Smoking and its treatment in addiction services: clients' and staff behaviour and attitudes.

BACKGROUND: High smoking prevalence has been observed among those misusing other substances. This study aimed to establish smoking behaviours and attitudes towards nicotine dependence treatment among clients and staff in substance abuse treatment settings. METHODS: Cross-sectional questionnaire survey of staff and clients in a convenience sample of seven community and residential addiction services in, or with links to, Europe's largest provider of mental health care, the South London and Maudsley NHS Foundation Trust. Survey items assessed smoking behaviour, motivation to quit, receipt of and attitudes towards nicotine dependence treatment. RESULTS: Eighty five percent (n = 163) and 97% (n = 145) response rates of clients and staff were achieved. A high smoking prevalence was observed in clients (88%) and staff (45%); of current smokers, nearly all clients were daily smokers, while 42% of staff were occasional smokers. Despite 79% of clients who smoked expressing a desire to quit and 46% interested in receiving advice, only 15% had been offered support to stop smoking during their current treatment episode with 56% reported never having been offered support. Staff rated smoking treatment significantly less important than treatment of other substances (p < 0.001), and only 29% of staff thought it should be addressed early in a client's primary addiction treatment, compared with 48% of clients. CONCLUSIONS: A large unmet clinical need is evident with a widespread failure to deliver smoking cessation interventions to an extraordinarily high prevalence population of smokers in addiction services. This is despite the majority of smokers reporting motivation to quit. Staff smoking and attitudes may be a contributory factor in these findings.

Association between DRD2/ANKK1 Taq1A genotypes, depression and smoking cessation with nicotine replacement therapy.

OBJECTIVES: Tobacco dependence and depression are believed to have a common familial component, most probably genetic, and mood disorders have been reliably associated with failure to stop smoking. Variant genotypes of the Taq1A (DRD2/ANKK1, 32806T, rs1800497) polymorphism have been associated with failure to stop smoking in some studies, but not others. We investigated the association between Taq1A genotypes and smoking cessation, while also considering mental health. MATERIALS AND METHODS: This was a prospective study in 419 smokers who attended a smoking cessation clinic and used standard doses of nicotine replacement therapy. DNA samples and baseline measures including demographics, severity of tobacco dependence, mental health history and history of drug misuse were taken. Smoking cessation at the end of treatment was biochemically verified using expired-air carbon monoxide. RESULTS: We found no simple relation between Taq1A genotype and smoking cessation, although the association between cessation and lifetime depression was significantly modified by genotype. The relationship was such that for those having only common alleles there was no association between depression and stopping smoking, whereas for those with at least one variant allele (A1A2/A1A1) depression was associated with a two-fold reduction in the likelihood of stopping. CONCLUSION: Those having a Taq1A variant allele and a history of depression are likely to experience particular difficulty when trying to stop smoking and may require treatment other than standard doses of nicotine replacement. This finding might explain previous conflicting results for Taq1A and smoking cessation in studies where depression history was not measured, and may help to explain the underlying link between depression and smoking.

Illicit drug use as a predictor of smoking cessation treatment outcome.

INTRODUCTION: Evidence from cross-sectional survey data suggests a negative association between illicit drug use and smoking cessation. In a prospective clinical cohort, we examined whether illicit drug users were less successful than other smokers when making an attempt to stop smoking. METHODS: A total of 100 smokers attending a tobacco dependence clinic were studied. Pretreatment questionnaire measures of illicit drug use, demographics, health history, and tobacco smoking were taken. Treatment consisted of seven weekly behavioral support sessions plus nicotine replacement therapy or bupropion. Short-term outcome was assessed at the end of the treatment by self-report and carbon monoxide (CO) verification. RESULTS: A total of 24 smokers (24%) had used illicit drugs during the previous 30 days. Drug users were less likely to stop smoking than were nonusers. The difference in CO-verified success rates was 26.1% (29.2% vs. 55.3%, 95% CI = 4.8%-47.4%), and the odds ratio was 0.33 (95% CI = 0.12-0.89). Adjustment for group differences on all the measured background and treatment characteristics affected this result only marginally. DISCUSSION: Illicit drug use appears to have a significant detrimental effect on the success of an attempt to stop smoking. This effect is not explained by differences between drug users and nonusers on established prognostic factors. These first results in a prospective sample support findings from a large U.S. population survey of smoking cessation rates in drug users and nonusers. If these results are corroborated, clinicians treating smokers should consider developing new protocols to improve outcomes in smokers using illicit drugs.

