Targeting heavy smokers in general practice: randomised controlled trial of transdermal nicotine patches

Smoking cessation in women. Special considerations

Women may be at relatively greater risk of smoking-related diseases than men but tend to have less success than men in quitting smoking. The failure of most outcome studies to report results by gender and the lack of statistical power for detecting significant gender differences currently do not allow for many firm conclusions to be drawn about smoking cessation rates in women, but several trends warrant attention and further study. First, the difference in cessation rates for women versus men may be even greater in trials of nicotine replacement therapies (NRT). This suggests that women benefit less from NRT relative to men, although this difference may depend on the particular form of NRT (e.g. inhaler versus gum). On the other hand, some non-NRT medications may reverse the poorer outcome of women, producing quit rates in women comparable with those in men. Gender differences in outcome, as well as overall success rates, with NRT and some of the non-NRT medications appear to be enhanced when treatment includes substantial behavioural counselling. However, while several of the non-NRT medications may be particularly appropriate to consider for treating women trying to quit smoking, adverse effects may limit widespread use of some of these drugs, such as clonidine and naltrexone. Thus, even if the gender differences in outcome with NRT versus non-NRT drugs are confirmed in further research, such findings do not necessarily justify limiting NRT use in women, because such treatment is clearly effective and is likely to be safer and more readily available than non-NRT medications. Nevertheless, study of the mechanisms by which some non-NRT drugs are effective in women may aid our understanding of factors that are more influential in smoking behaviour in women than in men. Secondly, smoking cessation treatment for women must address several other issues that often emerge, and these are most likely to require behavioural counselling that is tailored to these problems. These issues include concern about bodyweight gain, restrictions on medication use in pregnant smokers, variability in mood and withdrawal as a function of menstrual cycle phase, harnessing social support to foster abstinence, and the possibility that smoking-associated environmental cues may be more influential in smoking behaviour in women than men. Greater attention to gender differences in clinical trial outcomes and to addressing concerns of women smokers may aid in the development of substantially improved smoking cessation interventions for women.

[Smoking cessation in primary and specialized care: a real opportunity and a public health necessity]

AIM

To determine whether primary care provides a suitable framework for integrated treatment aimed at smoking cessation with systematic minimal intervention or pharmacological treatment with nicotine replacement therapy (NRT). To compare the results with those obtained in a specialized pneumology unit.

DESIGN

Prospective, quasi-experimental study.

SETTING

Primary and specialized care services.

PARTICIPANTS

357 smokers who were followed at a health center (166) or a specialized clinic (191) during a 6-month period.

INTERVENTIONS

Two types of intervention were used depending on the patients' degree of nicotine dependence: systematic minimal intervention for those with low dependence or who were still in the contemplation or precontemplation phase, and NRT for those with high dependence, in the preparation phase.

MAIN OUTCOME MEASURES

Twelve months after the start of the study, abstinence among participants who received systematic minimal intervention was 36.5% in primary care patients and 41.8% in specialized care patients (P>.05). Among participants who received NRT abstinence was 37.1% in the former group and 35.5% in the latter (P>.05). The percentage of patients lost to follow-up was 8.6% in specialized care and 6.3% in primary care.

CONCLUSIONS

The results lead us to recommend smoking cessation treatment integrated in the primary care setting, either with systematic minimal intervention or NRT.

Strike while the iron is hot: can stepped-care treatments resurrect relapsing smokers?

The efficacies of 2 group counseling step-up treatments for smoking cessation, cognitive-behavioral/skill training therapy (CBT) and motivational interviewing/supportive (MIS) therapy, were compared with brief intervention (BI) treatment in a sample of 677 smokers. Differential efficacy of the 2 step-up treatments was also tested in smokers at low and high risk for relapse (no smoking vs. any smoking during the first postquit week. respectively). All participants received 8 weeks of nicotine patch therapy. BI consisted of 3 brief individual cessation counseling sessions; CBT and MIS participants received BI treatment and 6 group counseling sessions. Neither CBT nor MIS treatment improved long-term abstinence rates relative to BI. Limited support was found for the hypothesis that high-risk smokers would benefit more from MIS than CBT. Other hypotheses were not supported.

[Tobacco detoxication at a primary care clinic: efficacy of medical counseling, minimal intervention and nicotine replacement therapy at the one-year follow-up]

OBJECTIVE

The main objective was to compare the efficacy of one-off tobacco counselling and of the systematic minimum intervention on making people give up smoking. A secondary aim was to evaluate the efficacy of nicotine replacement therapy (NRT) in the context of a primary care consultation.

DESIGN

Controlled and randomised clinical trial.

SETTING

Primary care.

PARTICIPANTS

Smokers who over 12 months attended a primary care clinic at an urban health centre (304 patients).

