Prevalence and Impact of Long-term Use of Nicotine Replacement Therapy in UK Stop-Smoking Services: Findings From the ELONS Study

Novel rapid-acting sublingual nicotine tablet as a cigarette substitution strategy

RATIONALE

Current nicotine replacement products provide a much slower onset of nicotine delivery than cigarettes, and hence are only marginally effective at supplanting cigarette smoking. Therefore, more effective forms of nicotine replacement are needed.

OBJECTIVES

This initial investigation characterized the pharmacokinetic (PK) and subjective effects of a novel sublingual (SL) nicotine tablet designed to deliver nicotine more rapidly to the bloodstream of smokers.

METHODS

Study 1 (N = 6) characterized the pharmacokinetics of a 2 mg nicotine SL tablet in comparison to an FDA-approved, marketed 2 mg nicotine lozenge. Study 2 (N = 24) assessed subjective responses of smokers to a single use of a 1 mg and 2 mg SL tablet.

RESULTS

Study 1 found that the time to maximum blood nicotine concentrations was significantly shorter for the SL tablet (14 min) than for the lozenge (82 min), and the initial rate of nicotine absorption was higher (0.4 ng/mL*min vs. 0.0 ng/mL*min), supporting the hypothesis that the SL tablet delivered nicotine more rapidly. Study 2 found that participants reported immediate relief of nicotine withdrawal symptoms after tablet administration, and craving reduction after the 2 mg tablet approached the degree reported for their usual brands of cigarettes (4.2 vs. 4.6 on a 7-point scale). Other subjective responses showed the tablet to be an appealing alternative to smoking.

CONCLUSIONS

The novel SL tablet studied shows promise as a nicotine substitution strategy for tobacco harm reduction and smoking cessation treatment. Additional studies are warranted to further investigate the potential of this new approach.

Extended Nicotine Patch Treatment Among Smokers With and Without Comorbid Psychopathology

INTRODUCTION

Individuals with psychiatric conditions smoke at higher rates than the general population and may need more intensive treatment to quit. We examined whether or not extended treatment with nicotine patch, combined with behavior counseling, would disproportionally benefit smokers with versus without a lifetime psychiatric condition.

METHODS

We conducted a secondary analysis of data from an effectiveness trial of treatment with 12 counseling sessions (48 weeks) and 21-mg nicotine patch (8, 24, or 52 weeks) among 525 adult daily smokers. A structured clinical interview assessed past and current psychiatric disorders (major depression, generalized anxiety disorder, alcohol abuse and/or dependence, and substance abuse and/or dependence), as described in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Abstinence was bioverified at week 52. Logistic regression evaluated the effect of the psychiatric status × treatment duration interaction on abstinence at week 52, covarying for sociodemographics, baseline psychological symptoms, and treatment adherence.

RESULTS

At baseline, 115 (21.9%) participants were diagnosed with one or more psychiatric conditions. The psychiatric status × treatment duration interaction was significant for week 52 abstinence (p = .027). Abstinence rates between smokers with versus without a psychiatric condition in the 24-week treatment arm (9.3% vs. 31.5% abstinent) significantly differed from the 8-week treatment arm (18.8% vs. 22.3%), p = .017. Abstinence rates for smokers with (22.5%) versus without a psychiatric condition (19.7%) in the 52-week treatment arm did not differ from those in the 8-week arm.

CONCLUSIONS

Targeted smoking cessation treatment, rather than extending treatment duration, may be especially warranted to optimize treatment for smokers with comorbid mood, anxiety, and substance use disorders.

IMPLICATIONS

Individuals with psychiatric conditions smoke at higher rates and have greater difficulty quitting compared to those in the general population, but little is known about how to best optimize treatment for this high tobacco burden population. The present study found that cessation response to extended duration treatment with the transdermal nicotine patch did not differ for smokers with versus without comorbid anxiety, mood, and substance use disorders in a large-scale clinical effectiveness trial. Development of targeted behavioral treatments may be required to optimize abstinence outcomes for this high-risk population, rather than simply extending the duration of pharmacotherapy treatments.

