Nicotine receptor partial agonists for smoking cessation

Nicotine receptor partial agonists for smoking cessation

Background

Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist). This is an update of a Cochrane Review first published in 2007.

Objectives

To assess the effectiveness of nicotine receptor partial agonists, including varenicline and cytisine, for smoking cessation.

Search methods

We searched the Cochrane Tobacco Addiction Group's Specialised Register in April 2022 for trials, using relevant terms in the title or abstract, or as keywords. The register is compiled from searches of CENTRAL, MEDLINE, Embase, and PsycINFO. 

Selection criteria

We included randomised controlled trials that compared the treatment drug with placebo, another smoking cessation drug, e‐cigarettes, or no medication. We excluded trials that did not report a minimum follow‐up period of six months from baseline.

Data collection and analysis

We followed standard Cochrane methods. Our main outcome was abstinence from smoking at longest follow‐up using the most rigorous definition of abstinence, preferring biochemically validated rates where reported. We pooled risk ratios (RRs), using the Mantel‐Haenszel fixed‐effect model. We also reported the number of people reporting serious adverse events (SAEs).

Main results

We included 75 trials of 45,049 people; 45 were new for this update. We rated 22 at low risk of bias, 18 at high risk, and 35 at unclear risk.

We found moderate‐certainty evidence (limited by heterogeneity) that cytisine helps more people to quit smoking than placebo (RR 1.30, 95% confidence interval (CI) 1.15 to 1.47; I2 = 83%; 4 studies, 4623 participants), and no evidence of a difference in the number reporting SAEs (RR 1.04, 95% CI 0.78 to 1.37; I2 = 0%; 3 studies, 3781 participants; low‐certainty evidence). SAE evidence was limited by imprecision. We found no data on neuropsychiatric or cardiac SAEs.

We found high‐certainty evidence that varenicline helps more people to quit than placebo (RR 2.32, 95% CI 2.15 to 2.51; I2 = 60%, 41 studies, 17,395 participants), and moderate‐certainty evidence that people taking varenicline are more likely to report SAEs than those not taking it (RR 1.23, 95% CI 1.01 to 1.48; I2 = 0%; 26 studies, 14,356 participants). While point estimates suggested increased risk of cardiac SAEs (RR 1.20, 95% CI 0.79 to 1.84; I2 = 0%; 18 studies, 7151 participants; low‐certainty evidence), and decreased risk of neuropsychiatric SAEs (RR 0.89, 95% CI 0.61 to 1.29; I2 = 0%; 22 studies, 7846 participants; low‐certainty evidence), in both cases evidence was limited by imprecision, and confidence intervals were compatible with both benefit and harm.

Pooled results from studies that randomised people to receive cytisine or varenicline found no clear evidence of difference in quit rates (RR 1.00, 95% CI 0.79 to 1.26; I2 = 65%; 2 studies, 2131 participants; low‐certainty evidence) and reported SAEs (RR 0.67, 95% CI 0.44 to 1.03; I2 = 45%; 2 studies, 2017 participants; low‐certainty evidence). However, the evidence was limited by imprecision, and confidence intervals incorporated the potential for benefit from either cytisine or varenicline. We found no data on neuropsychiatric or cardiac SAEs.

We found high‐certainty evidence that varenicline helps more people to quit than bupropion (RR 1.36, 95% CI 1.25 to 1.49; I2 = 0%; 9 studies, 7560 participants), and no clear evidence of difference in rates of SAEs (RR 0.89, 95% CI 0.61 to 1.31; I2 = 0%; 5 studies, 5317 participants), neuropsychiatric SAEs (RR 1.05, 95% CI 0.16 to 7.04; I2 = 10%; 2 studies, 866 participants), or cardiac SAEs (RR 3.17, 95% CI 0.33 to 30.18; I2 = 0%; 2 studies, 866 participants). Evidence of harms was of low certainty, limited by imprecision.

We found high‐certainty evidence that varenicline helps more people to quit than a single form of nicotine replacement therapy (NRT) (RR 1.25, 95% CI 1.14 to 1.37; I2 = 28%; 11 studies, 7572 participants), and low‐certainty evidence, limited by imprecision, of fewer reported SAEs (RR 0.70, 95% CI 0.50 to 0.99; I2 = 24%; 6 studies, 6535 participants). We found no data on neuropsychiatric or cardiac SAEs.

We found no clear evidence of a difference in quit rates between varenicline and dual‐form NRT (RR 1.02, 95% CI 0.87 to 1.20; I2 = 0%; 5 studies, 2344 participants; low‐certainty evidence, downgraded because of imprecision). While pooled point estimates suggested increased risk of SAEs (RR 2.15, 95% CI 0.49 to 9.46; I2 = 0%; 4 studies, 1852 participants) and neuropsychiatric SAEs (RR 4.69, 95% CI 0.23 to 96.50; I2 not estimable as events only in 1 study; 2 studies, 764 participants), and reduced risk of cardiac SAEs (RR 0.32, 95% CI 0.01 to 7.88; I2 not estimable as events only in 1 study; 2 studies, 819 participants), in all three cases evidence was of low certainty and confidence intervals were very wide, encompassing both substantial harm and benefit.

Authors' conclusions

Cytisine and varenicline both help more people to quit smoking than placebo or no medication. Varenicline is more effective at helping people to quit smoking than bupropion, or a single form of NRT, and may be as or more effective than dual‐form NRT. People taking varenicline are probably more likely to experience SAEs than those not taking it, and while there may be increased risk of cardiac SAEs and decreased risk of neuropsychiatric SAEs, evidence was compatible with both benefit and harm. Cytisine may lead to fewer people reporting SAEs than varenicline. Based on studies that directly compared cytisine and varenicline, there may be no difference or a benefit from either medication for quitting smoking.

Future trials should test the effectiveness and safety of cytisine compared with varenicline and other pharmacotherapies, and should also test variations in dose and duration. There is limited benefit to be gained from more trials testing the effect of standard‐dose varenicline compared with placebo for smoking cessation. Further trials on varenicline should test variations in dose and duration, and compare varenicline with e‐cigarettes for smoking cessation.

Can medications like varenicline and cytisine (nicotine receptor partial agonists) help people to stop smoking and do they cause unwanted effects?

Key messages

· Varenicline can help people to stop smoking for at least 6 months. Evidence shows it works better than bupropion and using only one type of nicotine replacement therapy (e.g. only patches). Quit rates might be similar to using more than one type of nicotine replacement therapy at the same time (e.g. patches and gum together).

· Cytisine can help people to stop smoking for at least 6 months. It may work as well as varenicline, but future evidence may show that while it helps, it is not quite as helpful as varenicline.

· Future studies should test the effectiveness and safety of cytisine compared with varenicline and other stop‐smoking medications, and should also  investigate giving cytisine or varenicline at different doses and for different lengths of time.

What are 'nicotine receptor partial agonists'?

Smoking tobacco is extremely bad for people’s health. For people who smoke, quitting is the best thing they can do to improve their health. Many people find it difficult to quit smoking. Nicotine receptor partial agonists (NRPAs) are a type of medication used to help people to stop smoking. They help to reduce the withdrawal symptoms people experience when they stop smoking, like cravings and unpleasant mood changes. They also reduce the pleasure people usually experience when they smoke. The most widely‐available treatment in this drug type is varenicline. Cytisine is another, similar medication. They may cause unwanted effects such as feeling sick (nausea) and other stomach problems, difficulties sleeping, abnormal dreams, and headache. They may also lead to potentially serious unwanted effects, such as suicidal thoughts, heart problems and raised blood pressure.

What did we want to find out?

We wanted to find out if using NRPAs can help people to quit smoking, and if they cause unwanted effects. We wanted to know:

· how many people stopped smoking for at least 6 months; and

· how many people had unwanted effects.

What did we do?

We searched for studies that investigated NRPAs used to help people quit smoking. People in the studies had to be chosen at random to receive an NRPA, or another NRPA, placebo (medication like the NRPA but with no active ingredients) or no treatment. They had to be adult tobacco smokers who wanted to stop smoking.

What did we find?

We found 75 studies that compared NRPAs with:

· placebo or no medicine;

· nicotine replacement therapy, such as patches or gum;

· bupropion (another medicine to help people stop smoking);

· another NRPA;

· e‐cigarettes.

The USA hosted the most studies (28 studies). Other studies took place in a range of countries across the world, some in several countries.

Main results

People are more likely to stop smoking for at least six months using varenicline than using placebo (41 studies, 17,395 people), bupropion (9 studies, 7560 people), or just one type of nicotine replacement therapy, like patches alone (11 studies, 7572 people). They may be just as likely to quit as people using two or more kinds of nicotine replacement therapy, like patches and gum together (5 studies, 2344 people).

Cytisine probably helps more people to stop smoking than placebo (4 studies, 4623 people) and may be just as effective as varenicline (2 studies, 2131 people).

For every 100 people using varenicline to stop smoking, 21 to 25 might successfully stop, compared with only 18 of 100 people using bupropion, 18 of 100 people using a single form of nicotine‐replacement therapy, and 20 of 100 using two or more kinds of nicotine‐replacement therapy. For every 100 people using cytisine to stop smoking, 18 to 23 might successfully stop.

The most common unwanted effect of varenicline is nausea, but this is mostly at mild or moderate levels and usually clears over time. People taking varenicline likely have an increased chance of a more serious unwanted effect that could result in going to hospital, however these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people without) and may include many that are unrelated to varenicline. People taking cytisine may also have a slightly increased chance of serious unwanted effects compared with people not taking it, but this may be less likely compared with varenicline.

What are the limitations of the evidence?

The evidence for some of our results is very reliable. We’re very confident that varenicline helps people to quit smoking better than many alternatives. We’re less sure of some other results because fewer or smaller studies provided evidence.

Several results suggest one treatment is better or less harmful than another, but the opposite could still be true.

How up to date is the evidence?

The evidence is up to date to 29 April 2022.

Nicotine receptor partial agonists for smoking cessation

BACKGROUND

Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist). This is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To assess the effectiveness of nicotine receptor partial agonists, including varenicline and cytisine, for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register in April 2022 for trials, using relevant terms in the title or abstract, or as keywords. The register is compiled from searches of CENTRAL, MEDLINE, Embase, and PsycINFO.  SELECTION CRITERIA: We included randomised controlled trials that compared the treatment drug with placebo, another smoking cessation drug, e-cigarettes, or no medication. We excluded trials that did not report a minimum follow-up period of six months from baseline.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our main outcome was abstinence from smoking at longest follow-up using the most rigorous definition of abstinence, preferring biochemically validated rates where reported. We pooled risk ratios (RRs), using the Mantel-Haenszel fixed-effect model. We also reported the number of people reporting serious adverse events (SAEs).

