Varenicline for smoking cessation: definite promise, but no panacea

Recent advancement in the synthesis of diverse spiro-indeno[1,2-b]quinoxalines: a review

The nitrogen-containing indeno[1,2-b]quinoxaline ring is a privileged structurally fused active system and has notable applications in various fields of chemistry.

Not Just a Pill: Toward a Tailored Antismoking Intervention for Respiratory Diseases

Tobacco cigarette smoking is a serious epidemic that kills several million people each year. Nevertheless, a significant percentage of patients with respiratory diseases continue to smoke after diagnosis, despite the assistance offered, thus reducing the efficacy of the treatments prescribed by the health providers and dramatically increasing the mortality rate. International guidelines have advocated the importance of including smoking cessation protocols in the management of patients' respiratory conditions and pointed out the need to deliver integrated and tailored interventions. Consistently with this framework, the commentary proposes a new clinical approach to smoking cessation in patients with respiratory diseases. This approach integrates, according to P5 personalized medicine, pharmacological and psychological aspects affecting smoking behaviors, overcoming the traditional approach mainly based on the pharmacological interventions.

Quitting smoking before and after varenicline: a population study based on two representative samples of US smokers

BACKGROUND

Varenicline is known to have greater efficacy than other pharmacotherapy for treating nicotine dependence and has gained popularity since its introduction in 2006. This study examines if adding varenicline to existing pharmacotherapies increased the population cessation rate.

METHODS

Data are from two cross-sectional US Current Population Surveys-Tobacco Use Supplements (2003 and 2010-2011). Smokers and recent quitters 18 or older (N=34 869 in 2003, N=27 751 in 2010-2011) were asked if they had used varenicline, bupropion or nicotine replacement therapies (NRT) in their most recent quit attempt. The annual cessation rate, as well as the per cent of smokers who had quit for ≥3 months, was compared between surveys.

RESULTS

Varenicline use increased from 0% in 2003 to 10.9% in 2010-2011, while use of bupropion decreased from 9.1% to 3.5%, and NRT from 24.5% to 22.4%. Use of any pharmacotherapy increased by 2.4 percentage points. Varenicline users stayed on cessation aids longer and were less likely to relapse than users of other pharmacotherapies in the first 3 months of a quit attempt, after which the difference was no longer significant. The change in annual cessation rate was negligible, from 4.5% in 2003 to 4.7% in 2010-2011 (p=0.36).

CONCLUSIONS

Addition of varenicline to the list of approved cessation aids has mainly led to displacement of other therapies. As a result, there was no meaningful change in population cessation rate despite a remarkable increase in varenicline use. The population impact of a new therapy is a function of more than efficacy or reach of the therapy.

Pharmacological intervention of nicotine dependence

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

Tobacco smoking: patterns, health consequences for adults, and the long-term health of the offspring

Tobacco use started several centuries ago and increased markedly after the invention of the cigarette making machine. Once people start smoking they find it difficult to quit the habit. This is due to the addictive effect of nicotine in tobacco smoke. Various epidemiologic and laboratory studies clearly showed that smoking is associated with various diseases such as heart diseases, asthma and emphysema and the associated increase in morbidity and mortality of smokers. Several studies implicate nicotine as the causative factor in tobacco smoke. Apart from nicotine, various carcinogens also occur in tobacco smoke resulting in an increase in the incidence of cancer in smokers. While the smoking habit is decreasing in developed countries, tobacco use increases in the developing countries. Smoking prevalence is also highest in poor communities and amongst those with low education levels. It is important to note that, although ther is a decline in the number of smokers in the developed countries, there is a three to four decades lag between the peak in smoking prevalence and the subsequent peak in smoking related mortality. It has been shown that maternal smoking induces respiratory diseases in the offspring. There is also evidence that parental smoking may program the offspring to develop certain diseases later in life. Various studies showed that maternal nicotine exposure during pregnancy and lactation via tobacco smoke of nicotine replacement therapy (NRT), program the offspring to develop compromised lung structure later in life with the consequent compromised lung function. This implies that NRT is not an option to assist pregnant or lactating smokers to quit the habit. Even paternal smoking may have an adverse effect on the health of the offspring since it has been shown that 2nd and 3rd hand smoking have adverse health consequences for those exposed to it.