INTERVENTIONS

Two kinds of intervention were conducted at random on patients with low nicotine dependence (one-off medical counselling and counselling integrated into what is known as the minimal intervention, but conducted systematically). NRT was administered through nicotine patches (11% nicotine) to patients with moderate-to-high nicotine dependence.

MEASUREMENTS AND MAIN RESULTS

Short-term cessation a year after the minimal intervention was 39% (29.4-49.3%), and maintained cessation 30.9% (29.4-49.3%), as against 11% (5.6-18.8%) short-term cessation in the group that received one-off counselling (p < 0.0001). Short-term tobacco cessation in the NRT group was 35.3% (24.1-47.8%), and maintained cessation 30.8%.

CONCLUSIONS

Primary care is a suitable context for an intervention against tobacco dependency, through the use of any of the established interventions: one-off medical counselling, systematic minimal intervention, or specialist drug treatment through NRT. Therefore, these kinds of intervention must form part of PC clinics' daily activity.

[Two-month results are predictors of outcome in a smoking cessation program]

BACKGROUND

The supportive smoking cessation counseling (SSCC) and nicotine replacement therapy (NRT) have been proved to be an effective aid to smoking cessation. The aim of this study was to determine whether the results obtained in a two-month treatment program to helping smokers quit by means of supporting smoking cessation counseling or nicotine replacement therapy included in the routine medical care, can be considered as predictors of success in the long term (one year).

SUBJECTS AND METHOD

A longitudinal and prospective study has been carried out, being included in the program all smoker patients who went a primary or specialist unit (n = 357) during a six-month term. The SSCC was carried out in those patients with a low nicotine dependence (Fagerström test < 7) or those who had not got a preparation stage yet. The NRT was tested in those patients with high nicotine dependence (Fagerström >= 7).

RESULTS

32 patients (9%) of the 357 did not turn up to the established controls,being thus considered as hopeless cases. The one-year study was completed by 177 patients in the SSCC group and 148 in the NRTgroup. Abstinence had been achieved by 39.2% of the SSCC group and by 36.2% of theNRT group 12 months later. Previously, in the SSCC group the observed abstinence after two months that the beginning of the program was 34% (27.4-40.7) and in the NRT group was 52.1% (44.5-59.8). The patients who were abstinents after two months of the beginning of the program were 19 times more likely to remain abstinent after a year (odds ratio, 19.4), showing in the SSCC group a sensitivity of 72.4% and a specificity of 90.7%, and in the NRT group the sensitivity was 93.2% and the specificity of 71.2%.

CONCLUSIONS

The results observed after two months of the beginning of the program are predictors of outcome and can allow modify the therapeutic attitude with the aim of achieve best rates of success.

Cost-effectiveness analysis of a family physician delivered smoking cessation program

OBJECTIVES

The objectives were to present a cost-effectiveness analysis of a smoking cessation program delivered by physicians and compare results to other smoking cessation interventions.

METHODS

Retrospective effectiveness figures from a previous evaluation of the smoking cessation program were supplemented with estimates based on researched assumptions. Net abstinence rates were determined for smokers, depending on their stage of readiness to quit, that is, "prepared," "contemplative," and "precontemplative," leading to an assessment of the number of smokers achieving abstinence as a result of the Smokescreen intervention. Costs were calculated from the perspectives of smokers, family physicians, organizers, trainers, and all parties combined. Assumptions were varied with a sensitivity analysis.

RESULTS

Baseline costs per additional abstainer were $183 based on physicians' intervention costs at 1995 prices. This is the figure most comparable to previously conducted economic evaluations of smoking cessation interventions. Sensitivity analysis varying the perspective and under optimistic and pessimistic assumptions about effectiveness produced a wide variety of estimates. The decision to include or exclude training costs had a particularly important bearing on the estimates. However, under reasonable assumptions the cost per additional quitter compares favorably to smoking and other medical and health care interventions worldwide.

CONCLUSIONS

The program appears cost-effective when compared to other smoking cessation and health promotion interventions and illustrates the potential for retrospective cost-effectiveness analysis of interventions.

Transdermal drug delivery systems and skin sensitivity reactions. Incidence and management

Transdermal devices are now marketed for the delivery of systemic medication through the skin. Advantages associated with transdermal drug delivery include avoidance of first-pass metabolism and variable absorption as well as improved patient compliance. Drugs currently available by this route include scopolamine, nitroglycerin (glyceryl trinitrate), estradiol, nicotine, clonidine, fentanyl, and testosterone. This novel development has brought about a specific constellation of skin problems which vary widely in incidence between drugs. It is important to vary the site of drug administration to minimize these reactions. Any eczematous reaction can be treated with a moderately potent topical corticosteroid. Patients with topical sensitivity are usually tolerant of oral challenge but systemic sensitization has been reported and caution is still advocated before proceeding to this step. The increasing use of transdermal drug delivery systems across many specialities means that problems of skin sensitivity are of growing relevance to the dermatologist, the hospital specialist, and the primary care physician.