Varenicline in the routine treatment of tobacco dependence: a pre-post comparison with nicotine replacement therapy and an evaluation in those with mental illness.

AIMS: To compare the effectiveness of varenicline with nicotine replacement for smoking cessation and to evaluate the safety and effectiveness of varenicline in people with mental illness. DESIGN: Evaluation of consecutive routine cases before and after the introduction of varenicline. SETTING: National Health Service (NHS) tobacco dependence clinic in London, UK. PARTICIPANTS: A total of 412 cases receiving routine care. INTERVENTION: Seven group support sessions over 6 weeks with either nicotine replacement therapy (NRT) (n = 204) or varenicline (n = 208). MEASUREMENTS: Verified abstinence 4 weeks after quit day, severity of withdrawal symptoms, incidence and severity of adverse drug symptoms, cost per patient treated and cost per successful short-term quitter. FINDINGS: Short-term cessation rates were higher with varenicline than NRT (odds ratio = 1.70, 95% confidence interval = 1.09-2.67). Varenicline was equally effective in those with and without mental illness. Craving to smoke, but not adverse mood, was less severe with varenicline than NRT. The cost per quitter was similar for varenicline and NRT. There was a higher incidence of adverse drug symptoms among those taking varenicline, but these were tolerated by most smokers. There was no evidence that varenicline exacerbated mental illness. CONCLUSIONS: In this setting and with group support varenicline appears to improve success rates over those achieved with NRT, and is equally effective and safe in those with and without a mental illness.

Evaluation of tobacco use cessation (TUC) counselling in the dental office.

Tobacco use cessation (TUC) in dentistry is critical to reducing the effect of a major risk factor for both oral and systematic diseases. The effect of TUC interventions has been widely reported. The data show that the success of TUC without professional support is negligible but that behavioural and pharmacological interventions are effective. Furthermore, the greater the intensity of support, the greater the quit rate and success rates are similar comparing different health care professionals including dental professionals. Although few studies have been performed in dental practice, it is clear that TUC should be embedded in routine oral health care. In addition to evaluating the effect of TUC, several studies have investigated barriers to implementing TUC in dental settings. A large number of barriers have been reported. These studies highlight the importance of further training for dental professionals but also identify the need for major cultural and policy changes to facilitate the provision of TUC. Research on barriers to TUC in dental care could be facilitated by employing qualitative or mixed methods designs and studies that evaluate the impact of changing such barriers on TUC provision. Such an approach will help to close the gap between research findings and implementation. Regarding the measurement of outcomes from TUC, no gold standards exist currently. Therefore both self-reported and biochemical measures of tobacco use should be reported in evaluation studies. It is also clear that feedback from biochemical testing of tobacco use can increase success rates in tobacco use cessation.

Tobacco, oral cancer, and treatment of dependence.

Tobacco dependence is recognised as a life-threatening disorder with serious oral health consequences which responds to treatment in the form of behavioural support and medication. While cigarette smoking is the most hazardous and prevalent form of tobacco use in the west, consideration also needs to be given to other forms such as bidi smoking in India, reverse smoking by several rural populations and use of snuff and chewing tobacco. The evidence that the use of tobacco is the major risk factor for oral cancer and potentially malignant lesions of the mouth is clear. Counseling to quit smoking is not applied in a systematic or frequent manner to people presenting with potentially malignant lesions of the oral cavity. This review makes recommendations for interventions by health professionals to encourage and aid cessation of tobacco use as a part of prevention of oral cancer.

Current approaches to the management of smoking cessation.