MAIN RESULTS

We included 75 trials of 45,049 people; 45 were new for this update. We rated 22 at low risk of bias, 18 at high risk, and 35 at unclear risk. We found moderate-certainty evidence (limited by heterogeneity) that cytisine helps more people to quit smoking than placebo (RR 1.30, 95% confidence interval (CI) 1.15 to 1.47; I² = 83%; 4 studies, 4623 participants), and no evidence of a difference in the number reporting SAEs (RR 1.04, 95% CI 0.78 to 1.37; I² = 0%; 3 studies, 3781 participants; low-certainty evidence). SAE evidence was limited by imprecision. We found no data on neuropsychiatric or cardiac SAEs. We found high-certainty evidence that varenicline helps more people to quit than placebo (RR 2.32, 95% CI 2.15 to 2.51; I² = 60%, 41 studies, 17,395 participants), and moderate-certainty evidence that people taking varenicline are more likely to report SAEs than those not taking it (RR 1.23, 95% CI 1.01 to 1.48; I² = 0%; 26 studies, 14,356 participants). While point estimates suggested increased risk of cardiac SAEs (RR 1.20, 95% CI 0.79 to 1.84; I² = 0%; 18 studies, 7151 participants; low-certainty evidence), and decreased risk of neuropsychiatric SAEs (RR 0.89, 95% CI 0.61 to 1.29; I² = 0%; 22 studies, 7846 participants; low-certainty evidence), in both cases evidence was limited by imprecision, and confidence intervals were compatible with both benefit and harm. Pooled results from studies that randomised people to receive cytisine or varenicline showed that more people in the varenicline arm quit smoking (RR 0.83, 95% CI 0.66 to 1.05; I² = 0%; 2 studies, 2131 participants; moderate-certainty evidence) and reported SAEs (RR 0.67, 95% CI 0.44 to 1.03; I² = 45%; 2 studies, 2017 participants; low-certainty evidence). However, the evidence was limited by imprecision, and confidence intervals incorporated the potential for benefit from either cytisine or varenicline. We found no data on neuropsychiatric or cardiac SAEs. We found high-certainty evidence that varenicline helps more people to quit than bupropion (RR 1.36, 95% CI 1.25 to 1.49; I² = 0%; 9 studies, 7560 participants), and no clear evidence of difference in rates of SAEs (RR 0.89, 95% CI 0.61 to 1.31; I² = 0%; 5 studies, 5317 participants), neuropsychiatric SAEs (RR 1.05, 95% CI 0.16 to 7.04; I² = 10%; 2 studies, 866 participants), or cardiac SAEs (RR 3.17, 95% CI 0.33 to 30.18; I² = 0%; 2 studies, 866 participants). Evidence of harms was of low certainty, limited by imprecision. We found high-certainty evidence that varenicline helps more people to quit than a single form of nicotine replacement therapy (NRT) (RR 1.25, 95% CI 1.14 to 1.37; I² = 28%; 11 studies, 7572 participants), and low-certainty evidence, limited by imprecision, of fewer reported SAEs (RR 0.70, 95% CI 0.50 to 0.99; I² = 24%; 6 studies, 6535 participants). We found no data on neuropsychiatric or cardiac SAEs. We found no clear evidence of a difference in quit rates between varenicline and dual-form NRT (RR 1.02, 95% CI 0.87 to 1.20; I² = 0%; 5 studies, 2344 participants; low-certainty evidence, downgraded because of imprecision). While pooled point estimates suggested increased risk of SAEs (RR 2.15, 95% CI 0.49 to 9.46; I² = 0%; 4 studies, 1852 participants) and neuropsychiatric SAEs (RR 4.69, 95% CI 0.23 to 96.50; I² not estimable as events only in 1 study; 2 studies, 764 participants), and reduced risk of cardiac SAEs (RR 0.32, 95% CI 0.01 to 7.88; I² not estimable as events only in 1 study; 2 studies, 819 participants), in all three cases evidence was of low certainty and confidence intervals were very wide, encompassing both substantial harm and benefit.

AUTHORS' CONCLUSIONS

Cytisine and varenicline both help more people to quit smoking than placebo or no medication. Varenicline is more effective at helping people to quit smoking than bupropion, or a single form of NRT, and may be as or more effective than dual-form NRT. People taking varenicline are probably more likely to experience SAEs than those not taking it, and while there may be increased risk of cardiac SAEs and decreased risk of neuropsychiatric SAEs, evidence was compatible with both benefit and harm. Cytisine may lead to fewer people reporting SAEs than varenicline. Based on studies that directly compared cytisine and varenicline, there may be a benefit from varenicline for quitting smoking, however further evidence could strengthen this finding or demonstrate a benefit from cytisine. Future trials should test the effectiveness and safety of cytisine compared with varenicline and other pharmacotherapies, and should also test variations in dose and duration. There is limited benefit to be gained from more trials testing the effect of standard-dose varenicline compared with placebo for smoking cessation. Further trials on varenicline should test variations in dose and duration, and compare varenicline with e-cigarettes for smoking cessation.

Revisiting time to translation: implementation of evidence-based practices (EBPs) in cancer control

PURPOSE

Previous studies estimate translation of research evidence into practice takes 17 years. However, this estimate is not specific to cancer control evidence-based practices (EBPs), nor do these studies evaluate variation in the translational process. We examined the translational pathway of cancer control EBPs.

METHODS

We selected five cancer control EBPs where data on uptake were readily available. Years from landmark publication to clinical guideline issuance to implementation, defined as 50% uptake, were measured. The translational pathway for each EBP was mapped and an average total time across EBPs was calculated.

RESULTS

Five cancer control EBPs were included: mammography, clinicians' advice to quit smoking, colorectal cancer screening, HPV co-testing, and HPV vaccination. Time from publication to implementation ranged from 13 to 21 years, averaging 15 years. Time from publication to guideline issuance ranged from 3 to 17 years, and from guideline issuance to implementation, - 4 to 12 years. Clinician's advice to quit smoking, HPV co-testing, and HPV vaccination were most rapidly implemented; colorectal cancer screening and mammography were slowest to implement.

CONCLUSION

The average time to implementation was 15 years for the five EBPs we evaluated, a marginal improvement from prior findings. Although newer EBPs such as HPV vaccination and HPV co-testing were faster to implement than other EBPs, continued efforts in implementation science to speed research to practice are needed.

A Comparative Study of the Cost and Uptake of Community Pharmacy "Stop Smoking and Emergency Contraception" Services from the Perspective of the National Health Service

Objective:

The objective was to explore if the community pharmacy (CP) stop smoking service (SSS) and emergency hormonal contraception patient group direction (EHC PGD) meet the needs of the English population and are cost-effective.

Methods:

This research was completed over 2 years. Public health resources provided details of CPs and provision of SSS and EHC PGD. Questionnaires were sent to smoking cessation/sexual health leads in local authorities to obtain information not available elsewhere. Questionnaires inquired about CP payment for provision of SSS and EHC PGD, overhead costs, successful outcomes, and validation methods. Quit rates at 4-weeks, 52-weeks, and lifetime determined SSS effectiveness. The effectiveness of EHC PGD was based on the probability of unintended pregnancy with/without levonorgestrel. Incremental cost-effectiveness ratio and cost of quality-adjusted life years (QALYs) gained were calculated. Descriptive statistics were determined. A priori of less than 0.05 (P < 0.05) was significant.

Findings:

SSS provision and uptake did not match local needs (smoking prevalence) even though increased CP SSS provision correlated with increased SSS success. Similarly, the need (based on teenage pregnancy rates) for EHC PGD did not correlate with the rate of CP provision but only with the uptake. Nevertheless, the provision of SSS and EHC PGD from CPs was cost-effective from an NHS perspective. Various assumptions were tested, but in all cases fell well below NICE QALY recommendations for cost-effectiveness.

Conclusion:

Provision of SSS and EHC PGD from CP does not meet the needs of the population even though the delivery of these services is cost-effective.

A bespoke smoking cessation service compared with treatment as usual for people with severe mental ill health: the SCIMITAR+ RCT

BACKGROUND

There is a high prevalence of smoking among people with severe mental ill health (SMI). Helping people with SMI to quit smoking could improve their health and longevity, and reduce health inequalities. However, those with SMI are less likely to access and engage with routine smoking cessation services than the general population.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation (BSC) intervention with usual stop smoking services for people with SMI.

DESIGN

A pragmatic, two-arm, individually randomised controlled trial.

SETTING

Primary care and secondary care mental health services in England.

PARTICIPANTS

Smokers aged ≥ 18 years with SMI who would like to cut down on or quit smoking.

INTERVENTIONS

A BSC intervention delivered by mental health specialists trained to deliver evidence-supported smoking cessation interventions compared with usual care.

MAIN OUTCOME MEASURES

The primary outcome was self-reported, CO-verified smoking cessation at 12 months. Smoking-related secondary outcomes were self-reported smoking cessation, the number of cigarettes smoked per day, the Fagerström Test for Nicotine Dependence and the Motivation to Quit questionnaire. Other secondary outcomes were Patient Health Questionnaire-9 items, Generalised Anxiety Disorder Assessment-7 items and 12-Item Short-Form Health Survey, to assess mental health and body mass index measured at 6 and 12 months post randomisation.

RESULTS

The trial randomised 526 people (265 to the intervention group, 261 to the usual-care group) aged 19 to 72 years (mean 46 years). About 60% of participants were male. Participants smoked between 3 and 100 cigarettes per day (mean 25 cigarettes per day) at baseline. The intervention group had a higher rate of exhaled CO-verified smoking cessation at 6 and 12 months than the usual-care group [adjusted odds ratio (OR) 12 months: 1.6, 95% confidence interval (CI) 0.9 to 2.8; adjusted OR 6 months: 2.4, 95% CI 1.2 to 4.7]. This was not statistically significant at 12 months (p = 0.12) but was statistically significant at 6 months (p = 0.01). In total, 111 serious adverse events were reported (69 in the BSC group and 42 in the usual-care group); the majority were unplanned hospitalisations due to a deterioration in mental health (n = 98). The intervention is likely (57%) to be less costly but more effective than usual care; however, this result was not necessarily associated with participants' smoking status.