Indicators of cigarette smoking dependence and relapse in former smokers who vape compared with those who do not: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey

BACKGROUND AND AIMS

It has been proposed that many smokers switch to vaping because their nicotine addiction makes this their only viable route out of smoking. We compared indicators of prior and current cigarette smoking dependence and of relapse in former smokers who were daily users of nicotine vaping products ('vapers') or who were not vaping at the time of survey ('non-vapers').

DESIGN

Cross-sectional survey-based comparison between vaping and non-vaping former smokers, including a weighted logistic regression of vaping status onto predictor variables, adjusting for covariates specified below.

SETTING

United States, Canada, Australia and England.

PARTICIPANTS

A total of 1070 people aged 18+ years from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey who reported having ever been daily smokers but who stopped less than 2 years ago and who were currently vapers or non-vapers.

MEASUREMENTS

Dependent variable was current vaping status. Predictor variables were self-reported: (1) smoking within 5 minutes of waking and usual daily cigarette consumption, both assessed retrospectively; (2) current perceived addiction to smoking, urges to smoke and confidence in staying quit. Covariates: country, sample sources, sex, age group, ethnicity, income, education, current nicotine replacement therapy use and time since quitting.

FINDINGS

Vapers were more likely than non-vapers to report: (1) having smoked within 5 minutes of waking [34.3 versus 15.9%, adjusted odds ratio (aOR) = 3.74, 95% confidence interval (CI) = 1.99, 7.03), χ2  = 16.92, P < 0.001]; having smoked > 10 cigarettes/day (74.4 versus 47.2%, aOR = 4.39, 95% CI = 2.22, 8.68), χ2  = 18.18, P < 0.001); (2) perceiving themselves to be still very addicted to smoking (41.3 versus 26.2%, aOR = 2.89, 95% CI = 1.58, 5.30, χ2  = 11.87, P < 0.001) and feeling extremely confident about staying quit (62.1 versus 36.6%, aOR = 3.22, 95% CI = 1.86, 5.59, χ2  = 17.36, P < 0.001). Vapers were not more likely to report any urges to smoke than non-vapers (27.7 versus 38.8%, aOR = 0.86, 95% CI = 0.44, 1.65, χ2  = 0.21, P = 0.643).

CONCLUSIONS

While former smokers who currently vape nicotine daily report higher levels of cigarette smoking dependence pre- and post-cessation compared with former smokers who are current non-vapers, they report greater confidence in staying quit and similar strength of urges to smoke.

Does the nicotine metabolite ratio moderate smoking cessation treatment outcomes in real-world settings? A prospective study

BACKGROUND AND AIMS

In smoking treatment trials comparing varenicline with transdermal nicotine replacement therapy (NRT), stratified by nicotine metabolite (3-hydroxycotinine/cotinine) ratio (NMR), the relative benefit of varenicline is greater among normal rather than slow metabolizers. This study tested if the relative effectiveness of varenicline and NRT is associated with NMR status in a natural treatment setting. A secondary aim was to test if this relationship is moderated by behavioural support.

DESIGN

Prospective observational multi-centre study with 4-week and 52-week follow-up.

SETTING

Nine English Stop Smoking Services (SSS).

PARTICIPANTS

Data came from 1556 smokers (aged ≥ 16 years) attending SSS between March 2012 and March 2013.

INTERVENTIONS

Participants received pharmacotherapy together with behavioural support.

MEASUREMENTS

The primary outcome was carbon monoxide-verified continuous abstinence at both follow-up times. Main explanatory variables were (1) NMR status [slow (NMR < 0.31, n = 451) versus normal (NMR ≥ 0.31, n = 1105) metabolizers]; (2) pharmacotherapy (varenicline versus NRT) and (3) behavioural support (individual versus group-based treatment). Analyses adjusted for baseline socio-demographic, SSS, mental/physical health and smoking characteristics.

