Treatment of nicotine dependence

The neural mechanisms of immediate and follow-up of the treatment effect of hypnosis on smoking craving

Hypnosis has a therapeutic effect on substance dependence. However, its neural basis remains unclear, which impedes its further clinical applications. This study investigated the mechanisms of smoking treatment based on hypnosis from two perspectives: immediate and follow-up effects. Twenty-four smokers screened from 132 volunteers underwent hypnosis suggestion and performed a smoking-related cue task twice during functional magnetic resonance imaging (fMRI) scanning (in normal and hypnotic states). The number of cigarettes smoked per day was recorded at follow-up visits. The smokers reported decreased craving after hypnosis. The activations in the right dorsal lateral prefrontal cortex (rDLPFC), the left insula and the right middle frontal gyrus (rMFG), and the functional connectivity between the rDLPFC and the left insula were increased in the hypnotic state. The reduced craving was related to the DLPFC-insula network, which reflected the immediate mechanism of hypnosis on smoking. The number of cigarette use at the 1-week and 1 month follow-up was correlated with the rMFG activation which reflecting hypnotic depth, suggesting the follow-up effect of hypnosis on smoking depended on the trait of smokers. We identified two different mechanisms of hypnosis effect on smoking, which have important implications for design and optimization of hypnotic treatments on mental disorders.

Craving control using nicotine replacement therapy in a teaching hospital

BACKGROUND

A period of hospitalisation is perhaps the longest period of enforced 'temporary abstinence' smokers have to endure and hence many crave during their admission. Cravings may result in patients' smoking on hospital premises. Nicotine replacement may reduce cravings, decrease smoking on hospital grounds and increase interest in quitting post-discharge.

AIM

The aim of this study was to compare the efficacy of two nicotine formulations in controlling inpatient cravings and enthusiasm for quitting post-discharge.

METHODS

Inpatients who were smokers were randomised to nicotine patch or inhaler on alternating days. Patients selected their preferred formulation, which was then used for the duration of the hospital stay. Craving control and formulation preference were assessed by visual analogue scales (VAS), and interest in quitting on a 3-point scale. Abstinence was confirmed by exhaled breath CO monitoring.

RESULTS

Patches were preferred by 64% of the 367 subjects. Fewer patients went outside to smoke after either formulation (37% before, 5% after enrolment). Cravings were reduced by both nicotine formulations (mean VAS score fell from 7.5 to 1.7). Interest in quitting post-discharge increased. Estimated mean exposure to nicotine was 5 mg/day (inhaler), 15 mg/day (transdermal patch) compared with 30 mg/day (cigarettes) before hospitalisation.

CONCLUSIONS

Many smokers crave and some smoke outside during a hospital admission. While the patch was the preferred formulation of nicotine replacement therapy, both were effective in reducing cravings, increasing motivation for quitting post-discharge and improving Hospital 'image' by reducing smoking on campus. Nicotine replacement therapy should be made available to inpatients in all hospitals and other places of enforced prolonged abstinence.

Nicotine and periodontal tissues

Tobacco use has been recognized to be a significant risk factor for the development and progression of periodontal disease. Its use is associated with increased pocket depths, loss of periodontal attachment, alveolar bone and a higher rate of tooth loss. Nicotine, a major component and most pharmacologically active agent in tobacco is likely to be a significant contributing factor for the exacerbation of periodontal diseases. Available literature suggests that nicotine affects gingival blood flow, cytokine production, neutrophil and other immune cell function; connective tissue turnover, which can be the possible mechanisms responsible for overall effects of tobacco on periodontal tissues. Inclusion of tobacco cessation as a part of periodontal therapy encourages dental professionals to become more active in tobacco cessation counseling. This will have far reaching positive effects on our patients' oral and general health.

