Smoking cessation treatment for COPD smokers: the role of pharmacological interventions.

Because stopping smoking is such a pressing necessity for COPD smokers physicians should use smoking cessation treatments aggressively. For optimal efficacy smoking cessation in COPD smokers should combine behavioral and pharmacological treatments. Three types of pharmacological treatments are proven to be safe and effective: Nicotine Replacement Therapy (NRT), Bupropion and Varenicline. Use of NRT, bupropion or varenicline, single or in combination, at standard doses or at high doses, for 8-12 weeks or for more than 6-12 months have proven to help these patients to quit. For optimizing efficacy these medications can also be introduced some weeks before actual quitting. In COPD smoking patients that are not interested in stopping completely or abruptly these medications can be used to aid cessation in a more gradual way. Pharmacotherapy to aid cessation in COPD smokers have proven to be highly cost effective.

Smoking cessation treatment for COPD smokers: the role of counselling.

Smoking cessation is the only therapeutic intervention that can prevent COPD smokers from the chronic progression of their disorder. The most important intervention for helping these smokers to quit is a combination of counseling plus pharmacological treatment. The characteristics of the counseling should be different depending if this intervention is offered to smokers with a previous diagnosis of COPD or if the intervention is offered to smokers who have been recently diagnoses with COPD. The counseling of patients who have been recently diagnosed should include: a) explanation of the direct relationship between smoking and COPD, b) encouraging these patients to quit and c) using of spirometry and measurements of CO as a motivational tools. The counseling of patients who have been previously diagnosed should include: a) encouragement to make a serious quit attempt, b) an intervention that increases motivation, self-efficacy and self-esteem, c) and the intervention should also control depression and be directed to weight gain control.

Smoking cessation in patients with respiratory diseases: a high priority, integral component of therapy.

Smoking cessation is the one of the most important ways to improve the prognosis of patients with respiratory disease. The Task Force on guidelines for smoking cessation in patients with respiratory diseases was convened to provide evidence-based recommendations on smoking cessation interventions in respiratory patients. Based on the currently available evidence and the consensus of an expert panel, the following key recommendations were made. 1) Patients with respiratory disease have a greater and more urgent need to stop smoking than the average smoker, so respiratory physicians must take a proactive and continuing role with all smokers in motivating them to stop and in providing treatment to aid smoking cessation. 2) Smoking cessation treatment should be integrated into the management of the patient's respiratory condition. 3) Therapies should include pharmacological treatment (i.e. nicotine replacement therapy, bupropion or varenicline) combined with behavioural support. 4) Respiratory physicians should receive training to ensure that they have the knowledge, attitudes and skills necessary to deliver these interventions or to refer to an appropriate specialist. 5) Although the cost of implementing these recommendations will partly be offset by a reduction in attendance for exacerbations, etc., a budget should be established to enable implementation. Research is needed to establish optimum treatment strategies specifically for respiratory patients.

Un nuevo planteamiento del tratamiento del tabaquismo / A new exposition of treatment of smoking habit

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Reducción hasta dejarlo: árbol de decisión / Cutting down on tobacco consumption until giving up the habit: decision tree

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Assessment of the smoker who wants to quit.

This paper describes assessments that can be useful when giving smokers help to stop. The assessments discussed are: motivation, amount smoked, dependence, lung function, carbon monoxide (CO), earlier cessation experience, knowledge of nicotine's role, comorbidity, body weight, vital signs and cardiovascular risk factors. The rationale for each assessment is given. The most important factors to assess are probably motivation, dependency and CO in expired air.

Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability.

