cessation and Promising Emerging Drugs

OBJECTIVE

Pharmacotherapy is commonly used during quit attempts and has shown an increase in the likelihood of achieving abstinence. However, with established pharmacotherapies, abstinence rates following a quit attempt remain low, and relapse is common. This review aims to investigate the efficacy and harm profiles of current and emerging pharmacotherapies.

METHODS

Literature review of current and emerging pharmacotherapies for smoking cessation and tobacco use disorder.

RESULTS

Emerging pharmacotherapies include new formulations of existing therapies, drug repurposing and some new treatments. New treatments are welcome and may incorporate different mechanisms of action or different safety and tolerability profiles compared to existing treatments. However, emerging pharmacotherapies have yet to demonstrate greater efficacy compared to existing treatments. The emergence of Electronic Nicotine Delivery Systems (ENDS) or 'vaping' is a feature of the current debate around tobacco use disorder. ENDS appear to facilitate switching but not quitting and are controversial as a harm minimisation strategy.

LIMITATIONS

Studies included a broad range of therapies and trial designs that should be compared with their differences taken into consideration.

CONCLUSION

Strategies to successfully quit smoking vary between individuals and may extend beyond pharmacotherapy and involve complex psychosocial factors and pathways.

Adaptive Smoking Cessation Using Precessation Varenicline or Nicotine Patch: A Randomized Clinical Trial

Importance

Adaptive pharmacotherapy, ie, starting a medication regimen and then modifying that regimen based on patient response, is common in many medical domains but is not common in smoking cessation. Recently, studies have found that adaptive treatment using precessation nicotine patches is efficacious for smoking cessation; however, adaptive treatment using precessation varenicline and adaptive treatment in clinical practice settings have not been fully assessed.

Objective

To determine whether adaptive pharmacotherapy leads to higher smoking abstinence rates than standard pharmacotherapy in a clinical practice setting.

Design, Setting, and Participants

This double-blinded stratified placebo-controlled randomized clinical trial compared adaptive treatment with standard treatment for smoking cessation. The study was conducted at a university health system in Durham, North Carolina, from February 2018 to May 2020 and was stopped early due to COVID-19. Data were analyzed as intent-to-treat from May 24, 2021, to February 27, 2022.

Interventions

Participants were allowed to choose varenicline or nicotine patches and were then randomized to adaptive or nonadaptive (standard) treatment. Participants started on their chosen medication (adaptive) or placebo (standard) 4 weeks before their target quit day. Two weeks later, participants were assessed for treatment response. Adaptive participants who did not decrease daily cigarettes smoked by at least 50% (nonresponders) received bupropion in addition to their chosen medication. Participants in the adaptative treatment group who did decrease daily cigarettes smoked by at least 50% (responders) and participants in the standard treatment group received additional placebo bupropion. Participants in the standard treatment group received varenicline starting 1 week before the target quit date or nicotine patches starting on the target quit day. All participants received brief behavioral support.

Main Outcome and Measures

The main outcome was biochemically verified 30-day continuous smoking abstinence 12 weeks after their target quit smoking day. Other measures included demographic characteristics, smoking history, and repeated smoking assessments.

Results

Of the planned 300 participants, a total of 188 participants (mean [SD] age, 49.1 [12.5] years; 102 [54%] female) were enrolled before the trial was stopped because of the COVID-19 pandemic. A total of 127 participants chose to use varenicline, including 64 randomized to adaptive treatment and 63 randomized to standard treatment, and 61 participants chose to use nicotine patches, including 31 randomized to adaptive treatment and 30 randomized to standard treatment. At baseline, participants smoked a mean (SD) of 15.4 (7.3) cigarettes per day. At 12 weeks after the target quit day, biochemically verified 30-day continuous smoking abstinence was observed in 23 of 95 participants (24%) in the adaptive treatment group and 8 of 93 participants (9%) in the standard treatment (odds ratio [OR], 3.38; 95% CI, 1.43-7.99; P = .004); among participants who used varenicline, 30-day continuous abstinence was 18 participants (28%) in the adaptive treatment group, and 5 participants (8%) in the standard treatment group (OR, 4.54; 95% CI, 1.57-13.15); among participants who used nicotine patches, 30-day continuous abstinence was 5 participants (16%) in the adaptive treatment group and 3 participants (10%) in the standard treatment group (OR, 1.73; 95% CI, 0.38-7.99). Sleep problems were more common for participants in the varenicline adaptive treatment group than in the varenicline standard treatment group (rate ratio, 1.74; 95% CI, 1.18-2.58; P = .03).

Conclusions and Relevance

This randomized clinical trial found that adaptive pharmacotherapy was efficacious for smoking cessation treatment in a practice setting.

Trial Registration

ClinicalTrials.gov Identifier: NCT02501265.

Pilot randomized controlled trial evaluating the effect of random nicotine delivery on cigarettes per day and smoke exposure

BACKGROUND

Many smokers report attempting to quit each year, yet most relapse, in part due to exposure to smoking-related cues. It is hypothesized that extinction of the cue-drug association could be facilitated through random nicotine delivery (RND), thus making it easier for smokers to quit. The current study aimed to evaluate the effects of RND on smoking cessation-related outcomes including cigarettes per day (CPD) and exhaled carbon monoxide (CO).

METHODS

Participants were current smokers (>9 CPD) interested in quitting. Novel trans-mucosal, orally dissolving nicotine films, developed by Bionex Pharmaceuticals, were used in the study. The pharmacokinetic profile of these films was assessed in single (Experiment 1) and multiple-dose (Experiment 2) administrations prior to the smoking cessation study (Experiment 3). In Experiment 3, participants were randomized 1:1:1 to recieve 4 nicotine films per day of either: placebo delivery (0 mg), steady-state delivery (2 mg), or random nicotine delivery (RND) (0 mg or 4 mg). After two weeks, participants were advised to quit (target quit date, TQD) and were followed up 4 weeks later to collect CPD and CO and to measure dependence (Penn State Cigarette Dependence Index; PSCDI) and craving (Questionnaire of Smoking Urges; QSU-Brief). Means and frequencies were used to describe the data and repeated measures ANOVA was used to determine differences between groups.

RESULTS

The pharmacokinetic studies (Experiment 1 and 2) demonstrated that the films designed for this study delivered nicotine as expected, with the 4 mg film delivering a nicotine boost of approximately 12.4 ng/mL across both the single and the multiple dose administration studies. The films reduced craving for a cigarette and were well-tolerated, overall, and caused no changes in blood pressure or heart rate. Using these films in the cessation study (Experiment 3) (n = 45), there was a significant overall reduction in cigarettes smoked per day (CPD) and in exhaled CO, with no significant differences across groups (placebo, steady-state, RND). In addition, there were no group differences in dependence or craving. Adverse events included heartburn, hiccups, nausea, and to a lesser extent, vomiting and anxiety and there were no differences across groups.

CONCLUSION

Overall, this pilot study found that RND via orally dissolving films was feasible and well tolerated by participants. However, RND participants did not experience a greater reduction in self-reported CPD and exhaled CO, compared with participants in the steady-state and placebo delivery groups. Future studies to evaluate optimal RND parameters with larger sample sizes are needed to fully understand the effect of RND on smoking cessation-related outcomes.