LIMITATIONS

Follow-up was not blind to treatment allocation. However, the primary outcome included a biochemically verified end point, less susceptible to observer biases. Some participants experienced difficulties in accessing nicotine replacement therapy because of changes in service provision. Efforts were made to help participants access nicotine replacement therapy, but this may have affected participants' quit attempt.

CONCLUSIONS

People with SMI who received the intervention were more likely to have stopped smoking at 6 months. Although more people who received the intervention had stopped smoking at 12 months, this was not statistically significant.

FUTURE WORK

Further research is needed to establish how quitting can be sustained among people with SMI.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72955454.

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. 23, No. 50. See the NIHR Journals Library website for further project information.

What do cost-effective health behaviour-change interventions contain? A comparison of six domains

OBJECTIVES

To help implement behaviour change interventions (BCIs) in practice it is important to be able to characterize their key components. This study compared broad features of cost-effective BCIs that addressed smoking, diet, physical activity, alcohol and sexual health. It also assessed the association of these with the magnitude of the cost-effectiveness estimates.

METHODS

A content analysis of 79 interventions based on 338 intervention descriptions was conducted, using the Behaviour Change Wheel (BCW) to classify intervention content in terms of intervention functions, and the BCT taxonomy to identify and categorise component Behaviour Change Techniques (BCT). Regression analysis identified the association of these with upper (pessimistic) and lower (optimistic) cost-effectiveness estimates.

RESULTS

The most and least common functions and BCT clusters were education (82.3%) and shaping knowledge (79.7%), and coercion (3.8%) and covert learning (2.5%). Smoking interventions contained the largest ([Formula: see text] = 12) number of BCTs and were most cost-effective. Several other factors were associated with worse (coercionfunction βupper = 36551.24; shaping knowledgeBCT βlower = 2427.78; comparison of outcomesBCT βupper = 9067.32; repetition and substitutionBCT βupper = 7172.47) and better (modellingfunction βlower = -2905.3; environmental restructuringfunction βupper = -8646.28; reward and threatBCT βupper = -5577.59) cost-effectiveness (p<0.05).

DISCUSSION

Cost-effective BCIs rely heavily on education with smoking interventions exhibiting the most comprehensive range of BCTs. Providing an example to aspire to, restructuring the environment and rewarding positive behaviour may be associated with greater cost-effectiveness.

Discovery and development of varenicline for smoking cessation

INTRODUCTION

Tobacco use causes one premature death every six seconds. Current smoking cessation aids include nicotine replacement therapies, bupropion, and varenicline. Although more than 70% of smokers express a desire to quit, fewer than 3% remain abstinent for more than one year, highlighting a critical need for more efficacious smoking cessation treatments. Areas covered: The authors discuss the rationale, preclinical and clinical development of varenicline for smoking cessation. They cover the development of varenicline as a partial agonist at α4β2 receptors, the primary neural substrate for nicotine reward. Then, they discuss evidence from preclinical studies indicating varenicline's efficacy in blocking nicotine reward, followed by clinical trials demonstrating safety and efficacy in sustaining abstinence in smokers. Finally, they cover post-market surveillance, including caution in heavy machine operators, putative cardiovascular risk, and the repealed warning for adverse neuropsychiatric events. Expert opinion: Varenicline development was based on strong theoretical rationale and preclinical evidence. Clinical studies indicate that varenicline is safe and more effective in sustaining abstinence than placebo, bupropion or nicotine replacement therapies. However, given that continuous abstinence rates across studies remain low (18 ~ 30% with varenicline; 4 ~ 10% with placebo), novel and more effective medications targeting other nicotinic or glutamate receptors for smoking cessation are required.

Is it cost-effective to provide internet-based interventions to complement the current provision of smoking cessation services in the Netherlands? An analysis based on the EQUIPTMOD

BACKGROUND AND AIM

The cost-effectiveness of internet-based smoking cessation interventions is difficult to determine when they are provided as a complement to current smoking cessation services. The aim of this study was to evaluate the cost-effectiveness of such an alternate package compared with existing smoking cessation services alone (current package).

METHODS

A literature search was conducted to identify internet-based smoking cessation interventions in the Netherlands. A meta-analysis was then performed to determine the pooled effectiveness of a (web-based) computer-tailored intervention. The mean cost of implementing internet based interventions was calculated using available information, while intervention reach was sourced from an English study. We used EQUIPTMOD, a Markov-based state-transition model, to calculate the incremental cost-effectiveness ratios [expressed as cost per quality-adjusted life years (QALYs) gained] for different time horizons to assess the value of providing internet-based interventions to complement the current package.). Deterministic sensitivity analyses tested the uncertainty around intervention costs per smoker, relative risks, and the intervention reach.

RESULTS

Internet-based interventions had an estimated pooled relative risk of 1.40; average costs per smoker of €2.71; and a reach of 0.41% of all smokers. The alternate package (i.e. provision of internet-based intervention to the current package) was dominant (cost-saving) compared with the current package alone (0.14 QALY gained per 1000 smokers; reduced health-care costs of €602.91 per 1000 smokers for the life-time horizon). The alternate package remained dominant in all sensitivity analyses.

CONCLUSION

Providing internet-based smoking cessation interventions to complement the current provision of smoking cessation services could be a cost-saving policy option in the Netherlands.

Moderators of smoking cessation outcomes in a randomized-controlled trial of varenicline versus placebo

RATIONALE AND OBJECTIVE

Varenicline has gained a reputation as the optimal intervention for treatment resistant smokers, yet more than half of those who try it do not succeed. To better understand individual differences in the effectiveness of varenicline, this study evaluates the effectiveness of varenicline for smoking cessation in a double-blind, placebo-controlled, randomized clinical trial and examines the influence of psychological factors on treatment outcome.

METHOD

Two hundred five cigarette smokers interested in quitting were randomly assigned to 12 weeks of varenicline or placebo. Outcomes examined were CO-confirmed continuous abstinence for the past month, average number of cigarettes smoked per day, and 7-day point prevalence.

RESULTS

Varenicline-treated participants were more likely than placebo to achieve continuous abstinence at the end of treatment (OR = 3.29; RR = 2.62), and 7-day point prevalence rates showed an effect of medication at each time point. Participants in both groups significantly reduced their smoking during the course of treatment and follow-up, and the medication by visit interaction was significant in the expected direction. Impulsivity and personality style emerged as moderators of the relationship between medication condition and treatment outcome.

CONCLUSIONS

In addition to replicating efficacy results for varenicline versus placebo, the present study shows that the efficacy of pharmacotherapy is influenced by psychological factors. In an era where pharmacotherapy is often perceived as the "silver bullet," we are reminded that smoking cessation is a dynamic process and intervention must be adaptable to address individual differences.

The Effect of an Inpatient Smoking Cessation Treatment Program on Hospital Readmissions and Length of Stay

OBJECTIVE

The objective of this study is to estimate the impact of an inpatient tobacco cessation treatment program on 30-day readmission rates and length of stay (LOS).

METHODS

Participants were 28,994 patients admitted to the hospital between July 2012 and July 2014. Smokers were identified through the electronic medical records system and were offered cessation treatment. Program effects were estimated by using a difference-in-differences approach, comparing all smokers to all nonsmokers before versus after introduction of the program. Readmission rates were modeled by using probit regression; LOS was modeled by using truncated negative binomial regression. Models controlled for age, sex, race, payer, hospital department, severity of illness, and intensive care unit days.

RESULTS

The hospital-initiated smoking cessation intervention had no significant effect on 30-day readmission rates or LOS. Other control variables had the expected signs and were statistically significant.

CONCLUSIONS

The evaluation of an inpatient tobacco dependence treatment did not find significant short-term changes in healthcare utilization in the first 30 days after initial hospitalization.

Nicotine receptor partial agonists for smoking cessation

BACKGROUND

Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist).

OBJECTIVES

To review the efficacy of nicotine receptor partial agonists, including varenicline and cytisine, for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('cytisine' or 'Tabex' or 'dianicline' or 'varenicline' or 'nicotine receptor partial agonist') in the title or abstract, or as keywords. The register is compiled from searches of MEDLINE, EMBASE, and PsycINFO using MeSH terms and free text to identify controlled trials of interventions for smoking cessation and prevention. We contacted authors of trial reports for additional information where necessary. The latest update of the specialised register was in May 2015, although we have included a few key trials published after this date. We also searched online clinical trials registers.

SELECTION CRITERIA

We included randomised controlled trials which compared the treatment drug with placebo. We also included comparisons with bupropion and nicotine patches where available. We excluded trials which did not report a minimum follow-up period of six months from start of treatment.

DATA COLLECTION AND ANALYSIS

We extracted data on the type of participants, the dose and duration of treatment, the outcome measures, the randomisation procedure, concealment of allocation, and completeness of follow-up.The main outcome measured was abstinence from smoking at longest follow-up. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where they were reported. Where appropriate we pooled risk ratios (RRs), using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Two trials of cytisine (937 people) found that more participants taking cytisine stopped smoking compared with placebo at longest follow-up, with a pooled risk ratio (RR) of 3.98 (95% confidence interval (CI) 2.01 to 7.87; low-quality evidence). One recent trial comparing cytisine with NRT in 1310 people found a benefit for cytisine at six months (RR 1.43, 95% CI 1.13 to 1.80).One trial of dianicline (602 people) failed to find evidence that it was effective (RR 1.20, 95% CI 0.82 to 1.75). This drug is no longer in development.We identified 39 trials that tested varenicline, 27 of which contributed to the primary analysis (varenicline versus placebo). Five of these trials also included a bupropion treatment arm. Eight trials compared varenicline with nicotine replacement therapy (NRT). Nine studies tested variations in varenicline dosage, and 13 tested usage in disease-specific subgroups of patients. The included studies covered 25,290 participants, 11,801 of whom used varenicline.The pooled RR for continuous or sustained abstinence at six months or longer for varenicline at standard dosage versus placebo was 2.24 (95% CI 2.06 to 2.43; 27 trials, 12,625 people; high-quality evidence). Varenicline at lower or variable doses was also shown to be effective, with an RR of 2.08 (95% CI 1.56 to 2.78; 4 trials, 1266 people). The pooled RR for varenicline versus bupropion at six months was 1.39 (95% CI 1.25 to 1.54; 5 trials, 5877 people; high-quality evidence). The RR for varenicline versus NRT for abstinence at 24 weeks was 1.25 (95% CI 1.14 to 1.37; 8 trials, 6264 people; moderate-quality evidence). Four trials which tested the use of varenicline beyond the 12-week standard regimen found the drug to be well-tolerated during long-term use. The number needed to treat with varenicline for an additional beneficial outcome, based on the weighted mean control rate, is 11 (95% CI 9 to 13). The most commonly reported adverse effect of varenicline was nausea, which was mostly at mild to moderate levels and usually subsided over time. Our analysis of reported serious adverse events occurring during or after active treatment suggests there may be a 25% increase in the chance of SAEs among people using varenicline (RR 1.25; 95% CI 1.04 to 1.49; 29 trials, 15,370 people; high-quality evidence). These events include comorbidities such as infections, cancers and injuries, and most were considered by the trialists to be unrelated to the treatments. There is also evidence of higher losses to follow-up in the control groups compared with the intervention groups, leading to a likely underascertainment of the true rate of SAEs among the controls. Early concerns about a possible association between varenicline and depressed mood, agitation, and suicidal behaviour or ideation led to the addition of a boxed warning to the labelling in 2008. However, subsequent observational cohort studies and meta-analyses have not confirmed these fears, and the findings of the EAGLES trial do not support a causal link between varenicline and neuropsychiatric disorders, including suicidal ideation and suicidal behaviour. The evidence is not conclusive, however, in people with past or current psychiatric disorders. Concerns have also been raised that varenicline may slightly increase cardiovascular events in people already at increased risk of those illnesses. Current evidence neither supports nor refutes such an association, but we await the findings of the CATS trial, which should establish whether or not this is a valid concern.

