Smoking Cessation 2009-2010

Here we are at the end of the 2009. What sort of year has it been for smoking cessation? The biggest development in the past year has been the passing of legislation giving the U.S. Food and Drug Administration (FDA) the right to regulate tobacco products. While it is too soon to see any dramatic effects, there are high hopes that in years to come this will have a big effect in reducing the number of people who suffer serious tobacco-caused illness.

The other major development in the United States has been continuing increases in tobacco taxes, including a meaningful increase in federal taxes on all tobacco products in April. I am confident that this will have a positive impact in reducing smoking prevalence this and next year, particularly when combined with increasing restrictions on smoking in public places. These legislative and policy factors take a little while to have their effects, but they are very important.

On the negative side we have seen state budgets for tobacco control shrink significantly, and smoking continuing to be presented in a normalizing or glamorizing way in movies.

On the treatment side we have seen plenty of reassuring evidence on the safety and efficacy of varenicline, and also treatment with nicotine patch plus another NRT product. Telephone quitlines and internet website continue to provide free counseling and support, and some cities also have specialist face-to-face smoking cessation services. However to me it remains disappointing to see so many US cities without high quality smoking cessation services.

So what does the future hold? In many ways there has never been a better time to quit smoking. Smoking has been banned on so many pubic places , and is so expensive per pack, that it has become a real hassle to be a smoker. When these factors are added to the known health effects of tobacco, and the growing social unacceptability of smoking, it makes for a growing movement towards smoking cessation.

If you are a smoker or a recent ex-smoker then I wish you all the best for a stress-free and smoke-free 2010. I hope that you will find some of the information on this blog helpful, and will consider sharing some of your experience. If you have a specific question about smoking cessation then I encourage you to try to use the “search Health Experts” function on the right, to find articles on specific topics. Also please feel free to share your questions or experiences by posting your comments.

Have a healthy, smoke-free and peaceful 2010.

Labels: 2009, 2010, cessation, cigarette smoking, jonathan foulds

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Want to be smoke-free in 2010? Start preparing now.

As we approach the beginning of the new year, many of us are considering our New Year resolutions for 2010. For many smokers, quitting will be near the top of the list. Particularly in these tough financial times, many smokers are deciding it doesn’t make financial sense to keep smoking. When it comes to new year resolutions, it’s not essential that the change start immediately from midnight on December 31st, but if there isn’t a plan to get started pretty soon afterwards there’s a real risk that the planned change never happens.

With the holiday season upon us, along with its parties and overeating, few of us are planning to start the diet or quit the cigarettes between now and New Year’s Eve. But when it comes to quitting smoking, there may be a few steps in preparation that can be made now that will make you more likely to successfully follow-through with a plan at the beginning of the new year. Here are a few things that should be considered:

1. Are you going to get any help, like seeing a smoking cessation specialist, calling a quitline or seeing your doctor?

2. Are you planning on taking any smoking cessation medicines, and if so will they require a doctor’s prescription?

3. Which day is going to be your “quit day” – the day you will quit smoking completely?

Once you start thinking about these questions, you will see that if you want to quit smoking successfully around the beginning of the new year, you may have to start taking some steps now. For example, if you are thinking of taking one of the prescription medicines like varenicline or bupropion, you should arrange to see your doctor now to get your prescription. These are both medicines that should be taken for a week prior to your planned quit day. Even if you aren’t sure about taking a medicine but plan on getting some counseling support, now is the time to start making phone calls to get that organized.

If you are unsure where to access counseling in your part of the United States you may want to call the national quitline number at: 1-800-QUITNOW (1-800-784-8669).
You can also use the “search health experts” box on the right side of this blog to find other sources of help and information on specific topics. Just type in “smoking “ and whatever other topic you are interested in and it should find something.

www.smokefree.gov is also a helpful website. Best of luck.

Labels: cessation, jonathan foulds, new year, quitting, resolution, Smoking

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A Classic Study: The lung Health Study

Every now and again I like to pick one of the classic research studies on smoking cessation in order to highlight some of the key findings. Today I’m going to focus on the part of the Lung Health Study.

The Lung Health Study is certainly one of the best smoking cessation studies ever carried out, partly because of the comprehensive nature of the assessment and follow-up of its 5,887 participants and partly because it was way ahead of its time in delivering a truly “state-of-the-art” intensive smoking cessation intervention which was compared in a randomized manner to the effects of “usual care”. The Lung Health Study (LHS) was a randomized clinical trial of smoking cessation and inhaled bronchodilator therapy in smokers 35 to 60 years of age who did not consider themselves ill but had evidence of mild to moderate airway obstruction. Almost 4,000 of the participants were randomly allocated to receive a very intensive smoking cessation intervention consisting of group treatment (12 group meetings over 10 weeks), combined with aggressive use of nicotine gum. Patients’ partners were also allowed to attend for treatment, patients were encouraged to attend for retreatment if they did not quit, and were provided with ongoing relapse prevention over the 5 years of the study. They were also encouraged to continue using the nicotine gum for as long as it was helpful, and to use it even if still smoking in order to get quit. This excellent intervention resulted in 35% quit rates at the end of the first year and 22% remained sustained quitters at 5 year follow-up (compared to 9% and 5% in the “usual care” group.

This cohort was followed up for 15 years and dozens of excellent research papers have been published describing the health effects and the factors associated with quitting smoking. But one of the key results was that when they did the 15 year follow up they found that significantly more people who had been randomized to receive the smoking cessation intervention were still alive, as compared to those who were randomized to “usual medical care”. At face value this may not sound so surprising but unlike most studies of smoking and mortality this was based on analysis of a randomization to smoking-cessation treatment versus no treatment and shows that those getting smoking cessation treatment had better survival, even though the long term sustained quit rate was only 22%. So if you want proof that intensive smoking cessation treatment saves lives, this is the study that proves it.
The authors of the study estimated that the unit cost for providing the smoking cessation treatment and relapse prevention program in this study was $2,000 per patient. In comparison to almost every other healthcare intervention, this is incredibly good value for a life-saving intervention. Just for comparison, the Tobacco Dependence Clinic at UMDNJ-School of Public Health tries to provide a similarly intensive treatment for over 500 new patients per year on $102,000 of funding (i.e. $200 per patient). Although I feel that a unit cost in the range of $500-$2000 is more realistic when all the costs are included, this shows that quality smoking cessation treatment, similar to that provided in the Lung Health Study, can be provided relatively efficiently outside of a research context.

The Lung Health Study provides an excellent guide to providing quality smoking cessation treatment and the health outcomes that can be obtained.

Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE; Lung
Health Study Research Group. The effects of a smoking cessation intervention on
14.5-year mortality: a randomized clinical trial. Ann Intern Med. 2005 Feb
15;142(4):233-9.

Anthonisen NR, Connett JE, Kiley JP, Altose MD, Bailey WC, Buist AS, Conway WA
Jr, Enright PL, Kanner RE, O'Hara P, et al. Effects of smoking intervention and
the use of an inhaled anticholinergic bronchodilator on the rate of decline of
FEV1. The Lung Health Study. JAMA. 1994 Nov 16;272(19):1497-505.

Foulds J, Gandhi KK, Steinberg MB, Richardson D, Williams J, Burke M, Rhoads GG. Factors associated with quitting smoking at a tobacco dependence treatment clinic. American Journal of Health Behavior 2006; 30:400-412

Labels: cessation, cigarette smoking, jonathan foulds, Lung Health Study, mortality, nicotine dependence treatment, tobacco dependence treatment

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Menthol: it helps the poison go down easier

I’m writing from the second conference on menthol and cigarettes, in Washington DC. This conference was organized to review the evidence on the effects of menthol in cigarettes and to discuss what further research is necessary and what actions should be taken.

To me, the presentations appeared to suggest that right now the evidence that menthol cigarettes are more harmful to health is weak. However, the evidence that menthol cigarettes are a starter product for youth and that menthol cigarettes can (under certain circumstances) be more addictive and harder to quit, is quite strong and getting stronger all the time.

My own presentation focused on data we have previously published (and that I’ve already discussed on this blog) showing that menthol cigarettes are harder to quit for African Americans, Latinos and for people on a low income. It was very fortunate that just yesterday a new study by colleagues at UMDNJ-School of Public Health came into the public domain and so I was able to discuss its findings.

I think that study, by Drs Dan Gundersen, Cris Delnevo and Olivia Wackowski, is a very important one. The paper, which will be published in the journal “Preventive Medicine” and appeared online yesterday, was based on the 2005 National Health Interview Survey. It focused on a representative sample of U.S. adult ever exclusive cigarette smokers who had ever tried to quit (n=7,815). It aimed to assess whether people who were primarily menthol smokers had a lower quit rate than people who were regular cigarette smokers (after adjusting for other characteristics of those groups). The study found that among African American and Hispanic smokers, those who smoke menthols have a significantly lower rate of quitting. Interestingly it found that among whites, there was an opposite effect, with white menthol smokers having a slightly higher quit rate than white regular cigarette smokers.

One of the pleasing parts for me about this study was that the results, in a representative sample of smokers who had tried to quit, were almost perfectly consistent with the results we had previously published based on people trying to quit at our smokers clinic (Gandhi et al, 2009). Like our clinic study, this new paper found that the effect of menthol on inhibiting smoking cessation is a sizeable one. For example, among African Americans, while 62% of regular cigarette smokers successfully quit, only 44% of menthol smokers were able to quit. Also like our clinic study, the effect remained significant after controlling for differences in the relevant characteristics of those who smoke regulars and menthols. Also like our clinic study, the menthol effect differed between white (non-Hispanic) smokers and minority smokers. But one thing that was different was that Dr Gundersen’s study found that white menthol smokers were actually MORE likely to quit than white non-menthol smokers. So the question remains, why the difference of effect of menthol on quitting smoking between whites and minorities?

I remain convinced that the underlying mechanism of action of menthol is to enable smokers to inhale more nicotine (and smoke) under circumstances that require it. The main circumstance requiring the smoker to inhale more nicotine per cigarette is a situation forcing the smoker to reduce their daily cigarette consumption. There are various forces requiring smokers to reduce their cigarette consumption, but a major one is money. In recent times as cigarettes have become more expensive across the United States, many smokers can no longer afford to smoke a pack a day. So they have to reduce to 5 or 10 cigarettes per day or try to quit. Of course we know that as smokers reduce, they rend to inhale more nicotine per cigarette (an effect often referred to as “nicotine compensation”). But inhaling more smoke per cigarette can cause harsh sensations in the throat. Menthol cools that effect, making it easier for larger doses of the poison to go down (Williams et al, 2007). But one of the effects of inhaling a higher dose of nicotine per cigarette is that each cigarette becomes more reinforcing and addictive. Although there is always more than one explanation for any effect, I believe that facilitation of increased nicotine inhalation is one of the main effects of menthol. But people who have plenty of money don’t need to smoke fewer each day, and inhale more from each one. So there is a socioeconomic difference in the effect. This is part of the reason for the difference of effect of menthol in whites and minorities. In our clinic study we found a similar menthol effect in unemployed whites that we did in employed African Americans (with no effect of menthol on quitting at all in employed whites).

I suspect that if national data is analyzed focusing on unemployed white smokers living in the north east of the U.S. (the highest cigarette cost area), who tried to quit in recent times (when high cigarette taxes kicked in), we would find a lower quit rate among the menthol than the non-menthol smokers in that group.

In terms of harms to health, we’d more easily find these in the short term by looking, for example, at pregnancy outcomes in menthol versus non-menthol smokers. I’m suggesting greater study of the effects of menthol in pregnancy because it’s a situation when many smokers try to cut down or quit, but many remain smoking, and in which the health impact can be measured in the short term (e.g. birth weight and complications).

I’m leaving this conference with a greater clarity that menthol added to cigarettes make it easier for young people to start smoking and harder for smokers to quit, because menthol helps the poison go down easier.


References

Gundersen D, Delnevo C, Wackowski O. Exploring the relationship between race/ethnicity, menthol smoking, and cessation, in a nationally representative sample of adults. Preventive Medicine (2009), doi:10.1016/j.ypmed.2009.10.003

Gandhi KK, Foulds J, Steinberg MB, Lou SE, Williams J. Lower quit rates among menthol cigarette smokers at a tobacco treatment clinic. International Journal of Clinical Practice 2009 Mar;63(3):360-7.

Williams JM, Gandhi KK, Steinberg ML, Foulds J, Ziedonis DM, Benowitz NL. Higher nicotine and carbon monoxide levels in menthol cigarette smokers with and without schizophrenia. Nicotine Tob Res. 2007 Aug;9(8):873-81.

Labels: African American, cessation, cigarette, ethnicity, Gundersen, Hispanic, jonathan foulds, latino, menthol, NHIS, race, Smoking, white

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Debunking myths about self-quitting (1989): a classic study.

Every now and again I’d like to pick a classic research study from the past which shaped our understanding of smoking cessation. Today I’m going to focus on a paper by Dr Sheldon Cohen and 16 other researchers (recognized experts in the field 20 years later) entitled “Debunking myths about self-quitting. Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves.”