Practitioners' Views on Nicotine Replacement Therapy in Pregnancy during Lapse and for Harm Reduction: A Qualitative Study

Many countries, including the UK, recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy. However, adherence to NRT is generally low, smoking lapse or relapse is common and using NRT to reduce the harm from the number of cigarettes smoked is only advocated in non-pregnant smokers. Two focus groups were conducted with 13 professionals involved in antenatal stop smoking services (SSS). The data were analysed thematically. Two themes were extracted that describe health professionals' attitudes towards using NRT either during lapses or to reduce smoking in women who cannot quit (harm reduction). These are presented around a social-ecological framework describing three hierarchical levels of influence within smoking cessation support: (1) Organizational: providing NRT during lapses could be expensive for SSS though harm reduction could result in services helping a wider range of clients. (2) Interpersonal: participants felt using NRT for harm reduction was not compatible with cessation-orientated messages practitioners conveyed to clients. (3) Individual: practitioners' advice regarding using NRT during smoking lapses varied; many were generally uncomfortable about concurrent smoking and NRT use and had strong reservations about recommending NRT when smoking during all but the briefest lapses. Further evidence is required to guide policy and practice.

A Randomized Controlled Trial of an Optimized Smoking Treatment Delivered in Primary Care

Background

The effectiveness of smoking cessation treatment is limited in real-world use, perhaps because we have not selected the components of such treatments optimally nor have treatments typically been developed for and evaluated in real-world clinical settings.

Purpose

To validate an optimized smoking cessation treatment package that comprises intervention components identified as effective in factorial screening experiments conducted as per the Multiphase Optimization Strategy (MOST).

Methods

Adult smokers motivated to quit were recruited from primary care clinics (N = 623). Participants were randomized to receive either recommended usual care (R-UC; 10 min of in-person counseling, 8 weeks of nicotine patch, and referral to quitline services) or abstinence-optimized treatment (A-OT; 3 weeks of prequit mini-lozenges, 26 weeks of nicotine patch + mini-lozenges, three in-person and eight phone counseling sessions, and 7-11 automated calls to prompt medication use). The key outcomes were self-reported and biochemically confirmed (carbon monoxide, CO <6 ppm) 7-day point-prevalence abstinence.

Results

A-OT participants had significantly higher self-reported abstinence rates than R-UC participants at 4, 8, 16, and 26 weeks (ORs: 1.91-3.05; p <. 001). The biochemically confirmed 26-week abstinence rates were lower than the self-reported 26-week rates, but revealed a similar treatment effect size (OR = 2.94, p < .001). There was no moderation of treatment effects on 26-week abstinence by demographic, psychiatric, or nicotine dependence variables. A-OT had an incremental cost-effectiveness ratio for 26-week CO-confirmed abstinence of $7,800.

Conclusions

A smoking cessation treatment that is optimized via MOST development meaningfully enhances cessation rates beyond R-UC smoking treatment in smokers seen in primary care.

Clinical Trial Registration

NCT02301403.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

WITHDRAWN: Reduction versus abrupt cessation in smokers who want to quit

BACKGROUND

The standard way to stop smoking is to quit abruptly on a designated quit day. A number of smokers have tried unsuccessfully to quit this way. Reducing smoking before quitting could be an alternative approach to cessation. Before this method is adopted it is important to determine whether it is at least as successful as abrupt quitting.

OBJECTIVES

1. To compare the success of reducing smoking to quit and abrupt quitting interventions. 2. To compare adverse events between arms in studies that used pharmacotherapy to aid reduction.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group specialised register using topic specific terms. The register contains reports of trials of tobacco addiction interventions identified from searches of MEDLINE, EMBASE and PsycInfo. We also searched reference lists of relevant papers and contacted authors of ongoing trials. Date of most recent search: July 2012.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that recruited adults who wanted to quit smoking. Studies included at least one condition which instructed participants to reduce their smoking and then quit and one condition which instructed participants to quit abruptly.

DATA COLLECTION AND ANALYSIS

The outcome measure was abstinence from smoking after at least six months follow-up. We pooled the included trials using a Mantel-Haenszel fixed-effect model. Trials were split for two sub-group analyses: pharmacotherapy vs no pharmacotherapy, self help therapy vs behavioural support. Adverse events were summarised as a narrative. It was not possible to compare them quantitatively as there was variation in the nature and depth of reporting across studies.

MAIN RESULTS

Ten studies were relevant for inclusion, with a total of 3760 participants included in the meta-analysis. Three of these studies used pharmacotherapy as part of the interventions. Five studies included behavioural support in the intervention, four included self-help therapy, and the remaining study had arms which included behavioural support and arms which included self-help therapy. Neither reduction or abrupt quitting had superior abstinence rates when all the studies were combined in the main analysis (RR= 0.94, 95% CI= 0.79 to 1.13), whether pharmacotherapy was used (RR= 0.87, 95% CI= 0.65 to 1.22), or not (RR= 0.97, 95% CI= 0.78 to 1.21), whether studies included behavioural support (RR= 0.87, 95% CI= 0.64 to 1.17) or self-help therapy (RR= 0.98, 95% CI= 0.78 to1.23). We were unable to draw conclusions about the difference in adverse events between interventions, however recent studies suggest that pre-quit NRT does not increase adverse events.

AUTHORS' CONCLUSIONS

Reducing cigarettes smoked before quit day and quitting abruptly, with no prior reduction, produced comparable quit rates, therefore patients can be given the choice to quit in either of these ways. Reduction interventions can be carried out using self-help materials or aided by behavioural support, and can be carried out with the aid of pre-quit NRT. Further research needs to investigate which method of reduction before quitting is the most effective, and which categories of smokers benefit the most from each method, to inform future policy and intervention development.

Pre-quit nicotine decreases nicotine self-administration and attenuates cue- and drug-induced reinstatement

BACKGROUND

Administration of smoking cessation medications in anticipation of a nominated quit date can promote abstinence. How this occurs is not widely understood, but may be due to the disruption of contingencies between smoking behaviour and acute drug effects.

AIMS

The aim of this study was to explore this relationship, we examined the effect of pre-quit nicotine replacement therapy on susceptibility to relapse in an animal model of nicotine dependence.

METHODS

Rats were trained to intravenously self-administer nicotine across 20 days. Continuous low-dose nicotine was administered via a mini-osmotic pump either across the last 7 days of self-administration and across 6 days of extinction, or across extinction only. Cue- and drug-induced reinstatements of responding were then measured with mini-pumps retained, the day after mini-pump removal or one week later.

RESULTS

Pre-quit nicotine administration markedly reduced self-administration across the last days of training as the response, and its associated cues, no longer reliably predicted an acute drug effect. Pre-quit, but not post-quit, nicotine administration significantly attenuated cue-induced reinstatement once mini-pumps were removed, indicating that the contingency disruption across training reduced the conditioned reinforcing properties of the cue at test. Both pre-quit and post-quit nicotine attenuated nicotine-primed reinstatement.

CONCLUSIONS

Together these results suggest that administration of a nicotine replacement prior to a nominated quit date may enhance resistance to relapse via disruption of the contingency between a response, its associated cues, and a rewarding nicotine effect.

Effect of Long-term Nicotine Replacement Therapy vs Standard Smoking Cessation for Smokers With Chronic Lung Disease: A Randomized Clinical Trial

IMPORTANCE

Smokers with chronic obstructive pulmonary disease (COPD) have particular difficulty quitting. Long-term nicotine replacement therapy (LT-NRT) might offer a strategy for reducing harm from cigarettes and provide a pathway for later cessation.

