The pharmacotherapy of smoking cessation

Tobacco heating system has less impact on bone metabolism than cigarette smoke

Cigarette smoking promotes osteoclast activity, thus increasing the risk of secondary osteoporosis, leading to osteoporosis-associated fracture and impaired fracture healing. Heated tobacco products (HTP) are considered potential reduced-risk alternatives to cigarettes. However, their impact on bone metabolism remains to be elucidated. We developed an in vitro model that mimics in vivo bone cell interactions to comparatively evaluate the effects of HTPs and cigarette smoke on bone cell functionality and viability. We generated an in vitro coculture system with SCP-1 and THP-1 cells (1:8 ratio) cultured on a decellularized Saos-2 matrix with an optimized coculture medium. We found that, following acute or chronic exposure, particulate matter extract from the aerosol of an HTP, the Tobacco Heating System (THS), was less harmful to the bone coculture system than reference cigarette (1R6F) smoke extract. In the fracture healing model, cultures exposed to the THS extract maintained similar osteoclast activity and calcium deposits as control cultures. Conversely, smoke extract exposure promoted osteoclast activity, resulting in an osteoporotic environment, whose formation could be prevented by bisphosphonate coadministration. Thus, THS is potentially less harmful than cigarette smoke to bone cell differentiation and bone mineralization - both being crucial aspects during the reparative phase of fracture healing.

Use of nicotine replacement therapy in young people entering custody in New South Wales, Australia

AIM

To describe the prevalence of nicotine dependence and acceptance of nicotine replacement therapy (NRT) in young people entering custody, where smoking is not allowed.

METHODS

Cross-sectional study in 2013.

SETTING

All New South Wales Juvenile Justice Centres.

PARTICIPANTS

Incarcerated youth, aged 12-21 years.

MAIN EXPOSURES

gender, age, ethnicity, cannabis use.

MAIN OUTCOMES

rates of smoking, cannabis use, nicotine dependence, NRT acceptance.

RESULTS

Data were collected from 252 Initial Reception Assessments (90.1% male, 56.3% Aboriginal, mean age 16.6 years ± 1.2 standard deviation). According to Fagerstrom screening, 207 (82.1%) young people smoked cigarettes immediately prior to their current incarceration, and of the smokers, 78 (38.4%) were nicotine dependent. Most young people (76.4%) were also daily cannabis users, with 85.6% of cigarette smokers also using cannabis daily. NRT (as 24-h nicotine patches prescribed for 2 weeks) was offered to 54 nicotine dependent and 7 non-dependent young people. Only 13 (21.3%) young people accepted NRT (all daily cannabis-using males), and only 2 young people completed the full prescription. Reasons for refusing or not completing NRT were a fear of 'weird dreams', sleeping issues or that it was no longer needed.

CONCLUSIONS

Many young people entering custody are nicotine-dependent cigarette smokers and daily cannabis users, and are at high risk of nicotine withdrawal on abstinence. NRT as patch therapy has poor acceptance in this group, except in young men who are daily cannabis users. Screening for nicotine dependence in high-risk young people should include questions about cannabis use, and alternatives to patch therapy deserve further research.

Is it safe to use smoking cessation therapeutics during pregnancy?

INTRODUCTION

Worldwide, 10 to 35% of pregnant women smoke. It is clear that smoking cessation has positive impacts for both the mother and child, yet many women are still unable to quit due to the addictive properties of nicotine. There are limited data surrounding their safety and efficacy in pregnancy.

AREAS COVERED

This review highlights evidence from clinical studies and animal experiments regarding the effects of smoking cessation therapeutics on pregnancy, neonatal and long-term postnatal outcomes.

EXPERT OPINION

There are insufficient data at this time to recommend the use of varenicline and/or bupropion for smoking cessation during pregnancy. In addition, the efficacy and safety of nicotine replacement therapy use for smoking cessation in pregnant women has not been clearly demonstrated. Until further studies are completed, there will continue to be considerable uncertainty regarding the use of these drugs in pregnancy despite the well-documented benefits of smoking cessation.

Assessing preferences for improved smoking cessation medications: a discrete choice experiment

BACKGROUND

The use of smoking cessation medications can considerably enhance the long-term abstinence rate at a reasonable cost, but only a small proportion of quitters seek medical assistance. The objective of this study was to evaluate the factors that influence the decision to use such treatments and the willingness-to-pay of smokers for improved cessation drugs.

METHOD

A discrete choice experiment was conducted amongst smokers in the French-speaking part of Switzerland. Choice sets consisted of two hypothetical medications described via five attributes (price, efficacy, possibility of minor side effects, attenuation of weight gain and availability) and an opt-out option. Various discrete choice models were estimated to analyse both the factors that influence treatment choice and those that influence the overall propensity to use a smoking cessation medication.