Brief interventions in substance abuse

Brief interventions in substance abuse refer to a group of cost-effective and time efficient strategies that aim at reduction of substance use and/or harm related to substance use. They are grounded in the scientific principles of harm reduction stage of change, motivational interviewing and feasibility of community-level delivery. This review discusses the characteristics, elements, and techniques of brief interventions for abuse of alcohol, tobacco and other drugs. The available evidence for effectiveness of these strategies vis-a-vis no treatment or extended treatment is also reviewed, which clearly supports these interventions to be effective, especially for alcohol abuse but also for others It is argued that India presents a fertile ground for application of these strategies and that Indian research in this area should be a top priority.

Clonidine for smoking cessation

BACKGROUND

Clonidine was originally used to lower blood pressure. It acts on the central nervous system and may reduce withdrawal symptoms in various addictive behaviours, including tobacco use.

OBJECTIVES

The aim of this review is to determine clonidine's effectiveness in helping smokers to quit.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search: October 1998.

SELECTION CRITERIA

We considered randomised trials of clonidine versus placebo with a smoking cessation endpoint assessed at least 12 weeks following the end of treatment.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of subjects, the dose and duration of clonidine therapy, the outcome measures, method of randomisation, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least twelve weeks follow-up in patients smoking at baseline. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model.

MAIN RESULTS

Six trials met the inclusion criteria. There were three trials of oral, and three of transdermal clonidine. Some form of behavioural counselling was offered to all participants in five of the six trials. There was a statistically significant effect of clonidine in one of these trials. The pooled odds ratio for success with clonidine vs placebo was 1.89 (95% confidence interval 1.30 to 2.74). There was a high incidence of dose-dependent side-effects, particularly dry mouth and sedation.

REVIEWER'S CONCLUSIONS

Based on a small number of trials, in which there are potential sources of bias, clonidine is effective in promoting smoking cessation. Prominent side-effects limit the usefulness of clonidine for smoking cessation.

Over-the-counter nicotine patch therapy for smoking cessation: results from randomized, double-blind, placebo-controlled, and open label trials

OBJECTIVES

The purpose of this study was to determine the efficacy and safety of the nicotine patch for smoking cessation in an over-the-counter environment. The years of study were 1994 to 1995.

METHODS

Parallel 6-week trials were conducted: a placebo-controlled trial of no-cost 22-mg, 24-hour nicotine patch therapy and an open label trial of the same therapy with patches purchased by subjects. Participants (n = 958) were 18 years or older, had smoked at least 15 cigarettes daily for at least 6 months, and were enrolled at 3 study sites. The main outcome measure was self-reported smoking abstinence confirmed by expired carbon monoxide measurements.

RESULTS

Smoking cessation rates in the placebo-controlled trial were 16.8% and 9.6% at week 6 and 8.7% and 4.3% at week 24 for the active patch and placebo groups, respectively. Smoking cessation rates in the open label-pay trial were 19.0% and 10.8% at weeks 6 and 24, respectively. A slight increase in adverse cardiovascular events was noted only in the open label-pay group in comparison with the placebo group.

CONCLUSIONS

In an over-the-counter environment, the 22-mg, 24-hour nicotine patch is effective and safe for smoking cessation treatment.

Open randomised trial of intermittent very low energy diet together with nicotine gum for stopping smoking in women who gained weight in previous attempts to quit

OBJECTIVE

To determine whether attempts to prevent weight gain will increase success rates for stopping smoking.

DESIGN

16 week, open, randomised study with 1 year follow up.

SETTING

Obesity unit.

SUBJECTS

287 female smokers who had quit smoking before but started again because of weight concerns.

INTERVENTION

Combination of a standard smoking cessation programme with nicotine gum and a behavioural weight control programme including a very low energy diet. A control group was treated with the identical programme but without the diet.

MAIN OUTCOME MEASURE

Sustained cessation of smoking.

RESULTS

After 16 weeks, 68/137 (50%) women had stopped smoking in the diet group versus 53/150 (35%) in the control group (P=0.01). Among these women, weight fell by mean 2.1 (95% confidence interval 2.9 to 1.3) kg in the diet group but increased by 1.6 (0.9 to 2.3) kg in the control group (P<0.001). After 1 year the success rates in the diet and control groups were 38/137 (28%) and 24/150 (16%) respectively (P<0.05), but there was no statistical difference in weight gain.

CONCLUSIONS

Combining the smoking cessation programme with an intervention to control weight helped women to stop smoking and control weight.

Prescription of transdermal nicotine patches for smoking cessation in general practice: evaluation of cost-effectiveness

BACKGROUND

The 1998 UK government White Paper Smoking Kills emphasises that normal practice should be for general practitioners (GPs), practice nurses, and others to offer advice and support to smokers in their efforts to stop. However, GPs are not allowed to write NHS prescriptions for nicotine-replacement therapy, even though this is the only effective pharmaceutical treatment available in the UK. We estimated the cost-effectiveness, for the NHS, of allowing GPs to prescribe transdermal nicotine patches for up to 12 weeks.