AUTHORS' CONCLUSIONS

Cytisine increases the chances of quitting, although absolute quit rates were modest in two recent trials. Varenicline at standard dose increased the chances of successful long-term smoking cessation between two- and three-fold compared with pharmacologically unassisted quit attempts. Lower dose regimens also conferred benefits for cessation, while reducing the incidence of adverse events. More participants quit successfully with varenicline than with bupropion or with NRT. Limited evidence suggests that varenicline may have a role to play in relapse prevention. The most frequently recorded adverse effect of varenicline is nausea, but mostly at mild to moderate levels and tending to subside over time. Early reports of possible links to suicidal ideation and behaviour have not been confirmed by current research.Future trials of cytisine may test extended regimens and more intensive behavioural support.

Effects of Televised Direct-to-Consumer Advertising for Varenicline on Prescription Dispensing in the United States, 2006-2009

INTRODUCTION

Televised direct-to-consumer advertising (DTCA) for prescription drugs is controversial, especially for tobacco cessation products such as varenicline, given safety concerns that arose only after its market approval. We aim to quantify the extent to which DTCA influenced varenicline use.

METHODS

We linked monthly DTCA television ratings with monthly prescription data from IMS Health's National Prescription Audit across top 75 media markets in 2006-2009. We used Poisson models with Generalized Estimating Equations to analyze effects of exposures to DTCA for both varenicline and nicotine replacement therapies on rate of dispensed varenicline prescriptions among smokers, controlling for population characteristics and varenicline-related events.

RESULTS

Varenicline prescriptions increased dramatically following DTCA launch and declined sharply after safety risks were publicized and US Food and Drug Administration (FDA) issued an advisory. DTCA had significant impact on new prescription dispensing in the subsequent month: before the FDA advisory, one additional exposure to varenicline DTCA was associated with a 1.8% (rate ratio [RR] = 1.018 [1.015-1.021]) higher rate of new prescriptions; no effect was observed after the advisory (RR = 1.000 [0.997-1.003]). Prior to the advisory, cross-product effects of nicotine replacement therapy advertising on varenicline prescribing were negligible (RR = 1.002 [0.999-1.004]); after the advisory, effects were positive (RR = 1.015 [1.012-1.019]).

CONCLUSIONS

DTCA for varenicline had a significant impact on varenicline prescribing when the drug's safety profile was not well characterized, supporting arguments to limit DTCA for newly approved products whose real-world safety is unclear.

IMPLICATIONS

We examined the fluctuations in varenicline use in association with DTCA for varenicline and other tobacco cessation aids. To our knowledge this is the first study to quantify the effects of televised DTCA for varenicline and other tobacco cessation aids on varenicline prescription dispensing. We believe that understanding these relationships is critical for formulating effective public health policy and interventions.

Cost-effectiveness analysis of clinical smoking cessation interventions in Thailand

AIMS

Clinical smoking cessation interventions have been found typically to be highly cost-effective in many high-income countries. There is a need to extend this to low- and middle-income countries and undertake comparative analyses. This study aimed to estimate the incremental cost-effectiveness ratio of a range of clinical smoking cessation interventions available in Thailand.

METHODS

Using a Markov model, cost-effectiveness, in terms of cost per quality-adjusted life years (QALY) gained, from a range of interventions was estimated from a societal perspective for males and females aged 40 years who smoke at least 10 cigarettes per day. Interventions considered were: counselling in hospital, phone counselling (Quitline) and counselling plus nicotine gum, nicotine patch, bupropion, nortriptyline or varenicline. An annual discounting rate of 3% was used. Probabilistic sensitivity analyses were conducted and a cost-effectiveness acceptability curve (CEAC) plotted. Comparisons between interventions were conducted involving application of a 'decision rule' process.

RESULTS

Counselling with varenicline and counselling with nortriptyline were found to be cost-effective. Hospital counselling only, nicotine patch and bupropion were dominated by Quitline, nortriptyline and varenicline, respectively, according to the decision rule. When compared with unassisted cessation, probabilistic sensitivity analysis revealed that all interventions have very high probabilities (95%) of being cost-saving except for nicotine replacement therapy (NRT) patch (74%).

CONCLUSION

In middle-income countries such as Thailand, nortriptyline and varenicline appear to provide cost-effective clinical options for supporting smokers to quit.

Smoking Cessation Intervention for severe Mental Ill Health Trial (SCIMITAR): a pilot randomised control trial of the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation service

BACKGROUND

There is a high prevalence of smoking among people who experience severe mental ill health (SMI). Helping people with disorders such as bipolar illness and schizophrenia to quit smoking would help improve their health, increase longevity and also reduce health inequalities. Around half of people with SMI who smoke express an interest in cutting down or quitting smoking. There is limited evidence that smoking cessation can be achieved for people with SMI. Those with SMI rarely access routine NHS smoking cessation services. This suggests the need to develop and evaluate a behavioural support and medication package tailored to the needs of people with SMI.

OBJECTIVE

The objective in this project was to conduct a pilot trial to establish acceptability of the intervention and to ensure the feasibility of recruitment, randomisation and follow-up. We also sought preliminary estimates of effect size in order to design a fully powered trial of clinical effectiveness and cost-effectiveness. The pilot should inform a fully powered trial to compare the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation (BSC) intervention with usual general practitioner (GP) care for people with SMI.

DESIGN

A pilot pragmatic two-arm individually randomised controlled trial (RCT). Simple randomisation was used following a computer-generated random number sequence. Participants and practitioners were not blinded to allocation.

SETTING

Primary care and secondary care mental health services in England.

PARTICIPANTS

Smokers aged > 18 years with a severe mental illness who would like to cut down or quit smoking.

INTERVENTIONS

A BSC intervention delivered by mental health specialists trained to deliver evidence-supported smoking cessation interventions compared with usual GP care.

MAIN OUTCOME MEASURES

The primary outcome was carbon monoxide-verified smoking cessation at 12 months. Smoking-related secondary outcomes were reduction of number of cigarettes smoked, Fagerstrom test of nicotine dependence and motivation to quit (MTQ). Other secondary outcomes were Patient Health Questionnaire-9 items and Short Form Questionnaire-12 items to assess whether there were improvements or deterioration in mental health and quality of life. We also measured body mass index to assess whether or not smoking cessation was associated with weight gain. These were measured at 1, 6 and 12 months post randomisation.

RESULTS

The trial recruited 97 people aged 19-73 years who smoked between 5 and 60 cigarettes per day (mean 25 cigarettes). Participants were recruited from four mental health trusts and 45 GP surgeries. Forty-six people were randomised to the BSC intervention and 51 people were randomised to usual GP care. The odds of quitting at 12 months was higher in the BSC intervention (36% vs. 23%) but did not reach statistical significance (odds ratio 2.9; 95% confidence interval 0.8% to 10.5%). At 3 and 6 months there was no evidence of difference in self-reported smoking cessation. There was a non-significant reduction in the number of cigarettes smoked and nicotine dependence. MTQ and number of quit attempts all increased in the BSC group compared with usual care. There was no difference in terms of quality of life at any time point, but there was evidence of an increase in depression scores at 12 months for the BSC group. There were no serious adverse events thought likely to be related to the trial interventions. The pilot economic analysis demonstrated that it was feasible to carry out a full economic analysis.

CONCLUSIONS

It was possible to recruit people with SMI from primary and secondary care to a trial of a smoking cessation intervention based around behavioural support and medication. The overall direction of effect was a positive trend in relation to biochemically verified smoking cessation and it was feasible to obtain follow-up in a substantial proportion of participants. A definitive trial of a bespoke cessation intervention has been prioritised by the National Institute for Health Research (NIHR) and the SCIMITAR pilot trial forms a template for a fully powered RCT to examine clinical effectiveness and cost-effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79497236.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment, Vol. 19, No. 25. See the NIHR Journals Library website for further project information.

Experiences of tobacco smoking and quitting in smokers with and without chronic obstructive pulmonary disease-a qualitative analysis

Background

Smokers with chronic obstructive pulmonary disease (COPD) seem to be a special subgroup of smokers that have a more urgent need to quit smoking but might find it more difficult to do so. This study aimed to explore which justifications for tobacco smoking and experiences of quitting were commonly shared in smokers with and without COPD, and which, if any, were specific to smokers with COPD.

Methods

In ten primary healthcare centres in the Netherlands, we conducted semi-structured, in-depth interviews in 10 smokers with and 10 smokers without COPD.

Results

Three themes were generated: ‘balancing the impact on health of smoking’, ‘challenging of autonomy by social interference’, ‘prerequisites for quitting’. All participants trivialized health consequences of smoking; those with COPD seemed to be less knowledgeable about smoking and health. Both groups of smokers found autonomy very important. Smokers with COPD were indignant about a perceived lack of empathy in their communication with doctors. Furthermore, smokers with COPD in particular had little faith in the efficacy of smoking cessation aids. Lastly, motivation for quitting was dominated by fluctuation and smokers with COPD specifically maintained that their vision of life was linked with quitting.

Conclusions

The participants showed many similarities in their reasoning about smoking and quitting. The corresponding themes argue for a less paternalistic regime in the communication with smokers with attention required for the motivational stage and room made for smokers’ own views, and with clear information and education. Furthermore, addressing social interactions, health perceptions and moral agendas in the communication with smokers with COPD may help to make smoking cessation interventions more suitable for them.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0382-y) contains supplementary material, which is available to authorized users.