RESULTS

Our results indicate that smokers are willing to pay for higher efficacy, less-frequent side effects and prevention of weight gain. Whether the drug is available over-the-counter or on medical prescription is of secondary importance. In addition, we show that there are several individual-specific factors influencing the decision to use such medications, including education level. Results also indicate substantial preference heterogeneity.

CONCLUSION

This study shows that there is a potential demand for improved cessation medications. Broader usage could be reached through lower out-of-pocket price and greater efficacy. Secondary aspects such as side effects and weight gain should also be taken into consideration.

Long-term consequences of fetal and neonatal nicotine exposure: a critical review

Cigarette smoking during pregnancy is associated with numerous obstetrical, fetal, and developmental complications, as well as an increased risk of adverse health consequences in the adult offspring. Nicotine replacement therapy (NRT) has been developed as a pharmacotherapy for smoking cessation and is considered to be a safer alternative for women to smoking during pregnancy. The safety of NRT use during pregnancy has been evaluated in a limited number of short-term human trials, but there is currently no information on the long-term effects of developmental nicotine exposure in humans. However, animal studies suggest that nicotine alone may be a key chemical responsible for many of the long-term effects associated with maternal cigarette smoking on the offspring, such as impaired fertility, type 2 diabetes, obesity, hypertension, neurobehavioral defects, and respiratory dysfunction. This review will examine the long-term effects of fetal and neonatal nicotine exposure on postnatal health.

Smoking cessation aids and strategies among former smokers in Canada

OBJECTIVES

There is a need to better understand the prevalence of use of pharmaceutical aids among former smokers, and explore concerns that those former smokers may have had about using such products. This paper examines the use of various cessation aids and strategies as well as reasons for not using cessation aids among a nationally representative sample of former smokers from Canada.

METHODS

Using data from the 2006 Canadian Tobacco Use Monitoring Survey (CTUMS), univariate analyses were performed to examine the use of different cessation aids, strategies to quit smoking, and reasons for not using cessation aids among former smokers who had quit in the previous two years.

RESULTS

In 2006, over one in four Canadians (27.1% or about 7.2 million persons) aged 15 and older was a former smoker. Overall, female former smokers were more likely to report that they reduced their consumption of cigarettes as a quitting strategy, whereas male former smokers were more likely to report using a pharmacological aids when quitting. Among reasons given for not using cessation aids, lack of trust that these products would work was the most common (15.4%), following by issue of cost (8.5%), concern about possible side effects (5.8%) and lack of information about products (1.8%).

CONCLUSION

These results suggest that men and women use different approaches to quit smoking. Our findings provide new insight which could be used to target cessation programs to the individuals where they are most likely to be effective.

Relationship between cigarette use and mood/anxiety disorders among pregnant methadone-maintained patients

This study investigates the association between cigarette use and current mood/anxiety disorders among pregnant opioid-dependent patients. Pregnant methadone-maintained women (N = 122) completed the Addiction Severity Index and Structured Clinical Interview for DSM-IV. Participants were categorized based on past 30 days cigarette use: no (n = 15) and any smoking (n = 107); this latter group was then subdivided into light (one to ten cigarettes/day; n = 55), and heavy smokers (11+ cigarettes/day; n = 52). Any smoking was significantly associated with any current mood/anxiety disorder (p < 0.001), any current mood disorder (p = 0.007), and any current anxiety disorder (p < 0.001). No significant association was found between specific level of cigarette use and mood/anxiety disorders. This association between smoking and psychiatric disorders has implications for the mental and physical health of methadone-maintained women and their children, and may contribute to the understanding of the physiological mechanisms underlying smoking and nicotine dependence.

Disrupting nicotine reinforcement: from cigarette to brain

Cigarette smoking is a tenacious addiction that is maintained to a significant extent by the reinforcing effects of nicotine. An emerging theme in smoking cessation treatment is the development of methods for interfering with these reinforcing effects. By attenuating nicotine reinforcement, treatments may enhance a smoker's chances of successfully remaining abstinent. Several treatment approaches will be described, including the use of denicotinized cigarettes, nicotine vaccines, nicotinic receptor agonists and antagonists, and modulators of brain reinforcement processes. These techniques highlight the numerous sites along the path between the cigarette and the brain that can be targeted for intervention. In addition to unimodal therapies, treatment combinations will be discussed that might more effectively block cigarette reward and thereby further enhance smoking abstinence.

