Effects of Nicotine Patch vs Varenicline vs Combination Nicotine Replacement Therapy on Smoking Cessation at 26 Weeks: A Randomized Clinical Trial

Assessment of Racial Differences in Pharmacotherapy Efficacy for Smoking Cessation: Secondary Analysis of the EAGLES Randomized Clinical Trial

IMPORTANCE

Understanding Black vs White differences in pharmacotherapy efficacy and the underlying reasons is critically important to reducing tobacco-related health disparities.

OBJECTIVE

To compare pharmacotherapy efficacy and examine variables to explain Black vs White differences in smoking abstinence.

DESIGN, SETTING, AND PARTICIPANTS

This study is a secondary analysis of the Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES) double-blind, placebo-controlled, randomized clinical trial, which took place at clinical trial centers, academic centers, and outpatient clinics in 29 states in the US. US Black and White smokers who smoked 10 or more cigarettes per day with and without psychiatric comorbidity were enrolled between November 2011 and January 2015. Data analysis was performed from July 2019 to January 2020.

INTERVENTIONS

Participants were randomized (1:1:1:1) in a double-blind, triple-dummy, placebo- and active-controlled (nicotine patch) trial of varenicline and bupropion for 12 weeks with follow-up through week 24.

MAIN OUTCOMES AND MEASURES

Biochemically verified continuous cigarette abstinence rate (CAR) from weeks 9 to 24. Baseline, postbaseline treatment, and safety characteristics were examined as variables to explain race differences in abstinence.

RESULTS

Of the 1065 Black smokers enrolled, 255 were randomized to receive varenicline, 259 received bupropion, 286 received nicotine replacement therapy (NRT [ie, nicotine patch]), and 265 received placebo. Among the 3044 White smokers enrolled, 778 were randomized to receive varenicline, 769 received bupropion, 738 received NRT, and 759 received placebo. Participants were predominantly female (614 Black [57.7%] and 1786 White [58.7%] women) and heavy smokers (mean [SD] cigarettes per day, 18.2 [7.9] for Black and 20.0 [7.5] for White smokers), with a mean (SD) age of 47.2 (11.2) years for Black and 46.5 (12.7) years for White participants. Treatment and race were associated with CAR for weeks 9 to 24. The CAR was 4.9% lower for Black vs White participants (odds ratio [OR], 0.53; 95% CI, 0.41-0.69; P < .001); differences were found across all treatments. Pooling psychiatric and nonpsychiatric cohorts, varenicline (OR, 2.63; 95% CI, 1.90-3.63; P < .001), bupropion (OR, 1.75; 95% CI, 1.25-2.46; P = .001), and NRT (OR, 1.52; 95% CI, 1.07-2.16; P = .02) had greater efficacy than placebo for White participants. Only varenicline (OR, 2.63; 95% CI, 1.26-5.48; P = .01) had greater efficacy than placebo for Black participants. Baseline, postbaseline, and safety characteristics differed by race, but these variables did not eliminate the association of race with CAR. Black participants had 49% reduced odds of CAR for weeks 9 to 24 compared with White participants in the adjusted model (OR, 0.51; 95% CI, 0.39-0.66; P < .001).

CONCLUSIONS AND RELEVANCE

Black and White smokers achieved the highest rate of abstinence while taking varenicline, suggesting that it is the best first-line therapy for these groups. However, Black smokers were less responsive to all therapies, including placebo. Understanding variables (eg, socioeconomic or biological) beyond those may lead to improved treatment outcomes for Black smokers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01456936.

Pharmacological strategies for smoking cessation in patients with chronic obstructive pulmonary disease: a pragmatic review

Introduction: Chronic obstructive pulmonary disease (COPD) is progressive inflammatory disease of the lungs in which smoking plays a significant pathogenic role. Smoking cessation is the only therapeutic intervention which was demonstrated to interfere with disease progression. Smoking cessation intervention can benefit from pharmacological therapies such as nicotine replacement therapies, bupropion, or varenicline which can be given individually or in combination, their effectiveness being demonstrated in various clinical trials enrolling COPD patients.Areas covered: The authors provide a pragmatic discussion of the clinical data of the main studies evaluating therapies for smoking cessation within COPD starting with the seminal Lung Health Study and continuing with more recent ones.Expert opinion: Smoking cessation is one of the most difficult therapeutic interventions in COPD, despite having the highest impact on disease progression and despite the demonstrated benefit of the discussed pharmacological therapies. Potential approaches to maximize its chance of success might be represented by prolonging the time of administration, combinational options, or sequential pharmacotherapy.

Longitudinal effects of smoking cessation on carotid artery atherosclerosis in contemporary smokers: The Wisconsin Smokers Health Study

BACKGROUND AND AIMS

We quantified the effects of smoking and smoking cessation on carotid artery atherosclerosis and wall thickness in two unique cohorts of smokers making a quit attempt.

METHODS

Our primary analysis included 726 smokers making a quit attempt in a randomized clinical trial with long-term follow-up. Our secondary analysis included 889 smokers making a quit attempt in a subsequent trial. Participants underwent carotid artery ultrasonography at baseline and up to 3 subsequent visits. Primary outcomes were changes in carotid plaque score and intima media-thickness (IMT). We calculated a smoking burden score (SBS) that reflected the number of visits in which participants reported smoking after the quit attempt. Multivariable regression examined relations between SBS and carotid artery outcomes with adjustments for cardiovascular disease risk factors.

RESULTS

In the primary analysis, participants were mean (standard deviation) 46.1 (10.3) years old (57.9% female) and smoked 21.1 (8.9) cigarettes per day (CPD). After a median of 7 years, lower SBS predicted less increase in carotid plaque score (Chi-squared = 13.0, p = 0.012). SBS independently predicted change in carotid plaque score (p = 0.007; SBS 0 vs 4) as did baseline CPD (p = 0.024) and age (p<0.0001). SBS did not affect carotid IMT change. In the secondary analysis, increasing SBS was associated with increased likelihood of new plaques over 3 years among participants that smoked ≥15 CPD, (Chi-squared = 6.51, p = 0.011).

CONCLUSIONS

Smoking cessation is associated with less progression of carotid plaque, but not IMT. Salutary associations of smoking cessation with carotid plaque progression are related to degree of abstinence.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.

Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.

Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.

Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

Two weeks of image-guided left dorsolateral prefrontal cortex repetitive transcranial magnetic stimulation improves smoking cessation: A double-blind, sham-controlled, randomized clinical trial

BACKGROUND

Previous studies have found that repetitive transcranial magnetic stimulation (rTMS) to the left dorsal lateral prefrontal cortex (LDLPFC) transiently reduces smoking craving, decreases cigarette consumption, and increases abstinence rates.

OBJECTIVE

We investigated whether 10 daily MRI-guided rTMS sessions over two weeks to the LDLPFC paired with craving cues could reduce cigarette consumption and induce smoking cessation.

METHODS

We enrolled 42 treatment-seeking nicotine-dependent smokers (≥10 cigarettes per day) in a randomized, double-blind, sham-controlled trial. Participants received 10 daily sessions over 2 weeks of either active or sham MRI-guided rTMS (10Hz, 3000 pulses each session) to the LDLPFC concurrently with video smoking cues. The primary outcome was a reduction in biochemically confirmed cigarette consumption with a secondary outcome of abstinence on the target quit date. We also recorded cue-induced craving and withdrawal symptoms.

RESULTS

Compared to sham (n = 17), participants receiving active rTMS (n = 21) smoked significantly fewer cigarettes per day during the 2-week treatment (mean [SD], 13.73[9.18] vs. 11.06[9.29], P < .005) and at 1-month follow-up (12.78[9.53] vs. 7.93[7.24], P < .001). Active rTMS participants were also more likely to quit by their target quit rate (23.81%vs. 0%, OR 11.67, 90% CL, 0.96-141.32, x2 = 4.66, P = .031). Furthermore, rTMS significantly reduced mean craving throughout the treatments and at follow-up (29.93[13.12] vs. 25.01[14.45], P < .001). Interestingly across the active treatment sample, more lateral coil location was associated with more success in quitting (-43.43[0.40] vs. -41.79[2.24], P < .013).

CONCLUSIONS

Daily MRI-guided rTMS to the LDLPFC for 10 days reduces cigarette consumption and cued craving for up to one month and also increases the likelihood of smoking cessation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02401672.

Motivational Interviewing to Encourage Quit Attempts Among Smokers Not Ready to Quit: A Trial-Based Economic Analysis

INTRODUCTION

This study used data from a randomized controlled trial evaluating the efficacy of motivational interviewing (MI) relative to health education (HE) and brief advice (BA) to encourage quit attempts and cessation in order to determine their relative cost-effectiveness.

AIMS AND METHODS

Urban community residents (n = 255) with low desire to quit smoking were randomized to MI, HE, or BA which differed in communication style and/or number of treatment sessions. Incremental cost-effectiveness ratios were used to compare the intensive interventions (MI and HE) to BA for facilitating quit attempts and smoking cessation. Costs were calculated from the perspective of an agency that might engage in program delivery. Sensitivity analysis examined different assumptions for MI training and pharmacotherapy costs.

RESULTS

Total intervention delivery time costs per participant for MI, HE, and BA were $46.63, $42.87, and $2.4, respectively. Cost-effectiveness ratios per quit attempt at 24 weeks were $380 for MI, $272 for HE, and $209 for BA. The cost per additional quit attempt for MI and HE relative to BA was $508 and $301, respectively. The cost per additional quit for MI and HE relative to BA was $2030 and $752, respectively. Four separate sensitivity analyses conducted in our study did not change the conclusion the HE had a lower Incremental Cost-Effectiveness Ratio for both quit attempts and cessation.

CONCLUSIONS

HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable for smokers who are less motivated to quit. Providing valuable cost information in choosing different clinical methods for motivating smokers to quit.