Currently available nicotine replacement therapy (NRT) medications provide effective treatment for tobacco dependence, typically doubling success rates compared with placebo. A strategy for further improving the efficacy of NRT is to combine one medication that allows for passive nicotine delivery (e.g. transdermal patch) with another medication that permits ad libitum nicotine delivery (e.g. gum, nasal spray, inhaler). The rationale for combining NRT medications is that smokers may need both a slow delivery system to achieve a constant concentration of nicotine to relieve cravings and tobacco withdrawal symptoms, as well as a faster acting preparation that can be administered on demand for immediate relief of breakthrough cravings and withdrawal symptoms. This article reviews 5 published studies that have examined the effectiveness of combination NRT compared with monotherapy in providing withdrawal relief and smoking cessation, and examines other factors relevant to the promotion of combination NRT for treating tobacco dependence. The data show that there are conditions under which combinations of NRT products provide greater efficacy in relieving withdrawal and enabling cessation than monotherapy, but the findings are not robust and additional research is warranted to better understand the magnitude and generality of the benefits of combination therapy. There are also regulatory and commercial obstacles that must be considered. Nonetheless, combination NRT has the potential to provide effective treatment of tobacco dependence in persons whose dependence is refractory to currently available treatments.

From reduced smoking to quitting: improvements in COPD symptoms and lung function: a case report.

This case report describes a smoker with chronic obstructive pulmonary disease (COPD) who had given up on trying to stop smoking because of many failed attempts. The patient, a 55-year-old woman, was, however, interested in reducing smoking and harm. During a long reduction phase, aided by nicotine replacement, the patient gained self-confidence, despite a depressive episode, and was finally able to quit smoking completely. Spirometry revealed several major improvements after reduction and abstinence.

Reduction of tobacco withdrawal symptoms with a sublingual nicotine tablet: a placebo controlled study.

Many smokers are unable to use gum as a cessation aid due to fillings, bridgework and dyspepsia or they reject it for esthetic reasons. The nicotine sublingual tablet is a new alternative to the nicotine polacrilex chewing gum that does not necessitate chewing. Twenty subjects used 2-mg sublingual nicotine tablets and placebo in a double-blind randomized crossover study of 2-day smoke-free periods. Craving and other withdrawal symptoms were rated on 100-mm visual analog scales (VAS) nine times over each 2-day period. Plasma nicotine concentrations in the afternoon of each study day were determined. A blood sample was also taken in the afternoon of a 2-day period with normal smoking. The mean number of nicotine tablets was 10 and seven on days 1 and 2, respectively. The corresponding number for placebo tablets was six and five. No subject used less than five tablets on any study day. The degree of nicotine substitution, defined as the quotient between the plasma levels achieved with the sublingual tablet and smoking, was 43, 30 and 23% for smokers with FTQ < or = 6, FTQ = 7 and FTQ > or = 8 (Fagerström Tolerance Questionnaire), respectively. Active treatment was significantly superior in decreasing craving and other withdrawal symptom scores compared to placebo treatment. Mean total scores were reduced by approximately 50%. Adverse events were mainly symptoms of local irritation such as a burning sensation in the throat or under the tongue, a lump in the throat and heartburn. These results demonstrate partial relief of the tobacco withdrawal syndrome with use of the sublingual tablet similar to that achieved from other forms of nicotine replacement.

Randomised trial investigating effect of a novel nicotine delivery device (Eclipse) and a nicotine oral inhaler on smoking behaviour, nicotine and carbon monoxide exposure, and motivation to quit.