The effects of smoking on bone health

Osteoporotic fractures are a major public health problem in most developed countries and an increasing concern in much of the developing world. This healthcare burden will increase significantly worldwide over the next 20 years due to aging of the population. Smoking is a key lifestyle risk factor for bone loss and fractures that appears to be independent of other risk factors for fracture such as age, weight, sex and menopausal status. This review discusses the effects of smoking on bone health in pre-menopausal and post-menopausal women and men. Data from twin studies and the three main published meta-analyses are presented. Possible mechanisms by which smoking affects bone mass are reviewed. Despite smoking being a major lifestyle risk factor for osteoporosis, the mechanisms underlying smoking-associated bone loss and fracture risk remain poorly understood. The effect appears dose-dependent, and may be, at least partially, reversible. However, more work is required to confirm and characterize the reversibility of smoking-associated bone defects. Finally, strategies for quitting smoking are discussed. Encouragement of lifestyle alterations, including smoking cessation, should be a major component of any bone therapeutic programme.

Social factors, psychopathology, and maternal smoking during pregnancy

We investigated the relative importance of sociodemographic factors and psychiatric disorders for smoking among 453 pregnant women in the National Epidemiological Survey on Alcohol and Related Conditions. Women with less than a high school education and those with current-year nicotine dependence had the highest risk of smoking (90.5%), compared with women with a college degree and without nicotine dependence (3.9%). More effective and accessible interventions for nicotine dependence among pregnant smokers are needed.

Fetal and neonatal exposure to nicotine in Wistar rats results in increased beta cell apoptosis at birth and postnatal endocrine and metabolic changes associated with type 2 diabetes

AIMS/HYPOTHESIS

Epidemiological studies report an increased risk of obesity and type 2 diabetes in children born to women who smoked during pregnancy. This study examines the effect of fetal and neonatal exposure to nicotine, the major addictive component of cigarettes, on postnatal growth, adiposity and glucose homeostasis.

METHODS

Female Wistar rats were given either saline (vehicle) or nicotine (1 mg kg(-1) day(-1)) during pregnancy and lactation. Serum and pancreas tissue were collected from the infant rats at birth. Postnatal growth was assessed weekly until the rats reached 26 weeks of age and glucose homeostasis was examined by OGTTs performed at 7 and 26 weeks of age.

RESULTS

Exposure to nicotine resulted in increased postnatal growth and adiposity. Nicotine exposure also resulted in dysglycaemia at 7 and 26 weeks of age. Serum insulin concentrations were decreased in the pups exposed to nicotine at birth. This was associated with increased beta cell apoptosis (pups of saline-treated mothers 8.8+/-1.21% apoptotic beta cells; pups of nicotine-treated mothers 27.8+/-3.1% apoptotic beta cells).

CONCLUSIONS/INTERPRETATION

Fetal and neonatal exposure to nicotine results in metabolic changes in the offspring that are consistent with obesity and type 2 diabetes. We propose that these metabolic changes may be a consequence of the initial insult to the beta cell during fetal life and that this animal model has many characteristics of diabetes in humans.

Naltrexone reduces the relative reinforcing value of nicotine in a cigarette smoking choice paradigm

RATIONALE

Human behavioral pharmacology studies can examine how medications that target different neurotransmitter systems influence different aspects of smoking. Naltrexone and bupropion have been shown to alter ad lib smoking behavior; however, medication effects on nicotine reward in a cigarette choice paradigm have yet to be investigated.

OBJECTIVE

This study explored the effects of an acute dose of naltrexone, bupropion, or placebo on the relative reinforcing value of nicotine from cigarette smoking using new nicotine and de-nicotinized (Quest, 0.6 and 0.05 mg = "denicotinized") cigarettes.

METHODS

In a double-blind, within-subjects design, 26 dependent smokers participated in three experimental cigarette smoking sessions following pretreatment with either naltrexone (50 mg), bupropion (300 mg), or placebo. After medication administration and 2 h of monitored deprivation from cigarettes and food, participants rated their responses to the initial exposure to the cigarettes and then participated in four choice sessions over a 2-h period during which they could take four puffs from either cigarette.

RESULTS

The relative reinforcing value of nicotine, as measured by the number of nicotine puffs chosen out of 16, was significantly lower following naltrexone compared to placebo. There were no effects of an acute dose of bupropion on nicotine choices.

CONCLUSIONS

These results suggest that naltrexone may reduce the relative reinforcing effects of nicotine via cigarette smoking and support ongoing investigation of opioid antagonists as potential smoking cessation pharmacotherapies.

