Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes.

OBJECTIVES

To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes.

DESIGN

Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results.

SETTING

Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes.

PARTICIPANTS

Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes.

INTERVENTIONS

Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies.

MAIN OUTCOME MEASURES

Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events.

DATA SOURCES

Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019.

REVIEW METHODS

Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model.

RESULTS

Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard.

LIMITATIONS

Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified.

CONCLUSIONS

Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK.

FUTURE WORK

Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041302.

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. 25, No. 59. See the NIHR Journals Library website for further project information.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to tobacco dependence and long-term use can lead to health problems including periodontal disease, cancer, and cerebrovascular and cardiovascular disease.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialised register in June 2015.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by the Cochrane Collaboration. We summarised outcomes as risk ratios (RRs). For subgroups of trials with similar types of intervention and without substantial statistical heterogeneity, we estimated pooled effects using a Mantel-Haenszel fixed-effect method.

MAIN RESULTS

We identified 34 trials that met the inclusion criteria, of which nine were new for this update, representing over 16,000 participants. There was moderate quality evidence from two studies suggesting that varenicline increases ST abstinence rates (risk ratio [RR] 1.34, 95% confidence interval (CI) 1.08 to 1.68, 507 participants). Pooled results from two trials of bupropion did not detect a benefit of treatment at six months or longer (RR 0.89, 95% CI 0.54 to 1.44, 293 participants) but the confidence interval was wide. Neither nicotine patch (five trials, RR 1.13, 95% CI 0.93 to 1.37, 1083 participants) nor nicotine gum (two trials, RR 0.99, 95% CI 0.68 to 1.43, 310 participants) increased abstinence. Pooling five studies of nicotine lozenges did increase tobacco abstinence (RR 1.36, 95% CI 1.17 to 1.59, 1529 participants) but confidence in this estimate is low as the result is sensitive to the exclusion of three trials which did not use a placebo control.Statistical heterogeneity was evident among the 17 trials of behavioural interventions: eight of them reported statistically and clinically significant benefits; six suggested benefit but with wide CIs and no statistical significance; and three had similar intervention and control quit rates and relatively narrow CIs. Heterogeneity was not explained by study design (individual or cluster randomization), whether participants were selected for interest in quitting, or specific intervention components. In a post hoc subgroup analysis, trials of behavioural interventions incorporating telephone support, with or without oral examination and feedback, were associated with larger effect sizes, but oral examination and feedback alone were not associated with benefit.In one trial an interactive website increased abstinence more than a static website. One trial comparing immediate cessation using nicotine patch versus a reduction approach using either nicotine lozenge or brand switching showed greater success for the abrupt cessation group.

AUTHORS' CONCLUSIONS

Varenicline, nicotine lozenges and behavioural interventions may help ST users to quit. Confidence in results for nicotine lozenges is limited. Confidence in the size of effect from behavioural interventions is limited because the components of behavioural interventions that contribute to their impact are not clear.

Evaluating the Effects of Varenicline on Craving, Withdrawal, and Affect in a Randomized, Double-Blind, Placebo-Controlled Clinical Trial of Varenicline for Smokeless Tobacco Dependence in India

This study examined changes in tobacco craving, withdrawal, and affect as correlates of efficacy in a phase-2 clinical trial of varenicline for smokeless tobacco dependence in India. Smokeless tobacco users (N = 237) at the All India Institute of Medical Sciences were randomized to placebo or varenicline. Abstinence was defined as cotinine-verified seven-day point prevalence cessation at end of treatment (EOT). General Linear Model repeated measures assessed the effects of treatment condition, time, abstinence state, and interaction effects on changes in craving, withdrawal, positive (PA) and negative affect (NA) from baseline to EOT. All participants showed a significant reduction in withdrawal (p < .001), total craving (p < .001), positive reinforcement (PR) craving (p < .001), and NA (p = .02), and an increase in PA (p = .04) from baseline to EOT. However, there were no differences between placebo and varenicline participants in measures of withdrawal, craving, or affect from baseline to week 3 or at EOT. Significant interactions between time and abstinence state were found for total craving (p = .008), PR craving (p < .001), and withdrawal (p = .001), indicating reductions in these processes among those abstinent vs. those still chewing smokeless tobacco. Additional research is needed concerning the effects of varenicline on craving, withdrawal, and affect among smokeless tobacco users.

