Efficacy of Pharmacotherapy for Smoking Cessation in Adolescent Smokers: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

This study aimed to evaluate the efficacy of pharmacotherapy for smoking cessation among adolescent smokers by using a meta-analysis of randomized controlled trials (RCTs).

METHODS

PubMed, EMBASE, and Cochrane Library were searched from the inception to January 20, 2018. We included RCTs of pharmacotherapy for smoking cessation among adolescent smokers aged less than 20 years. Data were pooled using a random-effects meta-analysis. The primary outcome measures were a smoking abstinence rate and its relative risk (RR) at the longest follow-up period in each study validated by biochemical markers.

RESULTS

Among a total of 1035 articles searched, nine RCTs, which involved 1188 adolescent smokers aged 12-20 years with 627 in the intervention group and 561 in the control group, were included in the final analysis. In the random-effects meta-analysis of all the nine trials, pharmacotherapy showed a increased abstinence rate (RR = 1.62; 95% confidence interval [CI] = 1.08 to 2.44, I2 = 0.0%), compared with the control group. Subgroup meta-analyses by follow-up period showed an increased abstinence rate at 4 weeks (RR = 1.87; 95% CI = 1.22 to 2.87; n = 4) and a nonsignificantly increased abstinence rate during the longer term follow-up periods at 8, 12, 24, and 52 weeks.

CONCLUSIONS

The current meta-analysis suggests that pharmacotherapy can be considered as an aid for smoking cessation in the short-term period among adolescent smokers. However, further large RCTs are warranted to determine its long-term efficacy and safety.

IMPLICATIONS

In this meta-analysis of nine RCTs with 1188 adolescent smokers aged 12-20 years, pharmacotherapy showed an increased abstinence rate, compared with the control group. In the subgroup meta-analyses by follow-up period, it showed the increased abstinence rate at 4 weeks and no efficacy on abstinence during the longer term follow-up periods up to 52 weeks. Further large RCTs are warranted to determine the long-term efficacy and safety of pharmacotherapy in adolescent smokers.

Efficacy and Safety of Varenicline for Adolescent Smoking Cessation: A Randomized Clinical Trial

IMPORTANCE

Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States and worldwide, and most tobacco users begin smoking in adolescence. Although advances have yielded efficacious pharmacotherapies to complement smoking cessation counseling in adults, far less progress has been made in addressing tobacco use in adolescence.

OBJECTIVE

To evaluate the efficacy and safety of varenicline tartrate for smoking cessation in adolescents and young adults.

DESIGN, SETTING, AND PARTICIPANTS

This 2-group randomized, placebo-controlled, double-blind intention-to-treat clinical trial enrolled a volunteer sample of treatment-seeking adolescent and young adult cigarette smokers (n = 157) aged 14 to 21 years at an outpatient clinical site in Charleston, South Carolina, from August 15, 2012, to October 20, 2017. Follow-up was completed on January 25, 2018. Data were analyzed from March 19, 2018, to August 11, 2018, with further revisions completed April 10, 2019.

INTERVENTIONS

Participants were randomized in a 1:1 ratio to a 12-week course of varenicline (n = 77) or placebo (n = 80). All participants received weekly smoking cessation counseling.

MAIN OUTCOMES AND MEASURES

The preselected primary efficacy outcome was urine cotinine level-confirmed 7-day abstinence at the end of treatment. Secondary efficacy outcomes included weekly abstinence throughout active treatment, abstinence at posttreatment follow-up visits, and time to first 7-day abstinence. The primary safety outcome was the frequency of treatment-emergent adverse events.

RESULTS

A total of 157 participants were enrolled (94 male [59.9%]; mean [SD] age, 19.1 [1.5] years). The varenicline and placebo groups did not differ in the primary outcome of cotinine-confirmed self-reported 7-day abstinence at the end of treatment (varenicline group, 4 of 45 [8.9%]; placebo group, 4 of 45 [8.9%]; risk ratio [RR], 0.97; 95% CI, 0.29-2.99; P = .96). However, among secondary outcomes, the varenicline group achieved self-reported earlier abstinence of at least 7 days (hazard ratio, 1.91; 95% CI, 1.12-3.27) and demonstrated higher rates of self-reported weekly abstinence during the full course of treatment (RR, 1.81; 95% CI, 1.09-2.99; P = .02) and at posttreatment follow-up (RR, 1.82; 95% CI, 1.01-3.28; P = .02). Study medication was generally well tolerated, and treatment-emergent adverse events did not differ between groups (any adverse events, 55 [71.4%] in the varenicline group vs 60 [75.0%] in the placebo group; RR, 0.95; 95% CI, 0.79-1.15; P = .61).

CONCLUSIONS AND RELEVANCE

When added to weekly cessation counseling for adolescent cigarette smokers, varenicline, compared with placebo, was well tolerated but did not improve end-of-treatment abstinence. However, varenicline may hasten abstinence and yield improvements in posttreatment abstinence outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01509547.

Pharmacological Treatment of Youth Substance Use Disorders

While the majority of youth who experiment with alcohol and drugs do not develop problematic levels of use, 5% of adolescents and 15% of young adults meet criteria for a substance use disorder (SUD). Pharmacotherapy, in combination with behavioral interventions, has the potential to increase the likelihood of successful treatment for youth struggling with SUD; however, the literature in this area is limited. To date, there are no Food and Drug Administration (FDA)-approved medications for adolescent SUD, other than buprenorphine, which has been approved down to 16 years of age for opioid use disorder. Despite alcohol and cannabis being the most commonly used substances during adolescence, only three medications have been tested among this demographic, and only two have warranted further study (i.e., naltrexone for alcohol and N-acetylcysteine for cannabis use disorder). Although less common in adolescents and young adults, the most promising pharmacological findings for this age group are for opioid (buprenorphine) and tobacco (bupropion and varenicline) use disorders. In addition, despite the recent marked increases in electronic nicotine delivery systems (i.e., vaping) among youth, treatment strategies are still in their infancy and no recommendation exists for how to promote cessation for youth vaping. Current findings are limited by: small, demographically homogeneous samples; few trials, including a substantial number of youth younger than 18; low retention; medication adherence rates; and minimal information on effective dosing levels and long-term outcomes. Overall, pharmacotherapy may be a potentially effective strategy to increase treatment effects; however, more rigorous research trials are warranted before FDA approval would be granted for any of the potential adjunctive medications in this age group.

Integrated Treatment of Adolescents with Co-occurring Depression and Substance Use Disorder

Substance use disorders (SUDs) are commonly co-occurring among adolescents with depression. Integrated treatment is important given treatment implications and increased rates of suicidality. All adolescents should be screened for SUD using Screening, Brief Intervention, and Referral to Treatment. Review of randomized controlled trials in adolescents reveals motivational enhancement therapy/cognitive behavioral therapy is an evidence-based intervention and should be considered first-line treatment. If depression does not improve, fluoxetine should be considered, as it is well-tolerated in substance-involved adolescents with depression. Adolescents who do not show improvement in SUD or who have severe SUD should be referred to evidence-based SUD treatment.

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.

Tobacco cessation interventions for young people

BACKGROUND

Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the update of a Cochrane Review first published in 2006.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register in June 2017. This includes reports for trials identified in CENTRAL, MEDLINE, Embase and PsyclNFO.

SELECTION CRITERIA

We included individually and cluster-randomized controlled trials recruiting young people, aged under 20 years, who were regular tobacco smokers. We included any interventions for smoking cessation; these could include pharmacotherapy, psycho-social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months' follow-up among those who smoked at baseline.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of candidate trials and extracted data. We evaluated included studies for risk of bias using standard Cochrane methodology and grouped them by intervention type and by the theoretical basis of the intervention. Where meta-analysis was appropriate, we estimated pooled risk ratios using a Mantel-Haenszel fixed-effect method, based on the quit rates at six months' follow-up.

