Smoking cessation: Tactics that make a difference
Telephone “quitlines,” Web support, text messaging, and drugs all boost the quit rate—if you set the stage
IN THIS ARTICLE
TABLE 2
Nicotine replacement therapy: Methods are similarly effective11
| THERAPY | ODDS RATIO (95% CI) | NO. OF PARTICIPANTS/TRIALS | NNT | DURATION OF THERAPY | COST OF 4 WEEKS (BRAND/GENERIC) † |
|---|---|---|---|---|---|
| Nasal spray | 2.35 (1.63–3.38) | 887/4 | 8.3 | 3–6 months | $560/NA |
| Inhaler | 2.14 (1.44–3.18) | 976/4 | 12.5 | 3 months, then 3-month taper | $504/NA |
| Lozenges | 2.05 (1.62–2.59) | 2,739/5 | 14.3 | Up to 12 weeks | $300/$240 |
| Patch | 1.84 (1.65–2.06) | 16,228/37 | 16.7 | 8–12 weeks | $110/$92 |
| NRT (all) | 1.77 (1.66–1.88) | 39,503/105 | * | ||
| Gum | 1.66 (1.51–1.81) | 17,819/52 | 12.5 | Up to 12 weeks | 4 mg: $234/$180 2 mg: $204/$150 |
| * Numbers not available. | |||||
| † Cost based on prices from Walgreen’s and Target Pharmacies, May and September 2007. | |||||
| NNT, number needed to treat; NA, product not available. | |||||
Sustained-release bupropion: Similar results to NRT
The other first-line therapy suggested by the AHRQ guidelines is sustained-release bupropion (Wellbutrin).2,3 A separate Cochrane Review analyzed the data from 36 studies using antidepressants and revealed that two thirds of the studies used bupropion.15 The odds of quitting smoking essentially doubled in the placebo-controlled studies when the patient used bupropion. This effect is similar to that of NRT. Neither the AHRQ guidelines nor the Cochrane Review recommend bupropion over NRT, or vice versa.
According to the Cochrane Review, there was no benefit to increasing the dosage of bupropion from 150 mg to 300 mg daily.15 Although the initial multidose study of bupropion showed a difference between dosages, it was not clinically significant by the end of the study.16 A larger, open-label randomized trial of 1,524 smokers followed for 1 year had similar results.17 At the 3-month evaluation, the higher dosage had superior efficacy, but that effect was not statistically significant by the end of the study.
Lastly, there is no benefit to continuing the bupropion beyond 7 weeks after the target quit date.
With other antidepressants, results vary
The Cochrane Review also looked at other antidepressants. There were four RCTs of nortriptyline (Aventyl/Pamelor) without NRT, totaling 777 smokers followed for at least 6 months.18-21 The pooled data essentially showed a doubling of the odds of quitting from 7% among controls to 17.2% in the treated groups (OR=2.79; 95% CI, 1.70–4.59). Adding nortriptyline to NRT did increase the quit rate, but not significantly. The dosage used in these studies (75–150 mg) is much lower than that used for depression, where significant side effects often interfere with treatment. Generally, the starting dosage for smoking cessation is 25 mg at bedtime. After 1 week, the dosage is increased to 50 mg, and the following week it is increased again to 75 mg. After a week at 75 mg, the dose is titrated upward only if necessary. The titration continues at an additional 25 mg weekly.
One of the four placebo-controlled studies included both nortriptyline and bupropion arms.20 The abstinence rates, as indicated by no smoking during the final week of treatment, were comparable for the two groups that received active medication. Treatment with bupropion or nortriptyline was significantly more effective than placebo. However, the effect was lost at the 1-year continuous-abstinence mark; the two drugs did not differ from each other or placebo (TABLE 3).
Other antidepressants were evaluated in the Cochrane study.15 Long-term studies of the tricyclic antidepressants doxepin and imipramine (Tofranil) were lacking. Nor were there statistically significant differences in smaller trials. Of the selective serotonin reuptake inhibitors, only fluoxetine (Prozac) had been studied in long-term trials, and none noted statistically significant differences. Likewise, venlafaxine (Effexor) was studied in only one trial in which the confidence interval allowed for a potentially useful clinical effect, but there was no statistically significant increase in 12-month quit rates.
TABLE 3
Varenicline, nortriptyline, bupropion—strong allies in patients’ efforts to quit
| THERAPY | ODDS RATIO (95% CI) | NO. OF PARTICIPANTS/TRIALS | NNT | DURATION OF THERAPY | COST OF 4 WEEKS (BRAND/GENERIC) † |
|---|---|---|---|---|---|
| Varenicline24,25 | 2.80 (2.03–3.88) | 1,161/2 | 7.6 | 12 weeks | $120/NA |
| Nortriptyline15 | 2.79 (1.70–4.59) | 703/4 | 9.8 | 12 weeks | $814/$8 |
| Sustained-release bupropion15 | 2.06 (1.77–2.40) | 6,443/19 | 10.2 | 7–12 weeks | $210/$100 |
| Clonidine23 | 1.89 (1.30–2.74) | 776/6 | 9.4 | 3–4 weeks | $74/$4 |
| Venlafaxine15 | 1.33 (0.59–3.00) | 136/1 | 20.4 | $145/NA | |
| Diazepam23 | 1.00 (0.39–2.54) | 76/1 | No difference | $209/$27 | |
| SSRI15 | 0.90 (0.68–1.18) | 1,768/6 | 20.7 | $170/$4 | |
| Buspirone23 | 0.71 (0.34–1.48) | 201/3 | 22.1 | $280/$84 | |
| * Cost based on prices from Walgreen’s and Target Pharmacies, May and September 2007. | |||||
| NNT, number needed to treat; SSRI, selective serotonin reuptake inhibitors; NA, not available. | |||||
Clonidine is an option, but side effects are an issue
Another Cochrane Review looked at the effectiveness of clonidine (Catapres) on smoking cessation.22 Most of the studies assessed withdrawal symptoms rather than abstinence. Of those that did assess quit rates, the pooled OR for clonidine compares favorably at 1.89 (95% CI, 1.30–2.74). Unfortunately, clonidine has significant side effects: sedation and postural hypotension. The starting dosage is 0.1 mg twice daily, and it may be titrated to a maximum dose of 0.4 mg daily. It should be used for 3 to 4 weeks only to decrease withdrawal symptoms. The smoker is then weaned off the drug.
The anxiolytics were the subject of another Cochrane Review.23 This review, however, did not recommend any anxiolytics, including diazepam and buspirone, for smoking cessation.
A new category of therapy: Nicotinic receptor agonists
