Randomised trial of two nicotine patch protocols distributed through a state quitline

Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes. This helps to reduce cravings and withdrawal symptoms, and ease the transition from cigarette smoking to complete abstinence. Although there is high-certainty evidence that NRT is effective for achieving long-term smoking abstinence, it is unclear whether different forms, doses, durations of treatment or timing of use impacts its effects.

OBJECTIVES

To determine the effectiveness and safety of different forms, deliveries, doses, durations and schedules of NRT, for achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning NRT in the title, abstract or keywords, most recently in April 2022.

SELECTION CRITERIA

We included randomised trials in people motivated to quit, comparing one type of NRT use with another. We excluded studies that did not assess cessation as an outcome, with follow-up of fewer than six months, and with additional intervention components not matched between arms. Separate reviews cover studies comparing NRT to control, or to other pharmacotherapies.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. We measured smoking abstinence after at least six months, using the most rigorous definition available. We extracted data on cardiac adverse events (AEs), serious adverse events (SAEs) and study withdrawals due to treatment.  MAIN RESULTS: We identified 68 completed studies with 43,327 participants, five of which are new to this update. Most completed studies recruited adults either from the community or from healthcare clinics. We judged 28 of the 68 studies to be at high risk of bias. Restricting the analysis only to those studies at low or unclear risk of bias did not significantly alter results for any comparisons apart from the preloading comparison, which tested the effect of using NRT prior to quit day whilst still smoking.  There is high-certainty evidence that combination NRT (fast-acting form plus patch) results in higher long-term quit rates than single form (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.17 to 1.37; I2 = 12%; 16 studies, 12,169 participants). Moderate-certainty evidence, limited by imprecision, indicates that 42/44 mg patches are as effective as 21/22 mg (24-hour) patches (RR 1.09, 95% CI 0.93 to 1.29; I2 = 38%; 5 studies, 1655 participants), and that 21 mg patches are more effective than 14 mg (24-hour) patches (RR 1.48, 95% CI 1.06 to 2.08; 1 study, 537 participants). Moderate-certainty evidence, again limited by imprecision, also suggests a benefit of 25 mg over 15 mg (16-hour) patches, but the lower limit of the CI encompassed no difference (RR 1.19, 95% CI 1.00 to 1.41; I2 = 0%; 3 studies, 3446 participants). Nine studies tested the effect of using NRT prior to quit day (preloading) in comparison to using it from quit day onward. There was moderate-certainty evidence, limited by risk of bias, of a favourable effect of preloading on abstinence (RR 1.25, 95% CI 1.08 to 1.44; I2 = 0%; 9 studies, 4395 participants). High-certainty evidence from eight studies suggests that using either a form of fast-acting NRT or a nicotine patch results in similar long-term quit rates (RR 0.90, 95% CI 0.77 to 1.05; I2 = 0%; 8 studies, 3319 participants). We found no clear evidence of an effect of duration of nicotine patch use (low-certainty evidence); duration of combination NRT use (low- and very low-certainty evidence); or fast-acting NRT type (very low-certainty evidence). Cardiac AEs, SAEs and withdrawals due to treatment were all measured variably and infrequently across studies, resulting in low- or very low-certainty evidence for all comparisons. Most comparisons found no clear evidence of an effect on these outcomes, and rates were low overall. More withdrawals due to treatment were reported in people using nasal spray compared to patches in one study (RR 3.47, 95% CI 1.15 to 10.46; 1 study, 922 participants; very low-certainty evidence) and in people using 42/44 mg patches in comparison to 21/22 mg patches across two studies (RR 4.99, 95% CI 1.60 to 15.50; I2 = 0%; 2 studies, 544 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that using combination NRT versus single-form NRT and 4 mg versus 2 mg nicotine gum can result in an increase in the chances of successfully stopping smoking. Due to imprecision, evidence was of moderate certainty for patch dose comparisons. There is some indication that the lower-dose nicotine patches and gum may be less effective than higher-dose products. Using a fast-acting form of NRT, such as gum or lozenge, resulted in similar quit rates to nicotine patches. There is moderate-certainty evidence that using NRT before quitting may improve quit rates versus using it from quit date only; however, further research is needed to ensure the robustness of this finding. Evidence for the comparative safety and tolerability of different types of NRT use is limited. New studies should ensure that AEs, SAEs and withdrawals due to treatment are reported.