The study was conducted because a prior paper, based on a small number of people (161) had suggested that people who quit on their own are generally quite successful (more so than people who go for professional treatment) and that heavy smokers were just as likely to quit successfully on their own as light smokers. The researchers decided to pool together the data from 10 larger studies of “self-quitters” (smokers making a quit attempt without receiving any formal treatment), in order to get to the truth on these questions.

They picked 10 “prospective” self-quitting studies that followed people up for at least 6 months (most were at least 12 months) and that provided biochemical or other verification of people’s claim to have quit. Using prospective studies avoids the self-selection and recall biases you get when you simply recruit a group of people and ask them what it was like for them when they tried to quit. The 10 studies had taken place all over the country and included over 5,000 smokers and so this was thought more likely to provide results that would be generalizable to the population of smokers trying to quit on their own in the United States. One other good aspect of this study was that it included different measures of quitting, and assessed outcomes at numerous time points, enabling an analysis of both continuous “not a puff” quitting after a single attempt, as well as long term “point prevalence” abstinence, that may be the result of repeated quits and relapses over time.

The median “not a puff” continuous quit rate a year later was 4.2% and the median “point prevalence, not smoked in the past week” quit rate at 12 months was 14%. Those who tried to quit completely on their own, and those who had a manual to help them had similar quit rates. The study also found that heavy smokers (those smoking over a pack a day) were less than half as likely to quit for a year as less heavy smokers (a pack per day or less).

The study examined whether the number of previous quit attempts predicted the likelihood of successful quitting on this quit attempt. It found that although those who had never tried to quit before had slightly lower quit rates, there was no significant relationship between the number of prior quit attempts and success this time. A substantial proportion (24%) of those who had quit at 6 months had relapsed back to smoking by 12 months.

So this study was successful in debunking a number of myths about quitting smoking that were prevalent at the time. It showed that smokers who simply try to quit on their own with no assistance, do not (as had been claimed, and is still sometimes claimed) have surprisingly high quit rate. In this study the one year quit rates were in the range 4-14% depending on your definition. It also showed that quit rates vary by simple measures of baseline ‘dependence,” with heavier smokers having lower quit rates than less heavy smokers. It also found that the number of previous quit attempts has relatively little influence on a smoker’s chances of successfully quitting on the next quit attempt. Finally the study showed that a substantial proportion of smokers (around a quarter) who quit for 6 months, are likely to relapse in the next 6 months. One of the main conclusions of the study was that, “quitting smoking (by oneself or with the aid of a program) should be viewed as a process and not as a discrete event.” Wise words.

20 years later, even although the core findings from this study have been replicated many times, we still hear some of the myths about quitting smoking being repeated. The classic mistake (which resulted in the small study that prompted this one) is to try to figure out how people quit by asking a handful of successful self-quitters what it was like for them. Don’t be surprised if they tell you that the last time (i.e. the successful one, so far) wasn’t too hard. But that would be missing out on data from the other 95% of quit attempts that were not successful.

Reference
Cohen S, Lichtenstein E, Prochaska JO, Rossi JS, Gritz ER, Carr CR, Orleans CT, Schoenbach VJ, Biener L, Abrams D, et al. Debunking myths about self-quitting. Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves. Am Psychol. 1989 Nov;44(11):1355-65.

Labels: cessation, classic, jonathan foulds, myths, self-quitting, Sheldon Cohen, Smoking, unassisted

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Help for young smokeless tobacco users: mylastdip.com

A month ago I wrote about the health risks from using smokeless tobacco:
http://www.healthline.com/blogs/smoking_cessation/2009/08/how-harmful-is-snuff-smokeless-tobacco.html

Today I’d like to mention a relatively new website that is designed to help young smokeless tobacco users (aged 14-25) to quit using smokeless tobacco, and to participate in a national cancer Institute-funded study of the usefulness of the site.
The website is called Mylastdip.com and was launched in October 2008. Over 500 people have enrolled on the site to take part in a free self-help quitting program. To enroll, participants must have an active e-mail address and be willing to complete some online questionnaires as part of the research program.
MyLasDip.com is free and available 24 hours a day, was developed by experts in smokeless tobacco cessation, and is based on methods that have been effective with thousands of smokeless tobacco users.

So check out: mylastdip.com

Labels: cessation, jonathan foulds, mylastdip.com, smokeless, tobacco

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Smoking after cancer diagnosis: Comment by Patrick Swayze’s doctor on CNN’s Larry King

Many people were saddened to hear of the recent death of the actor Patrick Swayze, after an almost two year battle with pancreatic cancer. Patrick Swayze was a very successful actor, most noted for his leading roles in the hit movies, Ghost and Dirty Dancing.

Within the past week, one of Patrick Swayze’s oncologists, Dr George Fisher, was interviewed on the CNN “Larry King Live” show and made the following comments:

LARRY KING: “He continued to smoke. Was that a bad idea?”

DR. GEORGE A. FISHER, ONCOLOGIST, STANFORD HOSPITAL & CLINICS: “I think at the point that one is already diagnosed with cancer, there's little additional harm in it. And if it -- it seems to provide him some comfort or partly identity of who he is, I certainly have no objections to that. But he would be the first to say that if you don't smoke, don't start. And if you do smoke, quit before you develop cancer.”

I suspect that Dr Fisher’s comments were referring to the specific context of someone suffering from a severe type of terminal cancer where the estimated life expectancy is in months rather than years, and not referring to all cancer diagnoses. So I think it is important that people, and particularly those people with a recent cancer diagnosis who are still smoking or recently quit, don’t take this comment out of context. Nowadays many types of cancer can be cured or effectively managed over a period of many years, and it is very clear that for many of these cancer diagnoses, the prognosis is much better if the patient quits smoking.

Below is a quote from a published review by an expert on this subject, Professor Ellen Gritz, of MD Anderson Cancer Center:
“The detrimental effect of smoking on cancer survival rates has been consistently demonstrated. Continued smoking after diagnosis has been found to negatively affect overall survival in patients with lung, head and neck, prostate, and cervical cancers. However, stopping smoking before diagnosis and treatment can have a positive influence on survival rates. Studies have generally indicated that the longer the interval between smoking cessation and initiation of cancer treatment, the better the prognosis.“

(Gritz ER, Fingeret MC, Vidrine DJ, Lazev AB, Mehta NV, Reece GP. Successes and failures of the teachable moment: smoking cessation in cancer patients. Cancer. 2006;106:17–27.)

Just last month the results of a very large study were published showing better outcomes for smokers who quit sooner after lung cancer diagnosis. I’ve copied the study summary below. Just to be clear, the research evidence shows that in the vast majority of cancer diagnoses, health outcomes will be improved by quitting smoking.