Effect of varenicline on smoking cessation through smoking reduction: a randomized clinical trial

IMPORTANCE

Some cigarette smokers may not be ready to quit immediately but may be willing to reduce cigarette consumption with the goal of quitting.

OBJECTIVE

To determine the efficacy and safety of varenicline for increasing smoking abstinence rates through smoking reduction.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled, multinational clinical trial with a 24-week treatment period and 28-week follow-up conducted between July 2011 and July 2013 at 61 centers in 10 countries. The 1510 participants were cigarette smokers who were not willing or able to quit smoking within the next month but willing to reduce smoking and make a quit attempt within the next 3 months. Participants were recruited through advertising.

INTERVENTIONS

Twenty-four weeks of varenicline titrated to 1 mg twice daily or placebo with a reduction target of 50% or more in number of cigarettes smoked by 4 weeks, 75% or more by 8 weeks, and a quit attempt by 12 weeks.

MAIN OUTCOMES AND MEASURES

Primary efficacy end point was carbon monoxide-confirmed self-reported abstinence during weeks 15 through 24. Secondary outcomes were carbon monoxide-confirmed self-reported abstinence for weeks 21 through 24 and weeks 21 through 52.

RESULTS

The varenicline group (n = 760) had significantly higher continuous abstinence rates during weeks 15 through 24 vs the placebo group (n = 750) (32.1% for the varenicline group vs 6.9% for the placebo group; risk difference (RD), 25.2% [95% CI, 21.4%-29.0%]; relative risk (RR), 4.6 [95% CI, 3.5-6.1]). The varenicline group had significantly higher continuous abstinence rates vs the placebo group during weeks 21 through 24 (37.8% for the varenicline group vs 12.5% for the placebo group; RD, 25.2% [95% CI, 21.1%-29.4%]; RR, 3.0 [95% CI, 2.4-3.7]) and weeks 21 through 52 (27.0% for the varenicline group vs 9.9% for the placebo group; RD, 17.1% [95% CI, 13.3%-20.9%]; RR, 2.7 [95% CI, 2.1-3.5]). Serious adverse events occurred in 3.7% of the varenicline group and 2.2% of the placebo group (P = .07).

CONCLUSIONS AND RELEVANCE

Among cigarette smokers not willing or able to quit within the next month but willing to reduce cigarette consumption and make a quit attempt at 3 months, use of varenicline for 24 weeks compared with placebo significantly increased smoking cessation rates at the end of treatment, and also at 1 year. Varenicline offers a treatment option for smokers whose needs are not addressed by clinical guidelines recommending abrupt smoking cessation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01370356.

Use of stop-smoking medications in the United States before and after the introduction of varenicline

AIMS

To evaluate trends in use of stop-smoking medications (SSMs) before and after varenicline (Chantix™) was introduced to the market-place in the United States, and to determine whether varenicline reached segments of the population unlikely to use other SSMs.

DESIGN

Cohort survey.

SETTING

United States.

PARTICIPANTS

A nationally representative sample of adult smokers in the United States interviewed as part of the International Tobacco Control Four Country Survey between 2004 and 2011. Primary analyses used cross-sectional data from 1737 smokers who attempted to quit (∼450 per wave).

MEASUREMENTS

Reporting an attempt to quit smoking; use of each of the following types of SSMs for the purpose of quitting smoking: nicotine gum, nicotine patch, other nicotine replacement therapy, bupropion and varenicline.

FINDINGS

There was a significant increase in the rate of use of any SSM among quit attempters across the study period [odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.10-1.21 per year]. This increase was largest after varenicline was introduced (OR = 1.16, 95% CI = 1.07-1.26 per year); however, there was a decline in nicotine patch use during this time (OR = 0.87, 95% CI = 0.76-0.99 per year). Varenicline users were generally similar to users of other SSMs but differed from those who did not use any SSMs, in that they tended to be older (OR = 5.46, P = 0.024), to be white (OR = 2.33, P = 0.002), to have high incomes (OR = 1.85, P = 0.005), to have high nicotine dependence prior to quitting (OR = 2.40, P = 0.001) and to have used medication in the past (OR = 3.29, P < 0.001).

CONCLUSIONS

The introduction of varenicline in the United States coincided with a net increase in attempts to quit smoking and, among these, a net increase in use of stop-smoking medications. The demographic profile of varenicline users is similar to the profile of those who use other stop-smoking medications and different from the profile of those who attempt to quit without any medication.

Clinician's guide to the updated ABCs of cardiovascular disease prevention

To facilitate the guideline-based implementation of treatment recommendations in the ambulatory setting and to encourage participation in the multiple preventive health efforts that exist, we have organized several recent guideline updates into a simple ABCDEF approach. We would remind clinicians that evidence-based medicine is meant to inform recommendations but that synthesis of patient-specific data and use of appropriate clinical judgment in each individual situation is ultimately preferred.

Exercise interventions for smoking cessation

BACKGROUND

Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain.

OBJECTIVES

To determine whether exercise-based interventions alone, or combined with a smoking cessation programme, are more effective than a smoking cessation intervention alone.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2014, and searched MEDLINE, EMBASE, PsycINFO, and CINAHL Plus in May 2014.

SELECTION CRITERIA

We included randomized trials which compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme (which we considered the control in this review). Studies were required to recruit smokers or recent quitters and have a follow-up of six months or more. Studies that did not meet the full inclusion criteria because they only assessed the acute effects of exercise on smoking behaviour, or because the outcome was smoking reduction, are summarised but not formally included.

DATA COLLECTION AND ANALYSIS

We extracted data on study characteristics and smoking outcomes. Because of differences between studies in the characteristics of the interventions used we summarized the results narratively, making no attempt at meta-analysis. We assessed risk of selection and attrition bias using standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified 20 trials with a total of 5,870 participants. The largest study was an internet trial with 2,318 participants, and eight trials had fewer than 30 people in each treatment arm. Studies varied in the timing and intensity of the smoking cessation and exercise programmes offered. Only one included study was judged to be at low risk of bias across all domains assessed. Four studies showed significantly higher abstinence rates in a physically active group versus a control group at end of treatment. One of these studies also showed a significant benefit for exercise versus control on abstinence at the three-month follow-up and a benefit for exercise of borderline significance (p = 0.05) at the 12-month follow-up. Another study reported significantly higher abstinence rates at six month follow-up for a combined exercise and smoking cessation programme compared with brief smoking cessation advice. One study showed significantly higher abstinence rates for the exercise group versus a control group at the three-month follow-up but not at the end of treatment or 12-month follow-up. The other studies showed no significant effect for exercise on abstinence.

AUTHORS' CONCLUSIONS

Only two of the 20 trials offered evidence for exercise aiding smoking cessation in the long term. All the other trials were too small to reliably exclude an effect of intervention, or included an exercise intervention which may not have been sufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense interventions in terms of both exercise intensity and intensity of support being provided, equal contact control conditions, and measures of exercise adherence and change in physical activity in both exercise and comparison groups.

Single dose varenicline may trigger epileptic activity

Varenicline is a new drug for smoking cessation, and its effect on epilepsy is not clear. The aim of this study was to investigate whether different doses of varenicline cause epileptic activity. Forty rats were randomly assigned to the following eight groups: control, saline, and 0.025, 0.04, 0.1, 0.5, 1, and 2 mg kg(-1) varenicline (single dose, i.p.). EEGs were recorded before the varenicline injection and during the following 240 min. While epileptic discharges were observed on the EEGs of the rats in all of the varenicline-treated groups, motor findings of epileptic seizure were not observed in some rats in these groups except the 1 and 2 mg kg(-1) groups. These findings indicate that different single doses of varenicline cause epileptic activity in rats.

"Meaningful use" provides a meaningful opportunity

A model is described for meeting the mandate that includes implementation of a comprehensive smoking (tobacco) cessation program for cancer patients as an alternative to the minimal intervention approach. The importance of an institution‐wide, automated system to identify and refer tobacco users to treatment is discussed within the context of implementing the meaningful use regulations for electronic health records.

Increased efficacy of a trivalent nicotine vaccine compared to a dose-matched monovalent vaccine when formulated with alum

Vaccination against nicotine is a potential treatment for tobacco smoking. Clinical trials show effect only in high antibody responders; therefore it is necessary to increase the effectiveness of nicotine vaccines. The use of a multivalent vaccine that activates several B cell populations is a possible approach to increase antibody response. The aim of this study was to investigate whether three different nicotine immunogens could be mixed to generate independent responses resulting in additive antibody titers, and whether this would alter nicotine distribution to a greater extent than antibodies generated by a monovalent vaccine. When immunogens were administered s.c. with alum adjuvant, the trivalent vaccine generated significantly higher titers and prevented the distribution of an i.v. nicotine dose to brain to a greater extent than an equivalent dose of a monovalent vaccine. The number of rats with antibody titers >1:10,000 was significantly increased in the trivalent group compared to the monovalent group. There were no correlations between the titers generated by the different nicotine immunogens in the trivalent vaccine, supporting the hypothesis that the immunogens generated independent responses from distinct populations of B cells. In contrast, when administered i.p. in Freund's adjuvant, the trivalent nicotine vaccine was not more immunogenic than its component monovalent vaccine. Vaccine immunogenicity was suppressed if unconjugated protein was added to the monovalent vaccine formulated in Freund's adjuvant, compared to monovalent vaccine alone. These data suggest a protein-protein interaction that affects titers negatively and is apparent when the vaccines are formulated with Freund's adjuvant. In summary, a trivalent nicotine vaccine formulated with alum showed significantly higher efficacy than a dose-matched monovalent vaccine and may offer a strategy for increasing nicotine vaccine immunogenicity. This approach may be generalizable to other nicotine immunogens or vaccines for other addictive drugs.

A clinician's guide to the ABCs of cardiovascular disease prevention: the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and American College of Cardiology Cardiosource Approach to the Million Hearts Initiative

Atherosclerotic cardiovascular disease (CVD) is the leading cause of death in the United States and worldwide. Fortunately, it is often preventable with early adoption of lifestyle modification, prevention of risk factor onset, and aggressive treatment of existing risk factors. The Million Hearts Initiative is an effort by the Centers for Disease Control that aims to prevent 1 million myocardial infarctions and strokes over the next 5 years. As part of this initiative, we present a simply organized "ABCDE" approach for guiding a consistent comprehensive approach to managing cardiovascular risk in daily clinical practice. ABCDE stands for assessment of risk, antiplatelet therapy, blood pressure management, cholesterol management, cigarette/tobacco cessation, diet and weight management, diabetes prevention and treatment, and exercise, interventions regularly used to reduce cardiovascular (CV) risk. Throughout this article we summarize recommendations related to each topic and reference landmark trials and data that support our approach. We believe that the ABCDE approach will be the core framework for addressing CV risk in our effort to prevent CVD.

