Effect of nicotine patch on energy intake and weight gain in postmenopausal women during smoking cessation

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting.

OBJECTIVES

To systematically review the effects of: (1) interventions targeting post-cessation weight gain on weight change and smoking cessation (referred to as 'Part 1') and (2) interventions designed to aid smoking cessation that plausibly affect post-cessation weight gain (referred to as 'Part 2').

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL; latest search 16 October 2020. Part 2 - We searched included studies in the following 'parent' Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, e-cigarettes, and exercise interventions for smoking cessation published in Issue 10, 2020 of the Cochrane Library. We updated register searches for the review of nicotine receptor partial agonists.

SELECTION CRITERIA

Part 1 - trials of interventions that targeted post-cessation weight gain and had measured weight at any follow-up point or smoking cessation, or both, six or more months after quit day. Part 2 - trials included in the selected parent Cochrane reviews reporting weight change at any time point.

DATA COLLECTION AND ANALYSIS

Screening and data extraction followed standard Cochrane methods. Change in weight was expressed as difference in weight change from baseline to follow-up between trial arms and was reported only in people abstinent from smoking. Abstinence from smoking was expressed as a risk ratio (RR). Where appropriate, we performed meta-analysis using the inverse variance method for weight, and Mantel-Haenszel method for smoking.

MAIN RESULTS

Part 1: We include 37 completed studies; 21 are new to this update. We judged five studies to be at low risk of bias, 17 to be at unclear risk and the remainder at high risk.  An intermittent very low calorie diet (VLCD) comprising full meal replacement provided free of charge and accompanied by intensive dietitian support significantly reduced weight gain at end of treatment compared with education on how to avoid weight gain (mean difference (MD) -3.70 kg, 95% confidence interval (CI) -4.82 to -2.58; 1 study, 121 participants), but there was no evidence of benefit at 12 months (MD -1.30 kg, 95% CI -3.49 to 0.89; 1 study, 62 participants). The VLCD increased the chances of abstinence at 12 months (RR 1.73, 95% CI 1.10 to 2.73; 1 study, 287 participants). However, a second study  found that no-one completed the VLCD intervention or achieved abstinence. Interventions aimed at increasing acceptance of weight gain reported mixed effects at end of treatment, 6 months and 12 months with confidence intervals including both increases and decreases in weight gain compared with no advice or health education. Due to high heterogeneity, we did not combine the data. These interventions increased quit rates at 6 months (RR 1.42, 95% CI 1.03 to 1.96; 4 studies, 619 participants; I² = 21%), but there was no evidence at 12 months (RR 1.25, 95% CI 0.76 to 2.06; 2 studies, 496 participants; I² = 26%). Some pharmacological interventions tested for limiting post-cessation weight gain (PCWG) reduced weight gain at the end of treatment (dexfenfluramine, phenylpropanolamine, naltrexone). The effects of ephedrine and caffeine combined, lorcaserin, and chromium were too imprecise to give useful estimates of treatment effects. There was very low-certainty evidence that personalized weight management support reduced weight gain at end of treatment (MD -1.11 kg, 95% CI -1.93 to -0.29; 3 studies, 121 participants; I² = 0%), but no evidence in the longer-term 12 months (MD -0.44 kg, 95% CI -2.34 to 1.46; 4 studies, 530 participants; I² = 41%). There was low to very low-certainty evidence that detailed weight management education without personalized assessment, planning and feedback did not reduce weight gain and may have reduced smoking cessation rates (12 months: MD -0.21 kg, 95% CI -2.28 to 1.86; 2 studies, 61 participants; I² = 0%; RR for smoking cessation 0.66, 95% CI 0.48 to 0.90; 2 studies, 522 participants; I² = 0%). Part 2: We include 83 completed studies, 27 of which are new to this update. There was low certainty that exercise interventions led to minimal or no weight reduction compared with standard care at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29; 4 studies, 404 participants; I² = 0%). However, weight was reduced at 12 months (MD -2.07 kg, 95% CI -3.78 to -0.36; 3 studies, 182 participants; I² = 0%). Both bupropion and fluoxetine limited weight gain at end of treatment (bupropion MD -1.01 kg, 95% CI -1.35 to -0.67; 10 studies, 1098 participants; I² = 3%); (fluoxetine MD -1.01 kg, 95% CI -1.49 to -0.53; 2 studies, 144 participants; I² = 38%; low- and very low-certainty evidence, respectively). There was no evidence of benefit at 12 months for bupropion, but estimates were imprecise (bupropion MD -0.26 kg, 95% CI -1.31 to 0.78; 7 studies, 471 participants; I² = 0%). No studies of fluoxetine provided data at 12 months. There was moderate-certainty that NRT reduced weight at end of treatment (MD -0.52 kg, 95% CI -0.99 to -0.05; 21 studies, 2784 participants; I² = 81%) and moderate-certainty that the effect may be similar at 12 months (MD -0.37 kg, 95% CI -0.86 to 0.11; 17 studies, 1463 participants; I² = 0%), although the estimates are too imprecise to assess long-term benefit. There was mixed evidence of the effect of varenicline on weight, with high-certainty evidence that weight change was very modestly lower at the end of treatment (MD -0.23 kg, 95% CI -0.53 to 0.06; 14 studies, 2566 participants; I² = 32%); a low-certainty estimate gave an imprecise estimate of higher weight at 12 months (MD 1.05 kg, 95% CI -0.58 to 2.69; 3 studies, 237 participants; I² = 0%).