METHODS

We used data from a randomised, placebo-controlled efficacy trial of nicotine patches and a survey of associated resource use in 30 GP surgeries in 15 English counties. We calculated the health benefit of nicotine-patch treatment in number of life years that would be saved by stopping smoking at various ages, and used an abstinence-contingent treatment model to calculate the incremental cost per life year saved by GP counselling with nicotine-patch treatment over GP counselling alone. Cost effectiveness was assessed on the basis that GPs would provide repeat NHS prescriptions for up to 12 weeks if the treatment was proving successful.

FINDINGS

If GPs were allowed to prescribe transdermal nicotine patches on the NHS, for up to 12 weeks, the incremental cost per life year saved would be: Pound Sterling 398 per person younger than 35 years; Pound Sterling 345 for those aged 35-44 years; Pound Sterling 432 for those aged 45-54 years; and Pound Sterling 785 for those aged 55-65 years.

INTERPRETATION

The low cost per life year saved would make GP intervention against smoking a cost-effective life-saving treatment. The priniciples of the government White Paper could be cost-effectively extended into general practice to reduce smoking and smoking-related illnesses.

Predictors and timing of adverse experiences during trandsdermal nicotine therapy

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

COPD: overview of definitions, epidemiology, and factors influencing its development

COPD is a heterogeneous collection of conditions that can affect various structures within the lung in a number of different ways. These various processes can all result in limitation of expiratory airflow. If severe enough, this physiologic abnormality defines COPD. The various conditions that can lead to this syndrome are prevalent and often relentlessly progressive. In aggregate, they represent an important public health problem. This supplement outlines diagnostic and therapeutic strategies by which the practitioner can assist patients suffering from this condition.

Effect of training on general practitioners' use of a brief intervention for excessive drinkers

OBJECTIVE

To determine among general practitioners (GPs) the effect of three different types of training on utilisation of a brief, controlled drinking intervention.

DESIGN

A non-randomised intervention study. Setting, participants: 96 GPs (64%) within the South Eastern Sydney Division of General Practice participated; 35 chose workshop training, 39 one-to-one training and 22 received a special kit by mail.

MAIN OUTCOME MEASURES

Identification by GPs of excessive drinkers by practice audits; use of the program determined by the number of patients recruited in 3 months and by GPs' use of the intervention 6 months after training.

RESULTS

41 (43%) GPs conducted practice audits, identifying 15.1% of males and 6.6% of females as excessive drinkers (regular excessive weekly consumption and/or binge). 179 patients were recruited by 36 GPs over 3 months, and 32% of these patients reported a reduction of alcohol consumption. 63% who attended workshop training, 57% who received one-to-one training, and 36% who received the kit by mail reported they were current users of the program at 6 months. Significantly fewer GPs who received the kit by mail reported ever using the program (59%) compared to the other groups (p < 0.01).

CONCLUSION

This naturalistic study found that workshops and one-to-one training sessions in doctors' surgeries achieved greater uptake of a brief intervention for problem drinkers than distribution of a special kit by mail.

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

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

Family physicians' utilization of a brief smoking cessation program following reinforcement contact after training: a randomized trial

BACKGROUND

Previous studies have examined methods of delivery of brief interventions and reinforcement contact and their effects on physicians' utilization of smoking cessation interventions. In this study the objectives were: (1) to determine the ongoing utilization by family physicians of a brief smoking cessation intervention 6 months after a training workshop and (2) to examine the effect of reinforcement contact on physician utilization. A supplementary aim was to assess point prevalence abstinence among patients identified as ready to quit smoking.

METHODS

This was a randomized controlled trial of family physicians (98 in the Contact and 100 in the Noncontact group). Training was conducted in a 2-hr workshop. Doctors in the Contact group received three brief telephone calls at 2 weeks, 2 months, and 4 months after training. Main outcome measures were: (1) utilization, determined by responses to a mailed questionnaire about use of the program, and (2) the number of booklets distributed by full-time doctors, collected by practice secretaries or research assistant.

RESULTS

At 6 months 88% of physicians (93% of the Contact group and 84% of the Noncontact group, P = 0.06) were current users of the smoking cessation intervention. Full-time physicians in the Contact group distributed significantly more booklets (40.1) over 6 months than those in the Noncontact group (32.8) (P < 0.05). Twenty-one percent of patients reported not smoking at follow-up at an average of 9.9 months after intervention.

CONCLUSIONS

Most doctors continued to use the program 6 months after training and reinforcement contact encouraged greater recruitment of patients.