OBJECTIVE

To compare the effect of LT-NRT vs standard smoking cessation (SSC) on exposure to cigarette smoke, harm related to smoking, and cessation among smokers with COPD.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded, randomized clinical trial recruited smokers who self-reported a diagnosis of COPD at any level of readiness to quit from May 23, 2014, through November 30, 2015. The 12-month follow-up was completed December 6, 2016. Patients were recruited at a clinical research unit of an academic medical center. Analysis was based on intention to treat and performed from March 8 through November 30, 2017.

INTERVENTIONS

Standard smoking cessation treatment included 10 weeks of NRT and 4 follow-up counseling sessions for those willing to make a quit attempt. Long-term NRT included 12 months of NRT and 6 follow-up counseling sessions regardless of initial willingness to quit. Overall, 198 patients were randomized to SSC, and 197 were included in the primary analysis; 200 patients were randomized to LT-NRT, and 197 were included in the primary analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was 7-day abstinence verified by carbon monoxide (CO) levels at 12 months. Secondary outcomes included cigarettes smoked per day (CPD), exposure to CO, urinary excretion of 4-methylnitrosamino-1-3-pyridyl-1-butanol (NNAL) (a smoking-related carcinogen), and adverse events.

RESULTS

Among 398 patients who were randomized (59.8% female; mean [SD] age, 56.0 [9.3] years), the mean (SD) CPD was 23.1 (12.3). Twelve-month follow-up was completed by 373 participants (93.7%), and 394 (99.0%) were included in the primary analysis. At 12 months, CO-verified abstinence occurred in 23 of 197 participants (11.7%) in the SSC arm and 24 of 197 (12.2%) in the LT-NRT arm (risk difference, 0.5%; 95% CI, -5.9% to 6.9%). Continuing smokers in the SSC and LT-NRT arms had similar, significantly reduced harms caused by smoking, including cigarette consumption by 12.4 and 14.5 CPD, respectively, exhaled CO level by 5.5 and 7.8 ppm, respectively, and mean urinary NNAL excretion by 21.7% and 23.0%, respectively. In multivariate analyses, continuing smokers with greater adherence to NRT experienced less reduction in NNAL exposure. The frequency of major adverse cardiac events was similar in both groups.

CONCLUSIONS AND RELEVANCE

Similar rates of cessation and similar reductions in exposure to tobacco smoke resulted with LT-NRT and SSC. Among continuing smokers, ongoing use of NRT was not associated with reductions in smoke exposure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02148445.

A Pilot Clinical Trial of Smoking Cessation Services Implemented in the Workplace for Service Industry Employees

PURPOSE

Evaluate the feasibility and preliminary efficacy of implementing evidence-based tobacco treatment at the workplace for service industry employees.

DESIGN

Randomized trial using 6 paired worksites (3 test and 3 delayed intervention control sites).

SETTING

US Northeast city.

PARTICIPANTS

Employees were recruited from university food service settings.

INTERVENTION

Comprehensive smoking treatment was provided at the workplace including individual counseling, free pharmacotherapy (dual nicotine replacement therapy or varenicline), and 5 weeks of contingency management that reinforced abstinence or reductions in smoking to encourage progress toward quitting.

MEASURES

Primary measures included a smoking status survey administered at the end of treatment at the test sites and before treatment began at the delayed intervention control sites.

ANALYSIS

Analyses compared rates of quit attempts and successful abstinence for at least 24 hours between the test and delayed intervention control sites.

RESULTS

Twenty-five employees were enrolled in treatment. The majority were single (12/25), black (16/25), and reported their educational attainment as high school or less (18/25). Employees in the test (vs delayed intervention control) sites reported higher rates of quit attempts (66.7% vs 12.5%, P = .02) and success quitting for at least 24 hours (53.3% vs 12.5%, P = .08). Participants rated the treatment as very helpful overall.

CONCLUSION

Findings support the feasibility and efficacy of providing workplace-based smoking cessation services and may inform strategies to increase access to treatment.

Understanding the implications of the biobehavioral basis of nicotine addiction and its impact on the efficacy of treatment

INTRODUCTION

Tobacco use remains the leading cause of preventable death in the United States. There are efficacious behavioral and pharmacological options for smoking cessation including three FDA approved therapies - nicotine replacement therapy, varenicline and bupropion. Nevertheless, uptake of smoking cessation treatments continues to be poor and there is a need for novel smoking cessation treatments. Areas covered: This article reviews the biobehavioral basis of nicotine addiction, its implications for smoking cessation treatments, the various neurotransmitter systems involved in nicotine addictive effects, and their potential therapeutic value. Included are discussions around the role of genetic factors in predicting response to pharmacotherapy and what we know about appropriate application of pharmacotherapy and behavioral interventions for tobacco use disorder. The evidence for harm reduction measures in individuals who are not willing or able to quit smoking is also reviewed. Expert commentary: Many neurotransmitter system targets have been investigated as a result of our understanding of the underlying neurobiology of tobacco use disorder, and there remain important targets that have yet to be fully explored. rTMS or combination therapies are proposed as possible novel strategies to improve smoking cessation.

Predicting Intention to Use Nicotine Replacement Therapy in People Attending Residential Treatment for Substance Dependence

OBJECTIVE

Nicotine replacement therapy (NRT) is recommended as a frontline smoking cessation tool for people attending mental health and substance dependence treatment services. Previous research suggests that NRT is underutilized in these settings. To improve the use of NRT among people attending residential treatment for substance use disorders, it is important that the factors influencing smokers' decisions to use NRT are understood. The study aimed to examine (1) smoking cessation strategies used by participants in previous quit attempts, (2) participants' attitudes toward NRT (i.e., safety concerns and perceived efficacy), and (3) the predictors of participants' intention to use NRT to support future quit attempts.

METHODS

Participants completed a cross-sectional survey that examined their smoking behaviors, previous experiences using smoking cessation strategies, attitudes and beliefs regarding NRT, and intention to use NRT as part of future quit attempts (N = 218). All participants were attending residential treatment for substance use disorders provided by We Help Ourselves, a large provider of specialist alcohol and other drug treatment in Australia.

RESULTS

The majority of respondents (98%) reported that they had smoked regularly in their lifetime, and 89% were current smokers. Forty-five percent of the current smokers reported that they had previously used NRT to support a quit attempt, with 54% reporting that they intended to use NRT to support a future quit attempt. Intentions to use NRT were not related to the participants' mental health status or the participants' perceptions regarding the safety or potential drawbacks associated with using NRT. However, participants were more likely to report that they would use NRT to support future quit attempts if they were female, had previously used NRT, and perceived NRT to be effective.

CONCLUSIONS

Improving the use of evidence-based smoking cessation strategies within substance use treatment continues to be a priority. To enhance the use of NRT among consumers attending mental health and addiction treatment services, NRT should be universally offered. Future research should consider strategies that help to improve participants' positive perceptions regarding the efficacy of NRT.

Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG

Tobacco smoking is the world's leading cause of premature death and disability. Global targets to reduce premature deaths by 25% by 2025 will require a substantial increase in the number of smokers making a quit attempt, and a significant improvement in the success rates of those attempts in low, middle and high income countries. In many countries the only place where the majority of smokers can access support to quit is primary care. There is strong evidence of cost-effective interventions in primary care yet many opportunities to put these into practice are missed. This paper revises the approach proposed by the International Primary Care Respiratory Group published in 2008 in this journal to reflect important new evidence and the global variation in primary-care experience and knowledge of smoking cessation. Specific for primary care, that advocates for a holistic, bio-psycho-social approach to most problems, the starting point is to approach tobacco dependence as an eminently treatable condition. We offer a hierarchy of interventions depending on time and available resources. We present an equitable approach to behavioural and drug interventions. This includes an update to the evidence on behaviour change, gender difference, comparative information on numbers needed to treat, drug safety and availability of drugs, including the relatively cheap drug cytisine, and a summary of new approaches such as harm reduction. This paper also extends the guidance on special populations such as people with long-term conditions including tuberculosis, human immunodeficiency virus, cardiovascular disease and respiratory disease, pregnant women, children and adolescents, and people with serious mental illness. We use expert clinical opinion where the research evidence is insufficient or inconclusive. The paper describes trends in the use of waterpipes and cannabis smoking and offers guidance to primary-care clinicians on what to do faced with uncertain evidence. Throughout, it recognises that clinical decisions should be tailored to the individual's circumstances and attitudes and be influenced by the availability and affordability of drugs and specialist services. Finally it argues that the role of the International Primary Care Respiratory Group is to improve the confidence as well as the competence of primary care and, therefore, makes recommendations about clinical education and evaluation. We also advocate for an update to the WHO Model List of Essential Medicines to optimise each primary-care intervention. This International Primary Care Respiratory Group statement has been endorsed by the Member Organisations of World Organization of Family Doctors Europe.

Examination of the mechanism of action of two pre-quit pharmacotherapies for smoking cessation

Background

There is substantial scope for improvement in the current arsenal of smoking cessation methods and techniques: even when front-line cessation treatments are utilized, smokers are still more likely to fail than to succeed. Studies testing the incremental benefit of using nicotine patch for 1–4 weeks prior to quitting have shown pre-quit nicotine patch use produces a robust incremental improvement over standard post-quit patch treatment. The primary objective of the current study is to test the mechanism of action of two pre-quit smoking cessation medications—varenicline and nicotine patch—in order to learn how best to optimize these pre-quit treatments.

Methods/Design

The study is a three group, randomized, open-label controlled clinical trial. Participants (n = 216 interested quitters) will be randomized to receive standard patch treatment (10 weeks of patch starting from a designated quit day), pre-quit patch treatment (two weeks of patch treatment prior to a quit day, followed by 10 weeks post-quit treatment) or varenicline (starting two weeks prior to quit day followed by 10 weeks post-quit). Participants will use study-specific modified smart-phones to monitor their smoking, withdrawal symptoms, craving, mood and social situations in near real-time over four weeks; two weeks prior to an assigned quit date and two weeks after this date. Smoking and abstinence will be assessed at regular study visits and biochemically verified.

Discussion

Understanding how nicotine patches and varenicline influence abstinence may allow for better tailoring of these treatments to individual smokers.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12614000329662 (Registered: 27 March 2014).

Protecting Children From Tobacco, Nicotine, and Tobacco Smoke

This technical report serves to provide the evidence base for the American Academy of Pediatrics' policy statements "Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke" and "Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke." Tobacco use and involuntary exposure are major preventable causes of morbidity and premature mortality in adults and children. Tobacco dependence almost always starts in childhood or adolescence. Electronic nicotine delivery systems are rapidly gaining popularity among youth, and their significant harms are being documented. In utero tobacco smoke exposure, in addition to increasing the risk of preterm birth, low birth weight, stillbirth, placental abruption, and sudden infant death, has been found to increase the risk of obesity and neurodevelopmental disorders. Actions by pediatricians can help to reduce children's risk of developing tobacco dependence and reduce children's involuntary tobacco smoke exposure. Public policy actions to protect children from tobacco are essential to reduce the toll that the tobacco epidemic takes on our children.

Does Extended Pre Quit Bupropion Aid in Extinguishing Smoking Behavior?

INTRODUCTION

Understanding the mechanisms by which bupropion promotes smoking cessation may lead to more effective treatment. To the extent that reduced smoking reinforcement is one such mechanism, a longer duration of pre quit bupropion treatment should promote extinction of smoking behavior. We evaluated whether 4 weeks of pre quit bupropion (extended run-in) results in greater pre quit reductions in smoking rate and cotinine and, secondarily, greater short-term abstinence, than standard 1 week of pre quit bupropion (standard run-in).

METHODS

Adult smokers (n = 95; 48 females) were randomized to a standard run-in group (n = 48; 3-week placebo, then 1-week bupropion pre quit) or an extended run-in group (4-week pre quit bupropion; n = 47). Both groups received group behavioral counseling and 7 weeks of post quit bupropion. Smoking rate (and craving, withdrawal, and subjective effects) was collected daily during the pre quit period; biochemical data (cotinine and carbon monoxide) were collected at study visits.

RESULTS

During the pre quit period, the extended run-in group exhibited a greater decrease in smoking rate, compared to the standard run-in group, interaction p = .03. Cigarette craving and salivary cotinine followed a similar pattern, though the latter was evident only among women. Biochemically verified 4-week continuous abstinence rates were higher in the extended run-in group (53%) than the standard run-in group (31%), p = .033.

CONCLUSIONS

The extended use of bupropion prior to a quit attempt reduces smoking behavior during the pre quit period and improved short-term abstinence rates. The data are consistent with an extinction-of-reinforcement model and support further investigation of extended run-in bupropion therapy for smoking cessation.

The Past, Present, and Future of Nicotine Addiction Therapy

The tobacco addiction treatment field is progressing through innovations in medication development, a focus on precision medicine, and application of new technologies for delivering support in real time and over time. This article reviews the evidence for combined and extended cessation pharmacotherapy and behavioral strategies including provider advice, individual counseling, group programs, the national quitline, websites and social media, and incentives. Healthcare policies are changing to offer cessation treatment to the broad population of smokers. With knowledge of the past and present, this review anticipates what is likely on the horizon in the clinical and public health effort to address tobacco addiction.

Combination therapy of varenicline with nicotine replacement therapy is better than varenicline alone: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Smoking is a major preventable cause of morbidity and premature death worldwide. Both varenicline and nicotine replacement therapy (NRT) help achieve smoking cessation. However, limited evidence exists regarding whether combination of varenicline and NRT is more effective than either alone. The aim of this research was to investigate the efficacy and safety of varenicline combined with NRT.

METHODS

A systematic search of MEDLINE, EMBASE, ClinicalTrial.gov, and Cochrane Library was conducted in November 2014. Two authors independently reviewed and selected randomized controlled trials. The quality of the studies was evaluated by the Jadad score. We carried out meta-analysis of both early (abstinence rate assessed before or at the end of treatment) and late (assessed after the end of the treatment) outcomes.

RESULTS

Three randomized controlled trials with 904 participants were included in this meta-analysis. All three were comparing combination therapy with varenicline therapy alone. The late outcomes were assessed in 2 of the 3 trials. Both the early and late outcomes were favorable for combination therapy (OR = 1.50, 95 % CI 1.14 to 1.97; OR = 1.62, 95 % CI 1.18 to 2.23, respectively). However, this significance diminished after eliminating a study with pre-cessation treatment using nicotine patch. The most common adverse events were nausea, insomnia, abnormal dreams, and headache. One study reported more skin reactions (14.4 % vs 7.8 %; p = 0.03) associated with combination therapy.

CONCLUSIONS

Combination therapy is more effective than varenicline alone, especially if pre-cessation treatment of nicotine patch is administrated. Adverse events of combination therapy are similar to mono-therapy except for skin reactions.

Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit

Chronic obstructive pulmonary disease (COPD), lung cancer, asthma and pulmonary tuberculosis are common pulmonary diseases that are caused or worsened by tobacco smoking. Growing observational evidence suggests that symptoms and prognosis of these conditions improve upon smoking cessation. Despite increasing numbers of (small) randomised controlled trials suggesting intensive smoking cessation treatments work in people with pulmonary diseases many patients are not given specific advice on the benefits or referred for intensive cessation treatments and, therefore, continue smoking.This is a qualitative review regarding smoking cessation in patients with COPD and other pulmonary disorders, written by a group of European Respiratory Society experts. We describe the epidemiological links between smoking and pulmonary disorders, the evidence for benefits of stopping smoking, how best to assess tobacco dependence and what interventions currently work best to help pulmonary patients quit. Finally, we describe characteristics and management of any "hardcore" smoker who finds it difficult to quit with standard approaches.

Does the Magnitude of Reduction in Cigarettes Per Day Predict Smoking Cessation? A Qualitative Review

INTRODUCTION

Reduction in cigarettes per day (CPD) aided by nicotine replacement therapy (NRT) increases cessation in smokers; however, it is unclear whether this is due to use of NRT or reduction per se. If the latter, a greater magnitude of reduction in CPD should increase the odds of cessation.

METHODS

The authors searched PubMed, Cochrane, PsychINFO, http://clinicaltrials.gov and their personal libraries for studies on smoking reduction. Seven of the 76 (9%) identified intervention trials and four of 28 naturalistic studies (14%) reported on the magnitude of reduction in relation to the odds of cessation.

RESULTS

Five of the seven intervention trials and three of the four naturalistic observational (cohort) studies found that increased reduction in CPD was associated with increased cessation. The intervention trials that reported effect sizes found that every 1% decrease in CPD or carbon monoxide was associated with a 3% to 4% increase in the odds of cessation. The naturalistic studies found that ordinal (eg, quartile) increases in participants' magnitude of reduction in CPD were associated with 50% to 290% increases in the odds of cessation. All of the naturalistic studies and four of the intervention trials included covariates; however, reduction's association with cessation could still be due to its association with NRT use or motivation.

CONCLUSION

Although prospective prediction does not necessarily indicate causality, our findings suggest reduction in CPD is a mechanism of increased cessation in prior NRT-aided reduction studies.

It's time to change the default for tobacco treatment

The World Health Organization estimates that 1 billion people will die from tobacco-related illnesses this century. Most health-care providers, however, fail to treat tobacco dependence. This may be due in part to the treatment 'default'. Guidelines in many countries recommend that health-care providers: (i) ask patients if they are 'ready' to quit using tobacco; and (ii) provide treatment only to those who state they are ready to quit. For other health conditions--diabetes, hypertension, asthma and even substance abuse--treatment guidelines direct health-care providers to identify the health condition and initiate evidence-based treatment. As with any medical care, patients are free to decline--they can 'opt out' from care. If patients do nothing, they will receive care. For tobacco users, however, the treatment default is often that they have to 'opt in' to treatment. This drastically limits the reach of tobacco treatment because, at any given encounter, a minority of tobacco users will say they are ready to quit. As a result, few are offered treatment. It is time to change the treatment default for tobacco dependence. All tobacco users should be offered evidence-based care, without being screened for readiness as a precondition for receiving treatment. Opt-out care for tobacco dependence is warranted because changing defaults has been shown to change choices and outcomes for numerous health behaviors, and most tobacco users want to quit; there is little to no evidence supporting the utility of assessing readiness to quit, and an opt-out default is more ethical.

Hardcore smokers: what do we know?

AIMS

The existence of smokers who are resistant to smoking cessation treatment has long been noted in the literature. There has been ongoing debate as to whether the proportion of these smokers is increasing as smoking prevalence rates stagnate. Studies define hardcore smokers inconsistently and within the context of specific illnesses, addiction, population, and/or theoretical paradigms. This review examines the existing literature related to hardcore smokers to develop a better understanding of what is known and not known about this group to guide smoking cessation treatment.

METHODS

PubMed MESH search and review of research publications from 1998 to 2012 (N=61).

RESULTS

Inconsistent definitions of hardcore smoking make it difficult to estimate prevalence rates and to identify specific characteristics of persistent smokers. Generally, persistent smokers have higher levels of nicotine dependence, are disproportionately from lower socioeconomic groups, start smoking at an earlier age, and are more likely to have a psychological co-morbidity.

DISCUSSION

Defining some smokers as hardcore is limiting. Targeted and tailored interventions for smoking cessation for persistent smoking have demonstrated effectiveness in a small number of studies. Treatment access barriers need to be addressed to improve the reach and effectiveness of cessation with persistent smokers. Efforts to limit early age initiation of tobacco use are a critical element in averting persistent smoking.

Nicotine patch preloading for smoking cessation (the preloading trial): study protocol for a randomized controlled trial

Background

The use of nicotine replacement therapy before quitting smoking is called nicotine preloading. Standard smoking cessation protocols suggest commencing nicotine replacement therapy only on the first day of quitting smoking (quit day) aiming to reduce withdrawal symptoms and craving. However, other, more successful smoking cessation pharmacotherapies are used prior to the quit day as well as after. Nicotine preloading could improve quit rates by reducing satisfaction from smoking prior to quitting and breaking the association between smoking and reward. A systematic literature review suggests that evidence for the effectiveness of preloading is inconclusive and further trials are needed.

Methods/Design

This is a study protocol for a multicenter, non-blinded, randomized controlled trial based in the United Kingdom, enrolling 1786 smokers who want to quit, funded by the National Institute for Health Research, Health Technology Assessment program, and sponsored by the University of Oxford. Participants will primarily be recruited through general practices and smoking cessation clinics, and randomized (1:1) either to use 21 mg nicotine patches, or not, for four weeks before quitting, whilst smoking as normal. All participants will be referred to receive standard smoking cessation service support.

Follow-ups will take place at one week, four weeks, six months and 12 months after quit day. The primary outcome will be prolonged, biochemically verified six-month abstinence. Additional outcomes will include point prevalence abstinence and abstinence of four-week and 12-month duration, side effects, costs of treatment, and markers of potential mediators and moderators of the preloading effect.

Discussion

This large trial will add substantially to evidence on the effectiveness of nicotine preloading, but also on its cost effectiveness and potential mediators, which have not been investigated in detail previously. A range of recruitment strategies have been considered to try and compensate for any challenges encountered in recruiting the large sample, and the multicentre design means that knowledge can be shared between recruitment teams. The pragmatic study design means that results will give a realistic estimate of the success of the intervention if it were to be rolled out as part of standard smoking cessation service practice.

Trial registration

Current Controlled Trials ISRCTN33031001. Registered 27 April 2012.

An exploratory examination of the mechanisms through which pre-quit patch use aids smoking cessation

RATIONALE AND OBJECTIVES

Patches are traditionally started on the day a quit attempt begins. Recently, a number of studies have established that the patch's effectiveness is improved by starting the treatment before quitting [pre-quit patch (PQP) use]. In an exploratory study, we investigate a proposed mechanism through which PQP use might promote abstinence: that PQP reduces satisfaction with smoking (either directly or via craving), which in turn leads to reduction and that smoking reduction promotes abstinence.

METHODS

Fifty-seven interested quitters used handheld computers to monitor their smoking satisfaction, withdrawal and smoking in real time for 17 days, leading up to a quit attempt. All participants received 21 mg/24 h patches for 2 weeks before and for up to 10 weeks after quitting. Carbon dioxide (CO)-verified 28-day abstinence was assessed.

