Medications Alone May Not Help Smokers Quit Over Long Term
By Will Boggs MD
NEW YORK—Medications intended to aid quitting do not appear to increase long-term cessation rates in adult smokers, according to findings from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS).
"We all know that smoking cessation is difficult and simply providing a pharmaceutical cessation aid is not enough to help smokers quit,” Dr. John P. Pierce from the University of California, San Diego, in La Jolla, told Reuters Health by email.
Several studies have suggested that the population effectiveness of pharmaceutical smoking cessation aids is less than that reported in the efficacy randomized trials, and some smokers cite concerns about effectiveness as a reason for not wanting to use available medications.
Dr. Pierce and colleagues used nationally representative data from TUS-CPS to estimate the impact of pharmaceutical aids on smoking cessation in adult smokers.
Only 34% of respondents used a pharmaceutical aid during their most recent quit attempt, and 18% had been abstinent for 30+ days at the time of their follow-up survey, the researchers report in the Journal of the National Cancer Institute, online December 21.
The percentage of smokers using a pharmaceutical aid did not change substantially between 2002-2003 (34.8%) and 2010-2011 (33.2%).
In contrast, a larger proportion of the 2010-2011 group (21.0%) than of the 2002-2003 group (14.8%) reported abstinence for 30+ days at follow-up.
In logistic models estimating the association between use of pharmaceutical aids and smoking cessation in matched data sets, there was no evidence that use of any pharmaceutical aid to quit was associated with an increased probability of 30 days or more of smoking abstinence at one-year follow-up.
Results were similar in separate analyses of varenicline, bupropion, and nicotine replacement.
“The randomized trials that showed that these pharmaceutical aids doubled the probability of long-term cessation also included significant behavioral counseling,” Dr. Pierce said. “Such counseling was not available to those who used pharmaceutical aids to quit in the community.”
“In addition to prescribing a smoking cessation aid, we should refer these patients to a quality behavioral counseling program such as is available from some of the best quitlines in the United States,” he said.
“While this study could bring useful attention to the benefits of counseling, it would be harmful if it discouraged cessation medication use when counseling was unavailable,” write Dr. Hilary A. Tindle and Dr. Robert A. Greevy from Vanderbilt University Medical Center, in Nashville, Tennessee in an accompanying editorial.
“It is important to underscore a major message of the study - that wherever possible, behavioral support should be used in conjunction with pharmacotherapy,” they note. “This cornerstone of smoking cessation treatment should be universally employed for all smokers making a quit attempt because it will achieve the highest quit rates and have the greatest positive clinical impact on individuals and populations.”
“It is equally important to emphasize that this study does not prove the ineffectiveness of pharmacotherapy when used without counseling,” they add. “Indeed, the consequences could be grave if these data were interpreted to discourage use of pharmacotherapy, which is already underutilized. If providers erroneously believed that FDA-approved medications required concomitant counseling to be effective, and consequently stopped recommending pharmacotherapy when they perceived that counseling was unavailable, then this could be an unintended yet major step backwards for tobacco control.”
Dr. Steven A. Schroeder, from the University of California San Francisco's Smoking Cessation Leadership Center, told Reuters Health by email, "Most smokers (at least 70%) want to quit, there are now more ex-smokers than current smokers, and smoking prevalence is at a modern low. Yet smoking continues to be the number one preventable cause of death. Thus, physicians should identify smokers, counsel them to quit (that act alone has been shown to double the chances of quitting), and offer them both counseling and medications. One easy way to provide that counseling is to refer the smoker to a toll-free telephone service." One such service in the U.S., for example, is 1-800-QUITNOW.
“Scores of randomized control trials have documented that quit rates are improved with the use of smoking-cessation medications, although the increase is relatively modest, and most smokers don’t quit on their first attempt,” he said. “While this is a provocative article, it is possible that they were not able to adjust for all the relevant variables. So medications, combined with counseling, should remain the gold standard way to help smokers quit.”
The Centers for Disease Control and Prevention provides an extensive list of quit-smoking resources at http://bit.ly/2btnLfT, and many states also have resources to help individuals quit.
J Natl Cancer Inst 2017.
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