A randomized phase II clinical trial of high-dose nicotine patch therapy for smokeless tobacco users

INTRODUCTION

Nicotine patch therapy has not been shown to be efficacious for increasing long-term (≥6 months) tobacco abstinence rates among smokeless tobacco (ST) users. Higher doses of nicotine patch therapy may be needed to increase tobacco abstinence rates in this population of tobacco users.

METHODS

We randomized ST users who used ≥3 cans/pouches per week to either 8 weeks of high-dose nicotine patch therapy (42mg/day) or matching placebo patch. Subjects were followed for 6 months after randomization.

RESULTS

Fifty-two subjects were randomized. Compared with placebo, high-dose nicotine patch therapy was associated with significantly higher prolonged tobacco abstinence at end-of-treatment (44% vs. 22%, odds ratio [OR] = 2.7, p = .050) and 3 months (40% vs. 19%, OR = 2.9, p = .047). High-dose nicotine patch therapy was associated with significant weight gain attenuation among tobacco abstinence subjects at 3 months (p = .013) and 6 months (p = .018). Compared with placebo, high-dose nicotine patch therapy was associated with nonsignificantly lower nicotine withdrawal scores. Adverse events were not significantly increased with high-dose nicotine patch therapy.

CONCLUSIONS

High-dose nicotine patch therapy is safe and increases short-term tobacco abstinence rates among ST users who use ≥3 cans/pouches per week. High-dose nicotine patch therapy is associated with significant long-term attenuation of weight gain. Future studies to investigate the long-term efficacy of high-dose nicotine patch therapy and the comparative efficacy of this approach compared with standard nicotine patch doses for ST users seems warranted.

Smokeless tobacco cessation in South Asian communities: a multi-centre prospective cohort study

AIM

To evaluate smokeless tobacco cessation in communities of South Asian origin.

DESIGN

Multi-centre prospective cohort study.

SETTING

Three tobacco cessation services offering specialist smokeless tobacco cessation outreach clinic support to South Asians (Bangladeshi, Indian and Pakistani) resident in England.

PARTICIPANTS

A total of 239 South Asian participants seeking to stop smokeless tobacco use between November 2010 and December 2011.

MEASUREMENTS

Socio-demographics, tobacco use and dependence, self-reported abstinence at 4 weeks and satisfaction measures.

FINDINGS

Participants' mean age was 45 [standard deviation (SD) = 13] years, were predominantly female (76%), of Bangladeshi origin (74%), either home carers (53%) or not working (29%). Sixty-three per cent were recruited from community locations, 21% through a clinical contact and 16% through friends and family. Mean daily number of smokeless tobacco intakes was 10 (SD = 7) and the mean dependence score was 4.5 (SD = 1.9). Sixty-three per cent of participants achieved continuous abstinence 4 weeks after quitting. Using nicotine replacement therapy (NRT) versus not using it [OR = 3.47, 95% confidence interval (CI): 1.25, 9.62] and below median (≤ 8) daily smokeless tobacco intakes (OR = 1.91, 95% CI: 1.07, 3.40) predicted successful abstinence.

CONCLUSION

South Asian smokeless tobacco users resident in England accessing services to help them stop appear to have short-term success rates comparable with smokers attending stop-smoking services, with higher success rates being reported by those using nicotine replacement therapy.

Predictors of successful short-term tobacco cessation in UK resident female Bangladeshi tobacco chewers

AIM

  To identify predictors of short-term smokeless tobacco cessation in Bangladeshi women resident in the United Kingdom.

DESIGN

  Prospective cohort study.

SETTING

  A tobacco cessation service offering culturally tailored smokeless tobacco cessation support.

PARTICIPANTS

  A total of 419 Bangladeshi women chewing paan with tobacco.