MAIN RESULTS

Forty-one trials involving more than 13,000 young people met our inclusion criteria (26 individually randomized controlled trials and 15 cluster-randomized trials). We judged the majority of studies to be at high or unclear risk of bias in at least one domain. Interventions were varied, with the majority adopting forms of individual or group counselling, with or without additional self-help materials to form complex interventions. Eight studies used primarily computer or messaging interventions, and four small studies used pharmacological interventions (nicotine patch or gum, or bupropion). There was evidence of an intervention effect for group counselling (9 studies, risk ratio (RR) 1.35, 95% confidence interval (CI) 1.03 to 1.77), but not for individual counselling (7 studies, RR 1.07, 95% CI 0.83 to 1.39), mixed delivery methods (8 studies, RR 1.26, 95% CI 0.95 to 1.66) or the computer or messaging interventions (pooled RRs between 0.79 and 1.18, 9 studies in total). There was no clear evidence for the effectiveness of pharmacological interventions, although confidence intervals were wide (nicotine replacement therapy 3 studies, RR 1.11, 95% CI 0.48 to 2.58; bupropion 1 study RR 1.49, 95% CI 0.55 to 4.02). No subgroup precluded the possibility of a clinically important effect. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions. Our certainty in the findings for all comparisons is low or very low, mainly because of the clinical heterogeneity of the interventions, imprecision in the effect size estimates, and issues with risk of bias.

AUTHORS' CONCLUSIONS

There is limited evidence that either behavioural support or smoking cessation medication increases the proportion of young people that stop smoking in the long-term. Findings are most promising for group-based behavioural interventions, but evidence remains limited for all intervention types. There continues to be a need for well-designed, adequately powered, randomized controlled trials of interventions for this population of smokers.

Applying a Social–Ecological Framework to Factors Related to Nicotine Replacement Therapy for Adolescent Smoking Cessation

Objective:

This systematic review synthesizes factors related to nicotine replacement therapy (NRT) use among adolescents seeking to quit smoking, using the social–ecological model as a guiding framework.

Data Source:

Searches of PubMED, ProQuest, EBSCOhost, and ERIC were conducted in July 2016.

Study Inclusion and Exclusion Criteria:

Original studies of cigarette smokers younger than 18 years that discussed NRT were included.

Data Extraction:

Two reviewers individually extracted study purpose, sample, design, and results.

Data Synthesis:

Factors were categorized by social–ecological model level and summarized.

Results:

A total of 103 907 articles were identified during initial search. After narrowing to peer-reviewed articles in English and eliminating reviews and adult-only studies, we reviewed 51 articles. These 51 articles identified factors from studies at each level of the social–ecological model: intrapersonal ( k = 20), interpersonal ( k = 2), organizational ( k = 7), community ( k = 11), and public policy ( k = 14).

Conclusion:

Findings provide insight into the applicability of NRT for adolescent smoking cessation, and factors by social–ecological model level highlight areas for additional research. Future adolescent NRT studies should assess factors at the interpersonal, organizational, and community levels, as well as the interactions between levels.

The Role of Pharmacotherapy in the Treatment of Adolescent Substance Use Disorders

Adolescent substance use disorders (SUDs) are a significant public health issue due to the associated morbidity, mortality, and societal cost. While effective for some adolescents, psychosocial interventions generally produce small-to-moderate reductions in substance use. Most youth relapse within 12 months of treatment. One approach to improve outcomes is through adjunctive pharmacotherapy. Medication assisted treatments have been shown to improve adult SUD treatment outcomes, and preliminary studies in adolescents suggest that combining medication with psychosocial interventions may also enhance SUD outcomes for youth. This article presents a comprehensive review and grading of the evidence from studies conducted in adolescents with SUDs.

Pharmacotherapy for Substance Use Disorders in Youths

Despite recent advances in psychosocial treatments targeting adolescent substance use disorders (SUD), effect sizes generally remain small to modest, and few treatment-enrolled youth achieve sustained abstinence. Among adults, SUD-targeted pharmacotherapies have emerged as viable options to complement psychosocial treatments and enhance outcomes. Developmental differences exist in pharmacodynamics and treatment-response, and comparatively little research has focused on SUD-targeted pharmacotherapies for youth. This article provides a review and synthesis of relevant published clinical trials focusing on youth SUDs and co-occurring/comorbid psychiatric and substance use disorders. It offers recommendations for clinical practice and further research based on the limited findings to date.

Emerging Pharmacologic Treatments for Adolescent Substance Use: Challenges and New Directions

Adolescence is a key period in the development of substance use and misuse. Substance use typically begins during adolescence and prevalence rates for many substance use disorders peak before age 21 years. Yet, despite clinical demand, treatments for youth rely almost entirely on psychosocial interventions that yield only modest benefit. One potential way to improve treatment effects is to augment the best available psychosocial interventions with pharmacotherapy. Although pharmacotherapy research has advanced care for adults with substance use disorders, no medication is indicated for adolescents and controlled trials with teenagers are scant. Optimizing treatments for youth will require closing this important gap in medication development research. In this paper we review the paucity of pharmacotherapy research for adolescent substance misuse, and we discuss how we can leverage human laboratory paradigms and technology to advance our understanding regarding if and how medications may improve treatment options for youths.

Varenicline and Nicotine Patch Therapies in Young Adults Motivated to Quit Smoking: A Randomized, Placebo-controlled, Prospective Study

This study compares the nicotine patch to placebo in young adult light smokers, and the nicotine patch to varenicline in heavy smokers. Volunteer daily smokers were recruited into a randomized, placebo-controlled study via community media, colleges and the army (aged 18-26 years). Those subjects with light tobacco dependence were randomized to (i) placebo patch (n = 86) and (ii) nicotine patch 10 mg/16 hr for 8 weeks (n = 94), and those with stronger dependence to (iii) nicotine patch 15 mg/16 hr for 8 weeks (n = 51) and (iv) varenicline for 12 weeks (n = 60). The primary outcome variable was self-reported smoking abstinence at week 12. Secondary outcome variables were self-reported smoking abstinence at weeks 4 and 26, and self-reported abstinence verified by saliva cotinine level at week 12. The prevalence of self-reported smoking abstinence did not differ statistically significantly in light smokers during the follow-up (week 4: 19.8% for placebo patch and 26.6% for nicotine patch 10 mg/16 hr; week 12: 17.4% versus 23.4%; week 26: 15.1% versus 20.2%), but the groups of heavy smokers differed significantly for 12 weeks (week 4: 19.6% for nicotine patch 15 mg/16 hr and 73.3% for varenicline, p < 0.001; week 12: 15.7% versus 36.7%, p = 0.018). This statistically significant difference did not endure for the entire follow-up (week 26: 9.8% versus 18.3%, p = 0.280). However, saliva cotinine verified abstinence at week 12 did not support self-reported abstinence. Varenicline may be more effective than the nicotine patch as a smoking cessation pharmacotherapy among young adult heavy smokers in the short-term.

Long-term efficacy of nicotine replacement therapy for smoking cessation in adolescents: a randomized controlled trial

BACKGROUND

A double-blind RCT on the short-term efficacy of nicotine patches compared to placebo patches among Dutch adolescents was conducted. The findings demonstrated that nicotine patches are efficacious for smoking cessation at end-of-treatment; however, only in highly compliant participants. We tested whether the effects of NRT also held in 6- (T7) and 12-month (T8) follow-up assessments.

METHODS

Adolescents aged 12-18 years, who smoked at least seven cigarettes a day and who were motivated to quit smoking were recruited at school yards and randomly assigned to either a nicotine patch (n=182) or a placebo patch (n=180) condition according to a computer generated list. Participants (N=257, age: 16.7 ± 1.13 years) attended an information meeting followed by a 6- or 9-week treatment. Smoking cessation, compliance, and potential covariates were measured by means of online questionnaires. Smoking cessation at T8 was biochemically validated by saliva cotinine.