Development of active and passive human vaccines to treat methamphetamine addiction

Methamphetamine (METH) abuse is a major worldwide epidemic, with no specific medications for treatment of chronic or acute effects. Anti-METH antibodies have the potential to save lives and reduce the crippling effects of METH abuse. While they are not expected to be the magic bullet to immediately cure addiction, immunotherapy could provide a breakthrough medication to continuously block or attenuate METH effects during a comprehensive addiction recovery plan. A unique challenge for METH antibody antagonists is the need to protect the brain from the complex direct and indirect adverse effects of long-term METH use. To meet this challenge, a new generation of passive monoclonal antibodies and active immunization therapies are at an advanced stage of preclinical development. Both of these vaccines could play an essential role in a well planned recovery program from human METH addiction by providing long-lasting protection from the rewarding and reinforcing effect of METH.

Implementation of inpatient and outpatient tobacco-cessation programs

PURPOSE

Two programs in which pharmacists have an active role in the provision of tobacco-cessation education are described.

SUMMARY

An algorithm for tobacco- cessation education was created for use in an inpatient tobacco-cessation program. Patient education handouts were created, and the content of each handout varied by the patient's level of readiness to make a quit attempt. Doctor of pharmacy students who were assigned to the general internal medicine clerkship rotation at the hospital provided tobacco-cessation education to patients. During monthly rotations, these students assess the smoking status of each patient, gauge the patient's readiness to quit, and provide brief tobacco-cessation education to those who smoke. Patients who are willing to quit smoking are asked if they can be contacted by a representative of the health system's tobacco-cessation program. This program includes a series of three group classes focusing on behavior modification and pharmacotherapy provided at a discounted price. An outpatient tobacco-cessation clinic was initiated to provide all patients of the network an opportunity to participate and have access to tobacco-cessation services. The clinic consists of group and individual classes using the principles and interventions highlighted in national clinical practice guidelines. All referred patients must attend an initial one-on-one visit with the clinical pharmacist before enrollment into the group class. During this visit, general medical information is collected, and the patient's stage of change and willingness to set a quit date are determined. A medication review for drug-smoking interactions is conducted, individual goals are discussed, and a care plan is created.

CONCLUSION

Tobacco-cessation services were implemented by pharmacists working in inpatient and outpatient settings.

Second primary tumors following tobacco dependence treatments among head and neck cancer patients

OBJECTIVES

To estimate the cumulative percentage of second primary tumors (SPTs) in head and neck (H&N) cancer patients and primary cancers in general Nicotine Dependence Center (NDC) population controls following tobacco dependence consultation seen between 1988 and 2001.

METHODS

A 1:1 matched pair design and a stratified Cox proportional hazard model were used. General NDC population controls were matched on age, gender, and NDC consult (type and date) to the H&N cancer patients. The study population included 101 H&N cancer patients (66 male, 35 female) with mean (SD) age of 58.7 (10.1) years.

RESULTS

Baseline demographics and length of follow-up were similar between groups. However, H&N cancer patients smoked more cigarettes per day than controls (P < 0.003). For H&N cancer patients, the median time from initial H&N cancer diagnosis to NDC consult was 7 months (range, 0-292 months). Following the NDC consult, 27 H&N cancer patients developed 32 SPTs; whereas among the controls, 12 patients developed 12 other cancers (P = 0.013). There was no difference in the development of non-tobacco-related cancers (P = 0.273). However, H&N cancer patients were more likely to develop tobacco-related cancers (P = 0.01). Furthermore, there was a trend where the H&N cancer patients who continued to use tobacco were more likely to develop tobacco-related cancers than those who remained abstinent (P = 0.10).

CONCLUSIONS

These findings confirm that H&N cancer patients are more prone to the development of tobacco-related cancers. Further, these findings suggest that H&N cancer patients who stop using tobacco are able to decrease the development of tobacco-related SPTs.