MEASUREMENTS

  Demographics, tobacco use and dependence and cessation attempt process and outcomes.

FINDINGS

  Client mean age was 48.92 [95% confidence interval (CI) 47.5, 50.34] years and the mean area social deprivation score was 3.65 (95% CI 3.33, 3.97). Mean daily smokeless tobacco intakes, as paan, was 9.96 (95% CI 9.22, 10.7); 69.8% were recruited from primary care, 78.8% received behavioural support and nicotine replacement therapy (NRT) and the remainder behavioural support alone. Self-reported 4-week continuous abstinence was 58.3%, predicted by NRT use [odds ratio (OR) = 4.93, 95% CI 2.02, 12.00], community recruitment (OR = 1.84, 95% CI 1.01, 3.35) and relatively lower social deprivation (IMD) score (OR = 1.98, 95% CI 1.18, 3.33).

CONCLUSION

  Bangladeshi women in the UK attending clinics to help cessation of paan with tobacco appear to be more likely to be successful in the short term if they use nicotine replacement therapy, are recruited via the community and have relatively lower levels of social deprivation.

Comparing an immediate cessation versus reduction approach to smokeless tobacco cessation

INTRODUCTION

Relatively few studies have investigated pharmacological or behavioral treatment of smokeless tobacco (ST) users who do not have immediate quit plans. In this study, we compared a reduction treatment approach with an immediate cessation approach in a population of ST users who reported no immediate plans to quit.

METHODS

Subjects randomly assigned to the immediate cessation condition set a quit date soon after enrollment and were offered 2 weeks of nicotine patch therapy to help in their cessation efforts. Subjects assigned to the ST reduction group were provided with their choice of either 4 mg nicotine lozenge or ST brand switching to help them reduce their ST use or levels of nicotine exposure, respectively. Quit date was 6 weeks after the onset of treatment. Follow-up was at 12 weeks and 26 weeks postenrollment and 26 weeks postquit.

RESULTS

Both 7-day point prevalence abstinence and prolonged abstinence rates following the quit date were significantly higher in the immediate cessation group versus the reduction group at 12 and 26 weeks (all p values ≤ .04) and for prolonged abstinence at 6 months postquit (p = .002). Significant reductions in ST use among nonquitters were observed for both groups (p < .0001) with no differences between groups.

CONCLUSION

Our study demonstrated that immediate cessation with an established quit date resulted in greater cessation success than a gradual reduction approach among ST users who do not have an immediate quit plan but are motivated to quit.

Pharmacological interventions for the treatment of smokeless tobacco use

Smokeless tobacco (SLT) is used in a variety of forms throughout the world. Long-term SLT use is associated with adverse health consequences. Effective pharmacotherapies are needed to treat SLT users who want to achieve tobacco abstinence. In the current review, we discuss the pharmacological interventions identified in a recent meta-analysis of interventions for SLT users, with inclusion of additional articles identified by searching PubMed up to August 2011. Nicotine replacement therapy (NRT) has been demonstrated to increase short-term tobacco abstinence rates and to alleviate craving and withdrawal symptoms among SLT users trying to quit. Bupropion sustained release has been shown to decrease craving and attenuate post-cessation weight gain among SLT users trying to quit. Varenicline is the only available medication demonstrated to increase long-term (≥6 months) tobacco abstinence rates among SLT users. Overall, findings from studies investigating pharmacotherapies for SLT users have been relatively disappointing. SLT reduction interventions may hold some promise for increasing abstinence rates among SLT users not interested in quitting. Additional investigations of higher dose NRT and combination pharmacotherapy are needed to advance the treatment of SLT users.

A pilot study of the efficacy of varenicline for the treatment of smokeless tobacco users in Midwestern United States

INTRODUCTION

Long-term smokeless tobacco (ST) use is known to increase the risk for oropharyngeal cancer, heart attack, and stroke. Varenicline has recently been demonstrated to increase ST abstinence rates among Swedish snus users. We have conducted a pilot study to obtain preliminary evidence of efficacy of varenicline for the treatment of ST users in Midwestern United States.