RESULTS

At T7, 8.1% and 5.7% of participants were abstinent in the nicotine and placebo patch groups, respectively. At T8, abstinence was 4.4% and 6.6%, respectively. Intention-to-treat analyses showed no significant effects of NRT on abstinence rates at T7 (OR=1.54, 95% CI=0.57, 4.16) and validated abstinence rates at T8 (OR=0.64, 95% CI=0.21, 1.93) neither after considering compliance nor after adjusting for covariates.

CONCLUSIONS

NRT fails in helping adolescents quit smoking at 6- and 12-month follow-ups. This finding suggests that a more intensive approach is needed to assist youngsters in their quit attempts.

Effective use of transdermal drug delivery in children

Transdermal administration offers a non-invasive and convenient method for paediatric drug delivery. The competent skin barrier function in term infants and older children limits both water loss and the percutaneous entry of chemicals including drugs; but the smaller doses required by children eases the attainment of therapeutic concentrations. Transdermal patches used in paediatrics include fentanyl, buprenorphine, clonidine, scopolamine, methylphenidate, oestrogens, nicotine and tulobuterol. Some patches have paediatric labelling supported by clinical trials whereas others are used unlicensed. Innovative drug delivery methods, such as microneedles and sonophoresis are being tested for their safety and efficacy; needleless injectors are primarily used to administer growth hormone; and two iontophoretic devices were approved for paediatrics. In contrast, the immature and rapidly evolving skin barrier function in premature neonates represents a significant formulation challenge. Unfortunately, this population group suffers from an absence of approved transdermal formulations, a shortcoming exacerbated by the significant risk of excessive drug exposure via the incompletely formed skin barrier.

Cholinergic transmission during nicotine withdrawal is influenced by age and pre-exposure to nicotine: implications for teenage smoking

Adolescence is a unique period of development characterized by enhanced tobacco use and long-term vulnerability to neurochemical changes produced by adolescent nicotine exposure. In order to understand the underlying mechanisms that contribute to developmental differences in tobacco use, this study compared changes in cholinergic transmission during nicotine exposure and withdrawal in naïve adult rats compared to (1) adolescent rats and (2) adult rats that were pre-exposed to nicotine during adolescence. The first study compared extracellular levels of acetylcholine (ACh) in the nucleus accumbens (NAc) during nicotine exposure and precipitated withdrawal using microdialysis procedures. Adolescent (postnatal day, PND, 28-42) and adult rats (PND60-74) were prepared with osmotic pumps that delivered nicotine for 14 days (adolescents 4.7 mg/kg/day; adults 3.2 mg/kg/day; expressed as base). Another group of adults was exposed to nicotine during adolescence and then again in adulthood (pre-exposed adults) using similar methods. Control rats received a sham surgery. Following 13 days of nicotine exposure, the rats were implanted with microdialysis probes in the NAc. The following day, dialysis samples were collected during baseline and following systemic administration of the nicotinic receptor antagonist mecamylamine (1.5 and 3.0 mg/kg, i.p.) to precipitate withdrawal. A second study compared various metabolic differences in cholinergic transmission using the same treatment procedures as the first study. Following 14 days of nicotine exposure, the NAc was dissected and acetylcholinesterase (AChE) activity was compared across groups. In order to examine potential group differences in nicotine metabolism, blood plasma levels of cotinine (a nicotine metabolite) were also compared following 14 days of nicotine exposure. The results from the first study revealed that nicotine exposure increased baseline ACh levels to a greater extent in adolescent versus adult rats. During nicotine withdrawal, ACh levels in the NAc were increased in a similar manner in adolescent versus adult rats. However, the increase in ACh that was observed in adult rats experiencing nicotine withdrawal was blunted in pre-exposed adults. These neurochemical effects do not appear to be related to nicotine metabolism, as plasma cotinine levels were similar across all groups. The second study revealed that nicotine exposure increased AChE activity in the NAc to a greater extent in adolescent versus adult rats. There was no difference in AChE activity in pre-exposed versus naïve adult rats. In conclusion, our results suggest that nicotine exposure during adolescence enhances baseline ACh in the NAc. However, the finding that ACh levels were similar during withdrawal in adolescent and adult rats suggests that the enhanced vulnerability to tobacco use during adolescence is not related to age differences in withdrawal-induced increases in cholinergic transmission. Our results also suggest that exposure to nicotine during adolescence suppresses withdrawal-induced increases in cholinergic responses during withdrawal. Taken together, this report illustrates important short- and long-term changes within cholinergic systems that may contribute to the enhanced susceptibility to tobacco use during adolescence.

Adolescents' use of nicotine replacement therapy for smoking cessation: predictors of compliance trajectories

RATIONALE

Previous research has shown limited efficacy of nicotine replacement therapy (NRT) among adolescents and generally low compliance rates. As higher compliance rates are associated with improved abstinence rates, the present study examined predictors of NRT compliance.

OBJECTIVES

This study aims to test whether different NRT compliance trajectories can be distinguished among adolescents, to test whether these trajectories can be predicted by demographic, smoking-related, and personality factors, and to examine abstinence rates for each trajectory.

METHODS

Data were used from a randomized controlled trial that tested the efficacy of nicotine patches versus placebo patches among 265 Dutch adolescents. During NRT treatment, adolescents filled out six online questionnaires in which they reported on the number of days they used the patches. Predictors (i.e., demographic and smoking-related factors and personality characteristics) and end-of-treatment abstinence were also administered through these self-reports. Latent class growth analysis (LCGA) was used to analyze compliance data by classifying individuals into similar growth trajectories.

RESULTS

Three compliance trajectories were found (i.e., "compliers" (n = 89), "moderate decreasers" (n = 41), and "strong decreasers" (n = 127)). The compliers can be characterized by higher levels of conscientiousness and agreeableness and lower levels of extraversion compared with the strong decreasers, and by higher levels of conscientiousness and education compared with the moderate decreasers. Among the compliers, a substantially higher percentage of adolescents achieved abstinence at end-of-treatment (10 %) compared with the moderate decreasers (3 %) and the strong decreasers (6 %).

CONCLUSIONS

These findings could be the starting point for person-tailored interventions that aim to enhance NRT compliance rates among adolescents.

Nurse-initiated intervention programs: future directions for cessation and prevention of adolescent smoking

Tobacco use in adolescence remains at unacceptable levels. Increasing teen knowledge about the dangers of smoking appears to be insufficient in changing adolescent attitudes regarding the use of tobacco. To incite change and increase their effectiveness, adult smoking cessation programs need to be tailored to adolescents. Ultimately, intrapersonal, interpersonal, and environmental factors that underlie tobacco use and smoking behaviors in adolescents must be identified. The nurse's role is both in identification of the adolescent smoker and assessment of the smoking behavior. Future directions in nursing practice, nursing education, and research surrounding tobacco use in youth are discussed.

Up in smoke? A preliminary open-label trial of nicotine replacement therapy and cognitive behavioral motivational enhancement for smoking cessation among youth in Los Angeles

In 2008-2009, we conducted a 6-week, open-label trial of transdermal nicotine replacement therapy and practical counseling for 34 adolescents seeking smoking cessation in Los Angeles. Dependent outcomes were study retention, use of the patch, and 7-day quit status at the end-of-study and at follow-up visits. Predictors of outcomes included cigarette dependence, withdrawal symptoms, demographic and psychiatric measures, and other substance use. Variables significant in bivariate analysis (p < .10) were retained in a multivariate model. Subjects had significant pre-to-post reductions in quit rates, dependence, and withdrawal symptoms. Subjects also reported a high number of comorbidities. Implications for clinicians are discussed.

Smoking cessation in community pharmacy practice-a clinical information needs analysis

Background

With the emerging role of pharmacists in implementing smoking cessation services and the recent evidence about smoking cessation pharmacotherapies, a needs analysis to assess baseline knowledge about current smoking cessation practice is needed; hence, training and development in this area can target possible ‘gaps’.

