Effectiveness of varenicline as an aid to smoking cessation in primary care: an observational study

[The prevalence of strategies for cessation of tobacco use in primary health care: an integrative review]

The habit of tobacco use/smoking, which is a major concern of Primary Health Care (PHC), is a serious public health problem and the main avoidable cause of death in the world. The relevance of actions, whose focus is to facilitate the cessation of this habit, motivates the discussion of studies that have different approaches to tackle this issue by seeking to train PHC professionals accordingly. A search was conducted in the Lilacs, MEDLINE and Web of Science databases for recent scientific publications (2010-2015). The key words were combined with Boolean operators and, after analysis of the articles found, 75 are discussed in this article since they have strategies with a higher prevalence in PHC. The conclusion drawn is that the brief or intense individual approach using the 5A method (Transtheoretical Model) is the most widely adopted, as well as bupropion and nicotine replacement patches. The increasing use of hard technology requires new studies that examine their impact on the treatment of smokers. It was clearly revealed that there is a need for health professionals to be better prepared to address the issue with the users, in addition to a lack of stimulus and proper conditions to work in the PHC team directly reflecting scientific advances in clinical practice.

Cardiovascular and neuropsychiatric risks of varenicline and bupropion in smokers with chronic obstructive pulmonary disease

BACKGROUND

Varenicline and bupropion are effective smoking cessation treatments, but there are concerns about their safety in smokers with COPD.

OBJECTIVE

To investigate whether varenicline and bupropion are associated with serious adverse cardiovascular and neuropsychiatric events in smokers with COPD.

METHODS

In a retrospective cohort study, we used data from 14 350 patients with COPD included in the QResearch database, which holds data from 753 National Health Service general practices across England. We identified patients with COPD who received a prescription of nicotine replacement therapy (NRT; N=10 426; reference group), bupropion (N=350) or varenicline (N=3574) in the period between January 2007 and June 2012. Patients were followed up for 6 months to compare incident cardiovascular (ie, ischaemic heart disease, stroke, heart failure, peripheral vascular disease and cardiac arrhythmias) and neuropsychiatric (ie, depression and self-harm) events using Cox proportional hazards models, adjusted for potential confounders. Propensity score analysis was used as an additional approach to account for potential confounding by indication. We also modelled the effects of possible unmeasured confounders.

RESULTS

Neither bupropion nor varenicline showed an increased risk of adverse events compared with NRT. Varenicline was associated with a significantly reduced risk of heart failure (HR=0.56, 95% CI 0.34 to 0.92) and depression (HR=0.73, 95% CI 0.61 to 0.86). Similar results were obtained from the propensity score analysis. Modelling of unmeasured confounding provided additional evidence that an increased risk of these adverse events was very unlikely.

CONCLUSION

In smokers with COPD, varenicline and bupropion do not appear to be associated with an increased risk of cardiovascular events, depression or self-harm in comparison with NRT.

Sex Differences in Varenicline Efficacy for Smoking Cessation: A Meta-Analysis

INTRODUCTION

Women have lower rates of quitting than men with both bupropion and nicotine replacement. It is unknown whether varenicline demonstrates differential efficacy for men and women. The purpose of this study was to conduct the first comprehensive meta-analysis of clinical trial data examining sex differences in the efficacy of varenicline for smoking cessation.

METHODS

Searching MEDLINE, EMBASE, and PsychINFO, 17 of 43 clinical trials of varenicline for smoking cessation published through December 31, 2014 were low-bias randomized double-blind placebo-controlled trials. Data (n = 6710 smokers, 34% female, n = 16 studies, 96% of available data) was analyzed with Metafor program in R. Outcome endpoints were 7-day point-prevalence (PP) and continuous-abstinence (CA) at week 12 (end of treatment), week 24 (6-month follow-up), and week 52 (12-month follow-up).

RESULTS

Using placebo, women were less likely than men to quit (PP-12, CA-24; P < .05 for sex). Using varenicline, similar rates of abstinence for men and women were demonstrated for all six outcomes (eg, PP-12 abstinence rates were 53% in both women and men). Varenicline versus placebo outcomes demonstrated that varenicline was more effective for women for short and intermediate outcomes (PP-12, CA-12, CA-24; P < .05 sex × medication interaction). For end-of-treatment PP, varenicline was 46% more effective for women. For continuous abstinence, varenicline was 34% (CA-12) and 31% (CA-24) more effective for women.

CONCLUSIONS

Unlike other smoking cessation medications, varenicline demonstrated greater efficacy among women smokers for short and immediate-term outcomes and equal efficacy for 1-year outcomes. Varenicline may be particularly useful for reducing the sex disparity typically seen in rates of smoking cessation.

IMPLICATIONS

Varenicline is currently the most effective FDA-approved smoking cessation medication and this is the first demonstration that women compared with men have a preferred therapeutic response for a smoking cessation medication when considering short-term outcomes. Importantly, this is also the first demonstration that women have similar rates of quitting to men when considering longer-term, 1-year outcomes.