A comparison of measures used to assess effectiveness of the transdermal nicotine patch at 1 year

This study examines outcome measures of abstinence among studies reporting 12-month outcomes of the nicotine transdermal patch using different measures of effectiveness. This was achieved by reviewing published randomized controlled studies reporting 1-year abstinence rates of the nicotine transdermal patch. Comparisons are made across studies of three outcome measures used to report abstinence: point prevalence, continuous, and prolonged abstinence. Studies that measured outcome in terms of continuous and prolonged abstinence at 1 year showed double the effect for the active patch compared to placebo; however, this difference was not always apparent in those studies using point prevalence as the outcome measure.

Evaluation of a national Quit and Win contest: determinants for successful quitting

BACKGROUND

Within the CINDI framework, a European "Quit and Win" contest was organized in 1994. In Finland the number of participants was 5,879 (0.6% of smokers). In the CINDI demonstration area, North Karelia (NK), the participants numbered 618 (2.0% of smokers). This study compared abstinence maintenance among the participants in NK with the rates found elsewhere in Finland and analyzed determinants for successful quitting.

METHODS

A follow-up study was conducted 12 months after the quit date with a sample of 2,114 participants. Response rates of 67-68% were achieved (n = 1,419). The abstinence was assessed at 1, 6, and 12 months. Two estimates are presented: (1) the proportion of abstainers among the respondents and (2) the proportion of abstainers among the sample, considering all nonrespondents smokers. The determinants for maintenance of smoking cessation were analyzed with logistic regression.

RESULTS

Using the first estimate, the rates at 1/6/12 months were 75/36/28% in NK and 70/28/21% elsewhere (P < 0.01). Using the second estimate, the corresponding rates were 50/24/19% in NK and 46/19/14% elsewhere. The most significant determinants for successful quitting were sex, age, marital status, level of withdrawal symptoms, previous quitting attempts, and support received.

CONCLUSIONS

The recruitment of smokers and the maintained cessation were more successful in the demonstration area. The difference between areas was explained by differences in the combined professional and lay support and by the sex and age distributions.

The cost-effectiveness of the nicotine transdermal patch for smoking cessation

BACKGROUND

Smoking is the single most preventable cause of premature mortality in the United States. In 13 double-blind, controlled trials, the nicotine transdermal patch has been demonstrated to be an effective aid to quitting smoking, even after 6 months of follow-up. Because physicians and payers may consider the cost of the patch to be prohibitive, we examine the cost-effectiveness of the nicotine patch as an adjunct to brief physician counseling during routine office visits.

METHODS

We estimate the effectiveness of both patch use with brief counseling and counseling alone from meta-analysis of clinical trials. Benefits are measured in terms of years of life gained by those who quit, discounted at 5%. Costs include physician time and patch prescriptions. The incremental cost-effectiveness is quantified as cost per additional year of life saved when patch plus counseling is compared with brief physician counseling alone.

RESULTS

Depending on age, the average costs per year of life saved range from $965 to $1,585 for men and from $1,634 to $2,360 for women. Incremental costs per year of life saved range from $1,796 to $2,949 for men and from $3,040 to $4,391 for women.

CONCLUSION

The nicotine patch is cost-effective and less costly per year of life saved than other widely accepted medical practices. Physicians and third-party payers should recommend the nicotine patch to patients who wish to stop smoking.

Retracing the steps of Marco Polo: from clinical trials to diffusion of interventions for smokers

We report the results from a series of four controlled trials which evaluate efficacy, effectiveness, and implementation of interventions for smokers, and then discuss diffusion of our program in feasibility studies both nationally in Australia and internationally. In our first study we reported that when general practitioners delivered moderately brief advice to smokers, they have a 36% abstinence rate at three years. In the second study we found that doctors achieve a 12% abstinence at one year after giving minimal advice to patients, and when using a more involved intervention, quit rates of just less than 20% at one year. In the third and fourth studies of utilization of the smoking cessation program we report that reinforcement contact following a 2-hour training workshop increased doctors' use of a smoking cessation program at 6 months compared to no contact. The challenge of translating research findings into practice for the benefit of doctors in Australia as well as in a low-income country such as China, is described in two feasibility studies. Over the past 11 years we have disseminated the program nationally in Australia, and over 4500 doctors have been trained. Diffusion theory provides a useful model which has guided us in our implementation efforts in Australia and is being used to allow us to introduce the smoking cessation intervention for Chinese doctors to use.

