{"id":1424,"date":"2010-02-07T16:37:55","date_gmt":"2010-02-07T21:37:55","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/tackling-tobacco-cessation\/"},"modified":"2011-07-19T17:45:09","modified_gmt":"2011-07-19T21:45:09","slug":"tackling-tobacco-cessation","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2010\/02\/07\/tackling-tobacco-cessation\/","title":{"rendered":"Tackling Tobacco Cessation"},"content":{"rendered":"<p>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 <a href=\"http:\/\/cardioexchange.org\/blogPost?postId=405\">weak safety study<\/a>. Absent from that post was a discussion of varenicline\u2019s 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).<\/p>\n<p>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 <a href=\"http:\/\/cardioexchange.org\/blogPost?postId=210\">counseling to avoid salt<\/a>), but it is among the most rewarding aspects of practice when a patient successfully quits.<\/p>\n<p>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.<\/p>\n<p>The numbers are informative (all Cochrane reviews).<\/p>\n<ul>\n<li> Among more than 110 clinical trials of <a href=\"http:\/\/www.cochrane.org\/reviews\/en\/ab000146.html\">nicotine replacement therapy <\/a>(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.<\/li>\n<li>Among 49 trials of\u00a0<a href=\"http:\/\/www.cochrane.org\/reviews\/en\/ab000031.html\">buproprion,<\/a> 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.<\/li>\n<li>Among 7 trials of\u00a0<a href=\"http:\/\/www.cochrane.org\/reviews\/en\/ab006103.html\">varenicline<\/a> (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.<\/li>\n<li>Finally, but just as critical, among nearly 30 trials of\u00a0<a href=\"http:\/\/www.cochrane.org\/reviews\/en\/ab000165.html\">physician counseling<\/a> (alone, without pharmacotherapy), brief advice or more intensive counseling increased the success rate by nearly 70-80% versus no advice (or usual care).<\/li>\n<\/ul>\n<p>In my practice, I try to offer brief advice (1\u20132 minutes\u2019 worth of discussion) to every active smoker. I then offer NRT, usually in combination with buproprion (I did not realize the data didn\u2019t 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.<\/p>\n<p>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 \u2013 I don\u2019t have my actual numbers.<\/p>\n<p><em><strong>So, what do you do? Have you<\/strong><\/em> <em><strong>identified any successful strategies? Do you have any clinical secrets to share?<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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\u2019s effectiveness, which was significant. At 12 weeks, 47% of varenicline users had been continuously abstinent, versus 14% of [&hellip;]<\/p>\n","protected":false},"author":277,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,7],"tags":[],"class_list":["post-1424","post","type-post","status-publish","format-standard","hentry","category-general","category-prevention"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1424","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/277"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1424"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1424\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1424"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1424"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1424"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}