IMPLICATIONS

All direct costs and activity-based time costs associated with delivering the intervention were analyzed from the perspective of an agency that may wish to replicate these strategies. A randomized controlled trial evaluating the efficacy of MI relative to HE and BA to encourage quit attempts and cessation determined their relative cost-effectiveness. HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable. Despite guideline recommendations, MI may not be the best approach to encourage quit attempts in diverse populations. Rather, a structured, intensive HE intervention might be the most cost-effective alternative.

More than Smoke and Patches: The Quest for Pharmacotherapies to Treat Tobacco Use Disorder

Tobacco use is a persistent public health issue. It kills up to half its users and is the cause of nearly 90% of all lung cancers. The main psychoactive component of tobacco is nicotine, primarily responsible for its abuse-related effects. Accordingly, most pharmacotherapies for smoking cessation target nicotinic acetylcholine receptors (nAChRs), nicotine's major site of action in the brain. The goal of the current review is twofold: first, to provide a brief overview of the most commonly used behavioral procedures for evaluating smoking cessation pharmacotherapies and an introduction to pharmacokinetic and pharmacodynamic properties of nicotine important for consideration in the development of new pharmacotherapies; and second, to discuss current and potential future pharmacological interventions aimed at decreasing tobacco use. Attention will focus on the potential for allosteric modulators of nAChRs to offer an improvement over currently approved pharmacotherapies. Additionally, given increasing public concern for the potential health consequences of using electronic nicotine delivery systems, which allow users to inhale aerosolized solutions as an alternative to smoking tobacco, an effort will be made throughout this review to address the implications of this relatively new form of nicotine delivery, specifically as it relates to smoking cessation. SIGNIFICANCE STATEMENT: Despite decades of research that have vastly improved our understanding of nicotine and its effects on the body, only a handful of pharmacotherapies have been successfully developed for use in smoking cessation. Thus, investigation of alternative pharmacological strategies for treating tobacco use disorder remains active; allosteric modulators of nicotinic acetylcholine receptors represent one class of compounds currently under development for this purpose.

Genetic Variant in CHRNA5 and Response to Varenicline and Combination Nicotine Replacement in a Randomized Placebo-Controlled Trial

It is unclear if genetic variants affect smoking cessation treatment response. This study tested whether variants in the cholinergic receptor nicotinic alpha 5 subunit (CHRNA5) predict response to smoking cessation medication by directly comparing the two most effective smoking cessation pharmacotherapies. In this genotype-stratified randomized, double-blind, placebo-controlled clinical trial (May 2015-August 2019 in St Louis, Missouri), smokers were randomized by genotype in blocks of six (1:1:1 ratio) to three conditions: 12 weeks of placebo (n = 273), combination nicotine patch and lozenge (combination nicotine replacement therapy, cNRT, n = 275), or varenicline (n = 274). All participants received counseling and were followed for 12 months. The primary end point was biochemically verified 7-day point prevalence abstinence at the end of treatment (EOT, week 12). Trial registration and eligibility criteria are on clinicaltrials.gov (https://clinicaltrials.gov/) (NCT02351167). We conducted the genetic analyses separately for 516 European ancestry (EA) smokers and 306 non-EA smokers (including 270 African American smokers). In African American smokers, there was a genotype-by-treatment interaction for EOT abstinence (χ²  = 10.7, degrees of freedom = 2. P = 0.0049): specifically, cNRT was more effective in smokers with rs16969968 GG genotype than was placebo, while varenicline was more effective in smokers of GA/AA genotypes. In EA ancestry smokers, there was no significant genotype-by-treatment interaction. In the whole sample, although both were effective at EOT, only varenicline, and not cNRT, was significantly effective relative to placebo at 6-month follow-up. Importantly, this study suggests that genetic information can further enhance smoking cessation treatment effectiveness.

Searching for Personalized Medicine for Binge Drinking Smokers: Smoking Cessation Using Varenicline, Nicotine Patch, or Combination Nicotine Replacement Therapy

OBJECTIVE

Heavy drinking is common among smokers and is associated with especially poor health outcomes. Varenicline may affect mechanisms and clinical outcomes that are relevant for both smoking cessation and alcohol use. The current study examines whether varenicline, relative to nicotine replacement therapy, yields better smoking cessation outcomes among binge drinking smokers.

METHOD

Secondary data analyses of a comparative effectiveness randomized controlled trial of three smoking cessation pharmacotherapies (12 weeks of varenicline, nicotine patch, or nicotine patch and lozenge) paired with six counseling sessions were conducted. Adult daily cigarette smokers (N = 1,078, 52% female) reported patterns of alcohol use, cigarette craving, and alcohol-related cigarette craving at baseline and over 4 weeks after quitting. Smoking cessation outcome was 7-day biochemically confirmed point-prevalence abstinence.

RESULTS

Binge drinkers had higher relapse rates than moderate drinkers at 4-week post-target quit day but not at the end of treatment or long-term follow up (12 and 26 weeks). Varenicline did not yield superior smoking cessation outcomes among binge drinkers, nor did it affect alcohol use early in the quit attempt. Varenicline did produce relatively large reductions in alcohol-related cigarette craving and overall cigarette craving during the first 4 weeks after quitting.

CONCLUSIONS

Varenicline did not yield higher smoking abstinence rates or reduce alcohol use among binge drinkers. Varenicline did reduce alcohol-related cigarette craving but this did not translate to meaningful differences in smoking abstinence. Varenicline's effects on smoking abstinence do not appear to vary significantly as a function of drinking status.

Anxiety Sensitivity and Distress Tolerance in Smokers: Relations With Tobacco Dependence, Withdrawal, and Quitting Success†

INTRODUCTION

This study examined relations of two affective vulnerabilities, high anxiety sensitivity (AS) and low distress tolerance (DT), with tobacco dependence, withdrawal, smoking cessation, and pharmacotherapy response.

METHODS

Smokers interested in quitting (N = 1067; 52.2% female, 28.1% African American) were randomized to 12 weeks of nicotine patch, nicotine patch plus nicotine lozenge, or varenicline. Baseline questionnaires assessed AS, DT, negative affect, anxiety, and dependence. Withdrawal was assessed the first-week post-quit via ecological momentary assessment.

RESULTS

DT, but not AS, predicted biochemically confirmed point-prevalence abstinence at multiple endpoints: weeks 4, 12, 26, and 52 post-quit (ps < .05); relations remained after controlling for pharmacotherapy treatment, AS, baseline negative affect, anxiety, and anxiety disorder history (ps < .05). Additional exploratory analyses examining week 4 abstinence showed DT predicted abstinence (p = .004) even after controlling for baseline dependence, post-quit withdrawal (craving and negative affect), and treatment. DT moderated treatment effects on abstinence in exploratory analyses (interaction p = .025); those with high DT were especially likely to be abstinent at week 4 with patch plus lozenge versus patch alone.

CONCLUSIONS

DT, but not AS, predicted abstinence over 1 year post-quit (higher DT was associated with higher quit rates), with little overlap with other affective measures. DT also predicted early abstinence independent of dependence and withdrawal symptoms. Results suggest low DT may play a meaningful role in motivation to use tobacco and constitute an additional affective risk factor for tobacco cessation failure beyond negative affect or clinical affective disorders.

IMPLICATIONS

People in a stop-smoking study who reported a greater ability to tolerate distress were more likely to quit smoking and remain smoke-free 1 year later. Smokers with high DT were more likely to be smoke-free 4 weeks after their target quit day if they received nicotine patch plus nicotine lozenge rather than nicotine patch alone.

TRIAL REGISTRATION

NCT01553084.

Factors That Explain Differences in Abstinence Between Black and White Smokers: A Prospective Intervention Study

BACKGROUND

Black-white differences in smoking abstinence are not well understood. This trial sought to confirm previously reported differences in quitting between blacks and whites and to identify factors underlying this difference.

METHODS

During enrollment, 224 black and 225 white low-income smokers were stratified on race and within race on age and sex to ensure balance on these factors known to impact abstinence. The intervention included varenicline for 12 weeks and six guideline-based smoking cessation counseling sessions. The primary endpoint was cotinine-verified 7-day point prevalence smoking abstinence at week 26. A priori socioeconomic, smoking, treatment process (eg, treatment utilization, side effects, withdrawal relief), psychosocial, and biological factors were assessed to investigate race differences in abstinence. Unadjusted odds ratios (OR) were used to compare abstinence between blacks and whites. Adjusted odds ratios from logistic regression models were used to examine predictors of abstinence. All statistical tests were two-sided.

RESULTS

Blacks were less likely to achieve abstinence at week 26 (14.3% vs 24.4%, OR = 0.51, 95% confidence interval [CI] = 0.32 to 0.83, P = .007). Utilizing best subsets logistic regression, five factors associated with race jointly predicted abstinence: home ownership (yes/no, OR = 3.03, 95% CI = 1.72 to 5.35, P < .001), study visits completed (range = 0-6, OR = 2.81, 95% CI = 1.88 to 4.20, P < .001), income (household member/$1000, OR = 1.03, 95% CI = 1.01 to 1.06, P = .02), plasma cotinine (per 1 ng/mL, OR = 0.997, 95% CI = 0.994 to 0.999, P = .002), and neighborhood problems (range = 10-30, OR = 0.88, 95% CI = 0.81 to 0.96, P = .003).

CONCLUSIONS

The race difference in abstinence was fully explained by lack of home ownership, lower income, greater neighborhood problems, higher baseline cotinine, and higher visit completion, which were disproportionately represented among blacks. Findings illuminate factors that make it harder for blacks in the United States to quit smoking relative to whites and provide important areas for future studies to reduce tobacco-related health disparities.

Pharmacovigilance Assessment of Cardiac Implications of Nicotine Replacement Therapy Among Smokers

PURPOSE

The purpose of this quantitative comparative study was to examine the possible relationship between nicotine replacement therapy (NRT) and cardiac disorder risk by comparing the rates of cardiac disorder risk of NRT with cardiac disorder risk of non-replacement drugs among smokers seeking smoking cessation.