RESULTS

During PQP treatment, participants reported significant reductions in both the satisfaction gained from smoking (p < 0.001) and their daily cigarette consumption (p < 0.001). Craving did not decrease; however, there was an interaction between time and nicotine dependence; craving decreased only among low dependent participants. Multilevel structural equation modelling revealed a direct effect of satisfaction on smoking rate. Craving did not mediate this relationship. Smoking reduction during the PQP treatment phase was not significantly associated with abstinence.

CONCLUSIONS

The real-time data collection protocol utilised allowed for a fine-grained examination of smoking during PQP treatment. The results suggest that the reduction in daily cigarette smoking typically observed during PQP treatment is due to reductions in satisfaction with smoking. Unlike previous studies, however, smoking reduction was not significantly related to later abstinence, even though the odds ratio was comparably. Potential clinical implications of these findings are discussed.

Quit now? Quit soon? Quit when you're ready? Insights about target quit dates for smoking cessation from an online quit date tool

BACKGROUND

Setting a target quit date (TQD) is often an important component in smoking cessation treatment, but ambiguity remains concerning the optimal timing (ie, quitting spontaneously versus delaying to prepare).

OBJECTIVE

We examined four questions about the timing of TQDs and smoking outcomes in secondary analyses of The iQUITT Study, a randomized trial of Internet and telephone treatment for cessation: (1) What are the characteristics of TQDs set using an online interactive quit date tool?, (2) What are the characteristics of individuals who use a quit date tool and do they differ from those who do not?, (3) Are there differences in smoker characteristics, treatment utilization, and cessation outcomes based TQD timing?, and (4) Is maintenance of an initial TQD predictive of abstinence or do changes to TQDs lead to cessation?

METHODS

A total of 825 adult current cigarette smokers were randomized to enhanced Internet or enhanced Internet plus telephone counseling. Latency to TQD in days was calculated as the date difference between the initial TQD and enhanced Internet registration; prospective TQD setters were stratified into four latency groups (0, 1-14, 15-28, 29+ days). Baseline variables, website utilization, and 3-month cessation outcomes were examined between prospective TQD groups. Desire and confidence to quit, number of TQDs, and website logins were tested as predictors of 30-day point prevalence abstinence (ppa) at 3 months (responder-only analyses). Classification and regression tree (CART) analysis explored interactions among baseline variables, website utilization, and latency to TQD as predictors of 30-day ppa.

RESULTS

There were few baseline differences between individuals who used the quit date tool and those who did not. Prospective TQDs were set as follows: registration day was 17.1% (73/427), 1-14 days was 37.7% (161/427), 15-28 days was 18.5% (79/427), and 29+ days was 26.7% (114/427). Participants with a TQD within 2 weeks had higher baseline self-efficacy scores but did not differ on smoking variables. Individuals whose TQD was the same day as registration had the highest logins, page views, number of TQDs set using the tool, and messages sent to other members. Logistic regression revealed a significant interaction between number of TQDs and website logins for 30-day ppa (P=.005). Among those with high logins, 41.8% (33/79) with 1 TQD were abstinent versus 25.9% (35/135) with 2+TQDs. Logins and self-efficacy predicted 30-day ppa in the CART model.

CONCLUSIONS

TQD timing did not predict cessation outcomes in standard or exploratory analyses. Self-efficacy and an apparent commitment to an initial TQD were the components most highly related to abstinence but only via interactions with website utilization. Findings highlight the importance of feeling efficacious about handling specific smoking situations and engaging with treatment. Additional research focused on increasing engagement in Web-based cessation studies is needed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00282009; http://clinicaltrials.gov/show/NCT00282009 (Archived by WebCite at http://www.webcitation.org/6Kt7NrXDl).

Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice

Strategies for assisting smoking cessation include behavioural counselling to enhance motivation and to support attempts to quit and pharmacological intervention to reduce nicotine reinforcement and withdrawal from nicotine. Three drugs are currently used as first line pharmacotherapy for smoking cessation, nicotine replacement therapy, bupropion and varenicline. Compared with placebo, the drug effect varies from 2.27 (95% CI 2.02, 2.55) for varenicline, 1.69 (95% CI 1.53, 1.85) for bupropion and 1.60 (95% CI 1.53, 1.68) for any form of nicotine replacement therapy. Despite some controversy regarding the safety of bupropion and varenicline, regulatory agencies consider these drugs as having a favourable benefit/risk profile. However, given the high rate of psychiatric comorbidity in dependent smokers, practitioners should closely monitor patients for neuropsychiatric symptoms. Second-line pharmacotherapies include nortriptyline and clonidine. This review also offers an overview of pipeline developments and issues related to smoking cessation in special populations such as persons with psychiatric comorbidity and pregnant and adolescent smokers.

Pharmacological intervention of nicotine dependence

Nicotine dependence is a major cause of mortality and morbidity all over the world. Various medications have been tried to treat nicotine dependence including nicotine replacement therapy, bupropion, and varenicline. A newer venture to nicotine dependence treatment is a nicotine vaccine which is yet to get footsteps in common practice. The present review assimilates various pharmacotherapeutic measures to address nicotine dependence. However, it is to be noted that psychological interventions, when combined with pharmacotherapy, offer the greatest benefits to the patients.

New terminology for the treatment of tobacco dependence: a proposal for debate

Tobacco dependence is characterised as a chronic, relapsing disorder that typically requires multiple quit attempts before successful, long-term abstinence is achieved (Steinberg, Foulds, Richardson, Burke, & Shah, 2006). Best practice, evidence-based treatment includes multiple-session counselling and pharmacotherapy, or the combination of both (Fiore et al., 2008). The field has moved past the notion that tobacco dependence is simply a bad habit, a vice, or a moral deficiency that can be overcome by willpower or education alone (Mars & Ling, 2008). However, the language used in discussing treatment has not always been consistent with this evidence. Some words and phrases used lend themselves to varied meanings, and could lead to significant misunderstanding not only among professionals in the field, but also among the general public (O'Brien, 2010; Davis, 1992; Perkins, 1999; Hughes, 2013). In this paper, we discuss some commonly used, problematic terminology, and suggest more appropriate terms (Table 1).

Is a combination of varenicline and nicotine patch more effective in helping smokers quit than varenicline alone? A randomised controlled trial

BACKGROUND

Nicotine replacement therapy (NRT) and varenicline are both effective in helping smokers quit. There is growing interest in combining the two treatments to improve treatment outcomes, but no experimental data exist on whether this is efficacious. This double-blind randomised controlled trial was designed to evaluate whether adding nicotine patches to varenicline improves withdrawal relief and short-term abstinence rates.

METHODS

117 participants seeking help to stop smoking were randomly allocated to varenicline plus placebo patch or varenicline plus nicotine patch (15 mg/16 hour). Varenicline use commenced one week prior to the target quit date (TQD), patch use started on the TQD. Ratings of urges to smoke and cigarette withdrawal symptoms were collected weekly over 4 weeks post-TQD. Medication use and smoking status were established at 1, 4 and 12 weeks. Participants lost to follow-up were included as continuing smokers.