METHODS

We conducted a randomized, placebo-controlled Phase II clinical trial to evaluate the potential efficacy of 12 weeks of varenicline for the treatment of ST users with an a priori decision rule that a 1-tailed p < .20 for the comparison of the primary endpoint was evidence to conclude that future studies were warranted. Subjects were followed for 6 months after randomization.

RESULTS

We randomized 76 subjects (38 varenicline and 38 placebo). Subjects were similar at baseline with a mean age of 41 years, and all were male. The biochemically confirmed point prevalence tobacco abstinence rates at end of treatment were 55.3% for varenicline and 42.1% for placebo (p = .126) and 47.4% and 31.6% (p = .080), respectively, at 6 months. Point prevalence ST abstinence rates at end of treatment for varenicline were 57.9% and 42.1% for placebo (p = .084) and 57.9% and 31.6% (p = .011), respectively, at 6 months. Varenicline was associated with significantly less craving compared with placebo. Varenicline was well tolerated with nausea and sleep disturbance being the most common side effects.

CONCLUSIONS

Varenicline decreases craving and may be effective for increasing tobacco abstinence rates among ST users. Larger trials may be warranted to confirm these results.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease, cancer, and cerebrovascular and cardiovascular disease.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: October 2010.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. We summarised as odds ratios. For subgroups of trials with similar types of intervention and without substantial statistical heterogeneity, we estimated pooled effects using a Mantel-Haenszel fixed-effect method.

MAIN RESULTS

Data from one study suggest that varenicline increases ST abstinence rates (Odds Ratio [OR] 1.6, 95% Confidence Interval (CI) 1.08 to 2.36) among Swedish snus users.Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (OR 0.86, 95% CI 0.47 to 1.57). Nicotine replacement therapy (patch, gum, and lozenge) was not observed to increase tobacco abstinence rates (OR 1.14, 95% CI: 0.91 to 1.42). There was statistical heterogeneity among the 14 trials of behavioural interventions; seven of them reported statistically and clinically significant benefits, four suggested benefit but with wide CIs, whilst two had similar intervention and control quit rates and relatively narrow CIs. Heterogeneity was not explained by the design (individual or cluster randomization), whether participants were selected for interest in quitting, or specific intervention components. Most trials included either telephone counselling, an oral examination and feedback about any ST induced mucosal changes, or both. In a post-hoc subgroup analysis there was some evidence that behavioural interventions which include telephone counselling might increase abstinence rates more than interventions with less contact. In one trial an interactive website increased abstinence more than a static website.

AUTHORS' CONCLUSIONS

Varenicline and behavioural interventions may help ST users to quit. Behavioural interventions incorporating telephone counselling or an oral examination are likely to increase abstinence rates.

Effects of sensory and behavioral substitutes following an experimentally induced stressor among abstinent smokeless tobacco users

Despite the well-known health risks associated with smokeless tobacco use, much is unresolved with respect to effective treatment for use of this substance. The present study examined the impact of a nicotine-free smokeless tobacco substitute and confectionary chewing gum on craving, withdrawal, and anxiety among 24 smokeless tobacco users following 24 hours of nicotine abstinence and a laboratory stressor. Although chewing gum did not impact withdrawal, craving, or anxiety compared to a no-product control condition, smokeless tobacco substitute administration resulted in a reduction of withdrawal and craving levels compared to the control condition following 24 hours of abstinence. Furthermore, significantly lower levels of craving and withdrawal were observed in both smokeless tobacco and smokeless tobacco substitute conditions compared to the control condition following the stressor. Results indicate that although general oral stimulation (eg, chewing gum) was not effective in reducing symptoms related to nicotine withdrawal, smokeless tobacco substitute use appears to be helpful in reducing withdrawal levels post-stressor. These data suggest that use of a smokeless tobacco substitute may be an effective aid in helping individuals wishing to quit, especially when managing stressors. (Am J Addict 2010;00:1-8).