Free, easy and effective: how young adults used 8 weeks of mailed nicotine patches and to what effect

Introduction

Research shows the mass distribution of free nicotine replacement therapy (NRT) is a high-impact, population-level strategy for smoking cessation; but underrepresentation of younger, and/or lighter, smokers challenges generalisability of findings to young adult smokers.

Aims

This naturalistic study examined how and with what effect young adult smokers used free nicotine patches provided through a mass mailout programme.

Methods

In total, 5,025 eligible 18–29 year-old smokers who accessed an online ordering platform received self-help materials and an 8-week course of patches matched to their consumption level (<10 cigarettes per day (cpd); ≥10 cpd). No other behavioural support occurred. Whether participants used patches correctly and achieved 30-day continuous abstinence at 6-month follow-up were assessed.

Results

Among 694 participants with complete data: 89% used some patches; 8% used the patches correctly for 8 weeks; 31.0% (95% confidence interval (CI) = 27.6, 34.7) achieved abstinence. Adjusted logistic regression analysis showed the highest odds of abstinence was associated with the correct use of patches (odds ratio = 2.8, 95% CI = 1.5, 5.1).

Conclusions

Mass distribution of free patches may be an effective public health measure for supporting younger, lighter smokers to attempt cessation, reduce consumption, or achieve abstinence. Emphasising why and how to use NRT for the entire treatment course may enhance outcomes.

Cost-Effectiveness of Community-Based Tobacco Dependence Treatment Interventions: Initial Findings of a Systematic Review

Introduction

Scientific literature evaluating the cost-effectiveness of tobacco dependence treatment programs delivered in community-based settings is scant, which limits evidence-based tobacco control decisions. The aim of this review was to systematically assess the cost-effectiveness and quality of the economic evaluations of community-based tobacco dependence treatment interventions conducted as randomized controlled trials in the United States.

Methods

We searched 8 electronic databases and gray literature from their beginning to February 2018. Inclusion criteria were economic evaluations of community-based tobacco dependence treatments conducted as randomized controlled trials in the United States. Two independent researchers extracted data on study design and outcomes. Study quality was assessed by using Drummond and Jefferson’s economic evaluations checklist. Nine of 3,840 publications were eligible for inclusion. Heterogeneity precluded formal meta-analyses. We synthesized a qualitative narrative of outcomes.

Results

All 9 studies used cost-effectiveness analysis and a payer/provider/program perspective, but several study components, such as abstinence measures, were heterogeneous. Study participants were predominantly English speaking, middle aged, white, motivated to quit, and highly nicotine dependent. Overall, the economic evaluations met most of Drummond and Jefferson’s recommendations; however, some studies provided limited details. All studies had a cost per quit at or below $2,040 or an incremental cost-effectiveness ratio (ICER) at or below $3,781. When we considered biochemical verification, sensitivity analysis, and subgroups, the costs per quit were less than $2,050 or the ICERs were less than $6,800.

Conclusion

All community-based interventions included in this review were cost-effective. When economic evaluation results are extrapolated to future savings, the low cost per quit or ICER indicates that the cost-effectiveness of community-based tobacco dependence treatments is similar to the cost-effectiveness of clinic-based programs and that community-based interventions are a valuable approach to tobacco control. Additional research that more fully characterizes the cost-effectiveness of community-based tobacco dependence treatments is needed to inform future decisions in tobacco control policy.