The benefits of stopping smoking and the role of nicotine replacement therapy in older patients

Considerable benefits accrue from stopping smoking in older patients. Reversal of the short term cardiovascular adverse effects of smoking is rapid. Long term risk reduction appears to occur as a result of decreased life-time exposure to tobacco smoke. The pharmacology of nicotine has not been studied in older patients but is unlikely to change in clinically important ways with advancing age. Nicotine replacement doubles long term success rates, compared with placebo, among younger smokers of > or = cigarettes per day. There is no reason to believe its efficacy should be less among older smokers. Transdermal nicotine is the replacement therapy of choice in older patients because of once-daily administration and good tolerability. Approximately half of the users of transdermal nicotine smoke concurrently with treatment. It is unlikely that concurrent smoking or high doses of nicotine replacement therapy will adversely effect healthy patients. While it is generally believed that patients with unstable coronary heart disease may be at risk from concurrent smoking during nicotine replacement therapy, it is unclear whether this risk is greater than the risk of smoking alone. Nicotine replacement therapy is a logical approach for motivated, older smokers who are unable to stop smoking by simpler means. Results can be augmented by including other interventions, such as counselling and follow-up support.

Effects of transdermal nicotine patches on ambulatory ECG monitoring findings: a double-blind study in healthy smokers

The cardiovascular effects and safety of transdermal nicotine patches were assessed in 50 healthy smokers using repeated 48 hour ambulatory electrocardiographic monitoring as a part of a smoking cessation program. Following baseline measurements, subjects were randomized to active (n = 25) or placebo (n = 25) treatment groups for a period of 2 weeks. Twenty-two patients in each group completed the trial. During the treatment period, subjects also received behavioral supportive therapy. Heart rate and blood pressure were significantly reduced relative to baseline both groups. In the active treatment group, mean values at baseline and after 2 weeks of double-blind treatments were as follows: heart rates, 74.0 and 71.3 beats/min, respectively; systolic blood pressure, 108.9 and 106.9 mmHg; and diastolic blood pressure, 69.7 and 68.2 mmHg, respectively. Values for the placebo group were as follows: heart rate, 73.2 and 69.6 beats/min; systolic blood pressure, 110.6 and 105.3 mmHg; diastolic blood pressure, 71.4 and 70.5 mmHg. The confidence intervals of the mean for the differences between the groups are as follows: heart rate, -4.0 +8.2; systolic blood pressure, -6.7, +10.1; diastolic blood pressure, -7.9, +3.9. There were no changes in the frequency of atrial or ventricular arrhythmia as documented by repeated 48 hour ambulatory ECG recordings from baseline period before stopping smoking compared with the treatment period in the active as well as in the placebo groups. No ischemic events were detected in any of the volunteers during either the baseline or treatment periods. As a measure of smoking abstinence, we assessed the level of carbon monoxide in expired air; in the active group, the mean levels fell from 14.2 to 4.4 ppm after smoking cessation and in the placebo group from 13.2 to 4.2 ppm. The mean urine cotinine level fell from 8.18 mmol/l at baseline to 5.74 mmol/l after 2 weeks of treatment in the active group and from 8.78 to 3.93 mmol/l in the placebo group. The number of cigarettes smoked per week in both treatment groups was significantly reduced: from 175.2 to 8.4 for the active group and from 136 to 8.6 for the placebo group. Eleven out of 22 subjects in each group quit smoking completely. Smoking withdrawal symptoms during the first week of treatment were more severe in the placebo group than in those on active treatment. There were no significant side effects in either the placebo or the active treatment groups. These results indicate that nicotine delivered by transdermal system is free of cardiac adverse effects in healthy volunteers.

General practitioners' promotion of healthy life styles: what patients think

The study examined the prevalence of cigarette smoking, alcohol consumption, exercising to keep fit and dieting to lose weight among general practice patients, and patients' perceptions of the role of the general practitioner in advising about life style. A cross-sectional survey using a self-administered questionnaire was completed by 13,017 patients aged 18 to 70 years who were attending one of 119 general practitioners from 40 group practices in metropolitan Sydney over a six- to eight-week period. More women than men reported dieting to lose weight, just over half of the men and women were exercising regularly to keep fit, 35 per cent of men and 29 per cent of women reported smoking, and 12 per cent of men and 10 per cent of women were drinking alcohol at levels considered hazardous or harmful. More young people were smoking, drinking hazardously or harmfully, dieting to lose weight and exercising than the older age groups, and their smoking rates exceeded those of the general population. Most patients reported that general practitioners should be interested in their life-style behaviours, particularly smoking. Substantially fewer patients (particularly women who drank excessively) reported receiving advice about their habits. General practitioners were more likely to give advice when smoking and drinking levels were very high. There were discrepancies between patients' expectations of the doctor's role in promoting healthy life styles, and their likelihood of receiving advice. Doctors could reduce the diseases associated with unhealthy practices. Developments in medical training in the 1990s may extend the way they engage in advising on issues of life style.