METHODS

The study used retrospective quantitative design, which involved the collection of secondary data from the adverse event reporting system (FAERS) database of the U.S Food and Drug Administration (FDA). Rates of cardiac disorder were compared between the NRT group and non- NRT (varenicline and bupropion) group. Statistical analyses involved using a 2x2 contingency table and logistic regression to calculate odds ratio (reporting odds ratio (ROR)).

RESULTS AND DISCUSSION

Unadjusted ROR was 0.45 (95% confidence interval [CI] 0.28, 0.70). With age and sex as confounding factors, the smokers in the NRT group still had lower odds of having cardiac disorder risk than the non-NRT group (adjusted ROR=0.44, 95% CI 0.28, 0.70).

CONCLUSION

Our study findings showed lower cardiac disorder risk with the NRT group compared to the non-NRT (varenicline and bupropion) group. While the study did not aim to undermine either using NRT or non-NRT for smoking cessation therapy to prevent smoking illness, the study results offer informed findings that could potentially improve current smoking cessation management using NRT intervention among smokers and enhance smokers' health outcome. Despite the negative signal detection of cardiac disorder risk with NRT as compared to non-NRT in final findings, we still recommend further research on the causal relationship between NRT and non-NRT and cardiac disorder risk.

Quitting Failure and Success With and Without Using Medication: Latent Classes of Abstinence and Adherence to Nicotine Monotherapy, Combination Therapy, and Varenicline

INTRODUCTION

Nonadherence to pharmacotherapies complicates studies of comparative pharmacotherapy effectiveness. Modeling adherence and abstinence simultaneously may facilitate analysis of both treatment acceptability and effectiveness.

METHODS

Secondary analyses of a three-arm randomized comparative trial of nicotine patch, varenicline, and combination nicotine patch and lozenge among adult daily smokers (N = 1086) were conducted. Adherence rates collected via interactive voice response systems during the first 27 days of quitting were compared across treatment conditions. Repeated measures latent class analyses of adherence and abstinence in 3-day parcels through 27 days of a quit attempt were conducted with treatment, demographic, and smoking history covariates.

RESULTS

Adherence varied across treatments and was lowest for nicotine lozenge use in combination nicotine replacement therapy (NRT). Five latent classes that differed significantly in 6-month abstinence rates were retained, including three subgroups of adherent participants varying in treatment response and two nonadherent groups varying in abstinence probabilities. Nonadherence was more likely among those receiving varenicline and combination NRT, relative to patch monotherapy. Varenicline and combination NRT did not promote abstinence among adherent latent classes but did promote abstinence among those partially adherent, relative to patch alone. Combination therapy attenuated increased risk of treatment disengagement with more years smoking. Minority smokers, those high in dependence, and those with shorter past abstinence were at increased risk for low-adherence and low-abstinence latent classes.

CONCLUSIONS

Varenicline and combination nicotine patch and lozenge are less likely to be used as directed and may not increase first-month abstinence better than patch alone when taken adherently.

IMPLICATIONS

This secondary analysis of adherence and abstinence in a comparative effectiveness trial shows that adherence is highest for the nicotine patch, next highest for varenicline, and lowest for combination nicotine patch and lozenge therapy due to low lozenge use. Distinct latent classes were found that varied in both first-month abstinence and adherence. Varenicline and combination NRT may not enhance abstinence over patch alone among smokers who take medication adherently. Adherent use of medication especially benefits those who are low in dependence and have positive quitting histories; it is less beneficial to at-risk smokers and members of racial minorities.

Psychiatric comorbidities in a comparative effectiveness smoking cessation trial: Relations with cessation success, treatment response, and relapse risk factors

BACKGROUND

Comorbid psychiatric diagnoses have been shown to predict cessation failure. The relative impact of various diagnoses on cessation and other cessation processes is rarely studied, particularly among a general population. The impact of psychiatric history among primary care patients seeking cessation services on nicotine dependence, cessation outcomes, treatment effects and adherence, and withdrawal symptoms was examined.

METHODS

Secondary data analysis of a multi-site comparative effectiveness smoking cessation trial was conducted. Adult smokers (n  = 1051; 52.5 % Female, 68.1 % white) completed a structured clinical interview at baseline to assess psychiatric diagnostic history (past-year and lifetime). Nicotine dependence was assessed via self-report measures at baseline. Point-prevalence abstinence was assessed at 8 weeks and 6 months post-quit. Withdrawal symptoms were assessed for one week pre- and post-quit using ecological momentary assessment. Treatment adherence was self-reported at 1, 4, 8, and 12 weeks post-quit.

RESULTS

Past-year substance use disorder, lifetime mood disorder, and > one lifetime diagnosis, were related to lower rates of short-term, but not long-term, cessation. Lifetime psychiatric diagnosis was related to elevated nicotine dependence, particularly to secondary dependence motives associated with instrumental tobacco use. History of psychiatric diagnosis was associated with increased withdrawal-related craving. There was little evidence that psychiatric diagnostic status moderated the effects of the tested pharmacotherapies on long-term abstinence.

CONCLUSIONS

Psychiatric diagnoses affect risk factors that exert their effects early in the post-quit process and highlight the potential utility of examining transdiagnostic risk factors to better understand the relations between psychiatric vulnerabilities and the smoking cessation process.

Varenicline versus nicotine replacement therapy for long-term smoking cessation: an observational study using the Clinical Practice Research Datalink

BACKGROUND

Smoking is the leading avoidable cause of illness and premature mortality. The first-line treatments for smoking cessation are nicotine replacement therapy and varenicline. Meta-analyses of experimental studies have shown that participants allocated to the varenicline group were 1.57 times (95% confidence interval 1.29 to 1.91 times) as likely to be abstinent 6 months after treatment as those allocated to the nicotine replacement therapy group. However, there is limited evidence about the effectiveness of varenicline when prescribed in primary care. We investigated the effectiveness and rate of adverse events of these medicines in the general population.

OBJECTIVE

To estimate the effect of prescribing varenicline on smoking cessation rates and health outcomes.

DATA SOURCES

Clinical Practice Research Datalink.

METHODS

We conducted an observational cohort study using electronic medical records from the Clinical Practice Research Datalink. We extracted data on all patients who were prescribed varenicline or nicotine replacement therapy after 1 September 2006 who were aged ≥ 18 years. We investigated the effects of varenicline on smoking cessation, all-cause mortality and cause-specific mortality and hospitalisation for: (1) chronic lung disease, (2) lung cancer, (3) coronary heart disease, (4) pneumonia, (5) cerebrovascular disease, (6) diabetes, and (7) external causes; primary care diagnosis of myocardial infarction, chronic obstructive pulmonary disease, depression, or prescription for anxiety; weight in kg; general practitioner and hospital attendance. Our primary outcome was smoking cessation 2 years after the first prescription. We investigated the baseline differences between patients prescribed varenicline and patients prescribed nicotine replacement therapy. We report results using multivariable-adjusted, propensity score and instrumental variable regression. Finally, we developed methods to assess the relative bias of the different statistical methods we used.

RESULTS

People prescribed varenicline were healthier at baseline than those prescribed nicotine replacement therapy in almost all characteristics, which highlighted the potential for residual confounding. Our instrumental variable analysis results found little evidence that patients prescribed varenicline had lower mortality 2 years after their first prescription (risk difference 0.67, 95% confidence interval -0.11 to 1.46) than those prescribed nicotine replacement therapy. They had similar rates of all-cause hospitalisation, incident primary care diagnoses of myocardial infarction and chronic obstructive pulmonary disease. People prescribed varenicline subsequently attended primary care less frequently. Patients prescribed varenicline were more likely (odds ratio 1.46, 95% confidence interval 1.42 to 1.50) to be abstinent 6 months after treatment than those prescribed nicotine replacement therapy when estimated using multivariable-adjusted for baseline covariates. Patients from more deprived areas were less likely to be prescribed varenicline. However, varenicline had similar effectiveness for these groups.

CONCLUSION

Patients prescribed varenicline in primary care were more likely to quit smoking than those prescribed nicotine replacement therapy, but there was little evidence that they had lower rates of mortality or morbidity in the 4 years following the first prescription. There was little evidence of heterogeneity in effectiveness across the population.

FUTURE WORK

Future research should investigate the decline in prescribing of smoking cessation products; develop an optimal treatment algorithm for smoking cessation; use methods for using instruments with survival outcomes; and develop methods for comparing multivariable-adjusted and instrumental variable estimates.

LIMITATIONS

Not all of our code lists were validated, body mass index and Index of Multiple Deprivation had missing values, our results may suffer from residual confounding, and we had no information on treatment adherence.

TRIAL REGISTRATION

This trial is registered as NCT02681848.

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. 24, No. 9. See the NIHR Journals Library website for further project information.

Non-inferiority trial comparing cigarette consumption, adoption rates, acceptability, tolerability, and tobacco harm reduction potential in smokers switching to Heated Tobacco Products or electronic cigarettes: Study protocol for a randomized controlled trial

Background

Despite the introduction of tobacco control measures, smoking remains highly prevalent in most EU countries. In Italy, one in four adults were still regular smokers in 2017. Increasing use of combustion-free delivering nicotine technologies for cigarette substitution may accelerate the current downward trends in smoking prevalence. Whether Heated Tobacco Products (HTPs) are more effective tobacco smoking substitutes that may potentially facilitate adoption and full conversion compared to e-cigarettes (ECs) is not known.

We have designed a prospective study to compare changes in cigarette consumption and adoption rates among smokers randomized to either HTPs or ECs. Product acceptability, tolerability, and their tobacco harm reduction potential will be also compared.

Methods

220 healthy smokers, not motivated to quit, will be randomized into a 12-weeks single-center, open label, non-inferiority trial comparing study outcomes from HTPs vs. ECs use. The primary outcome will be biochemically verified self-reported continuous abstinence at 12-weeks from the previous visit. Secondary outcomes will include: smoking reduction from baseline, adoption rates and product acceptability, tolerability, changes in step test values and in the level of selected biomarkers of exposure in exhaled breath (i.e. eCO) and in spot urine samples. A follow-up visit will be also included at 24-weeks to review product usage and smoking behavior under naturalistic condition of use.