Impact of smoking cessation before resection of lung cancer: a Society of
Thoracic Surgeons General Thoracic Surgery Database study.
Mason DP, Subramanian S, Nowicki ER, Grab JD, Murthy SC, Rice TW, Blackstone EH. Ann Thorac Surg. 2009 Aug;88(2):362-70; discussion 370-1.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute,
Cleveland Clinic, Cleveland, Ohio 44195, USA. masond2@ccf.org

BACKGROUND: Smoking cessation is presumed to be beneficial before resection of
lung cancer. The effect of smoking cessation on outcome was investigated.
METHODS: From January 1999 to July 2007, in-hospital outcomes for 7990 primary
resections for lung cancer in adults were reported to the Society of Thoracic
Surgeons General Thoracic Surgery Database. Risk of hospital death and
respiratory complications was assessed according to timing of smoking cessation,
adjusted for clinical confounders. RESULTS: Hospital mortality was 1.4% (n =
109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had
not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p
= 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing
of smoking cessation was categorized as current smoker, quit from 14 days to 1
month, 1 to 12 months, or more than 12 months preoperatively, respectively.
Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but
6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27
of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p =
0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose
timing of smoking cessation was categorized as above. CONCLUSIONS: Risks of
hospital death and pulmonary complications after lung cancer resection were
increased by smoking and mitigated slowly by preoperative cessation. No optimal
interval of smoking cessation was identifiable. Patients should be counseled to
stop smoking irrespective of surgical timing.

The CNN interview transcript is at:
http://transcripts.cnn.com/TRANSCRIPTS/0909/19/lkl.01.html

Labels: cancer, cessation, cigarette, CNN, diagnosis, George Fisher, jonathan foulds, Larry King, Patrick Swayze, Smoking, survival

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Smoking and HIV.

Twenty years ago, people who found out they had the Human Immunodeficiency Virus (HIV) felt as though they had been given a death sentence. At that time we did not have medicines that had been shown to be very effective in slowing the progression of the virus and preventing the onsite of diseases associated with AIDS. A large proportion of people who are HIV+ are also smokers, partly because some of the lifestyle behaviors that put one at risk of HIV also are risk factors for smoking (e.g. people who exhibit high risk behaviors such as having unprotected sex with multiple partners, or using intravenous drugs, also are much more likely to smoke). Unfortunately, back in the days before effective treatments for HIV/AIDS, HIV+ smokers didn’t see much point in quitting smoking because they perceived it as very likely that they would die from AIDS before suffering from smoking-caused diseases like lung cancer.

However, in the twentieth century we now know that with proper use of antiretroviral therapies, a 25 year-old who is HIV+ will likely live at least another 35 years, and probably longer with medical advances during that time. This is good news for people who are HIV+. Unfortunately one thing that hasn’t changed in line with effective HIV treatment is the perception of how important it is to quit smoking if you have HIV. While the smoking prevalence among U.S. adults recently dipped below 20%, studies among people who are HIV+ find a smoking prevalence of 45-74%. Often providers, recognizing that having HIV can lead to many stresses and challenges, feel reluctant to tackle the patient’s tobacco dependence. But there are many reasons why it is, if anything, MORE important to quit smoking if you are HIV+. Here are a few:

-Some of the antiretroviral medicines are metabolized more quickly if you smoke

-There is some evidence that antiretroviral medicines may increase cardiovascular risks, as does smoking, so it is important to avoid a double risk

- HIV+ smokers are three times more likely to contract certain serious AIDS-defining illnesses, such as bacterial pneumonia.

There has not been a very large amount of research on smoking cessation specifically in people with HIV, but the studies published so far tend to find results that are highly consistent with the studies in the general population of smokers. So there is every reason to expect that treatments proven effective for smoking cessation (e.g. nicotine replacement therapy and counseling) will also help HIV+ smokers to quit. Some specialist services are now being developed. One weblink was recently sent to me by AIDS specialist and colleague Dr Jonathan Shutter, and is worth checking out at: www.positivelysmokefree.com

I’d be interested in hearing comments on that website and also any experiences of quitting smoking after a positive HIV test.

Labels: AIDS, cessation, cigarette smoking, HIV, jonathan foulds, tobacco

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NRT to reduce and eventually quit smoking: does it work?

The package labeling recommendations and normal practice for use of nicotine replacement therapy (NRT, i.e. nicotine patch, gum etc) involves the smoker in picking a day when they will abruptly stop smoking, and start using the NRT as a substitute for smoking. However, over recent years product labeling in some countries (e.g. Great Britain) have allowed some of these products to be used to help the smoker initially reduce their tobacco consumption gradually before eventually quitting. This method has been called, “nicotine assisted reduction to stop”.

Earlier this year Dr David Moore and colleague at the University of Birmingham published a review of all randomized trials comparing NRT with other interventions in smokers declaring an interest in cutting down their cigarette consumption, but no intention to quit abruptly. The primary outcome examined in the review was 6 months of sustained abstinence from tobacco, and they compared the proportion achieving that using NRT with the proportion achieving that outcome when using a comparative intervention (placebo NRT). Note that all of the studies were conducted “double blind”, meaning that neither the smoker nor the researchers were who received NRT and who received placebo NRT until the end of the studies.

The study found 7 trials comparing NRT with placebo NRT. Most of the trials involved about 6 clinic visits. And allowed use of the NRT or placebo for around 12 months, with follow-up typically extending 3-12 more months. The participants in these studies were typically very heavy smokers, averaging over 25 cigarettes per day.

In the final analysis of all the trials, there were around a thousand smokers allocated to NRT and a similar number allocated to placebo NRT. 7% of those using NRT achieved 6 months sustained tobacco abstinence compared with 3 % of those using placebo NRT. All of the other outcomes were also better for the NRT group. For example, 22% of those using NRT had reduced their cigarette consumption by at least 50% at the end of the studies, as compared with 16% of those allocated to use placebo NRT.

There was little evidence to suggest that using NRT while continuing to smoke is dangerous (over and above the dangers of smoking). 4 people died who had used NRT, and 4 died who had used placebo. No other serious adverse events were more likely in the NRT condition. The only symptom found to be more common among those using NRT was nausea, with 9% experiencing nausea who had used NRT, compared to 5% who had used placebo. Very few people discontinued use of either active or placebo NRT because of adverse events ( <2% of each).

So what does this mean? On the one hand it is rather impressive that when you take a large group of smokers who say they are interested in reducing their consumption but are not interested in quitting, and give them NRT gum or inhaler to use for a long period of time, that in fact a significant (but small) proportion actually quit smoking (7%) and a larger proportion (22%) manage to sustain reduced smoking.

