October 18, 2012
Chronic Disease Management Could Help Cigarette Smokers Kick The Habit
Alan McStravick for redOrbit.com - Your Universe Online
Smoking rates among several target age groups have been in decline in the US. A new study of existing smokers focuses on their attempts at quitting and shows why there is a high likelihood those attempts will have been unsuccessful. Though there are several options available to smokers for cessation and ultimately for quitting outright, most smokers become frustrated and give up on quitting.
Nancy Rigotti, MD, director of the Tobacco Research and Treatment Center of the Massachusetts General Hospital (MGH) Department of Medicine has outlined the current available resources and recommends strategies that can help smokers who are struggling to quit. Her report, in the Oct 17 issue of JAMA, details her findings.
"Many smokers believe they have tried and failed all treatments because they — and their physicians — have not used existing treatments in the most effective way," Rigotti says. "Outdated product labeling by the Food and Drug Administration for nicotine replacement therapy contributes to this problem, as does the fear of possible side effects of FDA-approved medications. As a result, some smokers consider using newer untested and unregulated products like electronic cigarettes."
For her study, based on a grand rounds presentation at Northwestern University Feinberg School of Medicine, Rigotti presented a hypothetical smoking patient: a 50-year old man who had become discouraged because of previous unsuccessful attempts at quitting smoking. This hypothetical patient had used nicotine replacement therapy and had also tried using the antidepressant bupropion (Zyban). Due to both being unsuccessful, the patient was reluctant to try varenicline (Chantix), another FDA-approved smoking cessation medication, because of concern about possible serious side effects. The hypothetical patient, frustrated and feeling that he has exhausted all possibilities out there, asks his physician whether or not he should consider the electronic cigarette.
It is Rigotti´s contention that many quit attempts fail because smokers do not take advantage of existing treatments or, like the smoker in the example, don´t use them in the most effective way.
Previous research has shown that only one third of smokers who try to quit will use behavioral support or medication despite both methods having been proven to be effective. Additionally, even fewer smokers will combine both types of assistance, even though doing so further improves a smoker´s chance of success. Most smokers, like the patient in Rigotti´s example, may not even be aware of the support that is available free through the nationwide toll-free number 1-800-QUIT-NOW.
Rigotti also found that smokers who use nicotine replacement therapy (NRT) may not do so in the most effective way. Though many products are available, such as over-the-counter patches, gums and lozenges or prescription-only inhalers and nasal sprays, many smokers only use one product when previous studies have shown that combination of two of these methods is not only safe but also more effective.
A patch provides steady, prolonged relief of nicotine withdrawal symptoms. However, it is less effective at helping the smoker to combat sudden cravings that may be triggered by environmental cues like watching another smoker light a cigarette. These cravings are best handled with a shorter-acting product like a gum or lozenge.
Despite the strong evidence that combining NRT products is more effective than using single agents and support for combined therapy in the 2008 US Public Health Service Clinical Practice Guideline, the labels on these FDA approved products still caution smokers not to combine different nicotine replacement products.
Due to reports of behavioral changes in patients taking bupropion and varenicline, two FDA approved smoking cessation pharmaceutical options, many smokers may be discouraged from exploiting this option even though they have been shown to double a smoker´s odds of success when making an attempt at quitting.
Rigotti points out that in any individual it can be difficult to distinguish a side effect from the medication and the overall effects of nicotine withdrawal, which include nervousness and depression. She goes on to point out that both bupropion and varenicline are among the few truly effective options for treating tobacco dependence. For this reason, physicians and patients need to, together, weigh the small potential risk of side effects against the certain risk of continuing to smoke.
Rigotti concludes that these drugs´ benefits would certainly outweigh the risks involved, but she cautions physicians do need to monitor patients who start on these drugs for potential behavioral changes.
This brings us back to Rigotti´s hypothetical patient. She stresses, “In fact, he has not tried everything.”
Rigotti believes that with behavioral support, combined nicotine replacement treatment and a more adequate trial of the strategies that the hypothetical patient had previously abandoned, the smoker could see success on his next quit attempt. In particular, she would recommend he try the behavioral support to increase his confidence and she would encourage him also to use a quit line or other source of continuing support.
Exploring these evidence-based, FDA-approved options would be a better choice for him than electronic cigarettes, which have not undergone the rigorous process of determining their safety and effectiveness.
"Tobacco use kills approximately half of regular smokers, and treatment for tobacco use is one of the most cost-effective actions that physicians and health care systems can take," says Rigotti, who is also a professor of Medicine at Harvard Medical School. "Those of us who provide health care need to recognize tobacco dependence as the chronic condition that it is and give tobacco treatment as high a priority as we do other chronic diseases like diabetes or high blood pressure."
Rigotti believes that long-term management is a better strategy for treating tobacco dependence than expecting that it can be addressed in a single physician visit. She states that it is important for healthcare systems to provide ongoing assistance above and beyond the necessarily brief stop-smoking consultations delivered by primary care physicians. Her advice is that the health care system link these patients with additional resources, such as the national network of state-supported telephone quit lines.
Smoking continues to be the most preventable cause of death in this country. Through the work of Rigotti and others, and with the aid of physicians and healthcare systems, smokers can be made aware of all treatment options and therapies, increasing their chances of successfully quitting smoking.