{"id":969,"date":"2016-02-10T20:57:22","date_gmt":"2016-02-10T20:57:22","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=969"},"modified":"2017-08-21T11:09:30","modified_gmt":"2017-08-21T11:09:30","slug":"primary-care-corner-with-geoffrey-modest-md-smoking-cessation-comparison-of-therapies","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/02\/10\/primary-care-corner-with-geoffrey-modest-md-smoking-cessation-comparison-of-therapies\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Smoking Cessation Comparison of Therapies"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>A randomized controlled trial was compared different therapies to aid in smoking cessation (see\u00a0JAMA. 2016;315(4):371).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>1086 smokers (mean age 48, 52% women, 67% white\/28% black\/3% latino, mean income &gt;$35K in 46%) who had been smoking a\u00a0mean of 17 cigarettes\/d\u200b over mean of 29 years. Fagerstrom Test of Nicotine Dependence (FTND) score of 4.8, reflecting low-to-moderate dependence, with 77% smoking within 30 minutes of awakening<\/li>\n<li>Randomized to open-label varenicline, titrating up to 1mg bid as tolerated; nicotine replacement patch (NRT), starting with 8 weeks of 21-mg patch, then 2 weeks of 14-mg patch, then 2 weeks of 7-mg patch (but in those smoking 5-10 cigarettes\/d, 10 weeks of\u00a014-mg patch then 2 of 7-mg patch); or patch plus nicotine lozenges (C-NRT group), with patches as in other group plus 2 or 4mg lozenges and asked to use at least 5\/day. All interventions were for 12 weeks.<\/li>\n<li>All received 5 counseling sessions at the times of visits, and 1 telephone call.<\/li>\n<li>Smoking assessment was at 26 and 52 weeks post quit date by telephone interview; quit rates confirmed by exhaled carbon monoxide &lt;= 5\u00a0ppm, which &#8220;optimally distinguishes smokers from nonsmokers&#8221;.<\/li>\n<li>Results (none of these showed any significant difference for one method over another):\n<ul>\n<li>Medication adherence rates were similar: at week 8 &#8212; 45.2% for patch; 49.3% for varenicline;\u00a0and\u00a049.6% (patch) and 43.0% (lozenges) for\u00a0C-NRT<\/li>\n<li>7-day point-prevalence abstinence at 26 weeks post-quit date were:\n<ul>\n<li>8% for nicotine patch alone<\/li>\n<li>6% for varenicline<\/li>\n<li>6% for C-NRT (patch plus lozenges)<\/li>\n<\/ul>\n<\/li>\n<li>7-day point-prevalence abstinence at 52\u00a0weeks post-quit date were:\n<ul>\n<li>8% for nicotine patch alone<\/li>\n<li>1% for varenicline<\/li>\n<li>2% for C-NRT (patch plus lozenges)<\/li>\n<\/ul>\n<\/li>\n<li>Prolonged abstinence at 26 weeks (no smoking from day 7 to day 181 after quit date):\n<ul>\n<li>9% for nicotine patch alone<\/li>\n<li>5% for varenicline<\/li>\n<li>4% for C-NRT (patch plus lozenges)<\/li>\n<\/ul>\n<\/li>\n<li>\u200bAdverse events: more rash (11%) and itching\/hives (20%)with patch. More vivid dreams (23%),\u00a0insomnia (22.2%)\/sleepiness (16%), and\u00a0nausea (28.5%) with varenicline<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>So, a few points:<\/p>\n<ul>\n<li>Though there were some minor differences early in the study (varenicline and C-NRT were better than patch alone in reducing withdrawal and craving symptoms; C-NRT had higher initial abstinence rates), there was no difference at the 26 and 52-week marks<\/li>\n<li>This study does call into question the model of basal nicotine and rapid-acting lozenges for &#8220;break-through&#8221; urges, since there really was no difference in terms of clinically-relevant outcomes. Also, this study, unlike some others, did not show clinical superiority for varenicline over other treatments, with pretty clearly increased significant adverse events.<\/li>\n<li>And, putting this in perspective, in terms of preventing\u00a0cardiovascular disease, the single most effective intervention is smoking cessation for those who are smokers, more efficacious than lowering blood pressure, improving diabetic control, or using a statin or aspirin. This study confirms the efficacy of differing modalities in helping patients stop smoking. I would add that for some patients combination therapies work better\u00a0(NRT\u00a0plus bupropion, or even NRT\u00a0plus varenicline), though I usually try a single intervention first to minimize adverse events. Also, I would stress that motivational interviewing is really helpful both in helping patients get ready for smoking cessation as well as helping them through the process. And, at risk of my devolving (?again) to be a pariah, I have had some reasonable success with some patients by encouraging e-cigarettes as a crutch to stopping smoking (though I usually suggest the more traditional medical therapies, as above, first).<\/li>\n<\/ul>\n<p>See prior blogs:<\/p>\n<ul>\n<li><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/02\/26\/primary-care-corner-with-geoffrey-modest-md-varenicline-for-almost-ready-smoker-cessation\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/02\/26\/primary-care-corner-with-geoffrey-modest-md-varenicline-for-almost-ready-smoker-cessation\/<\/a> , a study which challenged the prevailing wisdom that smokers needed to be ready to quit to have any success (this study showed a 35% quit rate at one-year\u00a0for varenicline in those not ready to quit but willing to try to reduce their smoking, vs 18% with placebo. It would be great to repeat this multinational study with nicotine replacement therapy.<\/li>\n<li>For other blogs on smoking cessation, see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/smoking\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/smoking\/<\/a> , including some studies on combo therapies, use of cytisine.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Smoking Cessation Comparison of Therapies  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/02\/10\/primary-care-corner-with-geoffrey-modest-md-smoking-cessation-comparison-of-therapies\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-969","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/969","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=969"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/969\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=969"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=969"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=969"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}