OBJECTIVE: To monitor the effect of a novel nicotine delivery device that may produce fewer carcinogens (Eclipse) on cigarette smoking, carbon monoxide and nicotine concentrations, and motivation to give up smoking. The smoker's own brand of cigarette and a nicotine replacement product (Nicotrol inhaler) were used as comparisons. DESIGN: After baseline data were recorded, smokers were randomised to either Eclipse or inhaler for two weeks and then switched to the other product for another two weeks. Thereafter a second baseline was obtained. SETTING AND PARTICIPANTS: Fifty smokers were included and data are reported for the 40 with complete data sets. The smokers were not trying to quit but were interested in trying a new product to reduce their risk. They visited a smoking clinic 10 times during the six week period of the trial. INTERVENTION: No counselling to aid reduction by Eclipse or inhaler was given. MAIN OUTCOME MEASURES: At each visit smoking status and carbon monoxide concentrations were recorded. In half of the visits withdrawal symptoms, attitudes towards smoking, heart rate, and blood nicotine concentrations were also recorded. RESULTS: Eclipse use decreased the number of cigarettes smoked per day (cpd) from 19.1 cpd at baseline to 2.1 cpd (p < 0.001), but increased carbon monoxide concentrations in parts per million (ppm) from 21.0 ppm to 33.0 ppm (p < 0.001). A similar decrease in cigarettes smoked per day was seen with the Nicotrol inhaler, from 19.1 cpd to 4.8 cpd (p < 0.001), but carbon monoxide decreased from 21.0 ppm to 12.7 ppm (p < 0.001). The blood nicotine concentration remained fairly stable with Eclipse, increasing slightly from 16.8 ng/ml to 18.0 ng/ml, while for the inhaler a significant drop was noted, from 16.8 ng/ml to 12. 2 ng/ml (p < 0.002). Craving and withdrawal did not increase with Eclipse. Few significant adverse events occurred with Eclipse. CONCLUSIONS: Eclipse can dramatically decrease cigarette consumption without causing withdrawal symptoms or decreases in nicotine concentrations or motivation to quit altogether. Unlike the inhaler, Eclipse produces an increase in carbon monoxide concentration. Thus Eclipse may not be a safer cigarette.

Interventions for treatment-resistant smokers.

We can understand resistance to treatment in smokers in two ways. First, when there is no awareness that smoking can be responsible for a physical disease, e.g., chronic obstructive lung disease or a dependence disorder. Second, when smokers actually seek treatment but fail to respond positively. The first kind-resistance related to lack of awareness-may not be so common in adult US smokers, but is more common among young smokers. Information is crucial to increase awareness. However, such information must be presented in such a way that smokers respond to it. Whether a smoker takes action will also depend on what options and choices are available. Encouraging abrupt cessation as the only option is unlikely to motivate the smokers who have tried to quit many times and failed and those who do not want to give up completely. Alternatives such as quitting gradually-even harm-minimization-should be considered. Hopefully, taking some control over smoking with the help of, for example, nicotine replacement can increase self-efficacy and motivation to quit. For those who find it impossible to quit, harm-minimization procedures should definitely be invoked.

Nicotine replacement: a new approach to reducing tobacco-related harm.

Primary prevention is usually regarded as the most desirable goal in efforts to control tobacco-related diseases. However, this has not been very effective so far; moreover, it would take 30-40 yrs for primary prevention to translate into major health benefits. Modification of tobacco products and/or reduction of tobacco use may also have some impact on tobacco-related diseases. A tobacco dose-dependent risk has been observed in these diseases, including cancer, cardiovascular diseases, chronic nonspecific respiratory disorders, and problems during pregnancy. Reduced smoking (smoking fewer cigarettes, leading to a reduced intake of toxic substances) may be indicated in individuals who: 1) are failing in cessation attempts; 2) want to quit but are unable to do so; and 3) do not want to quit but want to reduce smoking. Studies have shown that nicotine replacement medications may be an untapped source in efforts to reduce smoking. Based on Austrian data, it is estimated that, approximately 10 yrs after implementation, a 1% reduction in smoking could save 14 male lung cancer deaths each year, and a 50% reduction would save 700 male lives. Inclusion of females and other tobacco-related diseases suggest that thousands of lives could be saved if smoking could be reduced by 50%. In the European Union, such a reduction in smoking could save > or = 100,000 lives annually. Even a 1% reduction would save 1,000 lives. In conclusion, reduced smoking should be explored as a valid method of reducing tobacco-related harm in those unwilling or unable to quit smoking.

Aiding reduction of smoking with nicotine replacement medications: hope for the recalcitrant smoker?