Effectiveness of varenicline and counselling for smoking cessation in an observational cohort study in China

OBJECTIVES

To evaluate the effectiveness of varenicline for smoking cessation in Chinese smokers in a real world cessation clinic practice.

DESIGN

A prospective observational study.

SETTING

Beijing, China.

PARTICIPANTS

A total of 924 smokers (883 men and 41 women) who attended a smoking cessation clinic of a large general hospital were assessed with data from structured questionnaires at baseline and follow-up at 1, 3 and 6 months. Trained physician counsellors provided free individual counselling for all subjects and follow-up interviews with brief counselling. 332 subjects additionally prescribed varenicline according to their own choice were compared with those without varenicline.

MAIN OUTCOME MEASURES

Primary outcomes were self-reported 7-day point prevalence abstinence rate and 3-month continuous abstinence rate at 6-month follow-up. Secondary outcomes were 7-day point prevalence abstinence rates at 1 and 3-month follow-up, and 1-month continuous abstinence rate at 3-month follow-up.

RESULTS

By intention-to-treat, the 7-day point prevalence abstinence rate with varenicline and counselling at 6 months was significantly higher than counselling only (37.0% vs 23.1%; OR, 1.75; 95% CI 1.46 to 2.62; p=0.001). The 3-month continuous abstinence rate at 6 months was higher with varenicline (33.1% vs 18.4%; OR, 2.04; 95% CI 1.61 to 2.99; p<0.001). Varenicline also showed better secondary outcomes.

CONCLUSIONS

Varenicline prescription in the smoking cessation clinic appeared to be effective with doubling of quit rates in Chinese smokers in a real world cessation clinic practice.

CLINICAL TRIAL REGISTRATION

NCT01935505; Results.

Varenicline as a Cause of Suicidal Outcomes

OBJECTIVE

Postmarketing analyses and case reports have associated varenicline use with suicidal behaviors. This article reviews postmarketing analyses, case reports, clinical trials, uncontrolled observational studies, controlled observational studies, and studies in smokers with psychiatric problems that have tested this association.

METHOD

The author searched the literature for relevant reports via computer and other searches to undertake a qualitative, systematic review.

RESULTS

Two pooled analyses of 10 and 17 placebo-controlled trials failed to find more suicidal outcomes in the varenicline condition. Seven large uncontrolled observational studies reported low rates of suicide outcomes in varenicline users (<0.1%), and 1 study reported a higher rate (6%). Five large controlled observational studies did not find more suicide outcomes in varenicline users than in those using prescribed bupropion or over-the-counter nicotine medications. Small placebo-controlled trials and observational studies of smokers with current psychiatric problems did not find varenicline was associated with suicidal outcomes.

CONCLUSIONS

Among the more valid study designs (pooled analyses of placebo controlled trials or large controlled observational studies), there is consistent evidence that varenicline either does not cause increased suicide outcomes, or if it does, the effect is very small. Warnings to consumers and clinicians should reflect, not just the results of postmarketing studies, but the results of the more valid research designs.

Effectiveness and safety of varenicline as an aid to smoking cessation: results of an inter-Asian observational study in real-world clinical practice

AIMS

To evaluate the effectiveness and safety of varenicline for smoking cessation among Asian adult smokers in real-world clinical practice.

METHODS

A multicentre, prospective, non-comparative, observational study conducted in China, India, Philippines and Korea. Adult smokers, willing to make a quit attempt, who reached a joint decision with the investigators to take varenicline received 1 mg twice daily (after 1-week titration) for 12 weeks. No exclusion criteria were specified. Effectiveness evaluations included smoking abstinence status for the 7-day period before the Week 12 visit and the last observed study visit, determined by verbal reporting using a nicotine use inventory and carbon monoxide levels if part of usual practice (end of study only). The safety profile of varenicline was also assessed.

RESULTS

Of 1377 subjects enrolled in the study, 1373 (99.7%) received varenicline and were evaluated for safety and effectiveness. Overall, 46.4% [95% confidence interval (CI): 43.73-49.07] of subjects successfully quit smoking by the end of the treatment phase at Week 12. When analysed by country, 57.1% (95% CI: 53.55-60.65) of subjects from China, 52.8% (95% CI: 45.21-60.25) of subjects from India, 51.0% (95% CI: 36.60-65.25) of subjects from Philippines and 20.3% (95% CI: 16.29-24.73) of subjects from Korea had quit smoking at Week 12. The most commonly reported treatment-related adverse event was nausea (11.5%).

CONCLUSIONS

This study demonstrates the effectiveness and acceptable safety profile of varenicline for smoking cessation in a real-world setting among Asian populations, with results consistent with those of varenicline randomised controlled trials.