A randomized clinical trial of nicotine lozenge for smokeless tobacco use

INTRODUCTION

Smokeless tobacco (ST) use is associated with adverse health consequences, and effective treatments are needed. Pilot data suggest that 4-mg nicotine lozenge decreases tobacco craving and nicotine withdrawal symptoms among ST users.

METHODS

We conducted a randomized, placebo-controlled multicenter clinical trial to evaluate the efficacy of 12 weeks of 4-mg nicotine lozenge for ST use.

RESULTS

We randomized 270 participants (136 active lozenge, 134 placebo). No significant differences were observed between the groups in biochemically confirmed all tobacco abstinence rates at Week 12 (36% lozenge vs. 27.6% placebo; odds ratio [OR] 1.5, 95% CI 0.7-2.1; p = .138). However, the 4-mg nicotine lozenge increased self-reported all tobacco abstinence (44.1% vs. 29.1%; OR 1.9, 95% CI 1.2-3.2; p = .011) and self-reported ST abstinence (50.7% vs. 34.3%; OR 2.0, 95% CI 1.2-3.2; p = .013) compared with placebo at the end of treatment (Week 12). Following target quit date (TQD), nicotine withdrawal symptoms decreased significantly with time (time effect = -.022 per day, SE = .003; p < .001) and was significantly lower for the active lozenge (treatment effect = -.213, SE = .071; p = .003). Tobacco craving also decreased significantly following TQD (time effect = -.071, SE = .006; p < .001) and was lower for the active nicotine lozenge (treatment effect = -.452, SE = .164; p = .006).

DISCUSSION

The 4-mg nicotine lozenge increased self-reported but not biochemically confirmed tobacco abstinence rates at 3 months. The use of the 4-mg nicotine lozenge is associated with decreased nicotine withdrawal symptoms and tobacco craving.

Factors associated with smokeless tobacco cessation in an Appalachian population

Identifying factors associated with successful tobacco quit attempts may help in the development and targeting of effective cessation strategies. This paper aims to describe factors associated with smokeless tobacco (ST) cessation and compares the results to findings in the smoking cessation literature. Prospective data on 116 men aged 19 to 70 and participating in a ST cessation program were used to examine correlates of successful ST cessation at 1-year post-intervention. Controlling for age, level of education (p=0.002) and daily coffee consumption (p=0.005) had significant independent associations with successful cessation. No ST use variables were significant predictors of cessation success. In a multivariable logistic regression model three factors were significantly associated with cessation: education (p=0.010), coffee consumption (p=0.019), and age (p=0.029). Factors associated with successful ST cessation in this sample are consistent with predictors of smoking cessation reported in the literature. Based on its widespread use and the strength of its association with successful quitting, the role of caffeine consumption in ST cessation merits further study.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease and cancer.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: March, 2007.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data.

MAIN RESULTS

Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (Odds Ratio (OR) 0.86, 95% Confidence Interval (CI): 0.47 to 1.57). Four trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of 12 behavioural interventions included in the meta-analyses. Six trials showed significant benefits of intervention. In post-hoc subgroup analyses, behavioural interventions which include telephone counselling or an oral examination may increase abstinence rates more than interventions without these components.

AUTHORS' CONCLUSIONS

Behavioural interventions should be used to help ST users to quit and telephone counselling or an oral examination may increase abstinence rates. Pharmacotherapies have not been shown to affect long-term abstinence.

Bupropion SR for the treatment of smokeless tobacco use

BACKGROUND

No pharmacotherapies have been shown to increase long-term (> or = 6 months) tobacco abstinence rates among smokeless tobacco (ST) users. Bupropion SR has demonstrated potential efficacy for ST users in pilot studies. We conducted a multicenter, randomized, double-blind, placebo-controlled, clinical trial to assess the efficacy and safety of bupropion SR for tobacco abstinence among ST users.