Objective

This study aimed at exploring pharmacy students’ knowledge about and attitudes toward smoking cessation, as compared to practicing community pharmacists and smoking cessation educators. The overall objective was to uncover underlying ‘gaps’ in pharmacy-based smoking cessation practice, particularly clinical gaps.

Setting

Final-year pharmacy students at the University of Sydney, practicing community pharmacists and smoking cessation educators in Australia.

Method

As no previous standard pharmacist-focused smoking cessation knowledge questionnaires exist, a review of the literature informed the development of such a questionnaire. The questionnaire was administered to a cohort of fourth-year pharmacy students at the University of Sydney, practicing pharmacists and smoking cessation educators. Data analysis was performed using Predictive Analytics SoftWare (PASW® Statistics 18). Mean total scores, independent t-tests, analysis of variances and exploratory factor analysis were performed.

Main outcome measure

To determine areas of major clinical deficits about current evidence related to smoking cessation interventions at the pharmacy level.

Results

Responses from 250 students, 51 pharmacists and 20 educators were obtained. Smoking educators scored significantly higher than pharmacists and students (P < .05), while score differences in the latter two groups were not statistically significant (P > .05). All groups scored high on ‘general’ knowledge questions as compared to specialised pharmacologic and pharmacotherapeutic questions. All respondents demonstrated positive attitudes toward the implications of smoking cessation. Factor analysis of the 24-item knowledge section extracted 12 items loading on 5 factors accounting for 53% of the total variance.

Conclusions

The results provide a valid indication of ‘gaps’ in the practice of up-to-date smoking cessation services among Australian pharmacy professionals, particularly in clinical expertise areas involving assessment of nicotine dependence and indications, dosages, adverse effects, contraindications, drug interactions and combinations of available pharmacotherapies. These gaps should be addressed, and the results should inform the design, implementation and evaluation of a pharmacy-based educational training program targeting current clinical issues in smoking cessation.

Short-term efficacy of nicotine replacement therapy for smoking cessation in adolescents: a randomized controlled trial

The aim of this randomized, double-blind placebo-controlled clinical trial is to test the efficacy and safety of nicotine replacement therapy (NRT) in promoting end-of-treatment abstinence among adolescents and whether this relation is moderated by medication compliance. Participants (N=257, age: 16.7±1.13 years) attended an information meeting followed by a 6- or 9-week treatment. Self-reported smoking cessation, compliance, and side effects were measured by means of online questionnaires. Intent-to-treat analyses showed that independent of compliance, NRT is effective in promoting abstinence rates after 2 weeks (OR=2.02, 95% CI=1.11-3.69), but not end-of-treatment abstinence. However, end-of-treatment abstinence rates significantly increased in high-compliant (OR=1.09, 95% CI=1.01-1.17) and not in low-compliant participants. No serious adverse events were found. Future research is warranted to disentangle the process involving the decrease in abstinence rates and compliance rates from the third week after the quit date onwards.

Tobacco cessation interventions for young people

BACKGROUND

Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the second update of a Cochrane review first published in 2006.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register in February 2013. This includes reports for trials identified in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsyclNFO.

SELECTION CRITERIA

We included randomized controlled trials, cluster-randomized controlled trials and other controlled trials recruiting young people, aged less than 20, who were regular tobacco smokers. We included any interventions; these could include pharmacotherapy, psycho-social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months follow-up among those who smoked at baseline.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the eligibility of candidate trials and extracted data. Included studies were evaluated for risk of bias using standard Cochrane methodology. Where meta-analysis was appropriate, we estimated pooled risk ratios using a Mantel-Haenszel fixed-effect method, based on the quit rates at longest follow-up.

MAIN RESULTS

Twenty-eight trials involving approximately 6000 young people met our inclusion criteria (12 cluster-randomized controlled trials, 14 randomized controlled trials and 2 controlled trials). The majority of studies were judged to be at high or unclear risk of bias in at least one domain. Many studies combined components from various theoretical backgrounds to form complex interventions.The majority used some form of motivational enhancement combined with psychological support such as cognitive behavioural therapy (CBT) and some were tailored to stage of change using the transtheoretical model (TTM). Three trials based mainly on TTM interventions achieved moderate long-term success, with a pooled risk ratio (RR) of 1.56 at one year (95% confidence interval (CI) 1.21 to 2.01). The 12 trials that included some form of motivational enhancement gave an estimated RR of 1.60 (95% CI 1.28 to 2.01). None of the 13 individual trials of complex interventions that included cognitive behavioural therapy achieved statistically significant results, and results were not pooled due to clinical heterogeneity. There was a marginally significant effect of pooling six studies of the Not on Tobacco programme (RR of 1.31, 95% CI 1.01 to 1.71), although three of the trials used abstinence for as little as 24 hours at six months as the cessation outcome. A small trial testing nicotine replacement therapy did not detect a statistically significant effect. Two trials of bupropion, one testing two doses and one testing it as an adjunct to NRT, did not detect significant effects. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions.

AUTHORS' CONCLUSIONS

Complex approaches show promise, with some persistence of abstinence (30 days point prevalence abstinence or continuous abstinence at six months), especially those incorporating elements sensitive to stage of change and using motivational enhancement and CBT. Given the episodic nature of adolescent smoking, more data is needed on sustained quitting. There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers. There is not yet sufficient evidence to recommend widespread implementation of any one model. There continues to be a need for well-designed adequately powered randomized controlled trials of interventions for this population of smokers.

HIV-infected adolescent, young adult and pregnant smokers: important targets for effective tobacco control programs

Tobacco use is inextricably linked to a number of health risks both in the general and HIV-infected populations. There is, however, a dearth of research on effective tobacco control programs among people living with HIV, and especially among adolescents, young adults and pregnant women, groups with heightened or increased vulnerability secondary to tobacco use. Adolescents and young adults constitute a growing population of persons living with HIV infection. Early and continued tobacco use in this population living with a disease characterized by premature onset multimorbidity and chronic inflammation is of concern. Additionally, there is an increased acuity for tobacco control among HIV-infected pregnant women to reduce pregnancy morbidity and improve fetal outcome. This review will provide an important summary of current knowledge of tobacco use among HIV-infected adolescents, young adults and pregnant women. The effects of tobacco use in these specific populations will be presented and the current state of tobacco control within these populations, assessed.

Nicotine replacement therapy for smoking cessation

BACKGROUND

The aim of nicotine replacement therapy (NRT) is 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

The aims of this review were: To determine the effect of NRT compared to placebo in aiding smoking cessation, and to consider whether there is a difference in effect for the different forms of NRT (chewing gum, transdermal patches, oral and nasal sprays, inhalers and tablets/lozenges) in achieving abstinence from cigarettes. To determine whether the effect is influenced by the dosage, form and timing of use of NRT; the intensity of additional advice and support offered to the smoker; or the clinical setting in which the smoker is recruited and treated. To determine whether combinations of NRT are more likely to lead to successful quitting than one type alone. To determine whether NRT is more or less likely to lead to successful quitting compared to other pharmacotherapies.

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 July 2012.

SELECTION CRITERIA

Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. 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 150 trials; 117 with over 50,000 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The risk ratio (RR) of abstinence for any form of NRT relative to control was 1.60 (95% confidence interval [CI] 1.53 to 1.68). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 55 trials) for nicotine gum; 1.64 (95% CI 1.52 to 1.78, 43 trials) for nicotine patch; 1.95 (95% CI 1.61 to 2.36, 6 trials) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials) for nicotine inhaler; and 2.02 (95% CI 1.49 to 2.73, 4 trials) for nicotine nasal spray. One trial of oral spray had an RR of 2.48 (95% CI 1.24 to 4.94). The effects were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. The effect was similar in a small group of studies that aimed to assess use of NRT obtained without a prescription. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum, but weaker evidence of a benefit from higher doses of patch. There was evidence that combining a nicotine patch with a rapid delivery form of NRT was more effective than a single type of NRT (RR 1.34, 95% CI 1.18 to 1.51, 9 trials). The RR for NRT used for a short period prior to the quit date was 1.18 (95% CI 0.98 to 1.40, 8 trials), just missing statistical significance, though the efficacy increased when we pooled only patch trials and when we removed one trial in which confounding was likely. Five studies directly compared NRT to a non-nicotine pharmacotherapy, bupropion; there was no evidence of a difference in efficacy (RR 1.01; 95% CI 0.87 to 1.18). A combination of NRT and bupropion was more effective than bupropion alone (RR 1.24; 95% CI 1.06 to 1.45, 4 trials). Adverse effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. There is no evidence that NRT increases the risk of heart attacks.