FINDINGS

Of participants, 44.2% [95% confidence interval (CI) = 41.7-46.6%] and 8.0% (95% CI = 6.8-9.5%) were continuously abstinent at 4 and 52 weeks. Varenicline was more effective than NRT at 4 weeks (P < 0.001) but only marginally so at 52 weeks (P = 0.061). There was no or inclusive evidence that NMR status moderated relative efficacy of varenicline and NRT at 4- [P = 0.60, Bayes factor (BF) = 0.25] or 52-week follow-ups (P = 0.74, BF = 0.73). However, this relationship was moderated by behavioural support (p = 0.012): the relative benefit of varenicline over NRT at 52-week follow-up was greater in slow, not normal, metabolizers receiving group rather than individual support (P = 0.012).

CONCLUSIONS

In a real-world setting, the nicotine metabolite ratio status of treatment-seeking smokers does not appear to contribute substantially to the differential effectiveness of varenicline and nicotine replacement therapy in Stop Smoking Services, when both pharmacotherapy and behavioural support are self-selected.

Maternal Nicotine Exposure Leads to Augmented Expression of the Antioxidant Adipose Tissue Triglyceride Lipase Long-Term in the White Adipose of Female Rat Offspring

Globally, approximately 10%-25% of women smoke during pregnancy. Since nicotine is highly addictive, women may use nicotine-containing products like nicotine replacement therapies for smoking cessation, but the long-term consequences of early life exposure to nicotine remain poorly defined. Our laboratory has previously demonstrated that maternal nicotine exposed (MNE) rat offspring exhibit hypertriglyceridemia due to increased hepatic de novo lipogenesis. Hypertriglyceridemia may also be attributed to impaired white adipose tissue (WAT) lipid storage; however, the effects of MNE on WAT are not completely understood. We hypothesize that nicotine-induced alterations in adipose function (eg, lipid storage) underlie dyslipidemia in MNE adults. Female 6-month-old rats exposed to nicotine during gestation and lactation exhibited significantly decreased visceral adipocyte cell area by 40%, attributed, in part, to a 3-fold increase in adipose triglyceride lipase (ATGL) protein expression compared with vehicle. Given ATGL has antioxidant properties and in utero nicotine exposure promotes oxidative stress in various tissues, we next investigated if there was evidence of increased oxidative stress in MNE WAT. At both 3 weeks and 6 months, MNE offspring expressed 37%-48% higher protein levels of superoxide dismutase-1 and -2 in WAT. Since oxidative stress can induce inflammation, we examined the inflammatory profile of WAT and found increased expression of cytokines (interleukin-1β, tumor necrosis factor α, and interleukin-6) by 44%-61% at 6 months. Collectively, this suggests that the expression of WAT ATGL may be induced to counter MNE-induced oxidative stress and inflammation. However, higher levels of ATGL would further promote lipolysis in WAT, culminating in impaired lipid storage and long-term dyslipidemia.

Characterising the nicotine metabolite ratio and its association with treatment choice: A cross sectional analysis of Stop Smoking Services in England

Pharmacotherapy provision based on Nicotine Metabolite Ratio (NMR) status (slow/normal metabolism) may improve smoking cessation rates. However, it is unclear whether NMR status is consistent across patient characteristics and current treatment choice. Data come from 1,826 participants attending Stop Smoking Services (SSS) across England in 2012/13. Sociodemographic, mental/physical health, smoking and treatment characteristics (nicotine replacement therapy vs. other pharmacotherapy; group vs. one-to-one behavioural support) were assessed. Salivary nicotine metabolites were measured and NMR (3-hydroxycotinine/cotinine) computed, characterising smokers as slow (NMR < 0.31) or normal (NMR ≥ 0.31) metabolisers. Normal metabolisers were older than slow metabolisers (Odds Ratio (OR) = 1.49, 95% Confidence Interval (CI) = 1.32-1.69) but no other characteristics were associated with NMR status. Overall, predictors accounted for only 7.3% of NMR variance. In adjusted analysis, pharmacotherapy type was not associated with NMR status, but normal metabolisers were less likely to use group support (OR = 0.67, 95% CI = 0.51-0.89). NMR status does not vary substantially across sociodemographic characteristics. Given its impact on pharmacotherapy efficacy, the lack of an association with pharmacotherapy choice suggests there is scope to use NMR status to optimise the selection and efficacy of smoking cessation pharmacotherapy. The unexpected association of NMR status with behavioural support should be explored further.