METHODS

Adult ST users were randomized to bupropion SR titrated to 150 mg twice daily (N=113) or placebo (N=112) for 12 weeks plus behavioral intervention. The primary endpoint was the 7-day point-prevalence tobacco abstinence rate at week 12. Secondary outcomes included prolonged and continuous tobacco abstinence rates, craving and nicotine withdrawal, and weight gain.

RESULTS

The 7-day point-prevalence tobacco abstinence rates did not differ between bupropion SR and placebo at the end treatment (53.1% versus 46.4%; odds ratio (OR) 1.3; p=0.301). The 7-day point-prevalence abstinence did not differ at weeks 24 and 52. The prolonged and continuous tobacco abstinence rates did not differ at weeks 12, 24, and 52. A time-by-treatment interaction was observed in craving over time with greater decreases in the bupropion SR group. At 12 weeks, the mean (+/-S.D.) weight change from baseline among abstinent subjects was an increase of 1.7 (+/-2.9)kg for the bupropion SR group compared to 3.2 (+/-2.7)kg for placebo (p=0.005).

CONCLUSIONS

Bupropion SR did not significantly increase tobacco abstinence rates among ST users, but it significantly decreased craving and weight gain over the treatment period.

An Epidemic that Deserves More Attention: Epidemiology, Prevention, and Treatment of Smokeless Tobacco

Smokeless tobacco (ST) use is common, especially in southern and rural areas. It is expected to become more popular with the recent move to sell more ST in areas where indoor smoking is banned. ST use usually starts in adolescence, which places this group at high risk. Nicotine dependence occurs almost exclusively in people who start using ST in their adolescent years, so it is crucial to prevent the introduction of ST to this age group. The debate over whether ST is a gateway to smoking or a bridge to quitting has not been fully answered. ST should not replace smoking where indoor smoking is banned. ST is less harmful than smoking, but nicotine replacement therapy (NRT) is much safer than ST. NRT and bupropion are helpful in the treatment of ST dependence by decreasing withdrawal symptoms and preventing weight gain after cessation.

Nicotine percentage replacement among smokeless tobacco users with nicotine patch

To obtain preliminary evidence on the safety and efficacy of high dose nicotine patch therapy among smokeless tobacco (ST) users who consume > or =3 cans of ST per week, we conducted a randomized, placebo-controlled clinical trial with 42 ST users randomized to nicotine patch doses of 21, 42, and 63 mg/day or placebo. Serum nicotine concentrations were measured during ad libitum ST use and nicotine replacement therapy, and percentages of nicotine replacement were calculated. We observed substantial inter-subject variability in nicotine concentrations with ad lib ST use. The mean percentage replacement of ad lib ST use serum nicotine concentrations approximated 100% with the 42 mg/day patch dose (mean+/-S.D., 98.4%+/-45%). Dosing with the 21 mg/day nicotine patch was associated with mean "under-replacement" (53.2%+/-17.1%), and the 63 mg/day nicotine was associated with mean "over-replacement" (159.2%+/-121.9%). We observed symptoms of nausea consistent with nicotine toxicity in two subjects in the 63 mg/day group while no subjects in the 42 mg/day reported these symptoms. We conclude that the use of 42 mg/day nicotine patch therapy is safe and should be considered as initial therapy in the clinical setting among ST users who use > or =3 cans/week.

Tobacco, oral cancer, and treatment of dependence

Tobacco dependence is recognised as a life-threatening disorder with serious oral health consequences which responds to treatment in the form of behavioural support and medication. While cigarette smoking is the most hazardous and prevalent form of tobacco use in the west, consideration also needs to be given to other forms such as bidi smoking in India, reverse smoking by several rural populations and use of snuff and chewing tobacco. The evidence that the use of tobacco is the major risk factor for oral cancer and potentially malignant lesions of the mouth is clear. Counseling to quit smoking is not applied in a systematic or frequent manner to people presenting with potentially malignant lesions of the oral cavity. This review makes recommendations for interventions by health professionals to encourage and aid cessation of tobacco use as a part of prevention of oral cancer.