AUTHORS' CONCLUSIONS

All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler 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 70%, regardless of setting. The 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.

The use of financial incentives in promoting smoking cessation

OBJECTIVE

Cigarette smoking is the leading cause of preventable death in the United States and world. Despite the availability of numerous therapies for smoking cessation, additional efficacious interventions are greatly needed. We provide a narrative review of published studies evaluating financial incentives for smoking cessation and discuss the parameters important for ensuring the efficacy of incentive interventions for smoking cessation.

METHODS

Published studies that evaluated the impact of incentives to promote smoking cessation and included an appropriate control or comparison condition were identified and reviewed.

RESULTS

Incentives are efficacious for promoting smoking abstinence across the general population of smokers as well as substance abusers, adolescents, patients with pulmonary disease, patients with serious mental illness and other challenging subgroups. To develop and implement an effective incentive treatment for smoking, special attention should be paid to biochemical verification of smoking status, incentive magnitude and the schedule of incentive delivery.

CONCLUSION

Consistent with the extensive literature showing that incentives are effective in reducing illicit drug use, a large body of evidence supports their effectiveness in reducing smoking. Continued efforts are warranted to further develop and disseminate incentive-based treatments for smoking cessation across clinical settings and populations.

Efficacy and tolerability of pharmacotherapies to aid smoking cessation in adolescents

Adolescent smoking remains a public health problem. Despite concerns regarding adolescent nicotine dependence, few well-designed smoking cessation studies have been conducted with teen smokers. This is particularly true regarding pharmacologic treatments for nicotine dependence. Currently, pharmacologic aids are not recommended for treating adolescent nicotine dependence, as efficacy has not been shown in this population. This review includes studies that have examined the efficacy of pharmacotherapy for smoking abstinence and/or reduction in cigarette consumption among adolescent smokers who want to quit smoking, laboratory-based adolescent studies that have examined the efficacy of these medications in reducing cravings and/or withdrawal symptoms, and/or studies that have assessed the tolerability of medications for smoking cessation in adolescent smokers. It provides information on the pharmacologic action of each medication, the efficacy of each medication for adolescent smoking cessation, the tolerability of each medication based on reported adverse events, and compliance with the medication protocols. Thirteen relevant articles were identified and included in the review. Nicotine patch (NP), nicotine gum, nicotine nasal spray, bupropion, and varenicline have been studied in adolescent smokers. The adverse events reported in the studies on pharmacology for adolescent smoking suggest that the side effect profiles for nicotine replacement therapy, bupropion, and varenicline are similar to those reported in adult studies. There is some evidence of efficacy of NP and bupropion at the end of treatment (efficacy of varenicline has not been assessed), but none of the medications included in this review were efficacious in promoting long-term smoking cessation among adolescent smokers. It is noted that many of the study protocols did not follow the recommended dose or length of pharmacotherapy for adults, rendering it difficult to determine the true efficacy of medication for adolescent smoking cessation. Future efficacy studies are warranted before recommending pharmacotherapy for adolescent smoking cessation.

Varenicline versus bupropion XL for smoking cessation in older adolescents: a randomized, double-blind pilot trial

INTRODUCTION

Despite tremendous potential public health impact, little work has focused on development of evidence-based smoking cessation treatments for adolescents, including pharmacotherapies. No prior studies have explored the feasibility and safety of varenicline and bupropion XL, 2 potentially promising pharmacotherapies, as smoking cessation treatments in adolescents.

METHODS

Treatment-seeking older adolescent smokers (ages 15-20) were randomized (double-blind) to varenicline (n = 15) or bupropion XL (n = 14), with 1-week titration and active treatment for 7 weeks. Structured safety, tolerability, and efficacy assessments (cotinine-confirmed 7-day point prevalence abstinence) were conducted weekly.

RESULTS

There were no serious adverse events. Two participants discontinued bupropion XL due to adverse effects, and none discontinued varenicline. Over the course of treatment, participants receiving varenicline reduced from 14.1 ± 6.3 (mean ± SD) to 0.9 ± 2.1 cigarettes/day (CPD, 4 achieved abstinence), while those receiving bupropion XL reduced from 15.8 ± 4.4 to 3.1 ± 4.0 CPD (2 achieved abstinence).

CONCLUSIONS

These preliminary results support the feasibility and safety of conducting adequately powered, placebo-controlled efficacy studies of varenicline and bupropion XL for adolescent smoking cessation.

Contingency management in the 21st century: technological innovations to promote smoking cessation

Information technology represents an excellent medium to deliver contingencies of reinforcement to change behavior. Recently, we have linked the Internet with a science-based, behavioral treatment for cigarette smoking: abstinence reinforcement therapy. Under abstinence reinforcement interventions, incentives are provided for objective evidence of abstinence. Several studies suggest that the intervention is effective in initiating abstinence. The intervention addresses limitations (access, cost, sustainability, and dissemination potential) inherent in traditional abstinence reinforcement delivery models. It can also be applied to vulnerable, at-risk populations, and to other behavior to promote health. Information technologies offer unprecedented and rapidly expanding opportunities to facilitate behavior change.

Nicotine withdrawal produces a decrease in extracellular levels of dopamine in the nucleus accumbens that is lower in adolescent versus adult male rats

The behavioral effects of nicotine withdrawal are lower in adolescent versus adult rats. However, the neurochemical mechanisms that mediate these developmental differences are unknown. Previous studies have shown that extracellular levels of dopamine in the nucleus accumbens (NAcc) are reduced in adult rats experiencing withdrawal. This study compared dopamine levels in the NAcc of male adolescent and adult rats experiencing nicotine withdrawal. Animals were prepared with subcutaneous pumps that delivered an equivalent nicotine dose in these age groups. Following 13 days of nicotine exposure, rats were implanted unilaterally with microdialysis probes into the NAcc and ipsilateral ventral tegmental area (VTA). The next day, dialysate levels were collected following systemic administration of the nicotinic-receptor antagonist mecamylamine to precipitate withdrawal. Mecamylamine produced an average % decrease in NAcc dopamine that was lower in adolescents (20%) versus adults (44%). Similar developmental differences were observed with the dopaminergic (DOPAC and HVA) but not serotonergic (5-HIAA) metabolites. A follow-up study compared NAcc dopamine in adolescent and adult rats receiving intra-VTA administration of bicuculline, which reduces gamma-aminobutyric acid (GABA) inhibition of dopamine transmission. The results revealed that blockade of GABA(A) receptors in the VTA produced a two-fold increase in NAcc dopamine of adults but not adolescents. These results provide a potential mechanism involving dopamine that mediates developmental differences in nicotine withdrawal. Specifically, they suggest that GABA systems are underdeveloped during adolescence and this reduced inhibition of dopamine neurons in the VTA may lead to reduced decreases in NAcc dopamine of young animals experiencing withdrawal.

