September 29, 2011
Smoking Cessation: What medications are most effective for smoking cessation?
Teaching Topic
Smoking Cessation
Clinical Practice
Treating Smokers in the Health Care Setting
M.C. Fiore and T.B. Baker
Tobacco use remains the chief avoidable cause of death in the United States; it is directly responsible for about one fifth of all deaths.
Clinical Pearl
How has the prevalence of smoking changed in the United States?
The prevalence of smoking has declined dramatically in the United States over the past half century, decreasing from about 42% in the 1960s to about 20% today. However, this decline has stalled recently, and higher prevalence rates are concentrated in populations with low incomes, low educational levels, and psychiatric conditions.
What approximate abstinence rates can be expected 6 months after initiating smoking cessation treatment with most medications?
A meta-analysis of 83 randomized trials examining the effectiveness of various medications with respect to the rate of abstinence 6 months after treatment showed that most medications for smoking cessation (e.g., nicotine patches, gum, lozenges, nasal spray, inhalers, and bupropion) approximately doubled the odds of achieving abstinence. The estimated 6-month abstinence rate among patients randomly assigned to placebo was about 14%, versus 19 to 26% across most pharmacotherapies.
Morning Report Questions
Q. What therapies are most effective for smoking cessation?
A. Varenicline and combination nicotine-replacement therapy (e.g., the nicotine patch plus a stronger form of nicotine-replacement therapy such as nicotine gum or lozenges) were associated with estimated abstinence rates of 33 and 37%, respectively. These rates were significantly higher than that associated with a representative monotherapy (the nicotine patch).
Q. What are the risks associated with the use of varenicline?
A. In 2010, on the basis of postmarketing surveillance, the FDA issued a black-box warning for both varenicline and bupropion concerning serious neuropsychiatric symptoms such as hostility, agitation, depressed mood, and suicidal thoughts and behavior. Also, a recent drug-safety communication from the FDA noted that varenicline may be associated with a small increase in the risk of cardiovascular events, including heart attack, and it called for physicians to weigh the risks and benefits of the use of varenicline in patients with cardiovascular disease.