Smokeless tobacco: an emerging addiction

Smokeless tobacco (ST) use is an important health issue in the United States, and chronic use leads to significant morbidity. ST users are exposed to levels of nicotine comparable with smokers and experience symptoms of nicotine withdrawal when attempting to stop. Clinical treatment of ST users requires an understanding of the unique characteristics of ST. This article reviews ST products, epidemiology, pharmacology, health risks, and treatment approaches.

Residential treatment for smokeless tobacco use: a case series

We developed and implemented a novel 8-day residential treatment program for smokeless tobacco (ST) use. A multidisciplinary team delivered behavioral treatment, nicotine patches were adjusted to achieve 100% replacement of baseline peak serum nicotine concentrations, and bupropion sustained-release was prescribed. Mean participant age (+/- SD) was 47.4 +/- 18.2 years. Mean nicotine patch dose at program end was 43.2 mg/day +/- 13.9 (range 14 to 66 mg/d). Median percent replacement by serum nicotine concentrations was 86.6% (IQR: 75-113.8%). At 1 year, the biochemically-confirmed (urine anabasine <2.0 ng/mL) self-reported 7-day point prevalence tobacco abstinence rate was 58% (14/24). A residential treatment program for ST users may be effective. More research is needed to replicate our findings and determine if comparable abstinence rates can be achieved with outpatient ST treatment programs using similar behavioral and pharmacotherapies.

Smokeless tobacco cessation guidelines for health professionals in England

Smokeless tobacco is used in the UK predominantly by members of the Indian, Pakistani and especially Bangladeshi communities. The most commonly used form is tobacco mixed with lime and additional psychoactive compounds, most notably areca nut. The resulting "quid" is chewed or held in the mouth. Studies from Asia indicate that use of this kind of product is linked with an increased risk of oral cancers and possibly low birth-weight infants. There is little high quality research evaluating interventions to promote cessation of smokeless tobacco use, especially of the forms used in the UK. However, what evidence there is suggests that advice to stop coupled with behavioural support and counselling may increase long-term abstinence rates by some 5-10%. It seems appropriate therefore to recommend that dentists, GPs and other relevant health professionals should routinely assess and record smokeless tobacco use in patients belonging to relatively high prevalence groups, that they ensure that smokeless tobacco users know the potential health risks (as well as the health risks of smoking) and that they advise them to stop and keep a record of the outcome. Dental professionals should also examine the oral cavity of smokeless tobacco users for lesions when the opportunity arises. Patients expressing an interest in stopping should be referred to specialist smoking cessation services for behavioural support and specialists in areas of high smokeless tobacco use will need to ensure that they are sufficiently knowledgeable and their services sufficiently accessible to these users. There is insufficient evidence to recommend the use of nicotine replacement therapy or bupropion to aid smokeless tobacco cessation. Research is needed in the UK to quantify the personal and population health risks from smokeless tobacco, the benefits of stopping, the effectiveness of interventions aimed at promoting cessation and patterns of use, knowledge and attitudes of users.

Smokeless tobacco use: harm reduction or induction approach?

BACKGROUND

Smokeless tobacco (ST) substitution for cigarettes as a method to reduce harm has been actively debated. Use of ST as a smoking cessation method or as a means to reduce cigarettes has been proposed. The impact of using ST in these ways is relatively unknown.

METHODS

A review of the different issues and studies related to using smokeless tobacco as a method to reduce tobacco toxin exposure and harm is presented.

RESULTS

The toxicity of the product itself varies by brand of ST and across countries. Of the existing studies, comparisons of consequences between cigarettes and ST show that cigarette smoking produces more negative health effects, is likely to have a higher addiction potential and more severe withdrawal, and leads to a higher rate of relapse than ST use. On the other hand, ST use facilitates the use of cigarettes, which is a deadly tobacco product. Additionally, ST is not a harmless product, and a less harmful product, medicinal nicotine, is available as an effective treatment approach. Furthermore, ST products are not under the same regulatory scrutiny as medicinal nicotine products.