Smoking Cessation Treatment for Adolescents

Cigarette smoking in the adolescent population remains a public health concern. A significant portion of the adolescent population currently uses tobacco. Nicotine is particularly addicting in adolescents, and quitting is difficult. The goals for adolescent cigarette smoking efforts must include both primary prevention and smoking cessation. Bupropion and nicotine replacement therapies—including nicotine patches, gum, and nasal spray—have been studied to a limited extent in the adolescent population. Varenicline has not been evaluated as a treatment modality in adolescents. Long-term quit rates in the pharmacotherapy trials have not been optimal; however, decreases in cigarettes smoked per day have been observed. Several evidencebased guidelines include recommendations for smoking cessation in adolescents that include counseling and pharmacotherapy. Pharmacotherapy may be instituted for some adolescents in addition to counseling and behavioral interventions. Therapy should be individualized, based on smoking patterns, patient preferences, and concomitant disease states. Smoking cessation support for parents should be instituted as well. The pharmacist can play a large role in helping the adolescent quit smoking. Further studies evaluating pharmacotherapy options for smoking cessation in adolescents are necessary. If pharmacotherapy is used, it should be individualized and combined with psychosocial and behavioral interventions.

A unified framework for addiction: vulnerabilities in the decision process

The understanding of decision-making systems has come together in recent years to form a unified theory of decision-making in the mammalian brain as arising from multiple, interacting systems (a planning system, a habit system, and a situation-recognition system). This unified decision-making system has multiple potential access points through which it can be driven to make maladaptive choices, particularly choices that entail seeking of certain drugs or behaviors. We identify 10 key vulnerabilities in the system: (1) moving away from homeostasis, (2) changing allostatic set points, (3) euphorigenic "reward-like" signals, (4) overvaluation in the planning system, (5) incorrect search of situation-action-outcome relationships, (6) misclassification of situations, (7) overvaluation in the habit system, (8) a mismatch in the balance of the two decision systems, (9) over-fast discounting processes, and (10) changed learning rates. These vulnerabilities provide a taxonomy of potential problems with decision-making systems. Although each vulnerability can drive an agent to return to the addictive choice, each vulnerability also implies a characteristic symptomology. Different drugs, different behaviors, and different individuals are likely to access different vulnerabilities. This has implications for an individual's susceptibility to addiction and the transition to addiction, for the potential for relapse, and for the potential for treatment.

Revue systématique d’essais comparatifs randomisés d’interventions d’abandon du tabac chez les jeunes

Contexte : Bien que l’usage de la cigarette demeure courant parmi les jeunes, on en sait encore bien peu sur la façon de les aider à cesser de fumer. Seulement quelques revues systématiques d’essais comparatifs randomisés (ECR) ont évalué l’efficacité des interventions d’abandon du tabac chez les jeunes.

Objectif : Résumer les connaissances sur l’efficacité des interventions visant à aider les jeunes à cesser de fumer en se basant sur des données probantes provenant d’ECR.

Sélection des études et extraction des données : Nous avons retenu tous les ECR publiés qui évaluaient les interventions d’abandon du tabac ciblant les jeunes âgés de 20 ans et moins et qui rapportaient l’abstinence au tabac selon une analyse en intention de traiter. Nous avons relevé les études pertinentes provenant de huit revues de synthèse décrivant des études portant sur des interventions d’abandon du tabac publiées entre 2002 et 2006, ainsi qu’une recherche menée dans les bases de données PubMed et PsycINFO entre 2001 et novembre  2006. Nous rapportons l’abstinence au tabagisme au moment du suivi le plus prolongé. Les auteurs ont sélectionné d’un commun accord les données retenues pour cette revue.

Résultats : Nous avons identifié 16 ECR auxquels ont participé 6 623 jeunes ; 11 études évaluant des interventions comportementales qui comprenaient 5 764 participants; quatre examinant des interventions pharmacologiques qui comptaient 529 participants ; et une se penchant sur l’acupuncture au laser qui comportait 330 participants. Trois interventions comportementales menées en milieu scolaire sur quatre et une intervention réalisée en milieu de soins de santé sur quatre ont fait augmenter de façon significative l’abstinence au tabac, quatre semaines à 24 mois suivant les interventions. Parmi les quatre ERC qui évaluaient les interventions pharmacologiques réalisées à l’aide soit de bupropion, de timbres ou de gommes à la nicotine, une étude, où le timbre à la nicotine a été utilisé en combinaison avec un counseling cognitivo-comportemental, a montré une hausse marquée, quoique non significative, de l’abstinence six mois après la date d’abandon.

Conclusion : Il existe encore peu de preuves démontrant l’efficacité des interventions d’abandon du tabac chez les jeunes. Quatre programmes en milieu scolaire et une intervention dans un établissement de santé ont mis en évidence une certaine efficacité, tandis que pour la thérapie pharmacologique, les résultats ne sont pas encore concluants.

Nicotine replacement therapy for smoking cessation

BACKGROUND

The aim of nicotine replacement therapy (NRT) is temporarily to 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

The aims of this review were:To determine the effect of NRT compared to placebo in aiding smoking cessation, and to consider whether there is a difference in effect for the different forms of NRT (chewing gum, transdermal patches, nasal spray, inhalers and tablets/lozenges) in achieving abstinence from cigarettes. To determine whether the effect is influenced by the dosage, form and timing of use of NRT; the intensity of additional advice and support offered to the smoker; or the clinical setting in which the smoker is recruited and treated. To determine whether combinations of NRT are more likely to lead to successful quitting than one type alone. To determine whether NRT is more or less likely to lead to successful quitting compared to other pharmacotherapies.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for papers with 'nicotine' or 'NRT' in the title, abstract or keywords. Date of most recent search July 2007.

SELECTION CRITERIA

Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow up of less than six months.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow up. 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 132 trials; 111 with over 40,000 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The RR of abstinence for any form of NRT relative to control was 1.58 (95% confidence interval [CI]: 1.50 to 1.66). The pooled RR for each type were 1.43 (95% CI: 1.33 to 1.53, 53 trials) for nicotine gum; 1.66 (95% CI: 1.53 to 1.81, 41 trials) for nicotine patch; 1.90 (95% CI: 1.36 to 2.67, 4 trials) for nicotine inhaler; 2.00 (95% CI: 1.63 to 2.45, 6 trials) for oral tablets/lozenges; and 2.02 (95% CI: 1.49 to 3.73, 4 trials) for nicotine nasal spray. The effects were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. The effect was similar in a small group of studies that aimed to assess use of NRT obtained without a prescription. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum, but weaker evidence of a benefit from higher doses of patch. There was evidence that combining a nicotine patch with a rapid delivery form of NRT was more effective than a single type of NRT. Only one study directly compared NRT to another pharmacotherapy. In this study quit rates with nicotine patch were lower than with the antidepressant bupropion.

AUTHORS' CONCLUSIONS

All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler 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 50-70%, regardless of setting. The 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.

Caractéristiques des adolescents fumeurs s'adressant aux consultations de tabacologie

In France, the prevalence of tobacco consumption is 31% for teenagers between 15 and 19 years old. Nevertheless, few French studies have been published on the characteristics of young smokers seeking smoking cessation services. The development of smoking cessation centres in France since 1999 was associated to the setting up of a e-transfer system in order to evaluate the adequacy between these services and the needs of smokers.

OBJECTIVE

To analyse the characteristics of smokers aged less than 19 years registered in the smoking cessation services national database.

METHODS

A cross-sectional population-based study has been conducted in the smoking cessation services participating in the national database. The study population included 321 young smokers attending the smoking cessation centres during the period 2001-2005.

RESULTS

The 321 smokers (mean age 16.6 years) were mostly girls (56.4%). A background of depression was declared by 19% of young smokers and an abnormal result was found for the hospital anxiety depression-screening test among 34% of the population for the anxiety scale and 6% for the depression scale. Mean daily tobacco consumption was 15.3 cigarettes per day and heavy nicotine dependence was found for 24.1% of the population. A nicotine replacement therapy was prescribed for every smoker.

CONCLUSION

Nicotine dependence was heavy for 24.1% of the 321 young smokers seeking smoking cessation services. More than 1/3 had an abnormal result for the hospital anxiety depression-screening test. Tailored interventions for smoking cessation should be available for adolescent's smokers, especially school-based services.

Getting it right: designing adolescent-centred smoking cessation services

AIMS

To demonstrate the importance of identifying adolescent preferences for smoking cessation in order to inform the design of effective adolescent cessation services.