Recruitment of participants started in May 2019 and enrolment is expected to be completed in November 2019.

Discussion

This will be the first study directly comparing Heated Tobacco Products with Electronic Cigarettes in term of reduction in cigarette consumption, adoption rates, product acceptability, tolerability, and tobacco harm reduction potential. This knowledge can contribute to a better understanding of the potential role of this new technology in the evolving nicotine consumer market.

Trial registration

ClinicalTrials.gov ID: NCT03569748.

Registered June 25, 2018.

https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=1&cx=-jg9qo4.

Comparative Effectiveness of Varenicline and Nicotine Replacement Therapy for Smoking Cessation in Older and Younger Smokers: A Prospective Cohort in Taiwan

Introduction

The effectiveness of varenicline compared with nicotine replacement therapy (NRT) in achieving smoking cessation in older smokers has not been investigated. This study prospectively compared the effectiveness of varenicline relative to NRT in smokers aged 25–54 years and separately in smokers aged 55 years or older.

Methods

Among 13 397 smokers participating in the Smoking Cessation Program in Taiwan, 2012–2015, 6336 (19.2%, aged ≥55) received varenicline and 7061 received NRT patch or gum (23.2%, aged ≥55). Participants self-reported smoking behaviors by phone interview after 6 months. Logistic regression models estimated odds ratios (ORs) and 95% confidence intervals (CIs) for 7-day, 1-month, and 6-month point-prevalence abstinence. Age-specific models adjusted for sex, education, marital status, smoke-years, nicotine dependence, medical institution, clinic visit number, and duration of medication received.

Results

Among smokers aged 25–54 years, varenicline users had a greater point-prevalence abstinence than NRT users (e.g., 7-day point-prevalence: 34.0% vs. 23.5%), with adjusted OR ranging from 1.23 (CI: 1.09–1.39; 6-month point-prevalence) to 1.37 (CI: 1.24–1.50; 1-month point-prevalence). Among smokers aged 55 years or older, point-prevalence was similar for varenicline and NRT users (e.g., 7-day point-prevalence: 32.3% vs. 33.1%), and ORs did not suggest that varenicline has greater effectiveness than NRT. Sex and level of nicotine dependence did not modify the age-specific effectiveness of varenicline relative to NRT.

Conclusions

Varenicline did not offer greater effectiveness in achieving abstinence than NRT for smokers 55 years or older, whereas it was more effective than NRT in smokers aged 25–54 years. These findings highlighted the need for age-specific approaches for effective tobacco control.

Implications

In this prospective investigation of a national cohort, older smokers (aged ≥55 years) who received varenicline did not have a greater point-prevalence abstinence after 6 months compared with those who used NRT patch or gum. Younger smokers (aged 25–54 years) who received varenicline had a greater likelihood of abstinence than NRT users. Sex and nicotine dependence did not modify the age-specific effectiveness of varenicline relative to NRT patch or gum. Age-appropriate approaches for effective tobacco control are needed.

Longitudinal Effects of Cigarette Smoking and Smoking Cessation on Aortic Wave Reflections, Pulse Wave Velocity, and Carotid Artery Distensibility

Background We evaluated the effects of smoking and smoking cessation on aortic wave reflections (augmentation index), aortic pulse wave velocity, and carotid artery distensibility and stiffness (distensibility coefficient, Young's elastic modulus). Methods and Results Current smokers underwent carotid, radial, and femoral artery tonometry and carotid ultrasound at baseline and 3 years after a quit attempt. Baseline associations of smoking heaviness markers (exhaled carbon monoxide and cigarettes smoked/d) and effects of smoking cessation at year 3 on changes in arterial measures were assessed using multivariable linear regression models. The 1417 smokers (54% female) were mean (SD) 49.3 (11.6) years old and smoked 17.2 (8.3) cigarettes/d (exhaled carbon monoxide 14.7 [8.2] parts per million). Arterial measures were associated more strongly with age, blood pressure (BP), and waist circumference than with smoking heaviness markers. Augmentation index was associated independently with carbon monoxide (P=0.004). Pulse wave velocity, distensibility coefficient, and Young's elastic modulus had small, inconsistent associations with smoking heaviness markers. At year 3, augmentation index improved with smoking cessation (P=0.006) despite more weight gain (2.54 vs 0.36 kg, P<0.001) and insulin resistance (P=0.001) among abstainers, but distensibility coefficient decreased (P=0.004). Changes in arterial measures were related more strongly to changes in BP than smoking cessation. Conclusions Arterial wave reflection and stiffness measures were associated more strongly with age, BP, and waist circumference than smoking heaviness. Smoking cessation was associated with weight gain and increased insulin resistance. Changes in arterial measures were predicted by changes in BP, highlighting the need to address weight gain and BP changes during a quit attempt.

Identifying sequential episodes of pharmacotherapy as a method for assessing treatment failure in comparative effectiveness research

PURPOSE

To describe and implement a novel method of measuring comparative effectiveness using sequential episodes of pharmacotherapy as a proxy for treatment failure.

METHODS

Retrospective cohort study using linked deidentified data from the British Columbia Ministry of Health during a government-sponsored smoking cessation reimbursement program.Three study cohorts were created based on first use of varenicline, bupropion, or nicotine replacement therapy (NRT), for adults aged 18 or older, in the period September 30th, 2011 to March 31st, 2013. The study cohorts were analyzed for sequential episodes of pharmacotherapy, defined as re-initiating a smoking cessation pharmacotherapy after an initial episode of treatment and washout period. The statistical analysis used propensity score adjusted log-binomial regression models with one-year and two-year fixed follow-up after a 12-week washout period. A sensitivity analysis excluded the washout period. A secondary analysis investigated predictors of receiving a sequential episode of smoking cessation pharmacotherapy RESULTS: 116,442 participants of the B.C. Smoking Cessation Program were analyzed. Compared to NRT, varenicline users were 13% less likely, and bupropion users were 18% less likely, to re-start smoking cessation therapy within 1-year after an initial course of treatment.

CONCLUSIONS

Sequential episodes of pharmacotherapy identified treatment failures to smoking cessation therapy. Based on sequential episodes of pharmacotherapy during a drug benefit policy of smoking cessation medications, varenicline and bupropion were more effective aids to smoking cessation than NRT. The method was also used to identify patient characteristics associated with treatment effectiveness.

Combination therapy of varenicline and bupropion in smoking cessation: A meta-analysis of the randomized controlled trials

BACKGROUND

The effects of the combination therapy of varenicline and bupropion in smoking cessation are still controversial.

METHODS

Databases including PubMed, EMBASE, Cochrane Library and Web of Science were scanned without time and language limitation. Subgroup analysis was performed to assess the effect of combination therapy in smokers with different level of nicotine dependence and cigarette consumption.

RESULTS

Four randomized controlled trials involving a total of 1230 smokers were included. Compared with varenicline monotherapy, combination treatment with varenicline and bupropion could significantly improve the abstinence rate at the end of treatment (RR 1.153, 95% CI 1.019 to 1.305, P=0.024). The benefit existed at 6months follow-up (RR 1.231, 95% CI 1.017 to 1.490, P=0.033), disappeared at 12months follow-up (RR 1.130, 95% CI 0.894 to 1.428, P=0.305), and mainly concentrated in highly dependent smokers (RR 1.631, 95% CI 1.290 to 2.061, P<0.001) and heavy smokers (RR 1.515, 95% CI 1.226 to 1.873, P<0.001) rather than individuals with low nicotine dependence (RR 0.989, 95% CI 0.815 to 1.199, P=0.907) or low cigarette consumption (RR 0.985, 95% CI 0.800 to 1.212, P=0.252). For safety outcomes, the combination treatment was associated with more anxiety (RR 1.717, 95% CI 1.176 to 2.505, P=0.005) and insomnia (RR 1.268, 95% CI 1.076 to 1.494, P=0.005) symptoms compared with varenicline monotherapy.

CONCLUSION

Compared with varenicline monotherapy, combination treatment with varenicline and bupropion can significantly improve the abstinence rate at the end of treatment and 6months follow-up, mainly in highly dependent smokers and heavy smokers.

Factors associated with smoking cessation and relapse in the Japanese smoking cessation treatment program: A prospective cohort study based on financial support in Suita City, Japan

INTRODUCTION

The purpose of this study is to clarify the effect of providing financial support and factors associated with smoking cessation and relapse in the Japanese smoking cessation treatment (SCT) program based on financial support.

METHODS

A prospective cohort study was conducted at the smoking cessation outpatients of hospitals or clinics in Suita City, Japan from May 2017 to September 2018. In all, 153 participants were recruited and received standardized treatment based on the SCT program. Participants were required to answer four questionnaires and register for the financial support program. Chi-squared test, Fisher’s exact test, non-paired t-test and log-binomial regression analysis were used to analyze the data.

RESULTS

Of the 153 participants, 140 participants completed a 12-week treatment and the completion rate was 91.5%. There were no factors significantly associated with smoking cessation and relapse (p<0.05). However, male, cigarettes smoked per day, having present diseases, having previous abstinence, living with family, cohabitation with smokers, desire to smoke at the start of treatment, self-efficacy at the start of treatment, desire to smoke at 4 weeks and self-efficacy at 4 weeks showed statistically significant odds ratio for success of smoking cessation. Similarly at 12 weeks, male, age at smoking initiation, cigarettes smoked per day, having previous abstinence, living with family, cohabitation with smokers, desire to smoke, self-efficacy and depression disorders showed statistically significant odds ratio for smoking relapse. In addition, the rate of abstainers using varenicline was 68.60%, which was higher than abstainers using nicotine patch (55.60%) and the relapse rate of participants using nicotine patch was 100.00%, significantly higher than for relapsers using varenicline (45.80%).

