Effect of Cytisine vs Varenicline on Smoking Cessation: A Randomized Clinical Trial.

Importance: Cytisine is more effective than placebo and nicotine replacement therapy for smoking cessation. However, cytisine has not been tested against the most effective smoking cessation medication, varenicline, which is associated with adverse events known to lead to discontinuation of therapy. Objective: To examine whether standard cytisine treatment (25 days) was at least as effective as standard varenicline treatment (84 days) for smoking cessation. Design, Setting, and Participants: This noninferiority, open-label randomized clinical trial with allocation concealment and blinded outcome assessment was undertaken in Australia from November 2017 through May 2019; follow-up was completed in January 2020. A total of 1452 Australian adult daily smokers willing to make a quit attempt were included. Data collection was conducted primarily by computer-assisted telephone interview, but there was an in-person visit to validate the primary outcome. Interventions: Treatments were provided in accordance with the manufacturers' recommended dosage: cytisine (n = 725), 1.5-mg capsules taken 6 times daily initially then gradually reduced over the 25-day course; varenicline (n = 727), 0.5-mg tablets titrated to 1 mg twice daily for 84 days (12 weeks). All participants were offered referral to standard telephone behavioral support. Main Outcomes and Measures: The primary outcome was 6-month continuous abstinence verified using a carbon monoxide breath test at 7-month follow-up. The noninferiority margin was set at 5% and the 1-sided significance threshold was set at .025. Results: Among 1452 participants who were randomized (mean [SD] age, 42.9 [12.7] years; 742 [51.1%] women), 1108 (76.3%) completed the trial. Verified 6-month continuous abstinence rates were 11.7% for the cytisine group and 13.3% for the varenicline group (risk difference, -1.62% [1-sided 97.5% CI, -5.02% to ∞]; P = .03 for noninferiority). Self-reported adverse events occurred less frequently in the cytisine group (997 events among 482 participants) compared with the varenicline group (1206 events among 510 participants) and the incident rate ratio was 0.88 (95% CI, 0.81 to 0.95; P = .002). Conclusions and Relevance: Among daily smokers willing to quit, cytisine treatment for 25 days, compared with varenicline treatment for 84 days, failed to demonstrate noninferiority regarding smoking cessation. Trial Registration: anzctr.org.au Identifier: ACTRN12616001654448.

Electronic cigarettes in physician practice.

There is growing evidence for the effectiveness of e-cigarettes as a quitting aid and, although not completely harmless, the scientific consensus is that they are substantially less harmful than smoking tobacco. More research is needed, but there is now sufficient empirical evidence and real-world experience over more than a decade to consider their use as a legitimate tobacco harm reduction tool for smokers who are unable or unwilling to quit with conventional strategies. Smokers should be advised that the highest success rates occur with daily use with nicotine e-liquid and newer e-cigarette models. After quitting smoking, it is preferable to aim ultimately to cease vaping if possible, but long-term use of e-cigarettes is safer than relapsing to smoking.

Three Decades of High-Dose Nicotine Gum Dependence Treated With Nicotine Patches.

INTRODUCTION: Some long-term nicotine gum users are addicted to nicotine and may need assistance to stop. There is no published evidence on the use of nicotine patches for this purpose. CASE DESCRIPTION: A 45-year old man presented with a 30-year history of high-dose nicotine gum use (up to 200mg nicotine per day). He was highly nicotine dependent and had failed repeatedly to stop using nicotine gum use in the past. Within a week of commencing nicotine patches he was able to cease nicotine gum with minimal discomfort and has remained nicotine-free for 6 months, with abstinence confirmed biochemically. His severe sweating disorder rapidly resolved with cessation of the gum. CONCLUSION: Nicotine patches may be an effective treatment for long-term nicotine gum addiction.

Smoking cessation in people with alcohol and other drug problems.

BACKGROUND: People who consume alcohol and other drugs are at particularly high risk of harm from smoking, yet tobacco use is commonly neglected in this patient group. OBJECTIVE: The objectives of this article are to increase awareness of the high risk of tobacco-related harm in people who consume alcohol and other drugs, identify the barriers to quitting and provide practical guidelines to assist quitting. DISCUSSION: People who are dependent on alcohol and other drugs are far more likely to die from a smoking-related illness than from their other drugs. Most are motivated to quit smoking; however, their quit rates are lower than in the general population. Substance users who also smoke can usually be treated with similar behavioural and pharmacological treatments as others who smoke, but generally require more intensive and longer treatment. Quitting smoking at the same time as undergoing other drug treatment does not undermine drug treatment outcomes and may improve them. Smoking cessation should be integrated into the routine care of patients who consume alcohol and other drugs.

Smoking and mental illness. An update for psychiatrists.

OBJECTIVE: We aimed to review research on smoking and mental illness and provide evidence-based guidelines for psychiatrists to help smoking patients quit. METHOD: We undertook a narrative review of the literature with a special focus on the Australian context. RESULTS: Although one in three people with mental illness smoke tobacco, smoking is often neglected in psychiatric practice. Smoking is a significant contributor to the health gap between people with mental illness and the general population. Smokers with mental illness are motivated to quit and are able to do so, albeit with lower quit rates. Quitting can lead to substantial improvements in mental wellbeing and physical health and does not exacerbate pre-existing mental illness. Psychiatrists should advise all smokers to quit and provide counselling, medication and support, based on the 5As framework. Approved pharmacotherapy - nicotine replacement therapy, varenicline and bupropion - is recommended for nicotine-dependent smokers. Smoking induces the metabolism of certain psychotropic drugs such as clozapine and olanzapine and dose reductions may be necessary after cessation. CONCLUSIONS: Psychiatrists have a duty of care to identify the smoking status of their patients and to provide evidence-based support to quit.

Tobacco smoking: options for helping smokers to quit.

BACKGROUND: Although great progress has been made on tobacco control, smoking remains one of the most important causes of preventable disease and death in the Australian population. The general practice team has much to offer in helping smokers to quit. OBJECTIVE: This article provides practical advice on structuring smoking cessation support in primary care using the 5As (Ask, Assess, Advise, Assist and Arrange follow-up) framework. Up-to-date information on pharmacotherapy and issues for special groups are also covered. DISCUSSION: The chances of successful quitting are maximised if the patient receives behavioural support combined with drug treatment, if nicotine-dependent. Special groups needing support include Aboriginal and Torres Strait Islander peoples, people with mental illness and pregnant women.

A critique of the Australian National Health and Medical Research Council CEO statement on electronic cigarettes.

This paper critically analyses a statement by Australia's National Health and Medical Research Council (NHMRC) on e-cigarettes in May 2022 that will be used to guide national policy. We reviewed the evidence and the conclusions drawn in the NHMRC Statement. In our view, the Statement is not a balanced reflection of the benefits and risks of vaping because it exaggerates the risks of vaping and fails to compare them to the far greater risks of smoking; it uncritically accepts evidence of harms from e-cigarettes while adopting a highly sceptical attitude towards evidence of their benefits; it incorrectly claims that the association between adolescent vaping and subsequent smoking is causal; and it understates the evidence of the benefits of e-cigarettes in assisting smokers to quit. The Statement dismisses the evidence that vaping is probably already having a positive net public health effect and misapplies the precautionary principle. Several sources of evidence supporting our assessment were published after the NHMRC Statement's publication and are also referenced. The NHMRC Statement on e-cigarettes does not present a balanced assessment of the available scientific literature and fails to meet the standard expected of a leading national scientific body.