An appraisal of practice guidelines for smoking cessation in people with severe mental illness

OBJECTIVE

To review the quality of current smoking cessation guidelines that include recommendations for people with severe mental illness.

METHODS

A systematic search of scientific databases, central government health authority websites, psychiatry peak bodies, guideline clearing houses and Google was undertaken for relevant smoking cessation guidelines. Three reviewers independently assessed guideline quality using the AGREE II (Appraisal of Guidelines for REsearch and Evaluation II) instrument. Two reviewers extracted recommendations specific to smokers with severe mental illness.

RESULTS

Thirteen guidelines met the inclusion criteria. Seven guidelines scored ⩾60% in at least four domains. Median scores for 'Editorial independence', 'Rigour of development', 'Stakeholder Involvement' and 'Applicability' were less than 60%. The highest median scores were for 'Scope and purpose' (87%, 69-96%) and 'Clarity of presentation' (87%, 56-98%). 'Editorial independence' (33.3%, 0-86%) and 'Rigour of development' (54%, 11-92%) had the lowest median domain scores. The guidelines varied greatly in their recommendations but the majority recommended nicotine replacement therapy, bupropion or varenicline as first-line pharmacotherapy, along with behavioural support.

CONCLUSION

Many guidelines did not adequately report their methods or the competing interests of the authors. Future guidelines development may benefit from more specifically addressing AGREE II criteria and the needs of smokers with severe mental illness.

Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study

BACKGROUND

Given the rapid increase in the popularity of e-cigarettes and the paucity of associated longitudinal health-related data, the need to assess the potential risks of long-term use is essential.

OBJECTIVE

To compare exposure to nicotine, tobacco-related carcinogens, and toxins among smokers of combustible cigarettes only, former smokers with long-term e-cigarette use only, former smokers with long-term nicotine replacement therapy (NRT) use only, long-term dual users of both combustible cigarettes and e-cigarettes, and long-term users of both combustible cigarettes and NRT.

DESIGN

Cross-sectional study.

SETTING

United Kingdom.

PARTICIPANTS

The following 5 groups were purposively recruited: combustible cigarette-only users, former smokers with long-term (≥6 months) e-cigarette-only or NRT-only use, and long-term dual combustible cigarette-e-cigarette or combustible cigarette-NRT users (n = 36 to 37 per group; total n = 181).

MEASUREMENTS

Sociodemographic and smoking characteristics were assessed. Participants provided urine and saliva samples and were analyzed for biomarkers of nicotine, tobacco-specific N-nitrosamines (TSNAs), and volatile organic compounds (VOCs).

RESULTS

After confounders were controlled for, no clear between-group differences in salivary or urinary biomarkers of nicotine intake were found. The e-cigarette-only and NRT-only users had significantly lower metabolite levels for TSNAs (including the carcinogenic metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) and VOCs (including metabolites of the toxins acrolein; acrylamide; acrylonitrile; 1,3-butadiene; and ethylene oxide) than combustible cigarette-only, dual combustible cigarette-e-cigarette, or dual combustible cigarette-NRT users. The e-cigarette-only users had significantly lower NNAL levels than all other groups. Combustible cigarette-only, dual combustible cigarette-NRT, and dual combustible cigarette-e-cigarette users had largely similar levels of TSNA and VOC metabolites.

LIMITATION

Cross-sectional design with self-selected sample.

CONCLUSION

Former smokers with long-term e-cigarette-only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette-only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.

PRIMARY FUNDING SOURCE

Cancer Research UK.