CONCLUSIONS

Further study is expected to clarify the effect of providing financial support and the factors associated with smoking cessation and relapse in the SCT program based on financial support.

Combined nicotine patch with gum versus nicotine patch alone in smoking cessation in Hong Kong primary care clinics: a randomised controlled trial

Background

The prevalence of daily cigarette smoking has dropped to 10% in Hong Kong (HK) in 2017, however, smoking still kills 5700 persons per year. Studies suggest that abstinence rates are higher with combined NRT than single NRT, although local data on safety and benefits of combined NRT are lacking. The aim of this study is to compare the effectiveness of combined NRT with single NRT among HK Chinese.

Methods

This is a one-year, two-arm, parallel randomised trial. Five hundred sixty smokers, who smoked ≥10 cigarettes/day for ≥1 year, were randomized to combined and single NRT. Combined NRT group received counseling and nicotine patch & gum. Single NRT group received counselling and nicotine patch. Primary outcome was abstinence rate measured as self-reported 7-day point prevalence with CO validated at 52 weeks. Secondary outcomes included smoking abstinence rates at 4, 12, & 26 weeks. Crude odds ratio and p-value were reported from logistic regression without adjustment; for trend analysis, adjusted odds ratio (AOR) and p-value were reported from Generalized Estimating Equation (GEE) (controlling for time). All AORs were adjusted for age, sex, baseline CO and clusters.

Results

Abstinence rates at 4, 12, 26 and 52 weeks were all higher in the combined NRT group (35.8, 21.9, 16.8, 20.1%) compared with the single NRT group (28, 16.8, 11.2, 14.3%). At 4 weeks, combined NRT group was more likely to quit smoking (OR 1.43, 95% CI, 1.00 to 2.05) than the single NRT group. From GEE analysis, combined NRT group had a significantly higher abstinence rate (23.6%) than the single NRT group (17.6%) across repeated measures at all-time points. Combined NRT group was more likely to quit smoking (OR 1.43, 95% CI, 1.15 to 1.77). No significant difference in the side effect profile was detected between groups.

Conclusions

Smokers given 8 weeks of combined NRT were more likely to quit smoking at 4, 12, 26 and 52 weeks compared with single NRT. Combined NRT was as well tolerated as single NRT and it should be further promoted in our community.

Trial registration

NCT03836560 from ClinicalTrial.gov, 9 Feb 2019.

Treatment With Bupropion and Varenicline for Smoking Cessation and the Risk of Acute Cardiovascular Events and Injuries: a Swedish Case-Crossover Study

Introduction

Bupropion and varenicline are non-nicotine medications used for smoking cessation that mitigate craving and withdrawal symptoms. We aim to investigate whether these drugs increase the risk of selected acute adverse outcomes when used in medical practice.

Methods

Population-based case-crossover design using data from Swedish health and administrative registers. Adult individuals diagnosed with acute myocardial infarction, stroke, suicide, suicide attempt, fall injury, or that suffered a road traffic crash from 01.10.2006 for bupropion, or from 01.03.2008 for varenicline, until 31.12.2013 were included. Different lengths of exposure periods were analyzed within the 12-week hazard period prior to the adverse outcome (1-14, 15-28, and 29-84 days). The control period was matched using the interval preceding the hazard period (85-168 days), and breaking it up into equivalent periods (85-98, 99-112, and 113-168 days). Conditional logistic regression with each case considered as one stratum was used to estimate adjusted odds ratios (OR) and confidence intervals (CI).

Results

Neither medication was associated with consistent higher risks for any of the adverse outcomes. For bupropion and varenicline, respectively, in the 1-14 days hazard period, OR (95% CI) were: myocardial infarction 1.14 (0.55 to 2.34) and 1.06 (0.70 to 1.62); stroke 1.16 (0.39 to 3.47) and 1.26 (0.72 to 2.17), and traffic crashes 0.85 (0.39 to 1.85) and 1.48 (0.90 to 2.41). In the other periods, ORs were similar or even lower. For falls and suicidal events ORs were generally below one for both drugs.

Conclusion

The available evidence suggests that if prescription guidelines are properly followed regarding potential contraindications both of these medications could be considered relatively safe.

Implications

The reliable exposure and diagnosis assessment used in this nationwide register-based study, along with the number of cases gathered makes this sample one of the largest of its type to assess potential side effects associated with the use of these drugs. Neither medication was associated with consistent higher risks for any of the adverse outcomes studied.

Treatment adherence and short-term outcomes of smoking cessation outpatient clinic patients

INTRODUCTION

Previous studies have shown that adherence to treatment is fundamental to success in smoking cessation. However, smoking cessation medication regimens are limited significantly by the struggle to adhere to them. This study was conducted to evaluate the factors associated with treatment adherence and quitting success in a group of patients that applied to our smoking cessation outpatient clinic (SCC).

METHODS

Patients that applied to SCC between April 2015 and December 2016 who were evaluated, found suitable for smoking cessation interventions and started pharmacological treatment were included in this study. Only those who could be reached by phone three months after their first application became participants. Those who had used the prescribed treatment for at least 30 days were grouped as treatment-adherent.

RESULTS

In total, data for 346 patients were evaluated. Mean (±SD) age was 44.3±13.9 years; most of them were male (63%), primary school graduated (36.1%), self-employed (43.7%), and had no comorbid diseases (71%). Bupropion was started in 52% of the patients, that rate was 35.8% for varenicline and 12.1% for a combination of the nicotine patch and gum. Mean days for treatment use was 20.9±18.5; 59% of the patients were non-adherent to their treatment and 51.7% had only one control visit number. Adverse reactions due to treatment were recorded in 25% of participants, and at their third month 37.9% of them had quit smoking. In multivariate logistic regression analysis, increase in control visit number, absence of adverse reaction, and varenicline use, were each associated with higher treatment adherence (p<0.001) and only being in the treatment-adherent group was associated with quit success (OR=3.01, 95% CI: 1.88–4.81, p=0.001).

CONCLUSIONS

This study showed that most patients did not use their prescribed SC treatments adequately; a main factor that affects quit success is treatment adherence. There is a need for closer monitoring and follow-up to ensure adequate use of treatment of patients.

Changes in carotid artery structure with smoking cessation

Carotid artery grayscale ultrasound echogenicity and texture features predict cardiovascular disease events. We evaluated the longitudinal effects of smoking cessation on four grayscale ultrasound measures. This was a secondary analysis of data from 188 age, sex, and body mass index (BMI)-matched smokers (94 eventual abstainers [EA], 94 continued smokers [CS]) from a smoking cessation trial that had carotid ultrasound examinations at baseline and after 3 years. General linear models that included time, smoking group (EA or CS), and a time*smoking interaction term were used to examine the impact of smoking abstinence on carotid artery grayscale marker values at year 3. Participants were mean (SD) 50.3 (11.4) years old (57% female, 86% white). The baseline grayscale median value (GSM) was inversely correlated with age, BMI, insulin resistance, and smoking pack-years (r = -0.20 to -0.30, p < 0.007 for all). There was a significant time*smoking status interaction for predicting GSM at year 3: GSM decreased significantly in the EA group compared to the CS group (-3.63 [13.00] vs CS 0.39 [12.06] units; p = 0.029). BMI increased more in the EA than the CS group (2.42 [3.00] vs CS 0.35 [2.57] kg/m²; p < 0.001). After adjusting for changes in BMI, the time*smoking status interaction no longer was significant (p = 0.138). From baseline to year 3, contrast increased similarly in both groups. Entropy and angular second moment did not change significantly in either group. Changes in carotid ultrasound echogenicity and grayscale texture features during a smoking cessation attempt are modest and mostly related to weight gain. Clinicaltrials.gov Identifier: NCT01553084.

Smoking cessation interventions for potential use in the lung cancer screening setting: A systematic review and meta-analysis

OBJECTIVES

Current guidelines recommend delivery of smoking cessation interventions with lung cancer screening (LCS). Unfortunately, there are limited data to guide clinicians and policy-makers in choosing cessation interventions in this setting. Several trials are underway to fill this evidence gap, but results are not expected for several years.

METHODS AND MATERIALS

We conducted a systematic review and meta-analysis of current literature on the efficacy of smoking cessation interventions among populations eligible for LCS. We searched PubMed, Medline, and PsycINFO for randomized controlled trials of smoking cessation interventions published from 2010-2017. Trials were eligible for inclusion if they sampled individuals likely to be eligible for LCS based on age and smoking history, had sample sizes >100, follow-up of 6- or 12-months, and were based in North America, Western Europe, Australia, or New Zealand.

RESULTS

Three investigators independently screened 3,813 abstracts and identified 332 for full-text review. Of these, 85 trials were included and grouped into categories based on the primary intervention: electronic/web-based, in-person counseling, pharmacotherapy, and telephone counseling. At 6-month follow-up, electronic/web-based (odds ratio [OR] 1.14, 95% CI 1.03-1.25), in-person counseling (OR 1.46, 95% CI 1.25-1.70), and pharmacotherapy (OR 1.53, 95% CI 1.33-1.77) interventions significantly increased the odds of abstinence. Telephone counseling increased the odds but did not reach statistical significance (OR 1.21, 95% CI 0.98-1.50). At 12-months, in-person counseling (OR 1.28 95% CI 1.10-1.50) and pharmacotherapy (OR 1.46, 95% CI 1.17-1.84) remained efficacious, although the decrement in efficacy was of similar magnitude across all intervention categories.

CONCLUSIONS

Several categories of cessation interventions are promising for implementation in the LCS setting.

Therapeutic challenges for concurrent ethanol and nicotine consumption: naltrexone and varenicline fail to alter simultaneous ethanol and nicotine intake by female alcohol-preferring (P) rats

RATIONALE AND OBJECTIVES

Simultaneous alcohol and nicotine consumption occurs in the majority of individuals with alcohol use disorder (AUD) and nicotine dependence. Varenicline (Var) is used to assist in the cessation of nicotine use, while naltrexone (Nal) is the standard treatment for AUD. Despite evidence that ethanol (EtOH) and nicotine (NIC) co-use produces unique neuroadaptations, preclinical research has focused on the effects of pharmacotherapeutics on a single reinforcer. The current experiments examined the effects of Var and Nal on EtOH, NIC, or EtOH+NIC intake.

