Nicotine replacement therapy in smoking cessation.

The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies. We searched the Cochrane Tobacco Addiction Group trials register in April 2001. Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months. We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measures was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto). We identified 108 trials; 94 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.73 (95% confidence interval 1.62-1.85), The odds ratios for the different forms of NRT were 1.66 for gum, 1.76 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 1.73 for nicotine sublingual tablet. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 to 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo. All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.

NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use. Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT.

Is nicotine replacement really ineffective? A reply to Stanley and Massey

There are 3 first-line medications for smoking cessation i.e. nicotine replacement therapy (NRT), varenicline (a partial nicotine receptor agonist) and slow-release (SR) bupropion. All 3 agents approximately double 1-year quit rates when used for 3 months, although varenicline seems to be a little more efficacious than bupropion SR. An un-blinded study comparing varenicline with nicotine patches are analysed in details and it is concluded that the validity of that study is low regarding the relative efficacy of varenicline versus NRT. Depression and suicidal attempts have been reported with varenicline use but it is probably not induced by varenicline but by the quitting process per se. It is recommended that the first agent to be used in smoking cessation should be NRT as it is the best documented product with mild side effects. It might be optimal to combine the patch with either gum, inhaler, sublingual tablets or nasal spray. In subjects that have failed with NRT, varinicline should be the choice. Bupropion SR is preferred to subjects with depression or smokers who have failed with the previous two agents, due to the many contra-indications and side effects of bupropion SR. With one of the 3 agents combined with follow-up visits with counselling, one can expect a 1-year quit rate around 20-25%.

All commercially available forms of nicotine replacement therapy (NRT) (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/pills) can help to quit smoking successfully. NRT increases the cessation rate by 50 to 70%. The combination of a nicotine patch with a rapid dosage form of NRT is more effective than a single type of NRT. There is no difference in efficacy between NRT and bupropion, the combination of NRT and bupropion is more effective than bupropion alone. The effects are largely independent of the duration of therapy, the intensity of the support provided or the setting in which the NRT was offered. According to Chilean experts, NRT can be used in adolescents, as chewing gum 2 mg adding behavioral therapy. If a pregnant woman expresses a clear desire to use NRT, it is suggested (i) discuss the associated risks and benefits with her, (ii) use it only if the cessation fails with non-pharmacological measures and iii) use the professional approach when deciding whether to offer the prescription of NRT, considering the level of addiction of the pregnant woman and the presence of comorbidities. TRN exists in Chile, but is not currently available in the public health system.

Aggressively treating smoking in persons with bipolar disorder is important but is often overlooked. The rates of smoking in bipolar disorder are second only to the rates of smoking in schizophrenia. It has been well established that people with severe mental illnesses such as bipolar disorder live, on average, 25 years less than the general population and no doubt this is due in part to modifiable risk factors such as tobacco dependence. Nicotine replacement therapy (NRT) is often the first-line treatment for people who wish to quit smoking. This can include patches only, gum only, lozenges only, nasal spray, inhaler, or some combination of a patch with an additional as-needed nicotine replacement medication. A nicotine patch combined with as-needed nicotine replacement medication nearly doubles the odds of quitting versus use of a patch alone (1). One of the most common errors in prescribing NRT is underdosing. This is particularly a problem in heavy smokers such as those with bipolar disorder or schizophrenia who may be smoking 2–3 packs of cigarettes per day. Strategies for these heavier smokers can include the use of multiple nicotine patches or having the person cut back their smoking to 1 pack of cigarettes per day before embarking on cessation. Another problem occurs in people who choose to quit with gum only or lozenges only if they do not use the products as directed. Both the gum and lozenge are designed to allow nicotine to be absorbed through the mucus membrane, because it is not well absorbed through the gut. Nicotine gum needs to be self-administered by the “chew and park” method, not chewed as one would regular gum. Nicotine lozenges should not be chewed, and liquids, particularly acidic beverages such as coffee, should not be consumed when they are in use, again to prevent all the nicotine from going into the gut rather than the bloodstream. For the patient presented above, it may be worth determining whether the NRT was administered in sufficient quantity and in the correct manner before excluding another trial of NRT (2). Bupropion, also known by the brand names Wellbutrin and Zyban when it is used for smoking cessation, can be used as monotherapy or in combination for smoking cessation. The combination of an NRT and bupropion for smoking cessation is more effective than either agent alone (1). Bupropion is often used for treatment of depressed mood in persons with bipolar disorder because it is thought to be less likely to increase mood cycling, although it is not Food and Drug Administrationapproved for the treatment of bipolar depression. The decision to use bupropion for smoking cessation can be made in much the same way as the decision to use it for mood would be made. In general, it would not be a good choice for people who have bipolar illness characterized by frequent or very severe manias or those with rapid cycling, CME Disclosure Annette M. Matthews, M.D., is Assistant Professor of Psychiatry at Oregon Health & Science University and a staff psychiatrist at the Portland Veterans Affairs Medical Center, Portland, OR. She currently has a U.S. Veterans Affairs Clinical Sciences Research and Development Award to study smoking in persons with bipolar disorder. Dr. Matthews reports no competing interests. Address correspondence to Annette M. Matthews, M.D., Portland VA Medical Center, 3710 SW US Veterans Hospital Road, PO Box 1035, Portland, OR 97207 Ask the Expert