AUTHORS' CONCLUSIONS

Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.

Nicotine replacement therapy versus control for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.

OBJECTIVES

To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long-term smoking cessation, compared to placebo or 'no NRT' interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017.

SELECTION CRITERIA

Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow-up of less than six months, except for those in pregnancy (where less than six months, these were excluded from the main analysis). We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews.

DATA COLLECTION AND ANALYSIS

Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. A subset of six trials conducted in pregnant women found a statistically significant benefit of NRT on abstinence close to the time of delivery (RR 1.32, 95% CI 1.04 to 1.69; 2129 participants); in the four trials that followed up participants post-partum the result was no longer statistically significant (RR 1.29, 95% CI 0.90 to 1.86; 1675 participants). Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare.

AUTHORS' CONCLUSIONS

There is high-quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non-ischaemic chest pain and palpitations.

Effects of isolated tobacco alkaloids and tobacco products on deprivation-induced food intake and meal patterns in rats

The ability of smoking to reduce body weight serves as motivation for continued smoking. It is unclear to what extent non-nicotine constituents in cigarettes are contributing to the weight-reducing effect of smoking. The purpose of the current study was to examine the effects of nicotine and four minor tobacco alkaloids (nornicotine, cotinine, anatabine, and anabasine) on food intake, one of the key regulators of body weight. In addition, a smokeless tobacco extract (STE) and e-cigarette (EC) refill liquid were used to model the effects of actual tobacco product exposure on food intake. Male Holztman rats were trained to lever press for food pellets during daily 2h sessions in operant chambers. In Experiment 1, the effects of subcutaneous injections of saline, nicotine (0.25-1.00mg/kg), nornicotine (0.50-6.00mg/kg), cotinine (1.00-100.00mg/kg), anatabine (0.25-3.00mg/kg), and anabasine (0.50-4.00mg/kg) were assessed. In Experiment 2, rats from Experiment 1 were used to examine the effects of nicotine, STE, and EC liquid. All alkaloids, except cotinine, produced a dose-dependent reduction in overall food intake. The highest doses of all drugs significantly reduced latency and response rate to obtain the first pellet. At some doses, nicotine, anatabine, and nornicotine reduced food intake within the first 45min without compensatory increases in intake later in the session. STE and EC liquid produced dose dependent decreases in food intake similar to nicotine alone. These data suggest that minor tobacco alkaloids have appetite suppressant effects and warrant further investigation into their effects on body weight, energy intake, and energy expenditure under free-feeding conditions. However, findings with STE and EC liquid suggest that nicotine is the primary constituent in these products to affect food intake, whereas levels of minor alkaloids in these products may be too low to influence food intake.

Worsening Dietary and Physical Activity Behaviors Do Not Readily Explain Why Smokers Gain Weight After Cessation: A Cohort Study in Young Adults

Introduction

The relationship between smoking cessation and weight gain is well established but the underlying mechanisms remain poorly understood. We aimed to determine whether postcessation weight gain was mediated by changing health behaviors.

Methods

A total of 281 smokers self-reported their demographic, smoking, and lifestyle characteristics in 2004-2006 (aged 26-36) and 2009-2011 (aged 31-41). Behaviors considered as potential mediators of weight gain were changes in consumption of breakfast, discretionary foods (servings/d), fruit and vegetables (servings/d), alcohol (g/d), takeaway food (times/wk), Diet Guideline Index score, leisure time physical activity (PA, min/wk), total PA (min/wk), time spent sitting (min/d), and TV viewing (h/d).

Results

In total, 124 smokers quit smoking during 5 years follow-up. After adjustment for age, sex, baseline body mass index, education, and follow-up length, smoking cessation was associated with average excess weight gain of 2.09kg (95% CI = 0.35-3.83). Compared with continuing smokers, quitters reported a higher Diet Guideline Index score and less consumption of alcohol at baseline and follow-up (all p < .05). In addition, there was a tendency towards healthier dietary and PA behaviors over 5 years among quitters than continuing smokers except for time spent sitting, although these differences did not reach statistical significance. Adjustment for changes in these behaviors made little difference to the magnitude of postcessation weight gain (β: 2.32kg, 95% CI = 0.54-4.10).