Nicotine addiction and treatment

The persistence of cigarette smoking despite widespread awareness of adverse health effects results from an underlying addiction to nicotine. Unaided attempts to quit smoking are generally unsuccessful. This article discusses nicotine addition and therapeutic techniques that have been or are being developed to relieve smoking withdrawal symptoms and promote abstinence from smoking. These techniques include nicotine chewing gum, skin patches, nasal sprays, and inhalers, as well as pharmacotherapies such as mecamylamine and clonidine, serotonergic treatments such as buspirone, and antidepressants such as buproprion. A nondrug approach using cigarette substitutes that mimic the airway sensations produced by cigarette smoke is also discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of nicotine in tobacco smoking: implications for tobacco control policy

This paper outlines some of the evidence that tobacco smoking is maintained by addiction to nicotine. Smokers often perceive that tobacco helps them cope with stress and aids their mental alertness. Nicotine withdrawal symptoms are one important factor preventing many smoker from quitting (only about 3% succeed with each unaided quit attempt). A number of policies are suggested to reduce the health consequences of smoking more quickly than at present. These include (a) banning all tobacco advertising and prosecuting retailers who sell illegally to children, in order to reduce the number of young people becoming addicted, (b) increasing the real price of tobacco in order to encourage more people to try to stop smoking, (c) providing specialist smokers' clinics in every large general hospital in order to assist highly motivated but addicted smokers to quit and (d) increasing the rate at which tobacco manufacturers must reduce permissible tar and carbon monoxide yields, such that in 20 years time only nicotine delivery products which are free of tar and carbon monoxide will be allowed.

Airway sensory replacement combined with nicotine replacement for smoking cessation. A randomized, placebo-controlled trial using a citric acid inhaler

STUDY OBJECTIVE

This study was conducted to determine if the combination of airway sensory replacement and nicotine replacement improves 10-week smoking abstinence rates over nicotine replacement alone.

DESIGN

Double-blind, randomized, placebo-controlled trial.

SETTING

Outpatient research clinic.

PARTICIPANTS

One hundred healthy volunteers who smoked at least one pack of cigarettes per day and desired to quit smoking.

INTERVENTIONS

Subjects received either citric acid (n = 41) or lactose placebo (n = 59) inhalers to cope with smoking urges for 10 weeks. All subjects received self-help materials and nicotine patches for 6 weeks. Return visits were at weeks 1, 4, 6, and 10. Abstinence was defined as zero cigarettes smoked since the quit date verified by exhaled carbon monoxide < or = 8 ppm at all return visits. Inhaler effects were measured by a standardized questionnaire.

MEASUREMENTS AND RESULTS

The primary outcome of continuous abstinence at the end of the 10-week treatment period was 19.5% (95% confidence interval [CI] = 7.4 to 31.6%) for the citric acid group vs 6.8% (95% CI = 0.4 to 13.2%) for the lactose group (p = 0.05). Relief from craving and short-term abstinence increased as airway sensations from the inhaler also increased. Abstinence at 10 weeks for subjects receiving strong airway sensations from the inhalers was 33.3% (95% CI = 14.5 to 52.1%). At 6 months, there was no difference in abstinence between the treatment groups (0% vs 5.1%, p = 0.20).

CONCLUSIONS

When combined with the nicotine patch, the citric acid inhaler improved 10-week smoking abstinence over lactose inhaler. The combination of airway sensory replacement and nicotine replacement may prove beneficial for smoking cessation.

Smoking habits of emergency department patients: an opportunity for disease prevention

OBJECTIVE

To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.

METHODS

A questionnaire was administered prospectively to all noncritical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.

RESULTS

The study patients were mostly young (mean age = 35 +/- 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36-0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46-0.64) of these patients were current smokers.

CONCLUSIONS

The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.

The scientific case that nicotine is addictive

Despite the wide-ranging and authoritative 1988 review by the US Surgeon General, views questioning the addictiveness of nicotine contine to be expressed in some quarters. This lack of complete consensus is not unexpected, since no universally agreed scientific definition of addiction exists. In this paper we briefly consider a number of lines of evidence from both the human and animal literature bearing on the addictiveness of nicotine. Patterns of use by smokers and the remarkable intractability of the smoking habit point to compulsive use as the norm. Studies in both animal and human subjects have shown that nicotine can function as reinforcer, albeit under a more limited range of conditions than with some other drugs of abuse. In drug discrimination paradigms there is some cross-generalisation between nicotine on the one hand, and amphetamine and cocaine on the other. A well-defined nicotine withdrawal syndrome has been delineated which is alleviated by nicotine replacement. Nicotine replacement also enhances outcomes in smoking cessation, roughly doubling success rates. In total, the evidence clearly identifies nicotine as a powerful drug of addiction, comparable to heroin, cocaine and alcohol.

Treatments for smokers

Research in treatments for smokers benefits from the feasibility of relatively large samples and well developed evaluative methodology. The field is currently dominated by nicotine replacement methods, for which some degree of efficacy has been clearly demonstrated. A number of psychological methods are widely used as well, although there is little consistent evidence that one specific method is better than any other. Two approaches to treating smokers can be distinguished, i.e. intensive clinic-based treatments and brief community-orientated interventions, e.g. in primary health care. The latter are applicable on a large scale, and aim to affect overall smoking prevalence. Among intensive treatments, the current state of the art would include nicotine replacement and group support of several weeks' duration. In primary health care, simple routine interventions are the preferred option.