METHODS

Animals were randomly assigned to one of four drinking conditions of 24-h access to a three-bottle choice paradigm, one of which always contained water. Drinking conditions were water only, 0.07 and 0.14 mg/mL NIC (NIC only), 15% and 30% EtOH (EtOH only), or 15% and 30% EtOH with 0.14 mg/mL NIC (EtOH+NIC). The effects of Var (0, 1, or 2 mg/kg) or Nal (0, 1, or 10 mg/kg) injections on maintenance and relapse consumption were determined during four consecutive days.

RESULTS

Var reduced maintenance and relapse NIC intake but had no effect on EtOH or EtOH+NIC drinking. Conversely, Nal reduced EtOH maintenance and relapse drinking, but had no effect on NIC or EtOH+NIC drinking.

DISCUSSION

The results indicate the standard pharmacological treatments for nicotine dependence and AUD were effective at reducing consumption of the targeted reinforcer but neither reduced EtOH+NIC co-use/abuse. These findings suggest that co-abuse may promote unique neuroadaptations that require models of polysubstance abuse to develop pharmacotherapeutics to treat AUD and nicotine dependence.

Temperance, Moral Friendship, and Smoking Cessation

The predominant approach of public health experts to cigarette smoking might be described as behaviorist, for it aims to eliminate this behavior without attending to human agency and intention. The requirement that physicians address smoking cessation at every patient visit also constitutes physicians as "managers" who focus narrowly on technical means to achieve predetermined ends. In this paper, I contrast such an approach with the Aristotelian tradition, according to which physician and patient ought to develop the virtue of temperance that would allow the patient to quit smoking. Although this model could potentially mitigate medicine's behaviorist-managerial tendencies, I follow Aristotle to argue that it requires a moral friendship in which participants share a conception of the human good and pursue that good together. Due to the intractable moral pluralism that characterizes contemporary life, physicians and patients are unlikely to achieve this sort of friendship, making Aristotelian medicine impracticable at present.

Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes to ease the transition from cigarette smoking to abstinence. It works by reducing the intensity of craving and withdrawal symptoms. Although there is clear evidence that NRT used after smoking cessation is effective, it is unclear whether higher doses, longer durations of treatment, or using NRT before cessation add to its effectiveness.

OBJECTIVES

To determine the effectiveness and safety of different forms, deliveries, doses, durations and schedules of NRT, for achieving long-term smoking cessation, compared to one another.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register, and trial registries for papers mentioning NRT in the title, abstract or keywords. Date of most recent search: April 2018.

SELECTION CRITERIA

Randomized trials in people motivated to quit, comparing one type of NRT use with another. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional intervention components not matched between arms. Trials comparing NRT to control, and trials comparing NRT to other pharmacotherapies, are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking abstinence was measured after at least six months, using the most rigorous definition available. We extracted data on cardiac adverse events (AEs), serious adverse events (SAEs), and study withdrawals due to treatment. We calculated the risk ratio (RR) and the 95% confidence interval (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 63 trials with 41,509 participants. Most recruited adults either from the community or from healthcare clinics. People enrolled in the studies typically smoked at least 15 cigarettes a day. We judged 24 of the 63 studies to be at high risk of bias, but restricting the analysis only to those studies at low or unclear risk of bias did not significantly alter results, apart from in the case of the preloading comparison. There is high-certainty evidence that combination NRT (fast-acting form + patch) results in higher long-term quit rates than single form (RR 1.25, 95% CI 1.15 to 1.36, 14 studies, 11,356 participants; I² = 4%). Moderate-certainty evidence, limited by imprecision, indicates that 42/44 mg are as effective as 21/22 mg (24-hour) patches (RR 1.09, 95% CI 0.93 to 1.29, 5 studies, 1655 participants; I² = 38%), and that 21 mg are more effective than 14 mg (24-hour) patches (RR 1.48, 95% CI 1.06 to 2.08, 1 study, 537 participants). Moderate-certainty evidence (again limited by imprecision) also suggests a benefit of 25 mg over 15 mg (16-hour) patches, but the lower limit of the CI encompassed no difference (RR 1.19, 95% CI 1.00 to 1.41, 3 studies, 3446 participants; I² = 0%). Five studies comparing 4 mg gum to 2 mg gum found a benefit of the higher dose (RR 1.43, 95% CI 1.12 to 1.83, 5 studies, 856 participants; I² = 63%); however, results of a subgroup analysis suggest that only smokers who are highly dependent may benefit. Nine studies tested the effect of using NRT prior to quit day (preloading) in comparison to using it from quit day onward; there was moderate-certainty evidence, limited by risk of bias, of a favourable effect of preloading on abstinence (RR 1.25, 95% CI 1.08 to 1.44, 9 studies, 4395 participants; I² = 0%). High-certainty evidence from eight studies suggests that using either a form of fast-acting NRT or a nicotine patch results in similar long-term quit rates (RR 0.90, 95% CI 0.77 to 1.05, 8 studies, 3319 participants; I² = 0%). We found no evidence of an effect of duration of nicotine patch use (low-certainty evidence); 16-hour versus 24-hour daily patch use; duration of combination NRT use (low- and very low-certainty evidence); tapering of patch dose versus abrupt patch cessation; fast-acting NRT type (very low-certainty evidence); duration of nicotine gum use; ad lib versus fixed dosing of fast-acting NRT; free versus purchased NRT; length of provision of free NRT; ceasing versus continuing patch use on lapse; and participant- versus clinician-selected NRT. However, in most cases these findings are based on very low- or low-certainty evidence, and are the findings from single studies.AEs, SAEs and withdrawals due to treatment were all measured variably and infrequently across studies, resulting in low- or very low-certainty evidence for all comparisons. Most comparisons found no evidence of an effect on cardiac AEs, SAEs or withdrawals. Rates of these were low overall. Significantly more withdrawals due to treatment were reported in participants using nasal spray in comparison to patch in one trial (RR 3.47, 95% CI 1.15 to 10.46, 922 participants; very low certainty) and in participants using 42/44 mg patches in comparison to 21/22 mg patches across two trials (RR 4.99, 95% CI 1.60 to 15.50, 2 studies, 544 participants; I² = 0%; low certainty).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that using combination NRT versus single-form NRT, and 4 mg versus 2 mg nicotine gum, can increase the chances of successfully stopping smoking. For patch dose comparisons, evidence was of moderate certainty, due to imprecision. Twenty-one mg patches resulted in higher quit rates than 14 mg (24-hour) patches, and using 25 mg patches resulted in higher quit rates than using 15 mg (16-hour) patches, although in the latter case the CI included one. There was no clear evidence of superiority for 42/44 mg over 21/22 mg (24-hour) patches. Using a fast-acting form of NRT, such as gum or lozenge, resulted in similar quit rates to nicotine patches. There is moderate-certainty evidence that using NRT prior to quitting may improve quit rates versus using it from quit date only; however, further research is needed to ensure the robustness of this finding. Evidence for the comparative safety and tolerability of different types of NRT use is of low and very low certainty. New studies should ensure that AEs, SAEs and withdrawals due to treatment are both measured and reported.

Review of the role of cigarette smoking in diabetic foot

Diabetic foot ulceration has been a serious issue over the past decades in Asia, causing economic and social problems. Therefore, it is important to identify and reduce the risk factors of diabetic foot. Cigarette smoking has been reported to be associated with diabetes and its macrovascular complications, but the relationship between smoking and diabetic foot ulcers is still unclear. In the present review, we summarize the effects of cigarette smoking on diabetic foot ulcers with respect to peripheral neuropathy, vascular alterations and wound healing. One underlying mechanism of these impacts might be the smoking-induced oxidative stress inside the cells. At the end of this review, the current mainstream therapies for smoking cessation are also outlined. We believe that it is urgent for all diabetic patients to quit smoking so as to reduce their chances of developing foot ulcers and to improve the prognosis of diabetic foot ulcers.

Ten-year experience of smoking cessation in a single center in Japan

BACKGROUND

Long-term, real-world data, as opposed to academic or research data, on outcomes of smoking cessation clinics are scarce. We assessed patient outcomes over a 10-year period at a smoking cessation clinic in a community teaching hospital in Japan and explored predictors of successful smoking cessation.

METHODS

We used data from a prospective registry of cigarette smokers who participated in a 3-month smoking cessation program comprising combined pharmacological treatment and cognitive behavioral therapy and explored factors associated with program execution and successful smoking cessation. The primary outcome was smoking cessation, defined by quitting completely between the 8-week and 12-week sessions, with verification according to exhaled carbon monoxide (CO) level of ≤10 ppm.

RESULTS

Between August 2007 and December 2017, 813 patients with nicotine dependence participated in the program. The number of participants decreased after Japan׳s 2010 tobacco tax increase. Among participants, 433 (53.3%) completed the program. In multivariate analysis, the number of cigarettes smoked daily (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.96, 0.99), cardiovascular disease (OR 1.75, 95% CI 1.16, 2.68), chronic obstructive pulmonary disease (OR 1.74, 95% CI 1.10, 2.78), and gastric/duodenal ulcer (OR 1.77, 95% CI 1.04, 3.08) were significantly associated with program completion. Among program completers, 288 (66.5%) achieved smoking cessation. Exhaled CO level (OR 0.94, 95% CI 0.93, 0.97) and mental disorders (OR 0.53, 95% CI 0.33, 0.85) were negatively associated with successful smoking cessation.

CONCLUSIONS

Baseline exhaled CO level and mental disorders were significantly associated with either success or failure of smoking cessation.

Cost-Effectiveness of Preoperative Smoking Cessation Interventions in Total Joint Arthroplasty

BACKGROUND

Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear.

