Smoking cessation: What should you recommend?
Fifty years after a landmark report on its perils, smoking remains a major public health problem. Here’s the latest on how best to help patients quit.
Adverse effects of e-cigarettes include minor irritation of the throat, mouth, and lungs. Among cigarette-naive patients, light-headedness, throat irritation, dizziness, and cough were most commonly reported. No serious adverse events have been reported, but the lack of long-term safety data is a source of concern.32
Additionally, minimal regulatory oversight of the e-cigarette industry exists. Currently, the FDA only has authority to regulate e-cigarettes that are marketed for therapeutic purposes, although the agency is seeking to extend its oversight to all e-cigarettes.
The bottom line: More data on safety and regulatory oversight are needed before recommendations on the use of e-cigarettes as a smoking cessation tool can be made.
Looking ahead
Several novel pharmacotherapies have been evaluated for smoking cessation in recent years. Among them is a nicotine vaccine that several drug companies have been pursuing. In theory, such a vaccine would create an immunologic reaction to nicotine in a smoker, thereby preventing the substance from reaching the brain and providing rewarding stimuli. A 2008 Cochrane review of 4 trials assessing the efficacy of nicotine vaccines for tobacco cessation found that none showed efficacy.34
Naltrexone, an opioid antagonist, has shown efficacy in helping those with opioid or alcohol dependence achieve abstinence from these substances, raising the possibility that it might aid in smoking cessation, as well. A 2013 Cochrane review of 8 trials found that this was not the case: Compared with placebo, naltrexone was not beneficial when used alone (RR=1.00; 95% CI, 0.66-1.51) or as an adjunct to NRT compared with NRT alone (RR=0.95; 95% CI, 0.70-1.30).35
Cytisine, an extract from plants in the Faboideae family, has been used in Eastern Europe for decades for smoking cessation. It appears to work as a nicotine receptor partial agonist similar to varenicline. The extract does not have FDA approval, but the National Institutes of Health’s Center for Complementary and Integrative Health is sponsoring early-stage safety trials that could lead to its approval in the United States.36
A 2012 Cochrane review identified 2 recent RCTs evaluating cytisine and found it to be effective in increasing smoking cessation rates vs placebo (RR=3.98; 95% CI, 2.01-7.87).13
CORRESPONDENCE
Paul Bornemann, MD, 3209 Colonial Drive, Columbia, SC 29203; paul.bornemann@uscmed.sc.edu.
ACKNOWLEDGEMENT
The authors thank Matt Orr, PhD, and Kathryn E. Bornemann for their help with this manuscript.