On the other hand, there were some characteristics of most of these research studies that make the situation quite different from the “real world” situation of smokers purchasing NRT for “reduce to quit” on their own. One difference is that in these studies the participants were provided with 6 visits including brief counseling to continue reducing their consumption. In the real world that is frequently unavailable (although it could be provided by networks of clinics, and telephone quitlines). In addition, because they were participating in placebo-controlled research studies, all of the participants were given their NRT for free. I understand the good reasons why the research has to be carried out this way, but I suspect it may have a relatively large influence on smoker behavior. I suspect that a much lower proportion of smokers would continue paying out of pocket for BOTH cigarettes and NRT for months and months, particularly if they had no intention of quitting (which implies that the double paying would continue forever).

So for me the message is that if you are a smoker who is not ready to quit abruptly and use NRT in the traditional way, then NRT can help you reduce your cigarette consumption gradually, and by doing this you are more likely to succeed in quitting in the long term. Importantly, the evidence suggests that dual use of cigarettes and nicotine gum or inhaler is not dangerous in terms of nicotine overdose.

Given that we know it is so easy to go back to regular smoking after a brief period of abstinence, I’d recommend that anyone thinking of following this gradual reduction program should have a clear plan and intention to quit smoking completely by a certain date, and that date should not be too far in the future (a month is OK, but 9 months is way too long for most people to persist with dual use towards quitting).

I’d also recommend that those using NRT this way really try to maximize their NRT use and minimize cigarette smoking as early as possible. That way they are more likely to learn to enjoy the NRT and get used to using it as their source for nicotine. Using minimal NRT only in places where you can’t smoke, is more likely to continue the use of cigarettes as the primary source for nicotine.

I’d be interested to hear comments from anyone who has used NRT, or any other methods, to gradually reduce their cigarette consumption. It would also be useful for readers to hear from the experiences of others. Have you tried gradual cigarette reduction, and how did it go?

The published paper by Dr Moore and colleagues can be accessed in full for free at:
http://www.bmj.com/cgi/content/full/338/apr02_3/b1024

Labels: cessation, cigarette smoking, David Moore, jonathan foulds, NRT, smoking reduction

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Avoid the vacation relapse

As we have discussed many times on this forum, quitting smoking can be difficult, but staying quit can be even harder. Part of the reason that relapse is so common among smokers who initially quit successfully (e.g. for a month) is that whereas during the first month the new ex-smoker is really determined and focused on quiting, its hard to maintain that level of motivation forever. The novelty wears off, and then a combination of circumstances leads to a lapse. The most common things leading to a lapse smoke are: availability of tobacco, experience of a negative mood state (e.g. anger, depression, anxiety, etc), and thoughts that enable smoking (“one wont hurt”….”it doesn’t really count if its someone else’s” etc).

Many ex-smokers say that they particularly want to smoke when they are in a “stressful” situation. At this time of year many of us are on or preparing to go on a vacation…often with family. Now although vacations are supposed to be fun and maybe relaxing, very often it doesn’t turn out that way. In fact vacation trips typically get a large number of points on “stress scales” that are designed to measure how much stress an individual has experienced recently. Part of the reason is that any change in ones life requires coping and adjustment and a vacation trip involves considerable changes (travel, different routine, different people etc). Family vacations in particular can be stressful to the parents (and also sometimes for the kids) and sometimes that stress can increase the risk of trying a cigarette again.

Even for people going on vacation without the kids, vacations can trigger lapse smoking. Very often vacations are viewed as a time to relax and wind down, or to blow off a bit of steam. That could include drinking alcohol and eating more than usual and also smoking. Some vacation lapses occur because the individual convinces him/herself that it doesn’t count if its on vacation. Unfortunately, as many of you know, these “innocent” lapse cigarettes very often lead to a full relapse.

So how can that be avoided? The first rule is “forewarned is forearmed”. This means that being aware that the although the vacation is intended to be fun, it may have its stressful moments which may trigger some desires to smoke. The next thing is to try to anticipate some of the triggers and make plans to avoid lapse smoking. Part of these plans should relate to how vulnerable you feel to relapsing. If you have only just quit a few weeks ago, and are still craving a cigarette on a frequent basis, then its probably not a great plan to go on vacation with a group of smokers to a place where smoking in bars and restaurants is allowed, (e.g. Las Vegas). Similarly, if you are still taking some form of smoking cessation medicine it is important to make plans in advance to ensure that you take enough with you so you don’t run out.

There are a few other things that you should prepare for. If you are flying internationally or even to certain US states you will probably have the opportunity to buy much cheaper cigarettes than in your home state. That should be anticipated and not treated as an opportunity too good to miss. It is also worth doing a bit of research to find out the indoor smoking policies at the place you are going. For those of us who are lucky enough to live in a place that has band smoking indoors it can come as a bit of a surprise to vacation in a place where half the people in the bar appear to be smoking. One final thing to do is to take stuff with you that you will find enjoyable and that can help you relax and take your mind off smoking. For some people it will be a couple of good books, for some its their Ipod with their favorite music (and don’t forget the charger), and for others it’s the running shoes so you can get fit while you have the time. Sometimes being on vacation and finding yourself at a loose end on a rainy afternoon can lead to thoughts of smoking also.

Of course the main thing is to go into the vacation with a positive attitude…and plan to do the fun and healthy things that it is sometimes hard to find time for when we are busy working or looking after the home. Make up your mind that nomatter what happens on the vacation, if you can return home without smoking that will be a success. Enjoy that hard earned vacation and the money you have saved by not smoking!

Labels: alcohol problem relapse, cessation, cigarette smoking, jonathan foulds, lapse

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Effects of nicotine replacement for smoking reduction

This week, Dr David Moore and colleagues at the University of Birmingham (UK) published a review of randomized controlled trials of nicotine replacement for reducing smoking in smokers who initially did not plan to quit. The review, published in the BMJ, included 7 trials involving 2767 smokers.

They found that of smokers entering these trials intending only to reduce their smoking almost 7% of those who used nicotine replacement and just over 3% of those who used placebo NRT eventually quit smoking for 6 months.

The study also examined whether there were any signs that it is unsafe to use nicotine replacement therapy while still smoking. They found that discontinuation of treatment due to serious adverse events was rare (less than 2% for both NRT and placebo groups). The only symptom that appeared to be significantly more frequent in those receiving NRT (rather than placebo) was nausea. 9% of those using NRT experienced some nausea and 5% of those receiving placebo reported nausea. So there does not appear to be any serious safety concerns with using NRT while reducing smoking.

