Smoking cessation: Tactics that make a big difference

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Applied Evidence

Smoking cessation: Tactics that make a big difference

J Fam Pract. 2007 October;56(10):817-824

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References

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Two RCTs have assessed varenicline against both bupropion and placebo (TABLE 3). Jorenby²⁴ (SOR: A) showed the varenicline-treated participants were significantly more likely to be continuously abstinent at 52 weeks than the placebo-or bupropion-treated groups (23% vs 10.3% placebo [OR=2.66; 95% CI, 1.72–4.11; P<.001] and 14.6% bupropion [OR=1.77; 95% CI, 1.19–2.63; P=.004]). Gonzales²⁵ (SOR: A) likewise showed the varenicline treated smokers were more likely to be continuously abstinent at 52 weeks than the placebo group (21.9% vs 8.4% [OR=3.09; 95% CI, 1.95–4.91; P<.001]). However, the difference between varenicline and bupropion did not reach statistical significance (21.9% vs 16.1% [OR=1.46; 95% CI, 0.99–2.17; P=.057]).

As with other medications, varenicline should be started at a low dose. The patient begins with 0.5 mg nightly for the first 3 nights, then increases to 0.5 mg twice a day for 4 days. The second week, the patient begins the 1 mg twice-daily dosing that is continued through treatment.

TABLE 3
Varenicline, nortriptyline, bupropion—strong allies in patients’ efforts to quit

THERAPY	OR (95% CI)	N (PARTICIPA NTS/TRAILS)	NNT	DURATION OF THERAPY	COST OF 4 WEEKS (BRAND/GENERIC)*
Varenicline^24,25	2.80 (2.03–3.88)	1161/2	7.6	12 weeks	$120/NA
Nortriptyline¹⁵	2.79 (1.70–4.59)	703/4	9.8	12 weeks	$814/$8
Sustained-release bupropion¹⁵	2.06 (1.77–2.40)	6443/19	10.2	7–12 weeks	$210/$100
Clonidine²³	1.89 (1.30–2.74)	776/6	9.4	3–4 weeks	$74/$4
Venlafaxine¹⁵	1.33 (0.59–3.00)	136/1	20.4		$145/NA
Diazepam²³	1.00 (0.39–2.54)	76/1	No difference		$209/$27
SSRI¹⁵	0.90 (0.68–1.18)	1768/6	20.7		$170/$4
Buspirone²³	0.71 (0.34–1.48)	201/3	22.1		$280/$84
*Cost based on prices from Walgreen’s and Target Pharmacies, May and September 2007.
OR, odds ratio; NNT, number needed to treat; SSRI, selective serotonin reuptake inhibitors; NA, not available.

Vaccines hold the promise of continued abstinence

Several promising ideas for the treatment of tobacco dependence are in development. There are several vaccines being studied.²⁶ When the immune system produces antibodies to nicotine in response to the vaccine, and when these antibodies bind to the nicotine, the resultant compound is too large to cross the blood-brain barrier. This prevents the reinforcing effect of nicotine. Initial studies of vaccines show that smokers do decrease the amount they smoke, but more importantly, abstinence is easier to maintain. However, the vaccine requires frequent boosters to maintain antibody titers that are effective.

NicVAX from Nabi Biopharmaceuticals was placed on a fast track for approval by the Food and Drug Administration. It is, however, still at least a year away from approval. The other 2 nicotine vaccines are probably several years beyond that for approval.²⁷

FAST TRACK

2 studies suggest that varenicline may be at least as good as—or better than—bupropion for long-term smoking cessation

Researchers are also studying other compounds that block the euphoria associated with smoking.²⁸ The initial studies of rimonabant (Acomplia), a cannabinoid blocker, have shown it is no better than other treatments already available. With its indication in some European countries for weight loss, it offered promise as an important option for patients who are concerned about the weight gain associated with smoking cessation. However, the FDA did not approve rimonabant for tobacco cessation when issuing its initial approval letter for weight loss in 2006. Because of safety concerns, the manufacturer subsequently withdrew the new drug application for rimonabant in 2007.

With much work, our patient kicks the habit

Ann began taking varenicline the day she left the office, and reached her quit date a week later.

FAST TRACK

Early studies suggest that nicotine vaccines may make abstinence from smoking easier to maintain

At her 1-month follow-up, Ann reported that it was actually easy for her to stay off the cigarettes. With the varenicline, she had lost the desire to smoke. I reminded her to work on the triggers for her smoking: I urged her to make sure that she did not light up when she made her morning coffee or got in the car. I also suggested she put $4 each morning into a jar on her dresser; so she would see how much she saved now that she wasn’t buying cigarettes.

At Ann’s next annual exam, we marked her in the computer system as a reformed smoker. She was very proud of that label. I asked her what she was doing with all that extra cash. She laughed: “My daughter spends it all! but not on cigarettes!”

Acknowledgments

This research was supported by the Intramural Research Program of the NIH, National Institute on Drug Abuse.

Correspondence
Agnes O. Coffay, MD, NIDA/IRP, 5500 Nathan Shock Drive, B altimore, MD 21224-6823. coffaya@mail.nih.gov