Smoking remains a widespread intractable behaviour and is a significant cause of morbidity and mortality worldwide. Effective approaches to smoking cessation include behavioural intervention and pharmacotherapy, in particular nicotine replacement therapy (NRT) and sustained-release bupropion (bupropion SR). Pharmacotherapy remains a popular choice of smoking cessation intervention for many smokers, and both NRT and bupropion SR, combined with behavioural interventions, achieve 1.5- to >2-fold increases in smoking cessation rates. Various national and international smoking cessation guidelines have been published recommending effective implementation of smoking cessation strategies. Recommendations include the systematic identification of smokers, assessment of their willingness to quit smoking, provision of advice promoting a cessation attempt, and administration of approved first-line therapies.

Randomized trial of nicotine replacement therapy (NRT), bupropion and NRT plus bupropion for smoking cessation: effectiveness in clinical practice.

BACKGROUND AND AIMS: Bupropion was introduced for smoking cessation following a pivotal trial showing that it gave improved efficacy over the nicotine patch and also suggesting combination treatment was beneficial. We tested in clinical practice for an effectiveness difference between bupropion and nicotine replacement therapy (NRT), whether the combination improves effectiveness and whether either treatment might be more beneficial for certain subgroups of smokers. DESIGN: Open-label randomized controlled trial with 6-month follow-up. SETTING: Four UK National Health Service (NHS) smoking cessation clinics. PARTICIPANTS: Smokers (n = 1071) received seven weekly behavioural support sessions and were randomized to an NRT product of their choice (n = 418), bupropion (n = 409) or NRT plus bupropion (n = 244). MEASURES: The primary outcome was self-reported cessation over 6 months, with biochemical verification at 1 and 6 months. Also measured were baseline demographics, health history, smoking characteristics and unwanted events during treatment. FINDINGS: Abstinence rates for bupropion (27.9%) and NRT (24.2%) were not significantly different (odds ratio = 1.21, 95% confidence interval = 0.883-1.67), and the combination rate (24.2%) was similar to that for either treatment alone. There was some evidence that the relative effectiveness of bupropion and NRT differed according to depression (χ(2) = 2.86, P = 0.091), with bupropion appearing more beneficial than NRT in those with a history of depression (29.8 versus 18.5%). Several unwanted symptoms were more common with bupropion. CONCLUSION: There is no difference in smoking cessation effectiveness among bupropion, nicotine replacement therapy and their combination when used with behavioural support in clinical practice. There is some evidence that bupropion is more beneficial than nicotine replacement therapy for smokers with a history of depression.

Treating heavy smokers in primary care with the nicotine nasal spray: randomized placebo-controlled trial.

AIMS: Of six established nicotine replacement therapy (NRT) formulations, only the gum and patch have been tested without specialist clinic support in placebo-controlled trials. We aimed to broaden the evidence base by examining if the nicotine nasal spray (NNS) could be effective with only brief support in general practice. DESIGN: Randomized placebo-controlled trial. SETTING: Twenty-seven English general practices. PARTICIPANTS: A total of 761 heavy smokers received brief support and 12 weeks of treatment with NNS (506) or placebo (255). MEASUREMENTS: The primary outcome was biochemically verified complete abstinence from smoking throughout weeks 3-12. FINDINGS: NNS compared with placebo more than doubled the number who successfully stopped smoking [15.4% versus 6.7%, odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.5-4.4]. Many participants reported minor irritant adverse symptoms. NNS was particularly effective among those who were more highly dependent on nicotine (OR = 6.17, 95% CI = 2.13-17.9). Of those who failed to stop during the first week (417, 54.8%), only one (0.2%) achieved later success. CONCLUSIONS: NNS is effective when given in primary care. The benefit was lower than in a specialist clinic but similar to that with the nicotine patch in primary care. Unlike most other NRT formulations, bupropion or varenicline, NNS was especially helpful for more dependent smokers. Continuing treatment of those initially failing was not beneficial. An initial 1-week prescription to those more dependent on nicotine is likely to be the most cost-effective NNS treatment protocol. These results should offer support to the effectiveness of the other NRT formulations untested in this setting.

Association of the serotonin transporter gene, neuroticism and smoking behaviours.