METHODS

Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis.

RESULTS

In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%.

CONCLUSION

Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA.

LEVEL OF EVIDENCE

Level II, economic and decision analyses.

A randomized controlled trial of 24 weeks of varenicline for tobacco use among cancer patients: Efficacy, safety, and adherence

OBJECTIVE

Continuing to smoke after a cancer diagnosis undermines prognosis. Yet few trials have tested Food and Drug Administration (FDA)-approved tobacco use medications in this population. Extended use varenicline may represent an effective treatment for cancer patients who smoke given barriers to cessation including a prolonged time line for relapse.

METHODS

A placebo-controlled randomized trial tested 12 weeks of varenicline plus 12 weeks of placebo (standard [ST]) vs 24 weeks of varenicline (extended [ET]) with seven counseling sessions for treatment-seeking cancer patients who smoke (N = 207). Primary outcomes were 7-day biochemically confirmed abstinence at weeks 24 and 52. Treatment adherence and side effects, adverse and serious adverse events, and blood pressure were assessed.

RESULTS

Point prevalence and continuous abstinence quit rates at weeks 24 and 52 were not significantly different across treatment arms (P's > 0.05). Adherence (43% of sample) significantly interacted with treatment arm for week 24 point prevalence (odds ratio [OR] = 2.31; 95% confidence interval [CI], 1.15-4.63; P = 0.02) and continuous (OR = 5.82; 95% CI, 2.66-12.71; P < 0.001) abstinence. For both outcomes, adherent participants who received ET reported higher abstinence (60.5% and 44.2%) vs ST (44.7% and 27.7%), but differences in quit rates between arms were not significant for nonadherent participants (ET: 9.7% and 4.8%; ST: 12.7% and 10.9%). There were no significant differences between treatment arms on side effects, adverse and serious adverse events, and rates of high blood pressure (P's > 0.05).

CONCLUSIONS

Compared with ST, ET varenicline does not increase patient risk and increases smoking cessation rates among patients who adhere to treatment. Studies are needed to identify effective methods to increase medication adherence to treat patient tobacco use effectively.

Fit & quit: An efficacy trial of two behavioral post-cessation weight gain interventions

While smoking cessation leads to significant improvements in both mortality and morbidity, post-cessation weight gain partially attenuates this benefit. Even though post-cessation weight gain is small (4.7 kg on average), it is a stated reason to delay cessation attempts and is associated with smoking relapse. Fit & Quit is a randomized, controlled efficacy trial that aims to examine the ability of a weight stability intervention and a weight loss intervention to reduce post-cessation weight gain. For this purpose, Fit & Quit will randomize participants to three conditions: (a) Small Changes, a weight gain prevention intervention; (b) Look AHEAD Intensive Lifestyle Intervention; and (c) a lower-intensity bibliotherapy intervention. All conditions will receive a highly efficacious behavioral (i.e., rate reduction skills, motivational interviewing) and pharmacological (i.e., varenicline) smoking cessation program. A total of 400 participants will be recruited and randomized to the three interventions. Participants will be recruited in waves, with 10 waves of approximately 40 participants per wave. The primary outcomes of this study include post-cessation weight gain and cessation status at 12-month follow-up. Fit & Quit will integrate and adapt the strongest evidence-based interventions available for weight management and smoking cessation. Fit & Quit is highly innovative in the areas of the target population, study design, and use of technology. For these reasons, we expect that Fit & Quit will make a significant public health contribution to curtailing the important cessation barrier of post-cessation weight gain.

Smoking and diabetes: dangerous liaisons and confusing relationships

The combined harmful effects of cigarette smoking and hyperglycemia can accelerate vascular damage in patients with diabetes who smoke, as is well known. Can smoking cause diabetes? What are the effects of smoking on macro and microvascular complications? Now growing evidence indicates that regular smokers are at risk of developing incident diabetes. Since the prevalence rates of smoking in patients with diabetes are relatively similar to those of the general population, it is essential to address the main modifiable risk factor of smoking to prevent the onset of diabetes and delay the development of its complications. Quitting smoking shows clear benefits in terms of reducing or slowing the risk of cardiovascular morbidity and mortality in people with diabetes. Does quitting smoking decrease the incidence of diabetes and its progression? What are the effects of quitting smoking on complications? The current evidence does not seem to unequivocally suggest a positive role for quitting in patients with diabetes. Quitting smoking has also been shown to have a negative impact on body weight, glycemic control and subsequent increased risk of new-onset diabetes. Moreover, its role on microvascular complications of the disease is unclear. What are the current smoking cessation treatments, and which ones are better for patients with diabetes? Stopping smoking may be of value for diabetes prevention and management of the disease and its macrovascular and microvascular complications. Unfortunately, achieving long-lasting abstinence is not easy and novel approaches for managing these patients are needed. This narrative review examines the evidence on the impact of smoking and smoking cessation in patients with diabetes and particularly in type 2 diabetes mellitus and its complications. In addition, management options and potential future directions will be discussed.

Thoracic Surgeons' Beliefs and Practices on Smoking Cessation Before Lung Resection

BACKGROUND

Smoking is a risk factor for complications after lung resection. Our primary aim was to ascertain thoracic surgeons' beliefs and practices on smoking cessation before lung resection.

METHODS

An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database.

RESULTS

The response rate was 23.6% (n = 200). Surgeons were divided when asked whether it is ethical to require that patients quit smoking (yes, n = 96 [48%]) and whether it is fair to have their outcomes affected by patients who do not quit (yes, n = 87 [43.5%]). Most do not require smoking cessation (n = 120 [60%]). Of those who require it, the most common required period of cessation is 2 weeks or more. Most believe that patient factors are the main barrier to quitting (n = 160 [80%]). Risk of disease progression (39% vs 17.5%, p = 0.02) and alienating patients (17.5% vs 8.8%, p = 0.04) were very important considerations of those who do not require smoking cessation versus those who do. Only 19 (9.5%) always refer to a smoking cessation program and prescribe nicotine replacement therapy and even fewer, 9 (4.5%), always refer to a program and prescribe medical therapy.

CONCLUSIONS

Thoracic surgeons are divided on their beliefs and practices regarding smoking cessation before lung resection. Most believe patient factors are the main barrier to quitting and have concerns about disease progression while awaiting cessation. Very few surgeons refer to a smoking cessation program and prescribe nicotine replacement therapy or medical therapy.

Longer duration of smoking abstinence is associated with waning cessation fatigue

BACKGROUND

Cessation fatigue, a construct theorized to reflect exhaustion of coping resources due to quitting smoking, has been found to predict relapse. This study examines the association between cessation fatigue and duration of abstinence among 1397 adult former smokers who participated in the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey (4CV). We hypothesized lower levels of cessation fatigue will be correlated with longer duration of abstinence.

METHOD

Data for this cross-sectional study were collected in a web-based survey which recruited national samples from Australia, Canada, England, and United States. Former smokers were abstinent up to five years.

RESULTS

Lower cessation fatigue was associated with longer duration of smoking abstinence. Cessation fatigue was highest in former smokers that had been quit for up to six months, with lower cessation fatigue found in those quit for at least seven months and another drop-off in fatigue observed for those quit for at least two years.

CONCLUSIONS

Cessation fatigue is highest soon after quitting smoking but declines over time for those who remain abstinent. Understanding the mechanisms by which cessation fatigue is related to abstinence could potentially offer insights into ways to help individuals sustain quitting.

Does cessation fatigue predict smoking-cessation milestones? A longitudinal study of current and former smokers

OBJECTIVE

Long-term abstinence can be undermined by cessation fatigue-an exhaustion of coping resources attributable to quitting smoking/staying quit. The current study examines the predictive validity of a Cessation Fatigue Scale (CFS; three subscales). Among current smokers, we hypothesized higher fatigue would predict longer latency to both quit initiation and achieving 7-day point prevalence abstinence (7-day PPA). Among recent quitters, we expected higher cessation fatigue would confer greater lapse/relapse risk. Lower rates of abstinence at 2-month follow-up were expected for those with higher fatigue.

METHOD

Current smokers motivated to quit in the next month (n = 301) and recent quitters (n = 242) were assessed biweekly over the course of 2 months. Retention rates were high (>85%). Cox and logistic regression analyses tested hypotheses.

RESULTS

Among smokers, greater emotional exhaustion predicted longer delay to achieving 7-day PPA (HR = .53, 95% CI [.40, -.68], p < .001) and lower likelihood of 7-day PPA at 2-month follow-up (OR = .27, 95% CI [.16, -.46], p < .001), even after controlling for nicotine dependence and motivation to quit. Among recent quitters, emotional exhaustion progressively increased over the first 6 weeks since quit initiation. Elevated exhaustion was associated with greater lapse (HR = 1.65, 95% CI [1.06, 2.56], p < .05) and relapse (HR = 2.33, 95% CI [1.37, 3.97], p < .01) risk, and lower likelihood of 7-day PPA at 2-month follow-up (OR = .39, 95% CI [.16, .94], p < .05), even after controlling for nicotine withdrawal and motivation to quit.

CONCLUSIONS

Cessation fatigue, as measured by the CFS's emotional exhaustion subscale, prospectively predicted important cessation milestones. Findings suggest that cessation fatigue is a novel process that undermines smoking cessation and a viable target for intervention. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Factors Associated with Recent Use of Nicotine Replacement Therapy Among Multiethnic Smokers Residing in Public Housing

Introduction

Understanding factors associated with increased use of nicotine replacement therapy (NRT) is critical to implementing cessation interventions for low-income individuals yet the factors associated with NRT use among low-income smokers are poorly understood.

Aims

Assess factors associated with NRT use among low-income public housing residents.

Methods

'Kick it for Good' was a randomised smoking cessation intervention study conducted among residents of public housing sites in Boston, MA. Secondary, cross-sectional analyses were conducted on smokers from a community-based intervention cessation intervention who reported making a quit attempt and use of NRT in the past 12 months (n = 234).