The authors concluded that nicotine replacement therapy is an effective intervention in achieving sustained smoking abstinence for smokers who have no intention or are unable to attempt an abrupt quit. Most of the evidence, however, comes from trials with regular behavioral support and monitoring and it is unclear whether using nicotine replacement therapy without regular contact would be as effective.

In one sense it is impressive that NRT is able to produce significantly more long term quitters, given that none of the people recruited to these trials wanted to quit at that point. On the other hand, the quit rate is not very high (under 7%).

For me, the other practical problem that wasn’t really addressed in the main conclusions was the issue of cost/payment for NRT. In these research trials participants are typically provided with NRT for free. But I don’t see many smokers, who are not trying to quit, paying out of pocket for NRT for 6-18 months while still paying for their cigarettes. Similarly, why publicly funded healthcare systems may subsidize NRT and counseling for those trying to quit, I don’t see this happening for smokers simply trying to gradually reduce with no intention of quitting.

So while it is good to know that NRT is safe and effective as an aid to reduced smoking, and that when used that way more smokers actually quit, I don’t see NRT being widely used in the real world the way it was in these clinical trials.

It is interesting that exposing smokers who arn’t planning to quit to NRT results in more of them quitting. I suspect that the same thing would happen were NRTs promoted as a treatment for nicotine withdrawal symptoms during periods of brief/temporary abstinence (eg while at work, in smokefree environments etc). Some are concerned that such use would diminish quitting. I suspect it would just teach many smokers that they can function quite well by getting their nicotine from a less harmful source…and prompt more to switch to NRT completely.

You can read the full report at: http://www.bmj.com/cgi/content/abstract/338/apr02_3/b1024

Labels: cessation, cigarette smoking, harm reduction, jonathan foulds, NRT

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Rethinking drinking

For very many smokers, drinking and smoking go together hand in hand. Consequently, when smokers try to quit smoking they often find that having a drink of alcohol triggers the desire to also have a smoke. In addition, once alcohol starts to cloud our thinking, ex-smokers sometimes “forget” that they are trying to quit smoking. So you are in a better position to quit smoking if you are already in control of your drinking, and able to avoid it completely if you wanted to during the first month of an attempt to quit smoking.

A new website has just been launched to help people check their drinking pattern, identify potential problems, and take steps to make sure their drinking is under control. http://www.rethinkingdrinking.niaaa.nih.gov was developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to provide the best evidence-based advice to people who may have a drinking problem. It is very user-friendly and includes links to other resources. I’d recommend it to anyone who wonders if they may be drinking too much. It could also help you ensure your drinking is under control prior to a quit attempt.

For additional information on alcohol use while trying to quit smoking, check out:

Effects of alcohol on smoking cessation – 1. 5/29/07 http://www.healthline.com/blogs/smoking_cessation/2007/05/effects-of-alcohol-on-smoking-cessation.html

Effects of alcohol on smoking cessation – 2. 5/29/07 http://www.healthline.com/blogs/smoking_cessation/2007/05/effects-of-alcohol-on-smoking-cessation_29.html

Labels: alcohol problem relapse, cessation, cigarette smoking, jonathan foulds, NIAAA, rethinking drinking

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Should health care services provide treatment for addicted smokers?

Last week’s issue of the leading medical journal, “The Lancet” included two comment articles on the issue of whether it makes sense to fund healthcare services to help smokers to quit.

Professor Simon Chapman (University of Sydney) argued that cessation services devour resources that could be better used for anti-tobacco mass-media campaigns and that these services give people the impression that smokers are unlikely to succeed alone. He has argued before that smoking cessation clinics should be abandoned.

Professor John Britton (University of Nottingham) defended the role of smoking cessation services. He acknowledged that population-level interventions (e.g. laws banning smoking in public places) have a greater potential to impact population smoking prevalence, but argued that impacting population smoking prevalence is not their primary purpose (any more than chemotherapy for cancer aims to decrease the population prevalence of cancer). He pointed out that we need treatment for the most addicted smokers, that the evidence from England shows that very high numbers of smokers are willing to use services when available (680,000 in England last year), and that cessation services are one of the most cost-effective healthcare interventions available.

I think part of the problem here is the perception that within the tobacco control tools at our disposal “population impact” strategies and “individual treatment” strategies represent an either/or choice. Quite simply, they are not. There are plenty of places where activities to increase the price of tobacco, ban smoking in public places, etc occur simultaneously with activities to provide more smokers with treatment to help them quit smoking (e.g. the United Kingdom, or some U.S. states). The relevant population-impact policy here is to persuade healthcare systems to routinely provide brief and specialist tobacco treatment options.

It is usually the case that population level interventions have a larger population impact than individual clinical interventions. Whether that involves eradicating the breeding-grounds of malaria-carrying mosquitos near population centers, or building a water purification plant it does not follow that it’s a waste of time to use anti-malarial medicines or treat people who catch infections.

Comparing effective population-based public health interventions with effective clinical interventions is like comparing apples and broccoli. They are both good for you, and having both is better than just one or neither. If the argument is about the use of scarce resources then tobacco treatment services should be evaluated against other clinical services (e.g. the treatment of alcohol problems, hypertension, diabetes or breast cancer), rather population-based policy interventions. If Chapman believes tobacco treatment services should be abandoned on the grounds of cost-effectiveness (on measures such as cost per quality adjusted life year gained), then he should simultaneously be arguing that a vast number of clinical services should be abandoned first, as tobacco treatment has amongst the biggest bang for the clinical treatment buck.

I have the utmost respect for both John Britton and Simon Chapman as tobacco control experts. But in this debate I have to agree with Professor Britton. If one wants to reduce the harms to health caused by smoking, it makes more sense to argue for more population-based interventions AND more clinical interventions, so that those addicted smokers who are persuaded to try to quit can have a better chance of doing so successfully.

Some recent statistics from the English smoking cessation services can be found at:
http://www.ic.nhs.uk/webfiles/publications/Stop%20smoking%20ANNUAL%20bulletins/SSS0708/SSS%202007-08%20final%20format%20v2.pdf

For the rationale for comprehensive tobacco control:
http://www.healthline.com/blogs/smoking_cessation/2008/05/why-comprehensive-tobacco-control.html

For a description of what a specialist tobacco treatment clinic does:
http://www.healthline.com/blogs/smoking_cessation/2008/02/what-does-tobacco-treatment-clinic-do.html

Labels: cessation, cigarette smoking, John Britton, jonathan foulds, nicotine dependence treatment, public health, services, simon chapman

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47 posts in 2008

This link contains a list of my posts in 2007:
http://www.healthline.com/blogs/smoking_cessation/2007/12/ninety-five-posts-in-2007.html

and here are the ones from 2008….