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Reply

Adolescent smoking is a significant public health concern, as early nicotine addiction leads to more severe addiction and reduced cessation success during adulthood. While nicotine replacement therapy (NRT) is an effective smoking cessation tool in adults, its efficacy in adolescents is less clear. This systematic review evaluates the effectiveness and safety of NRT for smoking cessation in adolescents. A comprehensive search of PubMed and Cochrane Library databases identified 12 studies (randomized controlled trials and observational) examining NRT in adolescents. Outcomes included smoking cessation rates, withdrawal symptom relief, smoking reduction, and adverse events. NRT demonstrated limited success in long-term smoking cessation among adolescents, with low cessation rates that often declined post-treatment. However, NRT was effective in reducing smoking frequency and in managing withdrawal symptoms in some cases. The safety profile was generally favourable, with mild side effects such as skin irritation, headaches, and nausea. While NRT can reduce smoking and alleviate withdrawal symptoms, its effectiveness in sustaining long-term cessation in adolescents is limited. Adherence challenges and side effects suggest a need for complementary behavioural support and further research into tailored NRT strategies for this population.

Reducing smoking during pregnancy is a public health priority. Nicotine replacement therapy (NRT) is offered routinely to pregnant women who smoke in the United Kingdom. However, evidence of treatment efficacy in this population is weak, most likely due to poor adherence. Guided by the Necessity-Concerns Framework, we conducted a qualitative study to better understand pregnant women's perceived needs and concerns regarding NRT use, with consideration of combination NRT. Semi-structured interviews were conducted by telephone with 18 pregnant or recently pregnant women in England and Wales, purposively sampled for different NRT-related experiences. Participants were recruited online via Facebook adverts and through a Stop Smoking Service. A hybrid approach of deductive and inductive thematic coding was used for analysis. Findings were organized around three themes: 1) the role of motivation to stop smoking; 2) necessity beliefs about using NRT; and 3) concerns about NRT. Some women reported fluctuating motivation for stopping smoking which undermined their NRT use. Others used NRT to cut down the number of cigarettes they smoked. Reasons for low NRT necessity beliefs included a preference for quitting unassisted, low or unrealistic expectations of efficacy, and overconfidence in achieving cessation (necessity testing). Concerns included safety, particularly around increased nicotine exposure with combination NRT, addictiveness, side effects, and capability to use. Pregnant women have multiple necessity beliefs and concerns that influence their use of NRT. Targeting these, alongside increasing and maintaining motivation to quit smoking, will likely help optimize NRT use in pregnancy and improve quit rates.

Nicotine replacement therapies (NRTs) represent an effective means of promoting smoking cessation, but they remain underutilized. Negative attitudes and false beliefs about nicotine and nicotine replacement may cause NRT underutilization. In a randomized, controlled, single-blind study of nicotine gum, 97 smokers were assessed on their attitudes and knowledge about nicotine, nicotine replacement, and smoking cessation therapy. Information from these self-report measures was used in an intervention that provided tailored, brief feedback to promote positive attitudes and accurate knowledge about NRT. Considerable variability in pretreatment attitudes and knowledge was observed across individuals. Moreover, attitudes and knowledge showed a consistent pattern of intercorrelation and were systematically related to smoking characteristics (e.g., prior use of NRT, nicotine dependence, treatment completion). The brief feedback intervention led to a significant global elevation in attitudes about nicotine, NRT, and assisted cessation but not knowledge about nicotine. Changes in attitudes and knowledge were not significantly related to gum use or smoking cessation. Recommendations for the appropriate application of brief feedback are offered.

Mailed distribution of free nicotine patches without behavioral support: Predictors of use and cessation

BackgroundSmoking is the leading preventable cause of death. A network meta-analysis of randomised trials has demonstrated that varenicline is the most efficacious treatment for short-term smoking cessation. However, there is...