Results

Among smokers who made a quit attempt in the past year, 29% reported using NRT. Black (prevalence ratio,PR = 0.52, 95% CI: 0.38-0.71) and Hispanic (PR = 0.52, 95% CI: 0.31-0.88) participants were less likely to report use of NRT compared with Whites. The prevalence of recent NRT use was greatest among those both asking for and receiving provider advice (PR = 1.90, 95% CI: 0.96-3.78).

Conclusions

Minority race and ethnicity and low provider engagement on NRT use were associated with lower NRT use. Providing barrier-free access to NRT and facilitating provider engagement with smokers regarding NRT use can increase NRT use among low-income populations.

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.

The effectiveness of varenicline versus nicotine replacement therapy on long-term smoking cessation in primary care: a prospective cohort study of electronic medical records

Background

There is limited evidence about the effectiveness of varenicline and nicotine replacement therapy (NRT) for long-term smoking cessation in primary care, or whether the treatment effectiveness differs by socioeconomic position (SEP). Therefore, we estimated the long-term effectiveness of varenicline versus NRT (> 2 years) on smoking cessation, and investigated whether effectiveness differs by SEP.

Methods

This is a prospective cohort study of electronic medical records from 654 general practices in England, within the Clinical Practice Research Datalink, using three different analytical methods: multivariable logistic regression, propensity score matching and instrumental variable analyses. Exposure was prescription of varenicline versus NRT, and the primary outcome was smoking cessation at 2 years' follow-up; outcome was also assessed at 3, 6, and 9 months, and at 1 and 4 years after exposure. SEP was defined using the Index of Multiple Deprivation.

Results

At 2 years, 28.8% (N = 20 362/70 610) of participants prescribed varenicline and 24.3% (N = 36 268/149 526) of those prescribed NRT quit; adjusted odds ratio was 1.26 [95% confidence interval (CI): 1.23 to 1.29], P < 0.0001. The association persisted for up to 4 years and was consistent across all analyses. We found little evidence that the effectiveness of varenicline differed greatly by SEP. However, patients from areas of higher deprivation were less likely to be prescribed varenicline; adjusted odds ratio was 0.91 (95% CI: 0.90 to 0.92), P < 0.0001.

Conclusions

Patients prescribed varenicline were more likely to be abstinent up to 4 years after first prescription than those prescribed NRT. In combination with other evidence, the results from this study may be used to update clinical guidelines on the use of varenicline for smoking cessation.

Identification of the 4-Position of 3-Alkynyl and 3-Heteroaromatic Substituted Pyridine Methanamines as a Key Modification Site Eliciting Increased Potency and Enhanced Selectivity for Cytochrome P-450 2A6 Inhibition

Cigarette smoking causes nearly one in every five deaths in the United States. The development of a specific inhibitor of cytochrome P450 2A6 (CYP2A6), the major nicotine-metabolizing enzyme in humans, which could be prescribed for the cessation of cigarette smoking, has been undertaken. To further refine the structure activity relationship of CYP2A6, previously synthesized 3-alkynyl and 3-heteroaromatic substituted pyridine methanamines were used as lead compounds. Isosteric pyridine replacement and appendage of all available positions around the pyridine ring with a methyl group was performed to identify a modification that would increase CYP2A6 inhibition potency, which led to 4g (IC₅₀ = 0.055 mM) as a primary analogue. Potent compounds were evaluated for CYP selectivity, human liver microsomal half-life, and compliance with the rules of five. Top compounds (i.e., 6i, IC₅₀ = 0.017 mM, >120 min half-life) are poised for further development as treatments for smoking and tobacco use cessation.

Effects of Negative Affect, Urge to Smoke, and Working Memory Performance (n-back) on Nicotine Dependence

BACKGROUND

Three key domains including negative emotionality, incentive salience, and executive function form the core functional elements of addictive behaviors. Variables related to these broader domains have been studied extensively in relation to one another; however, no studies to date, have examined models including variables from all three domains, in relation to nicotine dependence.

METHOD

Smokers (N = 117), 65.8% female, 78% white, mean age of 44.4 (SD = 10.8), enrolled in a smoking cessation program completed measures of negative affect (a component of negative emotionality), urge to smoke (incentive salience), and working memory (WM; a core executive function), during a baseline assessment period prior to initiating treatment.

RESULTS

Negative affect was associated with greater urge to smoke, and this elevated urge to smoke was associated with higher levels of nicotine dependence. Further, a significant moderated mediation indicated that WM moderated the relationship between increased urge to smoke and nicotine dependence. For those with low to average WM, urge to smoke was significantly related to nicotine dependence; however, for those with higher WM (+1 SD), urge to smoke stemming from negative affect was not associated with nicotine dependence.

CONCLUSIONS

To our knowledge, this is the first reported relationship between negative affect, urge to smoke, WM, and nicotine dependence. Although preliminary, results indicate that WM may moderate the relationship between urge to smoke associated with negative affect and nicotine dependence. Treatments targeting WM may be particularly useful for individuals with average to low WM who experience urge to smoke related to negative affect.

Muscarinic M5 receptors modulate ethanol seeking in rats

Despite the cost to both individual and society, alcohol use disorders (AUDs) remain a major health risk within society, and both relapse and heavy drinking are still poorly controlled with current medications. Here we demonstrate for the first time that a centrally active and selective negative allosteric modulator for the rat M₅ muscarinic acetylcholine receptor (mAChR), ML375, decreases ethanol self-administration and attenuates cue-induced reinstatement of ethanol seeking in ethanol-preferring (iP) rats. Importantly, ML375 did not affect sucrose self-administration or general locomotor activity indicative of a selective effect on ethanol seeking. Based on the expression profile of M₅ mAChRs in the brain and the distinct roles different aspects of the dorsal striatum have on long-term and short-term ethanol use, we studied whether intra-striatal microinjection of ML375 modulated ethanol intake in rats. We show in iP rats with an extensive history of ethanol intake that intra-dorsolateral (DL), but not intra-dorsomedial, striatal injections of ML375 reduced ethanol self-administration to a similar extent as the nicotinic acetylcholine receptor ligand varenicline, which has preclinical and clinical efficacy in reducing the reinforcing effects of ethanol. These data implicate the DL striatum as a locus for the effects of cholinergic-acting drugs on ethanol seeking in rats with a history of long-term ethanol use. Accordingly, we demonstrate in rats that selectively targeting the M₅ mAChR can modulate both voluntary ethanol intake and cue-induced ethanol seeking and thereby provide direct evidence that the M₅ mAChR is a potential novel target for pharmacotherapies aimed at treating AUDs.

Effectiveness of Pharmaceutical Smoking Cessation Aids in a Nationally Representative Cohort of American Smokers

Background

Despite strong efficacy in randomized trials, the population effectiveness of pharmaceutical aids in long-term smoking cessation is lacking, possibly because of confounding (factors that are associated with both pharmaceutical aid use and difficulty quitting). Matching techniques in longitudinal studies can remove this confounding bias.

Methods

Using the nationally representative Tobacco Use Supplement to the Current Population Survey (TUS-CPS), we assessed the effectiveness of medications to aid quitting among baseline adult smokers who attempted to quit prior to one year of follow-up in two longitudinal studies: 2002-2003 and 2010-2011. Pharmaceutical aid users and nonusers with complete data (n = 2129) were matched using propensity score models with 12 potential confounders (age, sex, race-ethnicity, education, smoking intensity, nicotine dependence, previous quit history, self-efficacy to quit, smoke-free homes, survey year, and cessation aid use). Using matched data sets, logistic regression models were fit to assess whether use of any individual pharmaceutical aid increased the proportion of patients who were abstinent for 30 days or more at follow-up.

Results

Propensity score matching markedly improved balance on the potential confounders between the pharmaceutical aid use groups. Using matched samples to provide a balanced comparison, there was no evidence that use of varenicline (adjusted risk difference [aRD] = 0.01, 95% confidence interval [CI] = -0.07 to 0.11), bupropion (aRD = 0.02, 95% CI = -0.04 to 0.09), or nicotine replacement (aRD = 0.01, 95% CI = -0.03 to 0.06) increased the probability of 30 days or more smoking abstinence at one-year follow-up.

Conclusions

The lack of effectiveness of pharmaceutical aids in increasing long-term cessation in population samples is not an artifact caused by confounded analyses. A possible explanation is that counseling and support interventions provided in efficacy trials are rarely delivered in the general population.

Electronic cigarettes for adults with tobacco dependence enrolled in a tobacco treatment program: A pilot study

INTRODUCTION

Electronic cigarettes (ECs) have emerged as a potential harm-reducing alternative for tobacco smokers. However, the role ECs might play in treatment settings is unclear. We conducted an exploratory study of treatment-seeking smokers enrolling in a standard tobacco treatment program who were provided with either a nicotine or non-nicotine EC to use as needed to cease tobacco smoking.

METHODS

Treatment-seeking smokers received standard tobacco treatment for 8weeks and were given nicotine transdermal patch therapy, behavioral counseling, and either a nicotine or non-nicotine EC to use as needed. Smoking and EC use patterns were tracked longitudinally to week 24.

RESULTS

40 subjects were enrolled into the study. At week 24, 6 subjects (15%) were abstinent, and the mean reduction in reported cigarettes smoked per day was 6.8±12. There were no significant differences in smoking outcomes between those who received a nicotine or non-nicotine EC (proportion abstinent at 24weeks: nicotine EC=4/20 (20%); non-nicotine EC=2/20 (10%); p=0.66). Among subjects assessed at follow-up, 62.5% were EC non-users.

CONCLUSIONS

The addition of a 2nd generation EC to outpatient tobacco treatment among tobacco smokers is feasible. Among those who quit smoking, half were still using the EC at 6-month follow-up. Appeal of the EC among smokers was variable, and those who had quit smoking tended to switch to lower strength nicotine solutions. Further research is needed to determine whether ECs can reduce harm and be an effective adjunct to existing tobacco treatment interventions.