Time to quit….now. 1/1/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/time-to-quitnow.html

Not a puff. 1/6/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/not-puff.html

How does your state or country tackle tobacco? 1/12/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/how-does-your-state-or-country-tackle.html

100. Do you wake at night to smoke? 1/16/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/do-you-wake-at-night-to-smoke.html

101.Swedish Snus: A Reply to Professor Tomar. 1/22/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/swedish-snus-reply-to-professor-tomar.html

102.What does a tobacco treatment clinic do? 2/6/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/what-does-tobacco-treatment-clinic-do.html

103.New study compares Chantix to the nicotine patch. 2/11/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/new-study-compares-chantix-to-nicotine.html

104.What is in cigarette smoke? 2/17/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/what-is-in-cigarette-smoke.html

105.Snus use in Sweden: another reply to Tomar. 2/19/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/snus-use-in-sweden-another-reply-to.html

106.Chantix and depression on stopping smoking. 2/26/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/chantix-and-depression-on-stopping.html

107. Marlboro Snus Isn’t Really Snus 3/4/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/marlboro-snus-isnt-really-snus.html

108. Smoking and lung function 3/7/08
http://www.healthline.com/blogs/smoking_cessation/2008/03/smoking-and-lung-function.html

109. Wearing the patch prior to quitting 3/21/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/wearing-patch-prior-to-quitting.html

110. Why Chantix may reduce alcohol consumption. 3/22/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/why-chantix-may-reduce-alcohol.html

111. How have New York and New Jersey reduced smoking? 3/24/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/how-have-new-york-and-new-jersey.html

112. Buy cigarettes on the internet? Expect a large invoice. 3/26/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/buy-cigarettes-on-internet-expect-large.html

113. Lung Cancer, Spiral CT and Tobacco Industry Funding 3/26/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/lung-cancer-spiral-ct-and-tobacco.html

114. Smoking and Lung Cancer 3/29/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/smoking-and-lung-cancer.html

115. Can cigarettes be made less deadly? 4/20/2008
http://www.healthline.com/blogs/smoking_cessation/2008/04/can-cigarettes-be-made-less-deadly.html

116. Vote for Healthline for Webby Award 4/20/2008
http://www.healthline.com/blogs/smoking_cessation/2008/04/vote-for-healthline-for-webby-award.html

117. Which U.S. states smoke most and least? 4/21/2008
http://www.healthline.com/blogs/smoking_cessation/2008/04/which-us-states-smoke-most-and-least.html

118. Smoking and suicide. 4/22/08
http://www.healthline.com/blogs/smoking_cessation/2008/04/smoking-and-suicide.html

119. Tobacco harm reduction. 4/25/08
http://www.healthline.com/blogs/smoking_cessation/2008/04/tobacco-harm-reduction.html

120. Become an ex. 4/30/08
http://www.healthline.com/blogs/smoking_cessation/2008/04/become-ex.html

121. Which kids in the US are most likely to use tobacco? 5/6/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/which-kids-in-us-are-most-likely-to-use.html

122. Unwise to cut tobacco control funding in tough times. 5/9/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/unwise-to-cut-tobacco-control-funding.html

123. Thanks to grand rounds 4.34 at Health Business Blog. 5/17/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/thanks-to-grand-rounds-434-at-health.html

124. Why comprehensive tobacco control? 5/18/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/why-comprehensive-tobacco-control.html


125. Thanks to the Dinosaur for grand rounds. 5/28/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/thanks-to-dinosaur-for-grand-rounds.html

126. Chantix (varenicline) safety. 5/28/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/chantix-varenicline-safety.html

127. Chantix safety at the US Veterans Affairs health service. 5/31/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/chantix-safety-at-us-veterans-affairs.html

128. Are Americans switching to smokeless tobacco? 6/09/08
http://www.healthline.com/blogs/smoking_cessation/2008/06/are-americans-switching-to-smokeless.html

129. Doctors under the influence: the real story. 6/30/2008
http://www.healthline.com/blogs/smoking_cessation/2008/06/doctors-under-influence-real-story.html

130. Happy Independence Day. 7/5/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/happy-independence-day.html

131. Extended treatment for some addicted smokers. 7/06/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/extended-treatment-for-some-addicted.html

132. What proportion of smokers become addicted? 7/13/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/what-proportion-of-smokers-become.html

133. Parental use and restrictions influence teen smoking. 7/19/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/parental-tobacco-use-and-restrictions.html

134. MPOWER: Bloomberg and gates pledge millions to tobacco control. 7/27/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/mpower-bloomberg-and-gates-pledge.html

135. Congress votes for FDA tobacco regulation. 7/30/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/congress-votes-for-fda-tobacco.html



136. UK National Smoking Cessation Conference. 8/1/08
http://www.healthline.com/blogs/smoking_cessation/2008/08/uk-national-smoking-cessation.html

137. Carbon-monoxide in cigarette smoke. 8/0208
http://www.healthline.com/blogs/smoking_cessation/2008/08/carbon-monoxide-in-cigarette-smoke.html

138. Effect of extended counseling on smoking cessation. 8/10/08
http://www.healthline.com/blogs/smoking_cessation/2008/08/effect-of-extended-counseling-on.html

139. Cigarette health warnings and bogus buy-ology. 12/16/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/cigarette-health-warnings-and-bogus-buy.html

140. Facts and fiction on stopping smoking. 12/20/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/facts-and-fiction-on-stopping-smoking.html

141. How to stop smoking with varenicline (Chantix). 12/20/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/how-to-quit-smoking-with-varenicline.html

142. Happy holidays. 12/25/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/happy-holidays.html

143. Get ready for smoke-free 2009. 12/28/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/get-ready-for-smoke-free-2009.html

Labels: blog, cessation, cigarette smoking, freedom from smoking, healthline, jonathan foulds, nicotine

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Why are mentholated cigarettes more addictive?