Smoking cessation interventions for potential use in the lung cancer screening setting: A systematic review and meta-analysis

OBJECTIVES

Current guidelines recommend delivery of smoking cessation interventions with lung cancer screening (LCS). Unfortunately, there are limited data to guide clinicians and policy-makers in choosing cessation interventions in this setting. Several trials are underway to fill this evidence gap, but results are not expected for several years.

METHODS AND MATERIALS

We conducted a systematic review and meta-analysis of current literature on the efficacy of smoking cessation interventions among populations eligible for LCS. We searched PubMed, Medline, and PsycINFO for randomized controlled trials of smoking cessation interventions published from 2010-2017. Trials were eligible for inclusion if they sampled individuals likely to be eligible for LCS based on age and smoking history, had sample sizes >100, follow-up of 6- or 12-months, and were based in North America, Western Europe, Australia, or New Zealand.

RESULTS

Three investigators independently screened 3,813 abstracts and identified 332 for full-text review. Of these, 85 trials were included and grouped into categories based on the primary intervention: electronic/web-based, in-person counseling, pharmacotherapy, and telephone counseling. At 6-month follow-up, electronic/web-based (odds ratio [OR] 1.14, 95% CI 1.03-1.25), in-person counseling (OR 1.46, 95% CI 1.25-1.70), and pharmacotherapy (OR 1.53, 95% CI 1.33-1.77) interventions significantly increased the odds of abstinence. Telephone counseling increased the odds but did not reach statistical significance (OR 1.21, 95% CI 0.98-1.50). At 12-months, in-person counseling (OR 1.28 95% CI 1.10-1.50) and pharmacotherapy (OR 1.46, 95% CI 1.17-1.84) remained efficacious, although the decrement in efficacy was of similar magnitude across all intervention categories.

CONCLUSIONS

Several categories of cessation interventions are promising for implementation in the LCS setting.

Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes to ease the transition from cigarette smoking to abstinence. It works by reducing the intensity of craving and withdrawal symptoms. Although there is clear evidence that NRT used after smoking cessation is effective, it is unclear whether higher doses, longer durations of treatment, or using NRT before cessation add to its effectiveness.

OBJECTIVES

To determine the effectiveness and safety of different forms, deliveries, doses, durations and schedules of NRT, for achieving long-term smoking cessation, compared to one another.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register, and trial registries for papers mentioning NRT in the title, abstract or keywords. Date of most recent search: April 2018.