Tobacco control for anesthesiologists

Anesthesiologists daily witness the consequences of tobacco use, the most common preventable cause of death. Smoking-related diseases such as atherosclerosis and chronic obstructive pulmonary disease increase anesthetic risk, and even smokers without overt disease are at increased risk for morbidity such as pulmonary and wound-related complications. Evidence suggests that stopping smoking will reduce the frequency of these complications. Nicotine and the other constituents of cigarette smoke, such as carbon monoxide, have important physiologic effects that may affect perioperative management. In addition, it is now apparent that the scheduling of elective surgery represents an excellent opportunity for smokers to quit in the long term. This review serves as an introduction to tobacco control for anesthesiologists, first examining issues of importance to perioperative management. It then discusses how anesthesiologists and other perioperative physicians can help address tobacco use, both at an individual level with their patients, and by contributing to the implementation of effective public health strategies in their countries. Anesthesiologists can play a key role in helping their patients quit smoking. Effective tobacco control measures applied to surgical patients will not only improve immediate perioperative outcomes but also long-term health.

Treating tobacco dependence: review of the best and latest treatment options

Globally, an estimated 85% of lung cancer in men and 47% of lung cancer in women is attributable to tobacco smoking. Tobacco dependence treatment remains the most cost-effective way to prevent morbidity and mortality from lung cancer. Several effective pharmacotherapies are available to treat tobacco dependence. However, the long-term effectiveness of these treatments has been limited because the majority of smokers who attempt to stop smoking eventually relapse. Approaching the treatment of tobacco use and dependence as a chronic disease and the development of innovative drug therapies offer new hope for the treatment of tobacco-dependent patients. The diagnosis of lung cancer provides a teachable moment to motivate patients to attempt tobacco abstinence on which clinicians should capitalize. We review the currently available pharmacologic approaches to the treatment of tobacco dependence.

Increased risk of relapse after stopping nicotine replacement therapies: a mathematical modelling approach

AIMS

To describe the effect of nicotine replacement therapy (NRT) on the risk of relapse as a function of time since the quit date.

DATA SOURCES

Meta-analysis of 21 published, randomized, controlled clinical trials, comparing NRT to placebo.

DATA EXTRACTION

A total of 6644 smokers were treated with NRT and 2766 smokers treated with placebo.

DATA SYNTHESIS

During treatment with the medication, NRT reduced the hazard ratio (HR) significantly compared with placebo [early HR = 0.62 (95% CI: 0.58-0.67)]. At the end of the average treatment duration (145 days), the HR was 0.81 (95% CI: 0.71-0.94), showing that the benefit was still present at this time. After stopping treatment, the HR increased progressively up to a value of 1.44 (95% CI, 1.18-1.76) showing that the risk of relapse was higher after stopping NRT than after stopping placebo. If NRT and placebo had not been stopped, the HR of smoking relapse would have been established at 0.95 (95% CI: 0.76-1.18, P = 0.64), indicating a similar risk of relapse with NRT and placebo. Moreover, the observed HR of smoking relapse was significantly higher than the expected HR of smoking relapse if NRT had been continued: the difference in HR is 1.51 (95% CI: 1.16-1.98, P < 0.003). This suggests that if NRT had been been continued, around 50% of relapses could have been prevented.

CONCLUSION

The protective effect of NRT against relapse slowly decreases as a function of time. After stopping NRT, the risk of relapse increases. It may be more beneficial not to stop NRT after the usual 3-6-month treatment period but to use NRT for longer periods of time.

Adherence to nicotine replacement therapy versus quitting smoking among Chinese smokers: a preliminary investigation

RATIONALE

There are over 300 million Chinese smokers, but use of nicotine replacement therapy (NRT) is rare. On the other hand, data on the factors associated with quitting and adherence to NRT use are scarce in the East.

OBJECTIVES

To describe adherence and other predictors of quitting smoking at the 12-month follow-up amongst Chinese smokers in Hong Kong.

METHODS

Chinese smokers (1186) who attended the Smoking Cessation Health Centre from August 2000 through January 2002 were studied. Trained counsellors provided individual counselling and carried out follow-up interviews. We used structured questionnaires at baseline and at 1, 3 and 12 months and an intention-to-treat approach for analysis.