Smoking cessation readiness: are your patients ready to quit?

PURPOSE

To explore the assessment of patient readiness to receive smoking cessation interventions using the transtheoretical model (TTM) and the five stages of change; and to give the primary care provider an evidence-based toolkit to assist in evaluating for readiness and supporting the smoking cessation process.

DATA SOURCES

Evidence-based literature, theoretical framework, and peer-reviewed articles.

CONCLUSIONS

Utilizing the TTM along with proper training and education of the provider and patient increases the probability that smoking cessation will occur. Combinations of pharmaceutical and nonpharmaceutical interventions are the most effective in smoking cessation.

IMPLICATIONS FOR PRACTICE

Providers can be prepared at every patient visit to address the smoking cessation needs of all patients. The toolkit provided in this article will help facilitate evaluation of readiness and support of effective, long-term smoking cessation and reduce eventual smoking-related morbidities.

Smoking cessation: significance and implications for children

A number of people in the USA who are still current smokers remain a staggering figure. Although this number continues to decrease, there is still a considerable amount of second-hand smoke. More importantly and for the purpose of this review, the detrimental effects of passive smoke in children is significant. We will not review the specific health effects of passive smoke, but for pediatricians, in particular, it is important to place in perspective programs that are available to influence the parents of children to stop smoking. Indeed, approximately 25% of all children aged 3-11 live in a household with at least one smoker. Despite the increasing number of communities in the states that have instituted restrictions or complete bans on smoking in the workplace and in many public areas, the principal site of smoking remains the home.

Effectiveness of smoking cessation therapies: a systematic review and meta-analysis

Background

Smoking remains the leading preventable cause of premature deaths. Several pharmacological interventions now exist to aid smokers in cessation. These include Nicotine Replacement Therapy [NRT], bupropion, and varenicline. We aimed to assess their relative efficacy in smoking cessation by conducting a systematic review and meta-analysis.

Methods

We searched 10 electronic medical databases (inception to Sept. 2006) and bibliographies of published reviews. We selected randomized controlled trials [RCTs] evaluating interventions for smoking cessation at 1 year, through chemical confirmation. Our primary endpoint was smoking cessation at 1 year. Secondary endpoints included short-term smoking cessation (~3 months) and adverse events. We conducted random-effects meta-analysis and meta-regression. We compared treatment effects across interventions using head-to-head trials and when these did not exist, we calculated indirect comparisons.

Results

We identified 70 trials of NRT versus control at 1 year, Odds Ratio [OR] 1.71, 95% Confidence Interval [CI], 1.55–1.88, P =< 0.0001). This was consistent when examining all placebo-controlled trials (49 RCTs, OR 1.78, 95% CI, 1.60–1.99), NRT gum (OR 1.60, 95% CI, 1.37–1.86) or patch (OR 1.63, 95% CI, 1.41–1.89). NRT also reduced smoking at 3 months (OR 1.98, 95% CI, 1.77–2.21). Bupropion trials were superior to controls at 1 year (12 RCTs, OR1.56, 95% CI, 1.10–2.21, P = 0.01) and at 3 months (OR 2.13, 95% CI, 1.72–2.64). Two RCTs evaluated the superiority of bupropion versus NRT at 1 year (OR 1.14, 95% CI, 0.20–6.42).

Varenicline was superior to placebo at 1 year (4 RCTs, OR 2.96, 95% CI, 2.12–4.12, P =< 0.0001) and also at approximately 3 months (OR 3.75, 95% CI, 2.65–5.30). Three RCTs evaluated the effectiveness of varenicline versus bupropion at 1 year (OR 1.58, 95% CI, 1.22–2.05) and at approximately 3 months (OR 1.61, 95% CI, 1.16–2.21). Using indirect comparisons, varenicline was superior to NRT when compared to placebo controls (OR 1.66, 95% CI 1.17–2.36, P = 0.004) or to all controls at 1 year (OR 1.73, 95% CI 1.22–2.45, P = 0.001). This was also the case for 3-month data. Adverse events were not systematically different across studies.

Conclusion

NRT, bupropion and varenicline all provide therapeutic effects in assisting with smoking cessation. Direct and indirect comparisons identify a hierarchy of effectiveness.