Socioeconomic variations in access to smoking cessation interventions in UK primary care: insights using the Mosaic classification in a large dataset of primary care records

BACKGROUND

Smoking prevalence is particularly high amongst more deprived social groups. This cross-sectional study uses the Mosaic classification to explore socioeconomic variations in the delivery and/or uptake of cessation interventions in UK primary care.

METHODS

Data from 460,938 smokers registered in The Health Improvement Network between 2008 and 2010 were analysed. Logistic regression was used to calculate odds ratios for smokers having a record of receiving cessation advice or a prescription for a cessation medication during the study period by Townsend quintile and for each of the 11 Mosaic groups and 61 Mosaic types. Both of these measures are area-level indicators of deprivation. Profiles of Mosaic categories were used to suggest ways to target specific groups to increase the provision of cessation support.

RESULTS

Odds ratios for smokers having a record of advice or a prescription increased with increasing Townsend deprivation quintile. Similarly, smokers in more deprived Mosaic groups and types were more likely to have a documented cessation intervention. The odds of smokers receiving cessation advice if they have uncertain employment and live in social housing in deprived areas were 35% higher than the odds for successful professionals living in desirable areas (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.20-1.52; absolute risks 57.2% and 50.1% respectively), and those in low-income families living in estate-based social housing were 50% more likely to receive a prescription than these successful professionals (OR 1.50, 95% CI 1.31-1.73; absolute risks 19.5% and 13% respectively). Smokers who did not receive interventions were generally well educated, financially successful, married with no children, read broadsheet newspapers and had broadband internet access.

CONCLUSIONS

Wide socioeconomic variations exist in the delivery and/or uptake of smoking cessation interventions in UK primary care, though encouragingly the direction of this variation may help to reduce smoking prevalence-related socioeconomic inequalities in health. Groups with particularly low intervention rates may be best targeted through broadsheet media, the internet and perhaps workplace-based interventions in order to increase the delivery and uptake of effective quit support.

Repetitive transcranial magnetic stimulation of the dorsolateral prefrontal cortex reduces nicotine cue craving

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) can noninvasively stimulate the brain and transiently amplify or block behaviors mediated through a region. We hypothesized that a single high-frequency rTMS session over the left dorsolateral prefrontal cortex (DLPFC) would reduce cue craving for cigarettes compared with a sham TMS session.

METHODS

Sixteen non-treatment-seeking, nicotine-dependent participants were randomized to receive either real high-frequency rTMS (10 Hz, 100% resting motor threshold, 5-sec on, 10-sec off for 15 min; 3000 pulses) or active sham (eSham) TMS over the DLPFC in two visits with 1 week between visits. The participants received cue exposure before and after rTMS and rated their craving after each block of cue presentation.

RESULTS

Stimulation of the left DLFPC with real, but not sham, rTMS reduced craving significantly from baseline (64.1±5.9 vs. 45.7±6.4, t = 2.69, p = .018). When compared with neutral cue craving, the effect of real TMS on cue craving was significantly greater than the effect of sham TMS (12.5±10.4 vs. -9.1±10.4; t = 2.07, p = .049). More decreases in subjective craving induced by TMS correlated positively with higher Fagerström Test for Nicotine Dependence score (r = .58, p = .031) and more cigarettes smoked per day (r = .57, p = .035).

CONCLUSIONS

One session of high-frequency rTMS (10 Hz) of the left DLPFC significantly reduced subjective craving induced by smoking cues in nicotine-dependent participants. Additional studies are needed to explore rTMS as an aid to smoking cessation.

“Hike up yer skirt, and quit.” what motivates and supports smoking cessation in builders and renovators

Construction-related occupations have very high smoking prevalence rates and are an identified priority population for efforts to promote cessation. This study sought to identify the smoking cessation supports and services which best suited this workforce group, and to identify gaps in reach of preventive health services. We performed qualitative text analysis on pre-existing conversations about smoking cessation among workers in this sector. The material appeared on a discussion forum about residential construction from 1998 and 2011. Roughly 250 unique user names appeared in these discussions. The qualitative analysis addressed knowledge, motivation, environmental influences, and positive and negative experiences with supports for cessation. Self-identified smokers tended to want to quit and described little social value in smoking. Actual quit attempts were attributed to aging and tangible changes in health and fitness. Peer-to-peer social support for cessation was evident. Advice given was to avoid cigarettes and smokers, to focus on personal skills, personal commitment, and the benefits of cessation (beyond the harms from smoking). Many discussants had received medical support for cessation, but behavioural counselling services appeared underutilized. Our findings support efforts toward more complete bans on workplace smoking and increased promotion of available behavioural support services among dispersed blue-collar workers.

[Smoking cessation in case of chronic kidney disease]

Smoking is one of the main causes of morbidity and mortality around the world. In France, despite increase of cost of cigarettes and exclusion of smoking in public places, daily smoking consummation remains high, particularly in women and young. Now, smoking is considered as a compartmental and/or psychologic and/or physic addiction. There are many categories of smokers and smoking cessation strategies must be tailored to individual level. Whatever the etiology of chronic kidney disease, in dialysis patient as transplanted, hypertension and vascular diseases are strong determinants of prognosis. In this way, there is a need for stronger involvement of nephrologists in the process of smoking cessation of their patients. Therapeutics and strategies are reviewed.

Project Impact: a pharmacotherapy pilot trial investigating the abstinence and treatment adherence of Latino light smokers

Light smoking is particularly prevalent among Latino smokers. Nicotine replacement (NRT) and varenicline are effective medications for smoking cessation for moderate-heavy smokers but have not been tested in light smokers, and thus, there are no treatment guidelines for use with light smokers. This pilot trial tested the efficacy of NRT and varenicline in increasing smoking abstinence among Latino light smokers. A 3-group (NRT, varenicline, and varenicline-placebo) randomized design was used, and Latino light smokers (≤10 cigarettes per day) received 12 weeks of treatment, which included a culturally informed behavioral health session and ongoing medication management visits. At follow-up, there were no abstinent participants in the placebo and NRT groups. However, 30% of participants in the varenicline group were abstinent at the 3-, 4-, and 6-month follow-up. This study represents the only investigation that specifically targets Latino light smokers using these treatments and characterizing their treatment adherence.

Treatment of tobacco dependence in people with mental health and addictive disorders

People with mental health and addictive disorders (MHADs) have higher rates of cigarette smoking, and less success in quitting smoking compared with the general population. Moreover, tobacco-related medical illness may be the leading cause of death in the MHAD population. We discuss the scope of this comorbidity, and approaches to the treatment of tobacco dependence in people with MHAD, including schizophrenia, mood disorders, anxiety disorders, and alcohol and substance use disorders. Finally, at the level of health systems, we emphasize the importance of integrated treatment of tobacco dependence in MHADs.

Evaluation of Face-to-Face Courses in Behavioural Support for Stop Smoking Practitioners

Introduction: In English National Health Service (NHS) Stop Smoking Services, stop smoking practitioners provide behavioural support and medication to support smokers wanting to quit. There is a need to develop an evidence base for the training of such practitioners. This study evaluated a national face-to-face skills training course in behavioural support for practitioners. Methods: Data were gathered from 169 trainees attending the NHS Centre for Smoking Cessation and Training (NCSCT) courses between October 2010 and August 2011. They provided confidence in competence ratings for 16 core competences before, immediately following and 3 months after training. At 3-month follow-up, they also described what they believed were the most important learning outcomes. Trainees also provided course evaluations in the form of ratings (n = 386, courses not yet followed up included). Results: Confidence ratings increased overall by 40% immediately after the course and the higher level of confidence was maintained at 3-month follow-up; 92% agreed or strongly agreed that the course was very useful and very interesting; 90% that it was very enjoyable; 88% that it improved their skills and 87% that they would recommend it. The learning outcomes rated as most important reflected the relevant behaviour change techniques. Conclusion: The NCSCT skills training course appears to result in a substantial improvement in confidence in ability to deliver smoking cessation support and trainees evaluate it highly. The next step is to assess improvements in observed practice and success rates.

Partial agonists for α4β2 nicotinic receptors stimulate dopaminergic neuron firing with relatively enhanced maximal effects

BACKGROUND AND PURPOSE

Partial agonists selective for α4β2 nicotinic ACh receptors have been developed for smoking cessation as they induce weak activation of native α4β2* receptors and inhibit effect of nicotine. However, it is unclear whether at brain functions there is an existence of receptor reserve that allows weak receptor activation to induce maximum physiological effects. We assessed the extent of α4β2 partial agonist-induced increase of firing rate in dopaminergic neurons and evaluated the influence of receptor reserve.

EXPERIMENTAL APPROACH

The relative maximal effects and potencies of six nicotinic agonists were assessed on recombinant human α4β2 and α7 receptors expressed in mammalian cell lines by measuring calcium influx. Agonist-induced increase of the spontaneous firing rate of dopaminergic neurons was recorded using microelectrodes in the ventral tegmental area of rat brain slices.

KEY RESULTS

All α4β2 partial and full agonists increased the firing rate concentration-dependently. Their sensitivity to subtype-selective antagonists showed predominant activation of native α4β2* receptors. However, partial agonists with relative maximal effects as low as 33% on α4β2 receptors maximally increased the firing rate and induced additional depolarization block of firing, demonstrating that partial activation of receptors caused the maximum increase in firing rate in the presence of a receptor reserve.

CONCLUSIONS AND IMPLICATIONS

Partial α4β2 agonists induced relatively enhanced effects on the firing rate of dopaminergic neurons, and the effect was mainly attributed to the existence of native α4β2* receptor reserve. The results have implications in the understanding of physiological effects and therapeutic efficacies of α4β2 partial agonists.

Nicotine receptor partial agonists for smoking cessation

BACKGROUND

Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist).

OBJECTIVES

The primary objective of this review is to assess the efficacy and tolerability of nicotine receptor partial agonists, including cytisine, dianicline and varenicline for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('cytisine' or 'Tabex' or 'dianicline' or 'varenicline' or 'nicotine receptor partial agonist') in the title or abstract, or as keywords. The register is compiled from searches of MEDLINE, EMBASE, PsycINFO and Web of Science using MeSH terms and free text to identify controlled trials of interventions for smoking cessation and prevention. We contacted authors of trial reports for additional information where necessary. The latest update of the specialised register was in December 2011. We also searched online clinical trials registers.