Cigarette consumption and smoking cessation are influenced in part by genes. Personality traits have also been implicated in the aetiology of smoking. Neuroticism, a personality trait with a heritable component, correlates well with anxiety and depression, increasing the risk of being a smoker and decreasing the chance of smoking cessation. Several prior studies in non-British populations have given conflicting results as to whether some genetic polymorphisms affect the relationship between smoking and neuroticism. This study investigated the influence of serotonin transporter (5HTTLPR) genotypes on a composite measure of neuroticism and cigarette consumption/smoking cessation in a British population. Although neuroticism was significantly associated with cigarette consumption and smoking cessation, genotype did not affect this relationship. Our results do not support initial interest in utilising 5HTTLPR genotypes in combination with neuroticism ratings for predicting outcome in smoking cessation clinical settings.

Association between dopamine transporter genotypes and smoking cessation: a meta-analysis.

This review assessed the evidence of an association between genotypes of the dopamine transporter (DAT1, SLC6A3) 3' untranslated region (3'UTR) variable number of tandem repeats (VNTR) and smoking cessation. Five studies (seven cohorts) comprising 2155 subjects were included in the meta-analysis. All gave data on the number of smokers who had stopped smoking and the number still smoking for those with one or more variant 9-repeat alleles and other genotypes. Three studies (comprising five cohorts) were cross-sectional population surveys and two were smoking cessation treatment programs with follow-up. Four of the five studies (six of the seven cohorts) showed a trend in favor of cessation when the variant 9-repeat allele was present, although only one study showed a statistically significant effect. The pooled odds ratio in favor of a greater likelihood of cessation for the variant 9-repeat allele was 1.15 [95% confidence interval (CI) = 0.97-1.37]. In a more refined analysis where cohorts within studies were treated as separate samples and adjusted odds ratios were used, the overall pooled odds ratio in favor of cessation with the 9-repeat alleles was 1.20 (95% CI = 1.01-1.43). These results support the hypothesis that the DAT1 3'UTR VNTR polymorphism is associated with smoking cessation. One or more variant 9-repeat alleles relative to the more common 10-repeat allele confers a greater likelihood of cessation, indicative of lower dependence on tobacco. The effect was a 20% increase in the odds of cessation for those with a variant allele.

Dopamine transporter polymorphisms are associated with short-term response to smoking cessation treatment.

OBJECTIVES: To examine the association between polymorphisms in the dopamine transporter gene (SLC6A3, DAT1) and treatment outcome in smokers attempting to quit using either nicotine replacement therapy or bupropion. METHODS: The sample consisted of 583 smokers recruited from a smoking cessation clinic, and followed throughout the 4 weeks of post-cessation treatment with behavioural support and either nicotine replacement therapy or bupropion. RESULTS: At 1 week after smoking cessation, the 3' untranslated region (3'UTR) variable number of tandem repeats (VNTRs) and the 30-bp intron 8 VNTR DAT1 genotypes were associated with the ability to stop smoking (3'UTR VNTR, odds ratio=2.0, 95% confidence interval=1.2-3.5, novel intron 8 VNTR, odds ratio=1.8, 95% confidence interval=1.0-2.9), controlling for potential confounders. The results were weaker and no longer significant at a 4-week follow-up. CONCLUSIONS: We find evidence, although modest, of a medium-sized effect of DAT1 genotype on the ability to stop smoking early in a smoking cessation attempt. If the effect is real, and is strongest in the very early stages of smoking cessation, this suggests that the primary utility of DAT1 screening in this field will be in the identification of those most at risk of early relapse after quitting.

Treatment of nicotine dependence with bupropion SR: review of its efficacy, safety and pharmacological profile.

Bupropion hydrochloride, an atypical antidepressant, is the first non-nicotine product that, in its sustained release form (bupropion SR), has been licensed as an aid for smoking cessation. The specialized literature on bupropion SR and smoking cessation is critically reviewed. The pharmacological profile, dosage and administration, contraindications, as well as the clinical efficacy, safety and tolerability data of bupropion are discussed. Recent reports suggest that its mode of actions might be different to what had originally been proposed. When prescribed appropriately, it appears to be a safe, well-tolerated and effective medication in combination with smoking cessation counselling--for a wide range of smokers, as shown in several multicentre double-blind, placebo-controlled clinical trials. Further research is needed on aspects such as the optimal duration of treatment, the potential role of combination therapy with NRT and psychological interventions, and to establish its effectiveness in smokers with other psychiatric disorders or when used with only minimal support by general practitioners.