DESIGN

Structured qualitative interviews drawing on means-end theory.

SETTING

Three youth-clubs and two secondary schools in south-east Wales.

PARTICIPANTS

Twenty-five male and female 13-18-year-olds, mainly daily smokers.

FINDINGS

Interviewees did not assume immediately that a smoking cessation service is something that will be available to them, and therefore they initially encountered difficulties in identifying attributes of such support. With further prompting interviewees were able to express a preference for support attributes, but these were not attributes that traditionally form part of cessation provision. Their main preference was for support from friends and family, access to nicotine replacement therapy and non-school-based, flexible support and guidance.

CONCLUSION

The results re-emphasize the inadequacies of existing cessation provision for meeting adolescent preferences and suggest that developing more adolescent-appropriate support requires a reconceptualization of existing interventions, with service users situated at the core of intervention design. The study highlights a number of service development points for intervention planners including: rethinking the timing and location of provision; placing more emphasis on the selection of facilitators; harnessing support from friends and family; and rooting these developments in broader tobacco control strategies.

A randomized controlled trial of a smoking cessation intervention for pregnant adolescents

BACKGROUND

The smoking prevalence rate among pregnant adolescents has been estimated at 59-62%, and 60-80% of these adolescents continue to smoke throughout their pregnancies.

OBJECTIVES

The aim of this study was to evaluate the short- and long-term effects of smoking cessation strategies tailored to the pregnant adolescent to attain and maintain abstinence. The specific aim was to examine differences in short- and long-term smoking behaviors among three groups: Teen FreshStart (TFS), Teen FreshStart Plus Buddy (TFS-B), and Usual Care (UC) control.

METHODS

In this randomized controlled intervention study, a 3-group (TFS, TFS-B, and UC) by 3-occasion (baseline, 8 weeks postrandomization, and 1-year following study entry) design was used. The study included 142 pregnant adolescents who were aged 14 to 19 years. Both self-reported smoking status collected on the Smoking History Questionnaire and saliva cotinine levels were used to identify smoking behaviors.

RESULTS

There were no significant differences among the three treatment groups at baseline in terms of the racial distribution, age, gestational age, age of menses initiation, number in family household, number of family members who smoked, or tobacco use. A significant difference between the UC group and the TFS-B group (p = .010) was seen in smoking behaviors measured 8 weeks following treatment initiation. At 1 year following study entry, however, there were no differences between the groups in smoking behaviors.

DISCUSSION

The TFS-B intervention was more effective in attaining short-term smoking cessation in the pregnant adolescent than TFS or UC. Findings suggest that the peer-enhanced programming had a limited effect but could not sustain the participant beyond postpartum (1 year following study entry). Future studies should include relapse prevention to sustain smoking abstinence into the postpartum period.

Tobacco cessation interventions for young people

BACKGROUND

Teenage smoking prevalence is around 15% in developing countries (with wide variation from country to country), and around 26% in the UK and USA. Although most tobacco control programmes for adolescents are based around prevention of uptake, there are also a number of initiatives to help those who want to quit. Since those who do not smoke before the age of 20 are significantly less likely to start as adults, there is a strong case for programmes for young people that address both prevention and treatment.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, and the bibliographies of identified trials. We also searched the 'grey' literature (unpublished materials), and contacted authors and experts in the field where necessary.

SELECTION CRITERIA

Types of studies: Randomized controlled trials, cluster-randomized controlled trials and controlled trials.

TYPES OF PARTICIPANTS

Young people, aged less than 20, who are regular tobacco smokers. Types of interventions: The interventions ranged from simple ones such as pharmacotherapy, targeting individual young people, through complex programmes targeting people or organizations associated with young people (for example, their families or schools), or the community in which young people live. We included cessation programmes but excluded programmes primarily aimed at prevention of uptake. Types of outcome measures: The primary outcome was smoking status at six months follow up, among those who smoked at baseline. We report the definition of cessation used in each trial (e.g seven- or thirty-day point prevalence abstinence, or sustained or prolonged abstinence), and we preferred biochemically verified cessation when that measure was available.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the eligibility of candidate trials identified by the searches, and extracted data from them. We categorized included trials as being at low, medium or high risk of bias, based on concealment of allocation, blinding (where applicable) and the handling of attrition and losses to follow up. We conducted limited meta-analyses of some of the trials, provided that it was appropriate to group them and provided that there was minimal heterogeneity between them. We estimated pooled odds ratios using the Mantel-Haenszel method, based on the quit rates at longest follow up for trials with at least six months follow up from the start of the intervention.

MAIN RESULTS

We found 15 trials, covering 3605 young people, which met our inclusion criteria (seven cluster-randomized controlled trials, six randomized controlled trials and two controlled trials). Three trials used or tested the transtheoretical model (stages of change) approach, two tested pharmacological aids to quitting (nicotine replacement and bupropion), and the remaining trials used various psycho-social interventions, such as motivational enhancement or behavioural management. The trials evaluating TTM interventions achieved moderate long-term success, with a pooled odds ratio (OR) at one year of 1.70 ( 95% confidence interval (CI) 1.25 to 2.33) persisting at two-year follow up with an OR of 1.38 (95% CI 0.99 to 1.92). Neither of the pharmacological intervention trials achieved statistically significant results (data not pooled), but both were small-scale, with low power to detect an effect. The three interventions (5 trials) which used cognitive behavioural therapy interventions did not individually achieve statistically significant results, although when the three Not on Tobacco trials were pooled the OR 1.87; (95% CI 1.00 to 3.50) suggested some measure of effectiveness. Although the three trials that incorporated motivational interviewing as a component of the intervention achieved a pooled OR of 2.05 (95% CI 1.10 to 3.80), the impossibility of isolating the effect of the motivational interviewing in these trials meant that we could not draw meaningful inferences from that analysis.

AUTHORS' CONCLUSIONS

Complex approaches show promise, with some persistence of abstinence (30 days point prevalence abstinence at six months), especially those incorporating elements sensitive to stage of change. There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers. Psycho-social interventions have not so far demonstrated effectiveness, although pooled results for the Not on Tobacco trials suggest that that this approach may yet prove to be effective; however, their definition of cessation (one or more smoke-free days) may not adequately account for the episodic nature of much adolescent smoking. There is a need for well-designed adequately powered randomized controlled trials for this population of smokers, with a minimum of six months follow up and rigorous definitions of cessation (sustained and biochemically verified). Attrition and losses to follow up are particularly problematic in trials for young smokers, and need to be kept to a minimum, so that management and interpretation of missing data need not compromise the findings.

Youth tobacco use: a global perspective for child health care clinicians

Tobacco dependence, responsible for approximately 4 million annual deaths worldwide, is considered to be a "pediatric disease." The smoking epidemic is spreading rapidly in developing countries. Factors contributing to youth smoking in developing countries include cultural traditions, tobacco's easy accessibility and moderate pricing, peer and family influences, and tobacco companies' advertisements and promotional activities. Secondhand tobacco smoke exposure is a substantial problem that causes increased rates of pneumonia, otitis media, asthma, and other short- and long-term pediatric conditions. Parental tobacco use results in children's deprivation of essential needs such as nutrition and education. In this article we review contemporary evidence with respect to the etiology of nicotine dependence among youth, the forms of youth tobacco products worldwide, global youth tobacco-control efforts to date, medical education efforts, and child health care clinicians' special role in youth tobacco-control strategies. In addition, we provide a review of currently available funding opportunities for development and implementation of youth tobacco-control programs.

Smoking rates and the state of smoking interventions for children and adolescents with chronic illness

Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

Tailoring nicotine replacement therapy: rationale and potential approaches

Nicotine replacement therapy (NRT) is an effective treatment for smoking cessation, but as with all such pharmacotherapies, the majority of smokers who use NRT products do not stop smoking or remain abstinent long term. Treatment outcome is affected by a range of individual-specific factors, as well as the pharmacokinetic profile of each NRT formulation. This has led to speculation that abstinence rates could be improved if NRT treatments were individually tailored to best match each individual's needs and preferences. There are also populations for whom special product and dosage considerations are warranted to maximise treatment safety.This paper reviews the rationale for NRT treatment, standard dose recommendations and recommendations for how to best match NRT treatment to the specific needs of individual smokers. We also review emerging evidence that genetic profiling may one day be a useful consideration for tailoring NRT treatment.