RESULTS

Among those who received NRT (1051/1186), the prevalence of adherence (self-reported NRT use for at least 4 weeks) was 16% (95% confidence interval 14-18%). The 7-day point prevalence quit rate at 12 months (not smoking any cigarette during the past 7 days at the 12 month follow-up) was 27% (95% CI, CI 24-29%). Stepwise logistic regression model showed that adherence to NRT use, a higher income, good perceived health and having more confidence in quitting were significant predictors of quitting. The quit rate in the adherent group (40%) was greater than that of the non-adherent group (25%) (P<0.001). Older age, male, higher education, experience of NRT use, perceiving quitting as more difficult and willingness to pay were significant predictors of adherence.

CONCLUSIONS

Clinically significant smoking cessation rates can be achieved among Chinese smokers in a clinic-based smoking cessation service. The NRT adherence was low and low adherence was associated with a lower quit rate. Trials of interventions to improve adherence and increase quit rates are needed.

Assisting with tobacco cessation

Tobacco use is the primary preventable cause of morbidity and mortality in the United States today. The consequences of smoking are well documented, and it is the responsibility of every health care provider to routinely screen and offer treatment to their patients who smoke. Nurses are no exception; we are uniquely qualified to provide practical skills training to our patients. Irrefutable data exist that even 3 minutes of counseling can have a positive influence that moves the patient who smokes further along the continuum toward quitting. The treatment recommendations and strategies that will be discussed are found in the Agency for Health Care Policy and Research guideline entitled "Treating Tobacco Use and Dependence." The algorithm will be broken down into practical interview questions and activities that every nurse can implement with his or her patients, regardless of practice setting.

The effectiveness of nicotine-patch therapy for smoking cessation in patients with schizophrenia

The purpose of this study was to determine the effectiveness of nicotine-patch therapy for smoking cessation in patients with schizophrenia. This was a longitudinal study and sixty-eight schizophrenic patients were assigned to 8 weeks of a nicotine-patch therapy program or a control group. The generalized estimating equation analysis revealed that there were significant reductions in the subjects' nicotine dependence (Fagerstrom Tolerance Questionnaire), the number of cigarettes per day, and CO levels over an 8-week period of nicotine-patch therapy and 3-month follow-up. The point-prevalence rates of abstinence from smoking were an abstinence of 26.9% at 8 weeks and 26.9% at a 3-month follow-up. At the 3-month follow-up, the rate of continuous smoking abstinence in the nicotine-patch group was 23.1%.

Cigarette Smoking and the Periodontal Patient

Evidence from cross-sectional and case-control studies in various populations demonstrates that adult smokers are approximately three times as likely as non-smokers to have periodontitis. The association between smoking and attachment loss is even stronger when the definition of periodontitis is restricted to the most severely affected subjects. Smokers have a diminished response to periodontal therapy and show approximately half as much improvement in probing depths and clinical attachment levels following non-surgical and various surgical modalities of therapy. Implant failures in smokers are twice those of non-smokers, with a higher failure rate in the maxillary arch accounting for the majority of the difference. Tobacco-induced alterations in microbial and host factors contribute to these deleterious effects of smoking on the periodontium. In longitudinal studies, the rate of periodontal disease progression is increased in smokers, but decreases to that of a non-smoker following tobacco cessation. Likewise, recent non-smokers respond to periodontal therapy in a manner similar to patients who have never smoked. Data regarding the impact of smoking on periodontal status included in this review will be helpful to dental health professionals as they counsel their patients regarding tobacco use. The role of dental health professionals in tobacco cessation is discussed, including the use of the five A's: ask--identify tobacco users; advise--advise them to quit; assess--evaluate the patient's readiness to quit; assist--offer assistance in cessation; and arrange--follow up on the patient's cessation efforts. The addition of pharmacotherapy to behavioral therapy, including nicotine replacement therapy and bupropion, can increase cessation rates. The most popular form of nicotine replacement therapy is the patch, and its use has been shown to double cessation rates compared to behavioral therapy alone. Use of bupropion in combination with nicotine replacement therapy may be particularly helpful for heavy smokers or smokers who have experienced multiple failed attempts at cessation. The American Academy of Periodontology Parameters of Care include tobacco cessation as a part of periodontal therapy, and the 2000 Surgeon General's Report on Oral Health in America encourages dental professionals to become more active in tobacco cessation counseling. Doing so will have far-reaching positive effects on our patients' oral and general health.