RESULTS

92% of participants used both medications during the first week after the TQD. The combination treatment generated no increase in nausea or other adverse effects. It had no overall effect on urges to smoke or on other withdrawal symptoms. The combination treatment did not improve biochemically validated abstinence rates at 1 week and 4 weeks post-TQD (69% vs 59%, p=0.28 and 60% vs 59%, p=0.91, in the nicotine patch and placebo patch arm, respectively), or self reported abstinence rates at 12 weeks (36% vs. 29%, p=0.39, NS).

CONCLUSIONS

The efficacy of varenicline was not enhanced by the addition of nicotine patches, although further trials would be useful to exclude the possibility of type II error.

TRIAL REGISTRATION

Clinicaltrials.gov

REGISTRATION NUMBER

NCT01184664.

An updated algorithm for choosing among smoking cessation treatments

Although meta-analyses have documented the efficacy of treatments for smoking cessation, and guidelines have outlined treatment elements, few algorithms for choosing among treatments have been described. The current algorithm updates the author's prior algorithm. The major decisions in the algorithm are (a) use a motivational treatment if the smoker is not currently interested in quitting, (b) assess factors that influence choice of treatment, (c) consider both gradual and abrupt cessation, (d) use combined patch+gum/inhaler/lozenge or varenicline as first line medications, (e) use individual, group, Internet, and phone counseling as first line psychosocial treatments, and (f) continue treatment after a lapse or relapse. Further research is needed to determine whether algorithms improve treatment outcomes.

Randomized trial of the effectiveness of combined behavioral/pharmacological smoking cessation treatment in Syrian primary care clinics

AIMS

Effectiveness of nicotine replacement therapy (NRT) for smoking cessation has not been evaluated in low income countries, such as Syria, where it is expensive and not widely available. We evaluated whether nicotine patch boosts smoking cessation rates when used in conjunction with behavioral support in primary care clinics in Aleppo, Syria.

DESIGN

Two arm, parallel group, randomized, placebo controlled, double-blinded multi-site trial.

SETTING

Four primary care clinics in Aleppo, Syria.

PARTICIPANTS

 Two hundred and sixty-nine adult primary care patients received behavioral cessation counseling from a trained primary care physician and were randomized to receive six weeks of treatment with nicotine versus placebo patch.

MEASUREMENTS

Primary end-points were prolonged abstinence (no smoking after a 2-week grace period) at end of treatment, and 6 and 12 months post-quit day, assessed by self-report and exhaled carbon monoxide levels of <10 p.p.m.

FINDINGS

Treatment adherence was excellent and nicotine patch produced expected reductions in urges to smoke and withdrawal symptoms, but no treatment effect was observed. The proportion of patients in the nicotine and placebo groups with prolonged abstinence was 21.6% and 20.0%, respectively, at end of treatment, 13.4% and 14.1% at 6 months, and 12.7% and 11.9% at 12 months.

CONCLUSIONS

 Nicotine patches may not be effective in helping smokers in low-income countries to stop when given as an adjunct to behavioural support.

Reduction versus abrupt cessation in smokers who want to quit

BACKGROUND

The standard way to stop smoking is to quit abruptly on a designated quit day. A number of smokers have tried unsuccessfully to quit this way. Reducing smoking before quitting could be an alternative approach to cessation. Before this method is adopted it is important to determine whether it is at least as successful as abrupt quitting.

OBJECTIVES

1. To compare the success of reducing smoking to quit and abrupt quitting interventions. 2. To compare adverse events between arms in studies that used pharmacotherapy to aid reduction.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group specialised register using topic specific terms. The register contains reports of trials of tobacco addiction interventions identified from searches of MEDLINE, EMBASE and PsycInfo. We also searched reference lists of relevant papers and contacted authors of ongoing trials. Date of most recent search: July 2012.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that recruited adults who wanted to quit smoking. Studies included at least one condition which instructed participants to reduce their smoking and then quit and one condition which instructed participants to quit abruptly.

DATA COLLECTION AND ANALYSIS

The outcome measure was abstinence from smoking after at least six months follow-up. We pooled the included trials using a Mantel-Haenszel fixed-effect model. Trials were split for two sub-group analyses: pharmacotherapy vs no pharmacotherapy, self help therapy vs behavioural support. Adverse events were summarised as a narrative. It was not possible to compare them quantitatively as there was variation in the nature and depth of reporting across studies.

MAIN RESULTS

Ten studies were relevant for inclusion, with a total of 3760 participants included in the meta-analysis. Three of these studies used pharmacotherapy as part of the interventions. Five studies included behavioural support in the intervention, four included self-help therapy, and the remaining study had arms which included behavioural support and arms which included self-help therapy. Neither reduction or abrupt quitting had superior abstinence rates when all the studies were combined in the main analysis (RR= 0.94, 95% CI= 0.79 to 1.13), whether pharmacotherapy was used (RR= 0.87, 95% CI= 0.65 to 1.22), or not (RR= 0.97, 95% CI= 0.78 to 1.21), whether studies included behavioural support (RR= 0.87, 95% CI= 0.64 to 1.17) or self-help therapy (RR= 0.98, 95% CI= 0.78 to1.23). We were unable to draw conclusions about the difference in adverse events between interventions, however recent studies suggest that pre-quit NRT does not increase adverse events.

AUTHORS' CONCLUSIONS

Reducing cigarettes smoked before quit day and quitting abruptly, with no prior reduction, produced comparable quit rates, therefore patients can be given the choice to quit in either of these ways. Reduction interventions can be carried out using self-help materials or aided by behavioural support, and can be carried out with the aid of pre-quit NRT. Further research needs to investigate which method of reduction before quitting is the most effective, and which categories of smokers benefit the most from each method, to inform future policy and intervention development.

Effects of 21 days of varenicline versus placebo on smoking behaviors and urges among non-treatment seeking smokers

Varenicline promotes smoking cessation and reduces urges to smoke. However, the mechanisms associated with these effects and their time course are not well characterized. One mechanism may be extinction, but the duration of the current dosing protocol may not be sufficient. We examined the effect of extended pre-treatment with varenicline on smoking behavior among 17 non-treatment seeking adult smokers. Using a within-subjects, double-blind, placebo-controlled crossover design, participants received standard dosing of varenicline for 21 days, followed by a 14-day washout period and 21 days of placebo; order counterbalanced. Cigarettes per day (CPD), smoking topography, smoking urges (QSU), and side effects were assessed every three days. Biomarkers (e.g. nicotine metabolites) were collected on days 1, 7, and 21. There was a significant drug by time interaction indicating a reduction in CPD during varenicline phase (between days 10-21), but no reduction during placebo. Varenicline also led to reductions in nicotine metabolites and urges to smoke. Among this sample of non-treatment seeking smokers, varenicline significantly reduced smoking behavior. Results have important treatment implications because changes in CPD and craving did not occur until after the typical one-week run-up period. This suggests that a longer duration of pre-treatment may be beneficial for some smokers.

Nicotine dependence among clients receiving publicly funded substance abuse treatment

BACKGROUND

Smoking and nicotine dependence (ND) are prevalent among substance abusers but little is known about characteristics of ND in this population. This information would help identify those most in need of smoking cessation programs. This study evaluated the associations of socio-demographic, tobacco- and substance use-related, and health/mental health factors to ND in adults receiving publicly funded substance abuse treatment in Tennessee.

METHODS

All Tennessee residents who received federal block grant-funded substance abuse treatment during July-December, 2004 were invited to participate in a 6 month post-intake telephone follow-up interview. Socio-demographic characteristics, perceived health and mental health, tobacco use history and patterns, and ND, assessed by the Fagerstrom Test of Nicotine Dependence (FTND), were obtained at follow-up. Alcohol and illicit drug use and smoking status prior to treatment were assessed at intake. This paper analyzes data for 855 clients who were current cigarette smokers at both intake and follow-up.