SELECTION CRITERIA

We included randomized controlled trials which compared the treatment drug with placebo. We also included comparisons with bupropion and nicotine patches where available. We excluded trials which did not report a minimum follow-up period of six months from start of treatment.

DATA COLLECTION AND ANALYSIS

We extracted data on the type of participants, the dose and duration of treatment, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow-up.The main outcome measured was abstinence from smoking at longest follow-up. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where they were reported. Where appropriate we pooled risk ratios (RRs), using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Two recent cytisine trials (937 people) found that more participants taking cytisine stopped smoking compared with placebo at longest follow-up, with a pooled RR of 3.98 (95% confidence interval (CI) 2.01 to 7.87). One trial of dianicline (602 people) failed to find evidence that it was effective (RR 1.20, 95% CI 0.82 to 1.75). Fifteen trials compared varenicline with placebo for smoking cessation; three of these also included a bupropion treatment arm. We also found one open-label trial comparing varenicline plus counselling with counselling alone. We found one relapse prevention trial, comparing varenicline with placebo, and two open-label trials comparing varenicline with nicotine replacement therapy (NRT). We also include one trial in which all the participants were given varenicline, but received behavioural support either online or by phone calls, or by both methods. This trial is not included in the analyses, but contributes to the data on safety and tolerability. The included studies covered 12,223 participants, 8100 of whom used varenicline.The pooled RR for continuous or sustained abstinence at six months or longer for varenicline at standard dosage versus placebo was 2.27 (95% CI 2.02 to 2.55; 14 trials, 6166 people, excluding one trial evaluating long term safety). Varenicline at lower or variable doses was also shown to be effective, with an RR of 2.09 (95% CI 1.56 to 2.78; 4 trials, 1272 people). The pooled RR for varenicline versus bupropion at one year was 1.52 (95% CI 1.22 to 1.88; 3 trials, 1622 people). The RR for varenicline versus NRT for point prevalence abstinence at 24 weeks was 1.13 (95% CI 0.94 to 1.35; 2 trials, 778 people). The two trials which tested the use of varenicline beyond the 12-week standard regimen found the drug to be well-tolerated during long-term use. The main adverse effect of varenicline was nausea, which was mostly at mild to moderate levels and usually subsided over time. A meta-analysis of reported serious adverse events occurring during or after active treatment and not necessarily considered attributable to treatment suggests there may be a one-third increase in the chance of severe adverse effects among people using varenicline (RR 1.36; 95% CI 1.04 to 1.79; 17 trials, 7725 people), but this finding needs to be tested further. Post-marketing safety data have raised questions about a possible association between varenicline and depressed mood, agitation, and suicidal behaviour or ideation. The labelling of varenicline was amended in 2008, and the manufacturers produced a Medication Guide. Thus far, surveillance reports and secondary analyses of trial data are inconclusive, but the possibility of a link between varenicline and serious psychiatric or cardiovascular events cannot be ruled out.

AUTHORS' CONCLUSIONS

Cytisine increases the chances of quitting, although absolute quit rates were modest in two recent trials. Varenicline at standard dose increased the chances of successful long-term smoking cessation between two- and threefold compared with pharmacologically unassisted quit attempts. Lower dose regimens also conferred benefits for cessation, while reducing the incidence of adverse events. More participants quit successfully with varenicline than with bupropion. Two open-label trials of varenicline versus NRT suggested a modest benefit of varenicline but confidence intervals did not rule out equivalence. Limited evidence suggests that varenicline may have a role to play in relapse prevention. The main adverse effect of varenicline is nausea, but mostly at mild to moderate levels and tending to subside over time. Possible links with serious adverse events, including serious psychiatric or cardiovascular events, cannot be ruled out.Future trials of cytisine may test extended regimens and more intensive behavioural support. There is a need for further trials of the efficacy of varenicline treatment extended beyond 12 weeks.

Smoking cessation interventions for patients with depression: a systematic review and meta-analysis

OBJECTIVES

We conducted a systematic literature review of smoking cessation interventions for patients with histories of depressive disorders or current significant depressive symptoms. We examined the comparative effectiveness of smoking cessation strategies on abstinence rates, differential effects of cessation strategies by depression status (i.e., history positive vs. current depression), and differential effects by gender.

DATA SOURCES

Peer-reviewed literature in MEDLINE, Embase, PsycINFO, and Cochrane Library.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Randomized controlled trials or secondary analysis of RCT data comparing two or more smoking cessation interventions or intervention to control, and reporting cessation outcomes in adults with depression.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two trained researchers screened articles for inclusion. When possible, we estimated pooled risk ratios with 95% confidence intervals by using a random effects model with the Mantel-Haenszel method. We synthesized other studies qualitatively. We classified each intervention as antidepressants, nicotine replacement therapy (NRT), brief smoking cessation counseling, smoking cessation behavioral counseling, or behavioral mood management.

RESULTS

We identified 16 unique RCTs, of which, only three trials recruited participants with current depression. Meta-analysis demonstrated a small, positive effect of adding behavioral mood management (RR = 1.41, 95% CI 1.01-1.96). All included antidepressant trials showed small, positive effects, but risk ratio summary was not significant (RR = 1.31, 95% CI 0.73-2.34). Three NRT trials demonstrated small, positive effects on smoking cessation rates. We found insufficient evidence to examine gender and depression status moderator effects.

LIMITATIONS

Few RCTs exist that test smoking cessation interventions among adults with depression. To make meaningful comparisons, we created broad intervention categories that contained heterogeneity.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Few trials enrolled smokers with current depression. Most of data identified were from subgroup analyses of patients history-positive for depression. However, several promising interventions exist. Healthcare providers should consider encouraging their patients with significant depressive symptoms or depression histories to seek smoking cessation services that include NRT and behavioral mood management.

A randomized placebo-controlled trial of varenicline for smoking cessation allowing flexible quit dates

INTRODUCTION

Current smoking cessation guidelines recommend setting a quit date prior to starting pharmacotherapy. However, providing flexibility in the date of quitting may be more acceptable to some smokers. The objective of this study was to compare varenicline 1 mg twice daily (b.i.d.) with placebo in subjects using a flexible quit date paradigm after starting medication.

METHODS

In this double-blind, randomized, placebo-controlled international study, smokers of ≥10 cigarettes/day, aged 18-75 years, and who were motivated to quit were randomized (3:1) to receive varenicline 1 mg b.i.d. or placebo for 12 weeks. Subjects were followed up through Week 24. Subjects were instructed to quit between Days 8 and 35 after starting medication. The primary endpoint was carbon monoxide-confirmed continuous abstinence during Weeks 9-12, and a key secondary endpoint was continuous abstinence during Weeks 9-24.

RESULTS

Overall, 493 subjects were randomized to varenicline and 166 to placebo. Continuous abstinence was higher for varenicline than for placebo subjects at the end of treatment (Weeks 9-12: 53.1% vs. 19.3%; odds ratio [OR] 5.9; 95% CI, 3.7-9.4; p < .0001) and through 24 weeks follow-up (Weeks 9-24: 34.7% vs. 12.7%; OR 4.4; 95% CI, 2.6-7.5; p < .0001). Serious adverse events occurred in 1.2% varenicline (none were psychiatric) and 0.6% placebo subjects. Fewer varenicline than placebo subjects reported depression-related adverse events (2.3% vs. 6.7%, respectively).

CONCLUSIONS

Varenicline 1 mg b.i.d. using a flexible quit date paradigm had similar efficacy and safety compared with previous fixed quit date studies.

Varenicline dose dependently enhances responding for nonpharmacological reinforcers and attenuates the reinforcement-enhancing effects of nicotine

INTRODUCTION

Varenicline (VAR), a partial nicotinic agonist, is one of the most effective smoking cessation pharmacotherapies. The therapeutic efficacy of VAR could be partly the result of substituting for and/or blocking the reinforcement-enhancing effects of nicotine (NIC). We assessed the effects of VAR alone and in combination with NIC (0.4 mg/kg) while rats pressed the lever for a moderately reinforcing visual stimulus (VS).

METHODS

Rats were injected with placebo (0.9% saline), NIC, VAR (0.1-1 mg/kg), or NIC + VAR. A follow-up study was conducted with a broader dose range of VAR-alone dosages (0.01-3.0 mg/kg). All drug manipulations were conducted in a between-subjects design to prevent confounding effects of repeated exposure.

RESULTS

There was a dose-dependent effect of VAR alone. Moderate doses of VAR (0.1 and 1.0 mg/kg) increased the number of VS presentations earned, while lower and higher VAR doses (0.01 and 3.0 mg/kg) did not change responding for the VS. VAR dose dependently attenuated the reinforcement-enhancing effects of NIC, with the highest dose (1.0 mg/kg) exhibiting the greatest antagonist effect.

CONCLUSIONS

The results of these studies support the assertion that the therapeutic efficacy of VAR may be due to the partial agonist characteristics of the drug, specifically, its ability to partially replace the reinforcement-enhancing effects of NIC as well as antagonize these effects.

Cost-effectiveness of tobacco control policies in Vietnam: the case of personal smoking cessation support

AIMS

To examine the cost-effectiveness of personal smoking cessation support in Vietnam.

DESIGN, SETTING AND PARTICIPANTS

We followed-up the population aged 15 years and over in 2006 to model the costs and health gains associated with five interventions: physician brief advice; nicotine replacement therapy (patch and gum); bupropion; and varenicline. Threshold analysis was undertaken to determine the price levels of pharmaceuticals for the interventions to be cost-effective. A multi-state life table model was constructed such that the interventions affect the smoking cessation behaviour of the age cohorts, and the resulting smoking prevalence defines their health outcomes. A health-care perspective was employed.

MEASUREMENTS

Cost-effectiveness is measured in 2006 Vietnamese Dong (VND) per disability-adjusted life year (DALY) averted. We adopted the World Health Organization thresholds of being 'cost-effective' if less than three times gross domestic product (GDP) per capita (VND 34,600,000) and 'very cost-effective' if less than GDP per capita (VND 11,500,000).

FINDINGS

The cost-effectiveness result of physician brief advice was VND 1,742,000 per DALY averted (international dollars 543), which was 'very cost-effective'. Varenicline dominated bupropion and nicotine-replacement therapies, although it did not fall within the range of being 'cost-effective' under different scenarios. The threshold analysis revealed that prices of pharmaceuticals must be substantially lower than the levels from other countries if pharmacological therapies are to be cost-effective in Vietnam.