OBJECTIVE: To assess the effect of the various nicotine replacement therapies (NRT) on smoking reduction. DESIGN: During an initial sampling week, the subjects familiarised themselves with nicotine gum, patch, nasal spray, vaporiser (vapour inhaler) and sublingual tablet. A crossover design was used during the next four study weeks; during two of these weeks the subjects could select one nicotine replacement product of their choice to use, whereas during the other two they were randomly assigned a product to use. SUBJECTS: 143 men and women smoking an average of 22.6 (SD 7.0) cigarettes per day and exhibiting a Fagerström Tolerance Questionnaire (FTQ) score of 7.0 (SD 1.9). INTERVENTIONS: Subjects were asked to use as much NRT as they wished, yet to smoke enough to feel comfortable. MAIN OUTCOME MEASURES: Self-reported cigarette consumption, exhaled carbon monoxide (CO), withdrawal symptom score, cotinine plasma levels and motivation to quit were monitored over a period of five weeks. RESULTS: Self-reported smoking declined steadily over the five weeks, from 22.6 (SD 7.0) to 10.4 (SD 1.0) (P<0.001) cigarettes daily (54% decrease), with the biggest drop (37%) during the first product-sampling week. Smoking reduction was greater on average during the weeks when the subjects could choose their nicotine product than when products were assigned. CO readings decreased from 22.7 (SD 8.5) to 14.8 (SD 8.4) ppm (P<0.001) confirming a reduction in smoking (35% decrease), although cotinine levels remained steady, suggesting that subjects were titrating nicotine to their original levels. Withdrawal scores decreased over time (32% decrease, P<0.001), showing that there was no discomfort associated with the smoking reduction, and motivation to quit was enhanced by the treatment in most subjects (93%). CONCLUSIONS: NRT for aiding smoking reduction appeared to be safe, was associated with a clinically significant reduction in smoke exposure over a five-week follow up, and increased motivation to stop smoking. A smoking reduction procedure may help the very recalcitrant smoker gain confidence and increase the control over his/her smoking behaviour. More controlled research is needed to follow up these promising results.

Effects of smoking cessation on insulin and cardiovascular risk factors--a controlled study of 4 months' duration.

OBJECTIVES: To investigate the effects on serum lipids, plasma fibrinogen, plasma insulin, plasma C-peptide and blood glucose, of smoking cessation after 4 months. To develop a group-based smoking intervention programme in primary health care. SETTING: Twenty health centres in primary health care in southern Sweden. SUBJECTS: Four hundred habitual smokers (> 10 cigarettes per day-1, > 10 years), recruited by advertisement in local papers. INTERVENTION: The smokers were randomized, after stratification for age and sex, to one intervention group (n = 200) and one control group (n = 200). The intervention group was offered supportive group sessions and free nicotine supplementation (patches, chewing gum). MAIN OUTCOME MEASURES: All participants were investigated at the start and after 4 months (medical history, physical examination, laboratory evaluation). Blood samples were drawn for determination of glucose, insulin and C-peptide, both in the fasting state and during an oral glucose tolerance test (OGTT), and for measurement of lipoproteins, fibrinogen, nicotine and cotinine. RESULTS: In the intervention group 98 of the subjects (48%) had quit smoking after 4 months. They were compared with the 156 subjects in the control group (91%) who were still daily smokers during the whole period. There were no significant differences in any variable between the two (total) experimental groups at baseline. Plasma nicotine and cotinine decreased (P < 0.001) in the intervention group following smoking cessation, and weight increased by 2.7 kg. In the intervention group HDL-cholesterol increased by 11% (P < 0.001), whereas HbA1c increased by 2% (P < 0.05) only in the control group. No changes occurred in levels of glucose, insulin, C-peptide and fibrinogen. CONCLUSION: The smoking cessation programme had a success rate of almost 50% over 4 months. Smoking cessation was associated with a marked increase in HDL-cholesterol levels but did not affect glucose tolerance. A concomitant weight increase may have blunted any independent beneficial effect of smoking cessation on glucose metabolism.