Smoking among participants in the childhood cancer survivors cohort: the Partnership for Health Study

PURPOSE

This article describes baseline data collection and the intervention design of Partnership for Health, a smoking cessation intervention for smokers in the Childhood Cancer Survivors Study. The purpose of this article is to evaluate demographic, psychosocial, and cancer-related factors that are associated with smoking behavior and mediators of smoking cessation.

PATIENTS AND METHODS

This study includes 796 smokers from the Childhood Cancer Survivors Study database who were diagnosed with cancer before the age of 21, had survived at least 5 years, and were at least 18 years of age at the time of the baseline survey. Correlates of smoking behaviors included smoking rate, number of recent quit attempts, and nicotine dependence; two key mediators of smoking cessation, readiness to quit smoking and self-efficacy, were also assessed.

RESULTS

Participants smoked, on average, 14 cigarettes/day; 53.2% were nicotine dependent, and 58% had made at least one quit attempt in the past year. Smoking behaviors were primarily associated with demographic variables; mediators of cessation were primarily associated with age at cancer diagnosis and perceived vulnerability to smoking-related illnesses. Severity of psychologic symptoms was associated with increased smoking rate, high nicotine dependence, and low self-efficacy. Support for quitting was related to smoking rate, number of quit attempts, readiness to quit smoking, and self-efficacy.

CONCLUSION

These findings indicate that many cancer survivors who smoke are receptive to smoking cessation interventions. Factors related to mediators of smoking cessation might be particularly good targets for intervention.

Simultaneous Analysis of Nicotine, Nicotine Metabolites, and Tobacco Alkaloids in Serum or Urine by Tandem Mass Spectrometry, with Clinically Relevant Metabolic Profiles

Background: Assessment of nicotine metabolism and disposition has become an integral part of nicotine dependency treatment programs. Serum nicotine concentrations or urine cotinine concentrations can be used to guide nicotine patch dose to achieve biological concentrations adequate to provide the patient with immediate relief from nicotine withdrawal symptoms, an important factor in nicotine withdrawal success. Absence of nicotine metabolites and anabasine can be used to document abstinence from tobacco products, an indicator of treatment success.

Methods: The procedure was designed to quantify nicotine, cotinine, trans-3′-hydroxycotinine, anabasine, and nornicotine in human serum or urine. The technique required simple extraction of the sample with quantification by HPLC–tandem mass spectrometry.

Results: The procedure for simultaneous analysis of nicotine, its metabolites, and tobacco alkaloids simultaneously quantified five different analytes. Test limit of quantification, linearity, imprecision, and accuracy were adequate for clinical evaluation of patients undergoing treatment for tobacco dependency. The test readily distinguished individuals who had no exposure to tobacco products from individuals who were either passively exposed or were abstinent past-tobacco users from those who were actively using a tobacco or nicotine product.

Conclusions: Nicotine, cotinine, trans-3′-hydroxycotinine, nornicotine, and anabasine can be simultaneously and accurately quantified in either serum or urine by HPLC–tandem mass spectrometry with imprecision &lt;10% at physiologic concentrations and limits of quantification ranging from 0.5 to 5 μg/L. Knowledge of serum or urine concentrations of these analytes can be used to guide nicotine replacement therapy or to assess tobacco abstinence in nicotine dependency treatment. These measurements are now an integral part of the clinical treatment and management of patients who wish to overcome tobacco dependence.

Tobacco smoking, nicotine, and nicotine and non-nicotine replacement therapies

Tobacco smoking is associated with an increased risk for the development of coronary and pulmonary vascular diseases and smoking cessation will greatly reduce this risk. Nicotine replacement and nonnicotine modalities have been used alone and in combination to help in smoking cessation. These treatment modalities appear to be safe in patients with known stable coronary artery disease.