CONCLUSIONS

Physician brief advice is a cost-effective intervention and should be included in the priority list of tobacco control policy in Vietnam. Pharmacological therapies are not cost-effective, and so they are not recommended in Vietnam at this time unless pharmaceuticals could be produced locally at substantially lower costs in the future.

Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) policy evaluation surveys

AIMS

To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support.

DESIGN

Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary).

SETTINGS

Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, the Netherlands, New Zealand, South Korea, Thailand, United Kingdom, Uruguay and United States.

PARTICIPANTS

Samples of smokers from 15 countries.

MEASUREMENTS

Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits.

FINDINGS

Prevalence of quit attempts in the last year varied from less than 20% to more than 50% across countries. Similarly, smokers varied greatly in reporting visiting health professionals in the last year (<20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available.

CONCLUSIONS

There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.

Varenicline as a smoking cessation aid in schizophrenia: effects on smoking behavior and reward sensitivity

RATIONALE

Smoking rates are up to five times higher in people with schizophrenia than in the general population, placing these individuals at high risk for smoking-related health problems. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, is a promising aid for smoking cessation in this population. To maximize treatment efficacy while minimizing risks, it is critical to identify reliable predictors of positive response to varenicline in smokers with schizophrenia.

OBJECTIVES

Negative symptoms of schizophrenia are related to dysfunctions in the brain reward system, are associated with nicotine dependence, and may be improved by nicotine or nicotinic receptor agonists, suggesting that smoking cessation may be especially difficult for patients with substantial negative symptoms. The purpose of the study was to evaluate negative symptoms as predictors of response to varenicline.

METHODS

Patients with schizophrenia (N = 53) completed a 12-week smoking cessation trial combining varenicline with cognitive behavioral therapy. Negative symptoms were assessed via the Scale for the Assessment of Negative Symptoms (Andreasen 1983). Outcomes included smoking abstinence as assessed by self-report and expired carbon monoxide. Change in performance on a probabilistic reward task was used as an index of change in reward sensitivity during treatment.

RESULTS

At week 12, 32 participants met criteria for 14-day point-prevalence abstinence. Patients with lower baseline symptoms of affective flattening (more typical affect) were more likely to achieve smoking abstinence and demonstrated larger increases in reward sensitivity during treatment.

CONCLUSIONS

These data suggest that affective flattening symptoms in smokers with schizophrenia may predict response to varenicline.

A cost-benefit analysis of the outpatient smoking cessation services in Taiwan from a societal viewpoint

INTRODUCTION

This study applied a cost-benefit analysis from a societal viewpoint to evaluate the Outpatient Smoking Cessation Services (OSCS) program.

METHODS

The costs measured in this study include the cost to the health sector, non-health sectors, the patients and their family, as well as the loss of productivity as a result of smoking. The benefits measured the medical costs savings and the earnings due to the increased life expectancy of a person that has stopped smoking for 15 years. Data were obtained from the primary data of a telephone survey, the literatures and reports from the Outpatient Smoking Cessation Management Center and government. Sensitivity analyses were conducted to verify the robustness of the results.

RESULTS

There were 169,761 cases that participated in the outpatient smoking cessation program in the years 2007 and 2008, of those cases, 8,282 successfully stopped smoking. The total cost of the OSCS program was 18 million USD. The total benefits of the program were 215 million USD with a 3% discount rate; the net benefit to society was 196 million USD. After conducting sensitivity analyses on the different abstinence, relapse, and discount rates, from a societal perspective, the benefits still far exceeded the costs, while from a health care perspective, there was only a net benefit when the respondent's abstinence rate was used.

CONCLUSIONS

From a societal perspective, the OSCS program in Taiwan is cost-beneficial. This study provides partial support for the policy makers to increase the budget and expand the OSCS program.

Necessity and readiness for smoking cessation intervention in dental clinics in Japan

BACKGROUND

The necessity and readiness for smoking cessation intervention in dental clinics was assessed by investigating smoking status and stage of behavior change in patients and the attitudes of dentists toward the effects of smoking on their patients, respectively.

METHODS

A self-administered questionnaire was mailed to 1022 dentists randomly selected from the Japanese Dental Association database. The questionnaire survey consisted of 1 section for dentists and 1 for patients aged 20 years or older and was scheduled to be completed at the dentists' clinics on a designated day in February 2008.

RESULTS

The response rate to the questionnaire was 78.2% from among target dental clinics and 73.7% and 74.7% for patient and dentist questionnaires, respectively. Data from 11,370 patients and 739 dentists were analyzed. The overall smoking prevalence among the patients (25.1%) was similar to that reported by the National Health and Nutrition Examination Survey, and young female patients had a markedly higher smoking prevalence. More than 70% of patients who smoked were interested in quitting. Although the prevalence of current smoking among dentists (27.1%) was significantly higher than that reported among Japanese physicians (15.0%), approximately 70% of dentists were concerned about the effects of smoking on patient health and prohibited smoking inside their clinic.

CONCLUSIONS

Many smokers who were interested in quitting, particularly young women, visited dental clinics, and most dentists believed that smoking was harmful for their patients. These results indicate that smoking cessation intervention in dental settings is necessary and that dentists are ready to provide such interventions.

The smoking cessation drug varenicline improves deficient P20-N40 inhibition in DBA/2 mice

Varenicline, an FDA approved smoking cessation pharmacotherapy, is an α4β2* nicotinic acetylcholine receptor (nAChR) partial agonist and an α7* nAChR full agonist. Both subtypes of nAChR are involved in modulating auditory evoked responses in rodents. In DBA/2 mice, an inbred strain, auditory evoked responses to paired auditory stimuli fail to inhibit to the second stimulus. This mouse strain replicates the auditory evoked response inhibition deficit experienced by the majority of schizophrenia patients. In this current study, we examined the effects of five different doses of varenicline (0.06, 0.3, 0.6, 3 and 6mg/kg) on auditory evoked responses in anesthetized DBA/2 mice. We also administered α4β2* and α7* nAChR selective antagonists prior to varenicline administration to determine which nAChR subtypes mediate the effects of varenicline. Four of the five doses of varenicline produced improvements in auditory evoked response inhibition deficits. Selective blockade of either the α4β2* or α7* nAChR in competition with 0.6mg/kg varenicline prevented varenicline induced improvements. In competition with a higher dose of varenicline (3mg/kg) only blockade of the α4β2* nAChR prevented varenicline induced improvement in auditory evoked response inhibition. These data indicate the importance of α4β2* nAChRs and the potential involvement of the α7* subtype in varenicline's effects on auditory evoked responses in DBA/2 mice.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of the introduction of smoke-free legislation on prescribing of stop-smoking medications in England

AIMS

To investigate whether there were changes in the rate of prescribing of smoking cessation medications in the months leading up to, and after, the introduction of smoke-free legislation in England.

DESIGN

Interrupted time-series analysis of prescribing rates using Autoregressive Integrated Moving Average (ARIMA) models.

SETTING

A total of 350 general practices in England who contribute data to The Health Improvement Network (THIN) database.

PARTICIPANTS

Patients in THIN aged 16+ identified from their medical records as smokers.

MEASUREMENTS

Monthly rates of prescribing of nicotine replacement therapy (NRT), bupropion and varenicline were calculated from THIN from 2000 to 2009 for all smokers and for subgroups defined by patient sex, age group, history of chronic disease and quintile of the Townsend Index of Deprivation. ARIMA models were built to assess whether there were changes in prescribing before or after the introduction of smoke-free legislation over and above any long-term and seasonal trends.

FINDINGS

There was a 6.4% (0.7-12.1) increase in prescribing of all smoking cessation medications in the 9 months before the introduction of smoke-free legislation and a 6.4% (1.1-11.7) reduction in the 9-month period afterwards. A 6.2% (1.4-11.0) increase in NRT prescribing and a 13.2% (4.3-22.2) increase in bupropion prescribing occurred in the 6- and 3-month periods, respectively, before smoke-free legislation was introduced, and a 5.5% (2.3-8.7) decline in NRT prescribing and a 13.7% (4.6-22.8) decline in bupropion prescribing in the 9 months post-legislation. The patterns of change in prescribing did not vary with patient demographics.

CONCLUSIONS

Numbers of primary care prescriptions for smoking cessation medications increased prior to the introduction of smoke-free legislation but decreased afterwards, suggesting a temporal displacement in prescribing activity rather than a change in the overall volume of prescribing. Effects observed were consistent across all population subgroups, suggesting that the changes in prescribing will neither widen nor reduce smoking-related health inequalities.

Protein kinase C epsilon modulates nicotine consumption and dopamine reward signals in the nucleus accumbens

Nicotine addiction and alcohol use disorders are very widespread and often occur together. Currently, there is no single drug approved for the simultaneous treatment of both conditions. Although these conditions share common genetic factors, the molecular mechanisms underlying their comorbidity are unknown. We have previously shown that mice lacking protein kinase C epsilon (PKCε) show decreased ethanol self-administration and reward as well as increased aversion to ethanol. Here we find that Prkce(-/-) mice self-administer less nicotine and show decreased conditioned place preference for nicotine compared with wild-type mice. In Prkce(-/-) mice, these behaviors are associated with reduced levels of α(6) and β(3) nicotinic receptor subunit mRNA in the ventral midbrain and striatum as well as a functional deficit in cholinergic modulation of dopamine release in nucleus accumbens. Our results indicate that PKCε regulates reward signaling through α(6)-containing nicotinic receptors and suggest that PKCε could be a target for the treatment of comorbid nicotine and alcohol addictions.

Management of Crohn's disease in smokers: is an alternative approach necessary?

Inflammatory bowel disease is a chronic condition with a pathogenic background that involves both genetic and environmental factors. Although important progress has been made regarding the former in the last decade, scarce knowledge is available for the latter. In this sense, smoking remains the most important environmental factor in IBD. Active smoking increases the risk of developing Crohn's disease (CD). Moreover, CD patients who start or continue smoking after disease diagnosis are at risk for poorer outcomes such as higher therapeutic requirements and disease-related complications, as compared to those patients who quit smoking or who never smoked. However, the harmful effect of active smoking is not uniform in all patients or in all clinical scenarios. Interventions designed to facilitate smoking cessation may impact the course of the disease. In this article, the available evidence of the deleterious effects of smoking on CD is reviewed in detail, and alternative therapeutic approaches to CD in smokers are proposed.