CONCLUSIONS

Considerably more research and product regulation is necessary prior to considering smokeless tobacco as a harm reduction method.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and health problems including periodontal disease and oral cancer

OBJECTIVES

To assess the effects of behavioural and pharmacotherapeutic interventions to treat ST use.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register (February 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966-February 2004), EMBASE (1988-January 2004), CINAHL (1982-February 2004), PsycINFO (1984-February 2004), Database of Abstract of Reviews of Effectiveness (DARE, The Cochrane Library, Issue 1, 2004).

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit, with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data.

MAIN RESULTS

One trial of bupropion did not detect a benefit of treatment after six months (Odds Ratio (OR) 1.00, 95% Confidence Interval (CI): 0.23 to 4.37). Three trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of eight trials of behavioural interventions included in the meta-analysis. Three trials showed significant benefits of intervention. In a post-hoc analysis the trials of interventions which included an oral examination and feedback about ST-induced mucosal changes had homogeneous results and when pooled showed a significant benefit (OR 2.41 95% CI: 1.79 to 3.24).

REVIEWERS' CONCLUSIONS

Behavioural interventions should be used to help ST users to quit. Pharmacotherapies have not been shown to affect long-term abstinence but larger trials are needed.

What have we learned from 20 years of research on smokeless tobacco cessation?

Although smoking cessation continues to get most of the attention from both researchers and practitioners, treatment for smokeless tobacco (SLT) dependence gets little consideration. The reasons are varied, but essentially smoking is more prevalent, has greater public health implications, and has been the subject of clean air laws and environmental issues that have focused the attention on a burned tobacco, thereby leaving SLT with scant public health attention. This is unfortunate, because the sales of SLT products, especially moist snuff, have increased consistently over the past decade; regular use of these products can result in oral cancer, other negative effects on oral health, and nicotine dependence or addiction. This article will review some unique issues of SLT use that affect cessation and the empirical research on interventions.

Treatments for spit tobacco use: a quantitative systematic review

AIMS

Spit tobacco use is prevalent in the United States and is associated with adverse health consequences. Health-care providers have neither evidence summaries nor evidence-based guidelines to assist them in treating patients who use spit tobacco.

DESIGN

We completed a systematic review of the literature to determine the efficacy and safety of pharmacological and behavioral interventions for the treatment of spit tobacco use.

FINDINGS

We found six randomized controlled trials testing pharmacological interventions and eight testing behavioral interventions. Using random-effects meta-analyses,bupropion sustained-release (SR) increased point prevalence tobacco abstinence at 12 weeks [odds ratio (OR) 2.1; 95% confidence interval (CI), 1.0-4.2]. Nicotine replacement therapy with patch or gum increased point prevalence tobacco abstinence at 6 months (OR 1.3; 95% CI, 1.0-1.6). Behavioral interventions increased long-term (6 month)point prevalence tobacco abstinence (OR 1.7; 95% CI, 1.1-2.9). Studies including an oral examination followed by feedback to the patient had the highest treatment effect.

CONCLUSIONS

Behavioral interventions for ST users are effective for increasing ST abstinence rates. Bupropion SR is probably effective and nicotine replacement therapy may be effective. This evidence from randomized controlled trials provides health-care professionals with information necessary to effectively treat spit tobacco use.

Who enrolls in a self-help cessation program for smokeless tobacco?

To further our understanding of the representativeness of the smokeless tobacco (SLT) user recruited to various treatment settings, and to suggest gaps in services available to SLT users, we first compared participants who enrolled in a self-help cessation program with two samples of nontreatment-seeking SLT users: SLT users identified through a random digit dialing (RDD) survey, and SLT users who came to 1 of 75 dental practices for a routine cleaning visit. We found that those in the self-help SLT cessation program were older, more educated, more likely to have made a serious quit attempt, and used more SLT weekly than those who did not seek treatment. Secondly, we compared SLT users seeking treatment in three different treatment settings varying in accessibility and intensity: self-help study participants, SLT users enrolled in a clinic-based study, and callers to the California Help Line for SLT cessation. Participants differed across the three studies on demographics, some measures of dependence, and history of SLT use.