Smoking Cessation


Rigotti NA. Strategies to help a smoker who is struggling to quit. JAMA. 2012; 308:1573-80. Comprehensive update of the strategies available to clinicians to assist smokers who are struggling to quit. Highlights that the simultaneous use of more than one form of nicotine replacement for greater than 12 weeks may increase the odds of success.

PMID: 23073954

Electronic Cigarettes

Prochaska JJ. The public health consequences of e-cigarettes: a review by the National Academies of Sciences. A call for more research, a need for regulatory action. Addiction. 2019; 114:587-89. This FDA-sponsored review summarizes the findings of more than 800 research studies on the safety of electronic nictotine delivery systems (published before widespread recognition of EVALI). The paper calls attention to the uncertain balance between harm reduction (e-cigarettes less toxic than continued tobacco smoking) and the risk of exposure in younger generations. 

PMID 30347473

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Halpern SD, Harhay MO, Saulsgiver K et al.  A pragmatic trial of e-cigarettes, incentives, and drugs for smoking cessation. N Engl J Med. 2018; 378:2302-2310. This study is noteworthy for finding low levels of abstinence at 6 months regardless of the strategy employed. Over 6,000 smokers were randomized to usual care or usual care plus one of the following groups: 1) free cessation aids (nicotine-replacement therapy or pharmacotherapy, with e-cigarettes if standard therapies failed); 2) free e-cigarettes, without a requirement that standard therapies had been tried; 3) free cessation aids plus $600 in rewards for sustained abstinence; or 4) free cessation aids plus $600 deposited as redeemable funds with money removed if cessation milestones were not met. Sustained 6-month abstinence was uniformly low - usual care with 0.1%, group 1 with 0.5%, group 2 with 1.0%, group 3 with 2%, and group 4 with 2.9%. There was no statistical difference between receiving e-cigarettes and usual care or free cessation aids. 

PMID: 29791259

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Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019; 380:629-637. In contrast to the Halpern study above, this RCT was noteworthy for finding higher rates of abstinence, particularly in those assigned to e-cigarettes. Of the 886 participants, abstinence rates were 18% among those randomized to e-cigarette group vs 9.9% in NRT group. Of note, among participants who were abstinent at one year, those in the e-cigarette group were more likely than NRT group to be using their assigned product (80% vs 9%). Please see ARDS section for article regarding e-cigarette or vaping associated lung injury.

PMID: 30699054

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Pharmacologic interventions

Single drug

Transdermal Nicotine Study Group. Transdermal nicotine for smoking cessation. Six-month results from two multicenter controlled clinical trials. JAMA 1991; 266:3133-8. This study assessed rates of continuous smoking abstinence among patients who had successfully quit after a 6-week trial of transdermal nicotine replacement. 26% of patients that had been randomized to 21 mg patches were not smoking at 6 months compared to 12% in the placebo group.

PMID: 1956099

Gonzales D, Rennard SI, Nides M, et al. Varenicline, an alpha4-beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized, controlled trial. JAMA 2006; 296:47-55. This, along with another simultaneously published study by Jorenby DE et al in the same issue, randomized over 1000 patients to 12 weeks of varenicline (Chantix), bupropion, or placebo. Continuous abstinence for weeks 9 through 52 were 21.9% for varenicline, 16.1% for bupropion, and 8.4% for placebo (p = .057 for varenicline vs bupropion.

PMID: 16820546

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Anthenelli EM, Morris C, Ramey TS, et al. Effects of varenicline on smoking cessation in adults with stably treated current or past major depression: a randomized trial. Ann Intern Med. 2013;159:390-400. This double-blinded placebo-controlled trial of cigarette smokers with stably treated past or current major depression found significantly improved rates of tobacco use cessation without adverse psychological effects. Patients on antipsychotics medications were not included.

PMID: 24042367

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Combination therapy

Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999; 340:685-91. This trial randomized nearly 900 patients to bupropion, a nicotine patch, bupropion plus a patch, or placebo. 12 month cessation rates were 30.3% for bupropion, 16.4% for the patch, 15.6% for placebo, and 35.5% with combined bupropion and patch. 12% of patients did not tolerate bupropion.

PMID: 10053177

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Long-term effects of smoking cessation interventions

Anthonisen NR, Skeans MA, Wise RA, et al. The effects of a smoking cessation intervention on 14.5 year mortality. Ann Intern Med 2005; 142:233-9. This article is noteworthy for showing smoking cessation reduces mortality even when the intervention is successful in only a minority of patients. The study compared a 10-week intervention that combined counseling and nicotine gum with usual care among smokers with obstructive lung disease. Quit rates at 5 years were 21.7% and 5.4% in the intervention and usual care groups, respectively. At 14.5 years, the hazard ratio for all-cause mortality in the usual care group vs. the intervention group was 1.18 (95% CI 1.02 to 1.37).

PMID: 15710956

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