Clinical Practice Guideline of Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on Pharmacological Treatment of Tobacco Dependence 2023

INTRODUCTION

There are multiple systematic reviews and meta-analyses on the efficacy and safety of pharmacological treatments against nicotine dependence. However, there are few guidelines to answer frequent questions asked by a clinician treating a smoker. Therefore, the aim of this paper is to facilitate the treatment of tobacco addiction.

MATERIAL AND METHODS

12 PICO questions are formulated from a GLOBAL PICO question: "Efficacy and safety of pharmacological treatment of tobacco dependence". A systematic review was carried out to answer each of the questions and recommendations were made. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system was used to grade the certainty of the estimated effects and the strength of the recommendations.

RESULTS

Varenicline, nicotine replacement therapy (NRT), bupropion and cytisine are more effective than placebo. Varenicline and combined nicotine therapy are superior to the other therapies. In smokers with high dependence, a combination of drugs is recommended, being more effective those associations containing varenicline. Other optimization strategies with lower efficacy consist of increasing the doses, the duration, or retreat with varenicline. In specific populations varenicline or NRT is recommended. In hospitalized, the treatment of choice is NRT. In pregnancy it is indicated to prioritize behavioral treatment. The financing of smoking cessation treatments increases the number of smokers who quit smoking. There is no scientific evidence of the efficacy of pharmacological treatment of smoking cessation in adolescents.

CONCLUSIONS

The answers to the 12 questions allow us to extract recommendations and algorithms for the pharmacological treatment of tobacco dependence.

Multifactorial Etiology of Adolescent Nicotine Addiction: A Review of the Neurobiology of Nicotine Addiction and Its Implications for Smoking Cessation Pharmacotherapy

Nicotine is the primary pharmacologic component of tobacco, and its highly addictive nature is responsible for its widespread use and significant withdrawal effects that result in challenges to smoking cessation therapeutics. Nicotine addiction often begins in adolescence and this is at least partially attributed to the fact that adolescent brain is most susceptible to the neuro-inflammatory effects of nicotine. There is increasing evidence for the involvement of microglial cells, which are the brain's primary homeostatic sensor, in drug dependence and its associated behavioral manifestations particularly in the adolescent brain. A hallmark of neuro-inflammation is microglial activation and activation of microglia by nicotine during adolescent development, which may result in long-term addiction to nicotine. This non-systematic review examines multifactorial etiology of adolescent nicotine addiction, neurobiology of nicotine addiction and the potential mechanisms that underlie the effects of nicotine on inflammatory signaling in the microglia, understanding how nicotine affects the adolescent brain. We speculate, that modulating homeostatic balance in microglia, could have promising therapeutic potential in withdrawal, tolerance, and abstinence-related neural adaptations in nicotine addiction, in the adolescent brain. Further, we discuss nicotine addiction in the context of the sensitization-homeostasis model which provides a theoretical framework for addressing the potential role of microglial homeostasis in neural adaptations underlying nicotine abuse.

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.

Using Ecological Momentary Assessment to Identify Mechanisms of Change: An Application From a Pharmacotherapy Trial With Adolescent Cannabis Users

OBJECTIVE

The present study used youth's in vivo reports of subjective responses to cannabis while smoking in their natural environments to identify real-world mechanisms of topiramate treatment for cannabis misuse.

METHOD

Participants were 40 cannabis users (≥ twice weekly in past 30 days), ages 15-24 years (47.5% female), with at least one cannabis use episode during the final 3 weeks of a 6-week, randomized clinical trial. Youth reported subjective "high" while smoking, stimulation, sedation, stress, craving, and grams of marijuana used in the natural environment via wireless electronic devices. Bayesian multilevel structural equation modeling (MSEM) evaluated mediation via indirect effect tests.

RESULTS

Significant within (daily) and between (person) variability and distinctive within and between effects supported the MSEM approach. Subjective high while smoking was significantly reduced for youth in the topiramate condition, relative to placebo, and the indirect effect of reduced subjective high on total grams of cannabis smoked that day was significant. Indirect effects through other subjective responses were not significant.

CONCLUSIONS

The results of this initial study suggest that altering subjective responses to smoking, specifically subjective high, may be a key target for developing adjunctive pharmacotherapies for cannabis misuse. More generally, this work provides an example for applying ecological momentary assessment and analytic techniques to evaluate mechanisms of behavior change in longitudinal data.

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.

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.

Prevention, early intervention, harm reduction, and treatment of substance use in young people

We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision-which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

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.

