The Evaluation and Treatment of Tobacco Use Disorder
A recent Cochrane review27 found that group therapy is more effective than self-help materials but is not consistently better than personal contact. Although groups are theoretically more cost-effective, their usefulness may be limited by participant recruitment and retention problems.28,29 Current evidence does not support efficacy of acupuncture or hypnosis as treatment for smoking cessation.17,30
Pharmacotherapy
Because success rates associated with nonpharmacologic treatments are generally lower, pharmacotherapy should be offered to every smoker willing to make a quit attempt unless there is a medical contraindication.10 The 5 pharmacologic agents approved by the US Food and Drug Administration for treatment of tobacco use disorder include 4 nicotine replacement therapies (NRT)—gum, patch, spray, inhaler—and one non-nicotine therapy, bupropion. All 5 agents promote similar success rates in long-term smoking cessation if they are prescribed to meet the needs of the individual smoker.31
Nicotine gum. A meta-analysis of randomized controlled trials among specialized cessation clinics found higher success rates for patients treated with nicotine gum compared with use of placebo gum at 6 months (27% vs 18%).32 This is in contrast with studies conducted in general medical practices, where success rates (12%) with nicotine gum at 6 months were no different from placebo.33 Higher quit rates in specialized smoking cessation clinics may be a result of more in-depth counseling, better-trained counselors, and inclusion of smokers with a higher motivation to quit. The gum is available without prescription and comes in 2-mg and 4-mg doses. The 4-mg dose is more efficacious in more dependent smokers.34 Treatment is recommended for 8 weeks.
Nicotine patches. The patches have been shown to be effective under controlled as well as real-world settings.35-37 A meta-analysis of 17 randomized trials estimated the efficacy of the nicotine patch as 27% at end of treatment and 22% at 6 months compared with 13% and 9%, respectively, for placebo.38 Treatment beyond 8 weeks did not increase efficacy. The patches are available in 16-mg and 21-mg dosages (with 14-mg and 7-mg step-down doses). Although weaning is strongly encouraged by most marketers of nicotine patches, current data do not support added beneficial effect for this step-down approach.38 The highest dose should be used for those who smoke more than 10 cigarettes per day and reduced dosage forms for light smokers. The optimal dosage for light smokers is not known because of limited data in this group. The patches are contraindicated for patients with systemic eczema, unstable angina, and within 1 month of a myocardial infarction.
Nicotine nasal spray. Abstinence rate at 6 months from meta-analysis was 31% for the spray compared with 14% for placebo.17 A dose is one spray into each nostril; each spray delivers 0.5 mg of nicotine. Patients should use 1 to 2 doses every hour for 6 to 8 weeks. A drawback is that the spray seems to have the highest addictive potential of all NRTs.39,40 Patients who experience withdrawal symptoms with abrupt cessation of treatment should be considered for 4 to 6 weeks of tapering. Tapering could be achieved by reducing the dose by half every week. The most commonly reported side effects of the nicotine nasal spray include nasal irritation, runny nose, sneezing, throat irritation, coughing, and watery eyes. Patients usually develop tolerance to these effects within the first week.
Nicotine inhaler. A unique feature of the nicotine inhaler is that it mimics the hand-to-mouth routine similar to cigarette smoking and may therefore reduce fears associated with abrupt cessation of the hand-to-mouth ritual. The inhaler consists of a plastic mouthpiece to which a cartridge is attached. The cartridge contains 10 mg (but delivers only 4 mg) of nicotine plus 1 mg of menthol. The inhaler is different from typical inhalers in that patients puff on the mouthpiece, and nicotine is absorbed in the mouth rather than the lungs. Abstinence rates at 6 months were 23% for the inhaler and 11% for placebo.17 Recommended dosage is 6 to 16 cartridges per day for 8 weeks. Patients should self-titrate their dosing based on severity of withdrawal symptoms experienced. Adverse events are generally mild, consisting of throat irritation and cough.
Bupropion. This is an alternative for smokers who either cannot tolerate nicotine replacement therapy or prefer non-nicotine treatment. The efficacy of bupropion for smoking cessation has been demonstrated in 2 randomized controlled trials.41,42 Abstinence rates at 6 months were approximately 30% for bupropion versus 17% for placebo. Common adverse effects are generally mild, consisting of insomnia and dry mouth; headache and tremors are less common. This drug is contraindicated for patients with history of seizures, anorexia or bulimia, head trauma, or heavy alcohol use, and is category B for pregnancy.