SELECTION CRITERIA

Randomized trials in people motivated to quit, comparing one type of NRT use with another. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional intervention components not matched between arms. Trials comparing NRT to control, and trials comparing NRT to other pharmacotherapies, are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking abstinence was measured after at least six months, using the most rigorous definition available. We extracted data on cardiac adverse events (AEs), serious adverse events (SAEs), and study withdrawals due to treatment. We calculated the risk ratio (RR) and the 95% confidence interval (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 63 trials with 41,509 participants. Most recruited adults either from the community or from healthcare clinics. People enrolled in the studies typically smoked at least 15 cigarettes a day. We judged 24 of the 63 studies to be at high risk of bias, but restricting the analysis only to those studies at low or unclear risk of bias did not significantly alter results, apart from in the case of the preloading comparison. There is high-certainty evidence that combination NRT (fast-acting form + patch) results in higher long-term quit rates than single form (RR 1.25, 95% CI 1.15 to 1.36, 14 studies, 11,356 participants; I² = 4%). Moderate-certainty evidence, limited by imprecision, indicates that 42/44 mg are as effective as 21/22 mg (24-hour) patches (RR 1.09, 95% CI 0.93 to 1.29, 5 studies, 1655 participants; I² = 38%), and that 21 mg are more effective than 14 mg (24-hour) patches (RR 1.48, 95% CI 1.06 to 2.08, 1 study, 537 participants). Moderate-certainty evidence (again limited by imprecision) also suggests a benefit of 25 mg over 15 mg (16-hour) patches, but the lower limit of the CI encompassed no difference (RR 1.19, 95% CI 1.00 to 1.41, 3 studies, 3446 participants; I² = 0%). Five studies comparing 4 mg gum to 2 mg gum found a benefit of the higher dose (RR 1.43, 95% CI 1.12 to 1.83, 5 studies, 856 participants; I² = 63%); however, results of a subgroup analysis suggest that only smokers who are highly dependent may benefit. Nine studies tested the effect of using NRT prior to quit day (preloading) in comparison to using it from quit day onward; there was moderate-certainty evidence, limited by risk of bias, of a favourable effect of preloading on abstinence (RR 1.25, 95% CI 1.08 to 1.44, 9 studies, 4395 participants; I² = 0%). High-certainty evidence from eight studies suggests that using either a form of fast-acting NRT or a nicotine patch results in similar long-term quit rates (RR 0.90, 95% CI 0.77 to 1.05, 8 studies, 3319 participants; I² = 0%). We found no evidence of an effect of duration of nicotine patch use (low-certainty evidence); 16-hour versus 24-hour daily patch use; duration of combination NRT use (low- and very low-certainty evidence); tapering of patch dose versus abrupt patch cessation; fast-acting NRT type (very low-certainty evidence); duration of nicotine gum use; ad lib versus fixed dosing of fast-acting NRT; free versus purchased NRT; length of provision of free NRT; ceasing versus continuing patch use on lapse; and participant- versus clinician-selected NRT. However, in most cases these findings are based on very low- or low-certainty evidence, and are the findings from single studies.AEs, SAEs and withdrawals due to treatment were all measured variably and infrequently across studies, resulting in low- or very low-certainty evidence for all comparisons. Most comparisons found no evidence of an effect on cardiac AEs, SAEs or withdrawals. Rates of these were low overall. Significantly more withdrawals due to treatment were reported in participants using nasal spray in comparison to patch in one trial (RR 3.47, 95% CI 1.15 to 10.46, 922 participants; very low certainty) and in participants using 42/44 mg patches in comparison to 21/22 mg patches across two trials (RR 4.99, 95% CI 1.60 to 15.50, 2 studies, 544 participants; I² = 0%; low certainty).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that using combination NRT versus single-form NRT, and 4 mg versus 2 mg nicotine gum, can increase the chances of successfully stopping smoking. For patch dose comparisons, evidence was of moderate certainty, due to imprecision. Twenty-one mg patches resulted in higher quit rates than 14 mg (24-hour) patches, and using 25 mg patches resulted in higher quit rates than using 15 mg (16-hour) patches, although in the latter case the CI included one. There was no clear evidence of superiority for 42/44 mg over 21/22 mg (24-hour) patches. Using a fast-acting form of NRT, such as gum or lozenge, resulted in similar quit rates to nicotine patches. There is moderate-certainty evidence that using NRT prior to quitting may improve quit rates versus using it from quit date only; however, further research is needed to ensure the robustness of this finding. Evidence for the comparative safety and tolerability of different types of NRT use is of low and very low certainty. New studies should ensure that AEs, SAEs and withdrawals due to treatment are both measured and reported.

Quit outcomes among clients ineligible for cessation medication through the state quitline: a retrospective, observational study

BACKGROUND

Distribution of tobacco cessation medications through state quitlines increases service utilization and quit outcomes. However, some state quitlines have moved to models in which callers are instructed to obtain quit medications through their health insurance pharmaceutical benefit. We aimed to investigate the impact of this policy on medication access and quit outcomes in the state quitline setting for clients who must obtain covered medications through the state Medicaid program. We hypothesized that clients with Medicaid who were referred by their healthcare provider would be more likely to report using quit medication and have higher quit rates compared to clients with Medicaid who engaged the quitline on their own.

METHODS

An observational, retrospective study was conducted using state quitline clients with Medicaid health insurance who were ineligible for quitline provided cessation medications. Clients were stratified by referral type: self-referred, passively referred, and proactively referred. Unadjusted and adjusted logistic regression was used to estimate the effect of referral type on both quit status and cessation medication use.