Combination treatment for nicotine dependence: state of the science

Both nicotine replacement and sustained-release buproprion double the odds of achieving short- and moderate-term abstinence from nicotine. However, questions remain about the efficacy of combining pharmacotherapies. Our purposes were to review the evidence for (1) combined pharmacotherapy and (2) multimodal treatment combining pharmacotherapy and behavioral treatment and to recommend combinations of treatments to reduce nicotine dependence. Combining first-line pharmacotherapies with each other or with investigational drugs shows little benefit. In contrast, trials combining specific behavioral treatments with first-line pharmacotherapies show enhanced smoking cessation rates, but benefits are not seen in all populations. We recommend future directions for research, including better specification of behavioral components and further examination of the length and timing of treatment.

Grey lungs and blue moods: smoking cessation in the context of lifetime depression history

OBJECTIVE

To present an overview of the relationship between depression and cigarette smoking and to provide recommendations for clinicians who wish to help patients with a history of depression to stop smoking.

METHOD

English language journal articles published in the last 15 years on clinical material related to depression history, smoking cessation and related health issues were collected via MEDLINE, PsycINFO and Cochrane Library database searches.

RESULTS

Nicotine dependence is associated with increased rates of depression prior to and after taking up smoking as well as increased rates of suicidal ideation. Depression history is associated with increased rates of nicotine dependence, problems with smoking cessation and depression after cessation. While nicotine replacement and counselling are effective for smoking cessation, standard smoking cessation strategies may not pay sufficient attention to the needs of smokers with a depression history. Some antidepressants (bupropion and nortriptyline) are particularly effective for those with a lifetime depression history as they appear to assist with dysphoria during withdrawal and prevent relapse. Psychological and lifestyle strategies, such as motivational interviewing, relaxation exercises and mood charts, assist in mood regulation over and above the standard smoking cessation treatments for smokers with a depression history, who require more attention to relapse of depression and smoking after quitting.

CONCLUSIONS

There is a complex and circular relationship between depression, smoking and medical illness that complicates smoking cessation in those who have a history of depression. Depression-history smokers require a multimodal approach to assist with mood regulation and nicotine withdrawal. Further research is required to identify effective strategies to reduce smoking in this context.

Smoking Cessation Strategies in Patients with Peripheral Arterial Disease: An Evidence-based Approach

INTRODUCTION

Smoking is the single most important aetiological factor for the development and progression of atherosclerosis. Unfortunately, most patients receive little or no treatment for their nicotine addiction. This review aims to make evidence based recommendations for smoking cessation as part of a comprehensive delivery of best medical therapy to patients with peripheral arterial disease.

METHODS

A search of MEDLINE (1966 to 2003) and the Cochrane library was undertaken for studies relating to smoking cessation. Major priority was given to meta-analyses of randomised controlled trials including Cochrane reviews.

RESULTS

Physician advise, nicotine replacement therapy and Bupropion are all evidence based treatments that have success in increasing the likelihood of permanent smoking cessation. A basic understanding of the psychology of addictive behaviour is essential so that appropriate advice and treatment can be tailored to individual patients.

CONCLUSIONS

Complete and permanent smoking cessation is by far the most clinically and cost effective intervention in patients with atherosclerosis. Greater awareness of smoking cessation strategies, by clinicians treating vascular patients, is essential for the effective delivery of best medical therapy.

Hypericum perforatum attenuates nicotine withdrawal signs in mice

RATIONALE

Hypericum perforatum is used as a natural antidepressant, and other antidepressants have been marketed to aid in smoking cessation.

OBJECTIVE

We investigated the effects of an extract of Hypericum perforatum (Ph-50) on withdrawal signs produced by nicotine abstinence in mice.

METHODS

Nicotine (2 mg/kg, four injections daily) was administered for 14 days to mice. Different doses of Ph-50 (125-500 mg/kg) were administered orally immediately after the last nicotine injection. In another experiment, Ph-50 (500 mg/kg) was orally administered in combination with nicotine, i) starting from day 8 until the end of the nicotine treatment period, or ii) during nicotine treatment and after nicotine withdrawal, or iii) immediately after the last nicotine injection. On withdrawal from nicotine, all animals were evaluated for locomotor activity and abstinence signs.

RESULTS

The locomotor activity reduction induced by nicotine withdrawal was abolished by Ph-50, which also significantly and dose-dependently reduced the total nicotine abstinence score when injected after nicotine withdrawal.

CONCLUSIONS

These data show that treatment with Hypericum perforatum attenuates nicotine withdrawal signs in mice. Further studies are necessary to test the possibility that it may be used for smoking cessation treatment in humans.

Substance misuse in patients with schizophrenia: a primary care guide

Smoking presents a substantial health and economic burden to people with schizophrenia. Comorbid use of other substances is common, under-recognised, and associated with a number of serious adverse consequences, such as psychotic relapse and poorer social outcomes. All patients with schizophrenia need to be screened for substance misuse. Effective interventions involve integrated, modified pharmacological and psychosocial strategies.