Neil Perlman,MD, The Quit Doctor

Report on efficacy of smoking
cessation medication and therapies

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Despite 36 years of Surgeon General warnings, 23.5% of adults still smoke in the United States [1]. An estimated 430,700 Americans die each year from diseases caused by smoking [2]. Smoking is responsible for an estimated one in five U.S. deaths and costs the U.S. at least $97.2 billion each year in health care costs and lost productivity. While cigarette companies have finally admitted that cigarette smoking is addictive, and pharmaceutical companies have produced and marketed several smoking cessation products, the success rate of smoking cessation is low. Just as hypertension and diabetes often require more then one medication for adequate control, successful smoking cessation may require multiple therapies for success..

Physician advice to encourage smoking cessation has been studied extensively over the last 15 years. There have been several large studies of physician advice that have shown quit rates of up to 10% [9,10]. Providing patients with printed smoking cessation information has some limited efficacy in helping smokers to quit, but cessation rates are not high [11 Follow-up for patients trying to quit smoking can increase the effectiveness of physician advice and double cessation rates.

Behavioral therapy as a means of smoking cessation has been studied extensively, and cessation rates average 20% for patients willing to participate in such therapy. For example, Lando et al. [16] found that the quit rates with the American Lung Association and American Cancer Society programs were 16% and 22%, respectively, at one year. The main disadvantage of this approach is that relatively few smokers (about 5%) are interested in attending classes at any given time [17].

Simple computer-tailored cessation messages may be an effective alternative for behavioral support. Strecher et al. [18] sent either a customized letter based on an interview from the doctor’s office or a generic “Quit for Good” pamphlet from the National Cancer Institute. The four-month cessation rates were 30.7% vs. 7.1% for smokers who smoke less than 20 cigarettes a day and 9% vs. 7.7% for those who smoke more than 20 cigarettes a day. A second study by the same author showed that adult smokers interested in quitting on their last exam had a 19.1% vs. 7.3% (<20 cigarettes a day) 6-month cessation rate if they were given a tailored letter vs. no letter. Interestingly, for smokers of more that one pack of cigarettes per day, the quit rate was not improved (7.3% vs. 9.8). Other studies confirm the utility of expert systems which generate tailored cessation messages (in the form of letter or pamphlet) in quitting [19,20,21,22].

The ease of once or twice a day dosing makes drug therapy a very attractive method of smoking cessation; however, use of drugs without concomitant behavioral interventions, and unrealistic expectations on the part of patients and physicians, tend to compromise the results of drug therapy. The most common medication used for smoking cessation has been in the form of nicotine replacement. Other medications include antidepressants [26], both as single agents and in combination with nicotine replacement.

Nicotine replacement is available as a gum, patch, nasal spray, and inhaler. The efficacy of nicotine replacement products is similar, with each agent leading to a doubling of the cessation rate versus placebo. The use of the patch has been shown to be cost-effective [30]. The product inserts for all transdermal nicotine products indicate that they should be used as part of a behaviorally-based cessation program. However, many patients receive the patch without any physician advice or behavioral support [30]; without behavioral help, studies have shown very low quit rates with nicotine patch (on the order of 5%). A meta-analysis of the effectiveness of the nicotine patch by Fiore et al. showed that subjects were more likely to become abstinent if counseling was a major intended reason for patient contacts, if there were at least weekly patient meetings in the first 4 weeks of treatment and if there were at least seven meetings in the first 12 weeks of treatment [31].

Of the anti-depressant medications available, only Bupropion has been approved by the FDA for smoking cessation. It works on both the dopamine and norepinephrine transmitter systems (Zyban; GlaxoSmithKlein; Research Triangle Park, NC). Zyban was developed specifically for smoking cessation, and comes with a smoker support program that includes messages on quitting and relapse prevention [32]. Bupropion at 300 mg/day showed a 36% quit rate at 4 weeks (n=156) but only a 19% 26 week quit rate. When combined with the nicotine patch, a 58% 4 week quit rate was achieved. Follow-up to 1 year suggested a continued benefit to bupropion therapy [33].

However, the costs of bupropion therapy are relatively high. Zyban, the most effective medication, costs $79.73 per month, with a standard 3-month therapy costing $239.19. Transdermal nicotine patches cost about $3 per day, or $270 for a 12-week program. If those two therapies are combined, as suggested by the study included in the PDR for Zyban, over $500 would be spent to help quit smoking, with only a 58% short-term quit rate. While this may seem high, a one pack-a-day smoker ($4/pack) will spend $120 per month or $1,460 annually. Nevertheless, the short-term expense is often perceived as prohibitive to the smoker

As discussed above, most smoking cessation efforts have consisted of short-term, acute interventions, and have had limited success. However, studies show that when smoking cessation plans incorporate long-term reinforcement of smoking cessation goals, the quit rates can increase significantly. In a study by Russell et al., general practitioners trained in simple smoking cessation techniques had double the rate of decline in overall smoking prevalence compared to brief advice-only practices [34]. Solberg et al. [35] organized a family practice to identify smokers, systematize brief advice following a stages-of-change model, and simplify follow-up. They found that the overall quit rate was 20% over a 2-year period.

In addition, there are indications that the ability to quit and stay quit is associated with a number of psychosocial and demographic variables [38,39]. For example, the majority of studies have found that men are more likely to quit than women [38,39,40], although data are equivocal [41,42,43]. Being married also seems to facilitate quitting and sustained cessation [39,40], although other forms of social support have been found to be beneficial as well [38]. Conversely, negative support from any source has been shown to be deleterious [44]. Not surprisingly, the number of other current smokers in the household has been shown to be negatively correlated with ability to quit and prevent relapse [39]. Additionally, the presence of smoking-related environmental cues (such as ashtrays and cigarette lighters) predicted lower cessation success rates [37].

Overall, these results suggest that smoking cessation programs which are responsive to the particular needs and presses of individual smokers would have a greater chance of success. Similarly, because more intensive treatments are associated with better outcomes [56], a long-term behavioral intervention that would be as easy to use as a daily pill or patch should considerably increase rates of smoking cessation and abstinence.

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