Conclusions

The weight gain associated with smoking cessation was not explained by worsening dietary and PA behaviors. Future research is needed to elucidate the complex mechanisms and particularly ways it may be prevented.

Implications

Fear of weight gain often discourages smokers from trying to quit but guidance on ways to most effectively avoid weight gain is lacking. It is important to identify what causes postcessation weight gain and the ways it may be prevented. The current study explored the effects of several changing dietary and PA behaviors on the relationship between smoking cessation and weight gain in 281 young Australian smokers. We found that quitters tended to adopt healthier dietary and PA behaviors than continuing smokers, so these behaviors did not readily explain the postcessation weight gain. Further investigations of other potential mechanisms are needed.

Smoking Cessation and Changes in Body Mass Index: Findings From the First Randomized Cessation Trial in a Low-Income Country Setting

Background

In high-income countries, quitting cigarette smoking is associated with weight gain, which can reduce motivation to abstain. Whether smoking cessation is associated with weight gain in a low-income country context has never been investigated. We aimed to determine the post-cessation changes in body mass index (BMI) and its predictors among smokers who received a smoking cessation intervention in a low-income country setting.

Methods

We performed post hoc analyses of data from 269 smokers who participated in a two-group, parallel-arm, double-blind, placebo-controlled randomized trial of combined nicotine replacement therapy (NRT) and behavioral counseling in primary care clinics in Aleppo, Syria. We used generalized estimating equation modeling to identify predictors of changes in BMI at 6 weeks and 6- and 12-month follow-ups after quit date.

Results

The mean pre-cessation BMI of the sample was 27.9kg/m2 (SD = 5.2). Over 12 months of follow-up, BMI of smoking abstainers averaged 1.8 BMI units (approximately 4.8kg) greater than non-abstainers (p = .012). Throughout the study, greater BMI was associated with being female (p = .048), reporting smoking to control weight (p < .001) and having previously failed to quit due to weight gain (p = .036).

Conclusion

Similar to findings from high-income countries, smoking cessation in Syria is associated with weight gain, particularly among women and those who have weight concerns prior to quitting. This group of smokers may benefit from tailored cessation interventions with integrated body weight management elements that take into consideration the prevailing local and cultural influences on diet and levels of physical activity.

Implications

This study provides the first evidence regarding post-cessation changes in BMI among smokers who attempt to quit in a low-income country setting. Our findings advance knowledge regarding post-cessation weight gain and offers insight for researchers and clinicians to identify smokers at higher risk of post-cessation weight gain. This information will help in delivering interventions that take into account the prevailing cultural influence on diet and physical activity and will ultimately help in designing future tailored cessation programs in Syria and other low-income countries with similar cultural background and level of development.

High-fat diet meal patterns during and after continuous nicotine treatment in male rats

Smoking to control body weight is an obstacle to smoking cessation, particularly in western cultures where diets are often rich in calories derived from fat sources. The purpose of this study was to investigate the effects of continuous nicotine administration on meal patterns in rats fed a high-fat diet. Male rats were housed in cages designed to continuously monitor food intake and implanted with minipumps to deliver approximately 1.00 mg/kg/day of nicotine or saline. Meal patterns and body weights were assessed for 2 weeks of treatment and 1 week posttreatment. When compared with controls, rats with continuous nicotine treatment exhibited a decrease in the average meal duration(s) during the first week of treatment and a modest, yet sustained reduction in daily number of meals over the 14-day treatment period. Nicotine-induced decreases in body weight gain were observed throughout the 2 weeks of treatment. No differences in meal patterns or body weight gain were seen for 1 week following cessation of treatment. Results from this study suggest that while continuous nicotine treatment decreases daily food intake, meal durations, meal numbers, and weight gain, cessation of this treatment does not result in significant compensatory increases. Understanding the effects of nicotine on feeding patterns and weight gain may allow for improvements in treatment protocols aimed at addressing the factors that contribute to tobacco use. (PsycINFO Database Record

Smoking cessation and long-term weight gain in the Framingham Heart Study: an application of the parametric g-formula for a continuous outcome