General practice

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Prospective study of factors predicting outcome of transdermal nicotine treatment in smoking cessation

OBJECTIVE

To assess the factors associated with cessation of smoking with transdermal nicotine and brief behavioural counselling.

DESIGN

Interviews, treatment, and follow up for 26 weeks.

SUBJECTS

1481 subjects recruited by mass media publicity who smoked > or = 15 cigarettes a day and were motivated to stop smoking.

INTERVENTIONS

Twelve weeks' treatment with transdermal nicotine and brief behavioural counselling at monthly visits.

MAIN OUTCOME MEASURE

Sustained smoking cessation for the 28 days before the visit at week 26 verified by expired carbon monoxide concentrations. The logistic regression analysis included all subjects.

RESULTS

Most subjects were dependent on nicotine, and the mean (SD) number of cigarettes smoked a day was 32 (12). Overall, 316/1481 subjects (21.3%) stopped smoking. Factors associated with stopping were being male (adjusted odds ratio 2.0; 95% confidence interval 1.5 to 2.7), age > or = 40 years (1.5; 1.1 to 2.0), living with a spouse or partner (1.5; 1.1 to 2.1), motivation ("want to quit" 1.7; 1.2 to 2.3), and concern about weight gain (1.7; 1.3 to 2.2). Negative associations were smoking marijuana (0.4; 0.2 to 0.8) and the presence of other smokers in the household (0.8; 0.6 to 0.9). Almost all subjects who smoked three or more cigarettes in the first four weeks of treatment resumed smoking in the long term (525/547, 96%).

CONCLUSIONS

Age, sex, marital status (living with a spouse or partner), motivation, concern about weight gain, recent marijuana smoking, and other smokers in the household were baseline factors associated with differences in outcome of smoking cessation attempts. Smoking three or more cigarettes in the first few weeks after stopping strongly predicted long term relapse.

The transdermal nicotine patch: results of a randomised placebo-controlled trial

OBJECTIVES

To evaluate the efficacy of the transdermal nicotine patch as an aid to smoking cessation when used as an adjunct to a cognitive-behavioural group intervention and to assess the effectiveness of the patch in ameliorating withdrawal symptoms.

DESIGN AND SETTING

Double-blind placebo-controlled randomised trial with six months' follow-up of those who returned to the hospital-based outpatients smoking cessation clinic.

SUBJECTS

Three hundred and thirteen smokers recruited from the local community. Mean age was 42 years, 48% were male, mean cigarette consumption was 29 per day and mean duration of smoking was 24 years.

INTERVENTION

Cognitive-behavioural intervention delivered in a group context, two hours once a week over five weeks, self-help manual, and 24-hour daily nicotine patch treatment for 10 weeks.

MAIN OUTCOME MEASURES

Point prevalence abstinence at three and six months, and sustained cessation from end of treatment to six months, with biochemical validation (expired carbon monoxide). We examined the effectiveness of the nicotine patch in ameliorating specific withdrawal symptoms by self-report of degree of severity.

RESULTS

The active nicotine patch resulted in significantly higher biochemically confirmed abstinence rates when compared with placebo at three months (48% v. 21%) and at six months (33% v. 14%). Six-months' continuous abstinence rates were also significantly higher among the active nicotine group (25%) compared with placebo (12%). The most common adverse events among active patch users were sleep disturbance and local skin irritation. The nicotine patch reduced the severity of some withdrawal symptoms. A low level of dependence was the strongest predictor of three and six months' abstinence.

CONCLUSIONS

The transdermal nicotine patch is effective when used as an adjunct to a group cognitive-behavioural intervention and it provides relief from withdrawal symptoms associated with nicotine dependence.

Skin sensitivity and transdermal drug delivery. A review of the problem

Transdermal devices are now marketed for the delivery of systemic medication through the skin. Advantages associated with transdermal drug delivery include avoidance of first-pass metabolism and improved patient compliance. Drugs currently available by this route include scopolamine (hyoscine), nitroglycerin (glyceryl trinitrate), estradiol, nicotine and clonidine. This novel development has brought in its wake a specific constellation of skin sensitivity problems, which vary widely in incidence between drugs. Varying the site of drug administration to minimise these reactions is important. Any eczematous reaction can be treated with a moderately potent topical steroid. Tolerance to oral challenge in those with topical sensitivity occurs, but caution is still advocated before proceeding to this step. The increasing use of transdermal drug delivery systems across many specialties means that problems of skin sensitivity are of growing relevance to the dermatologist, the hospital specialist and the primary care physician.