RESULTS

Proactively referred clients were less likely to use quit medication (53.6%) compared to self (56.9%) and passively referred clients (61.1%). Proactively referred clients had lower quit rates (31.4%), as compared to passively referred (36.0%) and self-referred (35.1%). In adjusted models, proactively referred clients were significantly less likely to be quit than passively referred clients (OR = 0.75, 95% CI: 0.56, 0.99). There were no statistically significant differences in medication use or number of coaching sessions among proactive, passive, and self-referred clients in adjusted models.

CONCLUSIONS

In adjusted models, medication use did not significantly differ by mode of entry in this population of Medicaid beneficiaries. Psychosocial factors such as intention to quit in the next 30 days, social support for quitting, education level, race, and ethnicity impacted quit status and differed by mode of entry. Quitlines should use tailored strategies to increase engagement and reduce barriers among proactively referred clients.

Mailed distribution of free nicotine patches without behavioral support: Predictors of use and cessation

INTRODUCTION

There is growing evidence that the mailed distribution of free nicotine replacement therapy (NRT), usually as part of smokers' helplines, can been effective in increasing the odds of cessation on a population level. However, limited information is available on the utilization of NRT when it is provided for free, and factors associated with regimen adherence have remained largely unexplored.

METHODS

In the context of a randomized controlled trial, 500 adult smokers across Canada hypothetically interested in free NRT were mailed a 5week supply of nicotine patches, but no other support was offered. Analyses evaluated which a priori-defined demographic and smoking characteristics predicted nicotine patch use at 8week follow-up of 421 patch recipients, as well as examined the association between patch use and smoking cessation at 6months.

RESULTS

At 8weeks, 10.9% had used all, 47.5% had used some but not all, and 41.6% had not used any of the provided nicotine patches. Lower age, unemployment, past NRT use and intent to quit in the next 30days at baseline (preparation stage of change) were all identified as independent predictors of some nicotine patch use. Only use of all patches was associated with greater odds of smoking cessation, compared to non-users (Adj. OR=2.96; 95%CI=1.06-8.27).

CONCLUSIONS

The mailed distribution of free nicotine patches to smokers at large can be effective at promoting cessation, particularly among financially disadvantaged groups, those with previous NRT experience and among individuals with already advanced intent to quit.

Impact of a Temporary NRT Enhancement in a State Quitline and Web-Based Program

Purpose:

To examine the impact of a nicotine replacement therapy (NRT) enhancement on quit outcomes.

Design:

Observational study using an intent to treat as treated analysis.

Setting:

Not available.

Participants:

A total of 4022 Idaho tobacco users aged ≥18 years who received services from the Idaho Tobacco Quitline or Idaho’s web-based program.

Intervention:

One-call phone or web-based participants were sent a single 4- or 8-week NRT shipment. Multiple-call participants were sent NRT in a single 4-week shipment or two 4-week shipments (second shipment sent only to those completing a second coaching call).

Measures:

North American Quitline Consortium recommended Minimal Data Set items collected at registration and follow-up. Thirty-day point prevalence quit rates were assessed at 7-month follow-up.

Analysis:

Multiple logistic regression models were used to examine the effects of program type and amount of NRT sent to participants while controlling for demographic and tobacco use characteristics.

Results:

Abstinence rates were significantly higher among 8-week versus 4-week NRT recipients (42.5% vs 33.3%). The effect was only significant between multiple-call program participants who received both 4-week NRT shipments versus only the first of 2 possible 4-week shipments (51.1% vs 31.1%). Costs per quit were lowest among web-based participants who received 4 weeks of NRT (US$183 per quit) and highest among multiple-call participants who received only 1 of 2 possible NRT shipments (US$557 per quit).

Conclusion:

To better balance cost with clinical effectiveness, funders of state-based tobacco cessation services may want to consider (1) allowing tobacco users to choose between phone- and web-based programs while (2) limiting longer NRT benefits only to multiple-call program participants.