Weight gain after smoking cessation can lessen the health benefits of, and reduce the incentives for, quitting smoking. Randomized clinical trials of smoking cessation have estimated this weight gain only over short periods of follow-up. We provide an estimate of long-term post-cessation weight gain in the Framingham Heart Study, a prospective observational study. We identified 2001 smokers free of diabetes, cancer, and cardiovascular disease in 1952. Using the parametric g-formula we estimated mean weight in 1972 if all smokers had quit at baseline versus if all had continued smoking. Our estimates were adjusted for demographic, socio-economic, and clinical factors at baseline and during follow-up. The estimated mean weight (95 % CI) at 20 years if all smokers had quit smoking was 75.2 kg (73.5, 76.6), compared with 70.2 kg (68.7, 71.8) if they had smoked 20 cigarettes/day and 73.4 kg (71.9, 74.6) if they had smoked 5 cigarettes/day (i.e., an estimated mean weight gain of 5.1 kg (3.1, 6.6) and 1.8 kg (0.8, 2.8), respectively). Smokers who were overweight or obese at baseline had a greater post-cessation weight gain on average. Our estimates suggest that smoking cessation can result in increases in body weight over 20 years. While the benefits of smoking cessation outweigh the risks due to post-cessation weight gain, our results highlight the need for long-term weight management interventions in combination with smoking cessation.

Horizons in the Pharmacotherapy of Obesity

Obesity drugs have had a chequered history. In the recent past, only the low efficacy, pancreatic lipase inhibitor orlistat was available worldwide and it was little used. The 5HT2C agonist, lorcaserin, and two combinations of old drugs have been approved in the United States but not in Europe. The diabetes drug liraglutide has been approved in both the US and Europe and seems likely to be most widely accepted. In view of regulators' caution in approving obesity drugs, some (like beloranib) may initially be progressed for niche obesity markets. New drug targets have been identified in brown adipose tissue with the aim of not only activating thermogenesis but also increasing the capacity for thermogenesis in this tissue. Attempts are being made to match the efficacy of bariatric surgery by mimicking multiple gut hormones. Unapproved pharmacotherapies are tempting for some patients. Others remain optimistic about more conventional routes to pharmacotherapy.

Predictors of marked weight gain in a population of health care and industrial workers following smoking cessation

Background

Concerns about postcessational weight gain might hamper rather than encourage smokers to quit smoking.

Methods

We conducted a comprehensive multi-institutional smoking cessation program for health care and industrial workers (n = 654) employed at University Hospital Basel (Switzerland) and two local health industry companies (Novartis International AG, F. Hoffmann-La Roche AG). The program contained counselling with an option of pharmacological support. Changes in body weight were observed during 24 months of follow-up. Factors associated with longitudinal weight gain (>5 % of baseline weight) were identified by cox-regression analysis.

Results

In 51 % of permanent quitters no significant changes of mean body weight were observed after 12 (0.52 kg, SD ±2.87 kg) and 24 months (0.40 kg, SD ± 2.99 kg). Marked weight gain following smoking cessation was characterized by a wide margin of changes. In more than a half of former smokers (58 %) weight increases were moderate (<5 kg), whereas excessive increases (>10 kg) were seen in only 10 % of quitters. Lower baseline BMI (HR 0.60, 95 % CI 0.40- 0.80, p = 0.03), daily consumption of less than ten cigarettes (HR 0.53, 95 % CI 0.27- 0.63, p = 0.04) and ischemic cardiopathy (HR 0.21, 95 % CI 0.07-0.62; p < 0.01) were associated with a lower risk for weight gain. Employees with lower educational levels (HR 2.60, 95 % CI 1.60-5.50, p < 0.01), diabetes mellitus (HR 3.05, 95 % CI 2.20-8.06, p = 0.02) and those smoking to reduce boredom in life (HR 1.68, 95 % CI 1.21-2.33, p < 0.01) were at highest risk.

Conclusion

Marked postcessational weight gain occurs less often than expected, but remains difficult to be predicted. Our findings might be helpful to alleviate weight concerns in the average smoker willing to quit.

Women and Smoking: The Effect of Gender on the Epidemiology, Health Effects, and Cessation of Smoking

Smoking is still the leading cause of premature morbidity and mortality. This paper examines new research on gender differences and the epidemiology of smoking, smoking-related morbidity and mortality, and factors that affect smoking cessation. The rate of decline in the prevalence of smoking has been slowing, especially among adolescent girls. New research suggests that, compared with men, women may be more susceptible to smoking-related morbidity and mortality. Gender-related barriers to smoking cessation include weight gain, sex hormones, and mood. Furthermore, the sensory aspects of smoking may have more of an effect on smoking treatment for women than for men. We discuss new studies that examine smoking-cessation interventions that may be particularly beneficial for women, including exercise (as an adjunct intervention), very low nicotine content cigarettes, and a variety of pharmacotherapy. Further research is needed to identify and target the gender-specific needs of smokers.