State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade

Tobacco use and tobacco smoke exposure are among the most important preventable causes of premature disease, disability, and death and therefore constitute a major pediatric health concern. The pediatric primary care setting offers excellent opportunities to prevent tobacco use in youth and to deliver cessation-related treatment to youth and parents who use tobacco. This report updates a "state-of-the-art" article published a decade ago on office-based interventions to address these issues. Since then there has been marked progress in understanding the nature, onset, and trajectories of tobacco use and nicotine addiction in youth with implications for clinical practice. In addition, clinicians need to remain abreast of emerging nicotine delivery systems, such as electronic cigarettes, that may influence uptake or continuation of smoking. Although evidence-based practice guidelines for treating nicotine addiction in youth are not yet available, research continues to build the evidence base toward that goal. In the interim, practical guidelines are available to assist clinicians in addressing nicotine addiction in the pediatric clinical setting. This article reports current practices in addressing tobacco in pediatric primary care settings. It reviews our increasing understanding of youth nicotine addiction, summarizes research efforts on intervention in the past decade and additional research needed going forward, and provides practical guidelines for pediatric health care providers to integrate tobacco use prevention and treatment into their clinical practice. Pediatric providers can and should play an important role in addressing tobacco use and dependence, both in the youth they care for and in parents who use tobacco.

Update of Adolescent Smoking Cessation Interventions: 2009-2014

The treatment of adolescent tobacco dependence is an imperative public health goal. Adolescent-focused smoking cessation interventions have shown modest results at most, indicating the need for the development of innovative and effective interventions for this vulnerable population. This review aims to provide an update of smoking cessation interventions for youth by reviewing the literature published between 2009 and November 2014 evaluating psychosocial and pharmacological interventions. Based on this examination, future directions for research in advancing the development of adolescent-focused tobacco treatments are provided.

Searching for phenotypes in smoking cessation treatment

BACKGROUND

It is important to define smoking phenotypes according to different variables, such as age, sex and degree of dependence, for which available treatments could have different efficacies.

OBJECTIVE

The main objective of our study was aimed at defining different combinations of these variables to allow the best possible treatment to be chosen in routine clinical practice.

METHODS

We reviewed the clinical records of smokers who had been treated in our Smoking Cessation Service. In all cases, the treatment programme consisted of a combination of behavioural therapy and optional drug treatment.

RESULTS

The group consisted of 3622 subjects, specifically 1757 men (48.5%). The mean age of the participants in the group was 48.11 ± 11.19 years. The mean score of the FTCD-questionnaire was 6.66 ± 2.38. In addition, 78% of the subjects smoked their first cigarette within 30 min after waking. For the total sample, continuous abstinence rate from 9 to 24 weeks was 57.7%. A multivariate analysis using the logistic regression model was implemented, and it showed that: (i) Nicotine Replacement Therapy was less effective in patients with high tobacco dependence, (ii) young subjects can be highly resistant to all treatments and (iii) subjects with low tobacco dependence can be treated with any treatment, but bupropion and varenicline provided the best results.

CONCLUSION

It was possible to identify several smoking phenotypes in which different treatments have different efficacies.

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.

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.

Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice

Strategies for assisting smoking cessation include behavioural counselling to enhance motivation and to support attempts to quit and pharmacological intervention to reduce nicotine reinforcement and withdrawal from nicotine. Three drugs are currently used as first line pharmacotherapy for smoking cessation, nicotine replacement therapy, bupropion and varenicline. Compared with placebo, the drug effect varies from 2.27 (95% CI 2.02, 2.55) for varenicline, 1.69 (95% CI 1.53, 1.85) for bupropion and 1.60 (95% CI 1.53, 1.68) for any form of nicotine replacement therapy. Despite some controversy regarding the safety of bupropion and varenicline, regulatory agencies consider these drugs as having a favourable benefit/risk profile. However, given the high rate of psychiatric comorbidity in dependent smokers, practitioners should closely monitor patients for neuropsychiatric symptoms. Second-line pharmacotherapies include nortriptyline and clonidine. This review also offers an overview of pipeline developments and issues related to smoking cessation in special populations such as persons with psychiatric comorbidity and pregnant and adolescent smokers.

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.

An updated algorithm for choosing among smoking cessation treatments

Although meta-analyses have documented the efficacy of treatments for smoking cessation, and guidelines have outlined treatment elements, few algorithms for choosing among treatments have been described. The current algorithm updates the author's prior algorithm. The major decisions in the algorithm are (a) use a motivational treatment if the smoker is not currently interested in quitting, (b) assess factors that influence choice of treatment, (c) consider both gradual and abrupt cessation, (d) use combined patch+gum/inhaler/lozenge or varenicline as first line medications, (e) use individual, group, Internet, and phone counseling as first line psychosocial treatments, and (f) continue treatment after a lapse or relapse. Further research is needed to determine whether algorithms improve treatment outcomes.