February 7th, 2010

Tackling Tobacco Cessation

Last week, I posted a Voices blog detailing my concerns about a recent randomized controlled trial of varenicline that, in my opinion, was just another weak safety study. Absent from that post was a discussion of varenicline’s effectiveness, which was significant. At 12 weeks, 47% of varenicline users had been continuously abstinent, versus 14% of placebo recipients. At 1 year, abstinence was 19% (varenicline) versus 7% (placebo).

In my primary care practice (and I work with veterans), smoking cessation counseling and treatment is very important; I consider it the most effective way to prevent cardiovascular disease in my patients (primary or secondary). It is obviously hard to do (just like counseling to avoid salt), but it is among the most rewarding aspects of practice when a patient successfully quits.

For that reason, I thought CardioExchange would be a nice venue to exchange tips and strategies that have worked for us to help patients quit smoking.

The numbers are informative (all Cochrane reviews).

  • Among more than 110 clinical trials of nicotine replacement therapy (NRT), be it skin patches, chewing gum, nasal spray, inhalers, or lozenges/tablets, NRT increased the success rate for quitting smoking 50%-70% versus placebo or no treatment. Importantly, the effect was largely independent of the type of NRT, duration of NRT, the intensity of additional support provided, and the setting in which the NRT was offered.
  • Among 49 trials of buproprion, the antidepressant increased the success rate by approximately 70% (versus placebo or an alternative drug) when used as the sole pharmacotherapy. Surprisingly, adding NRT to buproprion did not provide additional benefit.
  • Among 7 trials of varenicline (not including the recently published study), the medication was generally more effective than previously available treatments: increasing the success rate by more than 100% versus placebo, 50% versus bupropion, and 30% versus NRT.
  • Finally, but just as critical, among nearly 30 trials of physician counseling (alone, without pharmacotherapy), brief advice or more intensive counseling increased the success rate by nearly 70-80% versus no advice (or usual care).

In my practice, I try to offer brief advice (1–2 minutes’ worth of discussion) to every active smoker. I then offer NRT, usually in combination with buproprion (I did not realize the data didn’t support combination therapy! I will have to change my practice), taking the time to detail a schedule and discuss potential pitfalls if the patient is interested in initiating pharmacotherapy. I then ask them to return to clinic in 3 weeks so I can see how they are doing with quitting.

Anecdotally, I am consistently surprised at how many of patients have succeeded at quitting, or at least reduced their use down to 2-3 cigarettes a day. But, this is anecdotally – I don’t have my actual numbers.

So, what do you do? Have you identified any successful strategies? Do you have any clinical secrets to share?

9 Responses to “Tackling Tobacco Cessation”

  1. You asked for tips
    There are two randomized trials suggesting that showing smokers images of their diseased arteries helps to motivate cessation. I am in complete agreement with this concept. I get a carotid total plaque area assessment and show them an illustrated picture of their disease carotids together with their total atheroma burden. I find that by providing a very concrete visualization of their disease process and risk, they are much more likely to quit (I also provide pharmacotherapy), and we track whether there has been regression or progression of disease on subsequent visits.

  2. Thanks for the summary – it was quite helpful. I just discussed smoking cessation with 2 patients this week. Part of my discussion involves financial savings, given that most of my patients come from low income settings. Showing them pictures of graphics involving clogged arteries, or perhaps black lungs, is a great idea. All the same, I get the sense that many different physicians have counseled these patients about quitting, and they know plenty of reasons why…they just don’t have the discipline. The also do not have alternative means of stress management. In fact, I wonder if studies have looked at the effects of stress management techniques in facilitating smoking cessation…

  3. Opportunity for a trial?

    Great tips, great ideas. Has anybody done a trial of standard therapy (e.g. NRT or bupropion, now that we know they’re about even) plus personalized graphic image versus no image? That would be pretty interesting… and, if positive, the end-results would pay off the cost of obtaining/interpreting such images multiple-fold…

  4. How do I find those trials?
    Dan, could you provide a link of those RCTs? I’d be very curious to see them. I know that advocacy groups have used graphic images to reach out to (predominantly) youth audiences and describe the dangers of tobacco use, such as the American Cancer Society and the NYC Department of Health. But I’ve never seen its effectiveness studied. There are, however, lots of other interventions that have been studied: acupuncture, anxiolytics, exercise, partner support programs, financial incentives, hypnotherapy and so on, all with mixed success. I think Amit touches on the main challenge: people often use tobacco as a means of coping with daily stress, exhaustion, and anxiety, and there is no simple way to help people re-learn how to cope.

  5. Will gladly send you the PDF’s

    Dr Ross,

    They are two trials among a score that I am processing for a systematic review on process markers in cardiovascular medicine. If you email me directly (dhackam@uwo.ca), I shall send you the PDF’s, one of which I received directly from the authors (our library did not have a subscription).

  6. Putting on a health policy hat
    Also, an additional piece of food for thought, in this month’s issue of the American Journal of Public Health there was a study that adds to the literature examining the success of legislative smoking bans at reducing tobacco use. In this study (AJPH; 2010; 100:547-554), Massachusetts’ adults were followed every 2 years from 2001-2002 through 2005-2006. The investigators found that of the many potential predictors for tobacco cessation that were studied, the one most strongly predictive of cessation after 2 years was the perception of strong antismoking norms in one’s town. They did not study the effectiveness of different interventions used (i.e., varenicline vs. NRT vs. physician counseling), but this does continue to highlight the social complexity we physicians face when attempting to help our patients quit smoking.

  7. Cochrane review

    Thanks to Dan, who shared with me the RCTs and a Cochrane Review examining visual feedback of medical imaging to change health behavior. I thought everyone would be interested in the results, particularly the Cochrane review.

    5 trials in clinical populations were identified and results were mixed. 3 examined smoking cessation behaviors after showing patients arterial scans and found intervention patients had nearly 3x greater odds of quitting. However, 1 of these trials also examined physical activity and found no difference. Another study which examined diet and medication adherence found no difference. While the 5th study examined self-skin exams and found the intervention to improve behavior.

    The 4 trials reviewed that were conducted in non-clinical populations were also mixed: one favored the intervention, one the control, and no differences were found in the other 2.

    Clearly, more research on this intuitively valuable type of intervention is needed.

  8. …back to your original question…do you have any pearls or tips on how to get people off the wicked weed?

  9. Robin Motz, M.D., Ph.D. says:

    The only successful smoking cessation strategy I have is to tell my smoking patients that although they may not get lung cancer or a heart attack from smoking, I can guarantee 100% that if they live long enough they will end their lives attached to an oxygen tank, due to end-stage emphysema.