RESULTS

Sixty three percent of smokers were ND (FTND score ≥ 4). Correlates of ND included older age, poorer self-rated overall health, earlier age of onset of cigarette smoking and substance abuse, fewer smoking quit attempts in past year, single substance use (alcohol or illicit drug, vs. multiple substances) at intake, use of opiates/narcotics and sedatives, and past month self-reported depression.

CONCLUSION

ND was highly prevalent and correlated with specific types and patterns of substance abuse and depression. These results suggest that intensive smoking cessation interventions, involving behavioral support, pharmacotherapy, and mood management, are needed to effectively assist this population.

Continuing to wear nicotine patches after smoking lapses promotes recovery of abstinence

AIMS

  Smokers who lapse during a cessation attempt are at particularly high risk of relapse, so interventions to help smokers recover from lapses are urgently needed. Two recent studies have suggested continuing to use nicotine patches following a lapse may be a beneficial relapse prevention strategy. However, to date no study that uses approved doses of nicotine patches under real-world conditions has tested this hypothesis.

DESIGN AND SETTING

  Clinical trial conducted across eight US study sites.

PARTICIPANTS AND MEASUREMENTS

  Using data from 509 subjects (240 active; 269 placebo) who lapsed during weeks 3-5 of treatment in a randomized, double-blind placebo-controlled trial of 21-mg nicotine patches, we examined whether active nicotine patch use improved the chances of recovering abstinence (7-day point-prevalence) at weeks 6 and 10.

FINDINGS

  Active patch use (versus placebo) increased the likelihood of recovery from a lapse both at 6 weeks [8.3% versus 0.8%; relative risk (RR) = 11.0, P < 0.001] and at 10 weeks (9.6% versus 2.6%; RR = 3.7, P < 0.001).

CONCLUSIONS

  Continuing treatment to aid smoking cessation with active patches promotes recovery from lapses. Smokers should be encouraged to persist with patch treatment if they lapse to smoking.

The effects of extended pre-quit varenicline treatment on smoking behavior and short-term abstinence: a randomized clinical trial

Preclinical research and learning theory suggest that a longer duration of varenicline treatment prior to the target quit date (TQD) would reduce smoking rates before cessation and improve abstinence outcomes. A double-blind randomized controlled trial tested this hypothesis in 60 smokers randomized to either an Extended run-in group (4 weeks of pre-TQD varenicline) or a Standard run-in group (3 weeks of placebo, 1 week of pre-TQD varenicline); all the participants received 11 weeks of post-TQD varenicline and brief counseling. During the pre-quit run-in, the reduction in smoking rates was greater in the Extended run-in group than in the Standard run-in group (42% vs. 24%, P < 0.01), and this effect was greater in women than in men (57% vs. 26%, P = 0.001). The rate of continuous abstinence during the final 4 weeks of treatment was higher among women in the Extended group compared to women in the Standard run-in group (67% vs. 35%). Although these data suggest that extension of varenicline treatment reduces smoking during the pre-quit period and may further enhance cessation rates, confirmatory evidence is needed from phase III clinical trials.

Early cessation success or failure among women attempting to quit smoking: trajectories and volatility of urge and negative mood during the first postcessation week

Aversive symptoms of abstinence from nicotine have been posited to lead to smoking relapse and research on temporal patterns of abstinence symptoms confirms this assumption. However, little is known about the association of symptom trajectories early after quitting with postcessation smoking or about the differential effects of tonic (background) versus phasic (temptation-related) symptom trajectories on smoking status. The current study examined trajectories of urge and negative mood among 300 women using the nicotine patch during the first postcessation week. Ecological momentary assessments collected randomly and during temptation episodes were analyzed using hierarchical linear modeling yielding four individual trajectory parameters: intercept (initial symptom level), linear slope (direction and rate of change), quadratic coefficient (curvature), and volatility (scatter). Early lapsers, who lapsed during the first postcessation week, exhibited more severe tonic urge and phasic negative mood immediately after quitting, and more volatile tonic and phasic urge compared to abstainers. Late lapsers, who were abstinent during the first week but lapsed by 1 month, exhibited more severe tonic urge immediately after quitting compared to abstainers. These results demonstrate the importance of early postcessation urge and negative affect and highlight the value of examining both tonic and phasic effects of abstinence from nicotine.

Comparing abrupt and gradual smoking cessation: a randomized trial

AIMS

To compare abrupt and gradual smoking cessation.

DESIGN AND SETTING

Randomized trial and observational study, Internet, 2007-2010.

PARTICIPANTS

Smokers with no strong preference for abrupt or gradual quitting were randomly assigned to quitting immediately (n=472), or to gradually reducing their cigarette consumption over 2 weeks and then quit (n=502). Smokers who strongly preferred to quit abruptly were instructed to do so immediately (n=2456), those who strongly preferred gradual were instructed to reduce their cigarette consumption over 2 weeks, then quit (n=1801). Follow-up was conducted 4 weeks after target quit dates.

FINDINGS

Those who preferred abrupt quitting were the most motivated to quit and the most confident in their ability to quit. At follow-up, quit rates were 16% in those who preferred abrupt cessation, 7% in those who preferred gradual cessation and 9% in those who had no preference (p<0.001). In the latter group, quit rates were equal for those randomized to abrupt or gradual (9%, p=0.97). In those who expressed a strong preference for either method, there were interactions between quitting method, motivation to quit and confidence in ability to quit: those who had low levels of motivation or low levels of confidence were more likely to quit at follow-up if they preferred and used abrupt rather than gradual.

CONCLUSIONS

In those who had no strong preference for either method, abrupt and gradual produced similar results. Those who preferred and used the abrupt method were more likely to quit than those who preferred and used the gradual method, in particular when they had low motivation and confidence.

Efficacy of varenicline to prompt quit attempts in smokers not currently trying to quit: a randomized placebo-controlled trial

INTRODUCTION

Nicotine replacement therapy to aid smoking reduction increases the probability of a future quit attempt among smokers not currently planning to quit smoking. We tested whether varenicline, a partial nicotine agonist, would also increase future quit attempts.

METHODS

This randomized, placebo-controlled trial recruited 218 smokers who were interested in quitting but had no plans to quit in the next month. Participants used varenicline (2 mg/day) or placebo for 2-8 weeks plus received brief counseling on methods to reduce cigarettes/day. The primary measure was the incidence of a quit attempt within 6 months of study entry. Secondary measures were point prevalence abstinence, motivation to stop smoking, and reduction in cigarettes/day.

RESULTS

Varenicline increased the incidence of a quit attempt more than placebo at the Nebraska site (73% vs. 41%; p < .001) but not at the Vermont site (45% vs. 51%; p = .45). Varenicline increased most other measures of quit attempts, motivation and abstinence, independent of site. The beneficial effects of varenicline in quit attempts appeared to be mediated by greater reductions in cigarettes/day, dependence, craving, and cigarette satisfaction. Varenicline had a greater effect on quit attempts in less-dependent smokers, in minority smokers, and in those who had less prior cessation or reduction activity. Adverse events were minimal.

CONCLUSIONS

Varenicline increased quit attempts in smokers who are not currently trying to quit at one of the two study sites and improved most all secondary outcomes independent of site. This appeared to be due to decreasing cigarettes/day and level of dependence.