Youth smoking cessation: an update for primary care physicians

Tobacco use is a major public health problem, and onset usually begins in youth. This article reviews current knowledge and evidence of specific aspects of smoking in youth, tobacco control strategies, and smoking cessation interventions that target young people. Finally, it provides recommendations for primary care physicians.

Safety and efficacy of the nicotine patch and gum for the treatment of adolescent tobacco addiction

OBJECTIVES

To determine the safety and efficacy of the nicotine patch and gum for adolescents who want to quit smoking.

DESIGN

Double-blind, double-dummy, randomized, 3-arm trial with a nicotine patch (21 mg), nicotine gum (2 and 4 mg), or a placebo patch and gum; all participants received cognitive-behavioral group therapy.

SETTING

Inner-city, outpatient clinic on the East Coast. Subjects. Thirteen- to 17-year-old adolescents who smoked > or =10 cigarettes per day (CPD), scored > or =5 on the Fagerstrom Test of Nicotine Dependence, and were motivated to quit smoking. Intervention. Twelve weeks of nicotine patch or gum therapy with cognitive-behavioral therapy, with a follow-up visit at 6 months (3 months after the end of treatment).

MAIN OUTCOME MEASURES

Safety assessed on the basis of adverse event reports for all 3 groups, prolonged abstinence, assessed through self-report and verified with exhaled carbon monoxide (CO) levels of < or =6 ppm, in intent-to-treat analyses, and smoking reduction (CPD and thiocyanate concentrations) among trial completers.

RESULTS

A total of 120 participants were randomized (72% white, 70% female; age: 15.2 +/- 1.33 years; smoking: 18.8 +/- 8.56 CPD; Fagerstrom Test of Nicotine Dependence score: 7.04 +/- 1.29) from 1999 to 2003. Participants started smoking at 11.2 +/- 1.98 years of age and had been smoking daily for 2.66 +/- 1.56 years; 75% had at least 1 current psychiatric diagnosis. Mean compliance across groups was higher for the patch (mean: 78.4-82.8%) than for the gum (mean: 38.5-50.7%). Both the patch and gum were well tolerated, and adverse events were similar to those reported in adult trials. Changes in mean saliva cotinine concentrations throughout treatment were not statistically significant. Intent-to-treat analyses of all randomized participants showed CO-confirmed prolonged abstinence rates of 18% for the active-patch group, 6.5% for the active-gum group, and 2.5% for the placebo group; the difference between the active-patch and placebo arms was statistically significant. There was no significant effect of patch versus gum or gum versus placebo on cessation outcomes. Abstinence rates at the 3-month follow-up assessment were sustained but were not significantly associated with treatment group. Mean smoking rates, but not CO or thiocyanate concentrations, decreased significantly in all 3 arms but not as a function of treatment group.

CONCLUSIONS

Nicotine patch therapy combined with cognitive-behavioral intervention was effective, compared with placebo, for treatment of tobacco dependence among adolescent smokers. Decreases in the numbers of cigarettes smoked appeared to be offset by compensatory smoking. Additional study of nicotine gum, with enhanced instructional support, is needed to assess its efficacy among adolescent smokers.

Effects of smoking and smoking abstinence on cognition in adolescent tobacco smokers

BACKGROUND

In adult animals and humans, nicotine can produce short-term cognitive enhancement and, in some cases, neuroprotection. Recent work in animals, however, suggests that exposure to nicotine during adolescence might be neurotoxic. We tested for evidence of acute and chronic effects of tobacco smoking on cognition in adolescents who smoked tobacco daily and were compared with adolescent nonsmokers.

METHODS

Verbal working memory, verbal learning and memory, selective, divided, sustained attention, mood, symptoms of nicotine withdrawal, and tobacco craving were examined in 41 adolescent daily smokers and 32 nonsmokers who were similar in age, gender, and education. Analyses were controlled for general intelligence, reading achievement, parental educational attainment, baseline affective symptoms, and lifetime exposure to alcohol and cannabis.

RESULTS

In adolescent smokers, cessation of tobacco use increased tobacco craving, symptoms of nicotine withdrawal, and depressed mood. Adolescent smokers were found to have impairments in accuracy of working memory performance irrespective of recency of smoking. Performance decrements were more severe with earlier age of onset of smoking. Adolescent smokers experienced further disruption of working memory and verbal memory during smoking cessation. As a group, male smokers initiated smoking at an earlier age than female smokers and were significantly more impaired during tests of selective and divided attention than female smokers and nonsmokers.

CONCLUSIONS

Adolescent daily tobacco smokers experience acute impairments of verbal memory and working memory after smoking cessation, along with chronic decrements in cognitive performance that are consistent with preclinical evidence that neurotoxic effects of nicotine are more severe when exposure to nicotine occurs at earlier periods in development.

Recent marijuana blunt smoking impacts carbon monoxide as a measure of adolescent tobacco abstinence

Adolescent tobacco smokers have a higher prevalence of marijuana (MJ) smoking than adolescents who do not smoke tobacco. As part of an adolescent smoking cessation trial, we examined whether MJ smoking, and specifically "blunt" (gutted cigars filled with MJ) smoking, elevated participants' likelihood of a false indication of cigarette smoking on the basis of breath carbon monoxide (CO) testing. Using clinical data from 37 adolescents (mean age 15.1+/-1.4 years, 78% female) who participated in a smoking-cessation trial in Baltimore between 1999 and 2002, and who on at least one occasion, reported abstinence from tobacco smoking for at least 7 days, we analyzed 146 cigarette-abstinent-visit exhaled CO concentrations classified into blunt occasions (12 participants, 33 visits), nonblunt MJ occasions (seven participants, 20 visits), and non-MJ occasions (27 paricipants, 93 visits). Repeated-measures logistic regression revealed that blunt occasions were associated with CO > or = 8 ppm, compared to nonblunt occasions (p = 0.013). Blunt occasions also tended to be associated with the more youth-appropriate cutoff CO > or = 6 ppm, compared to non-MJ occasions (p =0.054). Blunt smoking impacted the interpretation of measures of exhaled CO for tobacco cessation.

Nicotine therapy in adulthood reverses the synaptic and behavioral deficits elicited by prenatal exposure to phenobarbital

A major objective in identifying the mechanisms underlying neurobehavioral teratogenicity is the possibility of designing therapies that reverse or offset drug- or toxicant-induced neural damage. In our previous studies, we identified deficits in hippocampal muscarinic cholinergic receptor-induced membrane translocation of protein kinase C (PKC)gamma as the likely mechanism responsible for adverse behavioral effects of prenatal phenobarbital exposure. We therefore explored whether behavioral and synaptic defects could be reversed in adulthood by nicotine administration. Pregnant mice were given milled food containing phenobarbital to achieve a daily dose of 0.5-0.6 g/kg from gestational days 9-18. In adulthood, offspring showed deficits in the Morris maze, a behavior dependent on the integrity of septohippocampal cholinergic synaptic function, along with the loss of the PKCgamma response. Phenobarbital-exposed and control mice then received nicotine (10 mg/kg/day) for 14 days via osmotic minipumps. Nicotine reversed the behavioral deficits and restored the normal response of hippocampal PKCgamma to cholinergic receptor stimulation. The effects were regionally specific, as PKCgamma in the cerebellum was unaffected by either phenobarbital or nicotine; furthermore, in the hippocampus, PKC isoforms unrelated to the behavioral deficits showed no changes. Nicotine administration thus offers a potential therapy for reversing neurobehavioral deficits originating in septohippocampal cholinergic defects elicited by prenatal drug or toxicant exposures.