My colleagues and I just published a research study which examined the quit rates of patients attending our specialist Tobacco Dependence Clinic, and focused on the differences between those who smoked mentholated cigarettes and those who smoked non-menthol cigarettes.
Consistent with numerous other studies, we found that far more African American (81%) and Latino (66%) smokers smoked menthols, as compared with non-Latino Whites (32%). But the more interesting finding was that while African American and Latino smokers of non-menthol cigarettes had similar quit rates to whites, the quit rates of those smoking menthols was significantly lower. For example, African Americans who smoked menthols had half the odds of quitting of African Americans who smoked regular non-menthol cigarettes.
This “menthol effect” on quitting occurred despite the fact that menthol smokers typically smoked fewer cigarettes per day. So why do many smokers, and particularly African Americans and Latinos find menthol cigarettes to be particularly hard to quit?
In an earlier study we found that menthol cigarette smokers have higher nicotine, cotinine and carbon-monoxide levels than non-menthol smokers. This suggests that they tend to inhale more smoke from each cigarette. Menthol stimulates cold receptors and may therefore cool the harshness of cigarette smoke and make it easier to inhale larger amounts. It seems that the “menthol effect” is more pronounced in situations where the smoker may need to try to inhale more nicotine from fewer cigarettes. Thus in New Jersey, where we have amongst the highest cigarette taxes in the country, many people on low incomes can no longer afford to smoke a pack or two per day, but they have become addicted to that amount of nicotine. When a smoker reduces their cigarette consumption it is typical that they “compensate” by inhaling more from each one. This can be easily achieved, without any conscious effort, by taking larger puffs. But there comes a point where the larger puffs are difficult to sustain because of the smoke harshness causing an unpleasant effect on the throat. But for menthol cigarettes the larger puff means a larger cooling effect from the menthol. So the menthol enables the smoker to inhale more nicotine per cigarette, and perhaps obtain a stronger “hit” and become more addicted.
So it is possible that even if you are a relatively light smoker of menthol cigarettes, you may be more nicotine dependent than the simple daily cigarette consumption would imply. A summary of the new study may be found at: http://www.ncbi.nlm.nih.gov/pubmed/19222622?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


For more information about our Tobacco Dependence Clinic, check out: http://www.healthline.com/blogs/smoking_cessation/2008/02/what-does-tobacco-treatment-clinic-do.html

Labels: addiction, cessation, cigarette smoking, jonathan foulds, menthol

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What percentage of smokers can quit for $750?

It is sometimes suggested that the best way to get people to quit smoking is to pay them a decent amount of money to do so. Studies to date have found that financial incentives don’t have much effect on quitting, but in these studies the incentives on offer were often relatively weak (eg. $40).

However, a large trial has just been published in the New England Journal of Medicine today, which examined this issue. The team of researchers, led by Dr Kevin Volpp of the Philadelphia VA Medical Center, recruited 878 smokers at a large multinational company and randomly allocated each one to either (a) information about smoking cessation programs available within 20 miles or (b) the same information, plus a $100 incentive for completing a program, $250 incentive for quitting during the first 6 months, and $400 incentive to remain quit 6 months later (i.e. total potential incentive = $750).

What proportion of smokers do you think would be quit 9-12 months after receiving the incentive offer?

In this study 5% of the no-incentive group attended the smoking cessation programs, but 15% of the incentive group did. 21% of the incentive group quit in the first 6 months, compared with 12% of those with no incentives. And 15% of the incentive group remained quit 9-12 months after receiving the offer, compared with 5% of those just receiving the information about quit smoking programs (but no incentives).

Among the very heavy smokers (2 packs/day or more) in the study none of those with no incentives succeeded in quitting (0/27), and 2/22 (9%) of those offered the incentives succeeded in quitting.

Among those who participated in smoking cessation programs those who had incentives had higher quit rates (46% vs 21%).

This study therefore shows that if smokers are offered access to smoking cessation programs and a $750 incentive to quit, they are more likely to succeed (15%), than those with no incentive (5%).

The study participants were all employees and 90% were white. It remains to be seen if this effect would generalize to other groups. The authors point out the estimated financial benefit of having employees stop smoking is $3400 per year (savings in healthcare costs, absenteeism etc), and that it may therefore be cost effective to provide employees with incentives to quit. The effectiveness of such incentives also requires that smoking cessation programs be available, which they often are not.

It is worth highlighting what this study did NOT show. It did not show that all you have to do to get smokers to quit is offer them $750. In fact 85% of the smokers offered that incentive were unable to quit. Secondly, the findings from this study do not imply that we don’t need treatment services for smokers, we just need to pay them to quit. On the contrary, all the smokers in this study had treatment services available to them.

So it looks like an extra 10% of smokers can quit when offered $750 incentive, and when some treatment services are available. This is a worthwhile increase. The more complicated challenge is turning that finding from a research study into something that could be implemented on a wider scale. I dont believe there will be general acceptance of the principle of paying people to change their unhealthy behaviors. I also suspect that there may be more problems of implementation outside a thorough research study. Whats to stop a non-smoker claiming to be a smoker so they will be eligible for the bonus when they are (still) not smoking a year later? Can the average employer arrange the biochemical verifications necessary for the research study?

Ultimately I believe money may be better spent making sure all smokers have easy access to quality treatment services at no cost, and making sure they are fully aware of the personal benefits that will come to them from succeeding in quitting (cost savings from not buying cigarettes, improved health, lower health insurance premium etc).

Ref: Volpp K et al. A randomized, controlled trial of financial incentives for smoking cessation. N Eng J Med, 2009, 360:699-709

Labels: cessation, cigarette smoking, financial incentive, jonathan foulds

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Get ready for a smoke-free 2009

So here we are approaching the end of 2008 and the beginning of 2009. Wouldn’t it be great to reach this time next year having gone the whole year without smoking? So now is the time to really get yourself ready to quit. One of the first things to do is to choose a Quit Date.

Many people at this time of year will choose January 1, and that is as good a time as any. Some may choose to put it off a little for good reasons. One reason might be “I’m going to be drinking and smoking on New Year’s eve and I want to start my quit day with a clear head and without having smoked at all after midnight the night before.” In that case why not pick January 2 as your quit day?

Another reason to delay a little bit might be because you intend to use Chantix or Zyban and havn’t got your prescription yet, and so won’t have time to get it and take it for 7 days (as advised on the labeling) prior to the quit day by January 1. In that case see your doctor and get started on your medicine as soon as possible.But regardless of which individual day you choose to quit on, don’t delay it for too long. I’d suggest that any date that is more than two weeks into the year is delaying too long unless you have an exceptionally good reason. And once you have chosen your date, its immediately time to start getting ready.You may want to review my post on the health effects of smoking to remind yourself of some of the main reasons for quitting:How bad is smoking for your health? 2/18/07 http://www.healthline.com/blogs/smoking_cessation/2007/02/how-bad-is-smoking-for-health.html

You may want to plan how you might cope with nicotine withdrawal symptoms, as suggested in this post: Ten tips for coping with nicotine withdrawal. 3/7/07 http://www.healthline.com/blogs/smoking_cessation/2007/03/ten-tips-on-coping-with-tobacco.html

You will certainly want to make a plan to get rid of all your tobacco:
Get rid of all your tobacco. 6/16/07 http://www.healthline.com/blogs/smoking_cessation/2007/06/get-rid-of-all-your-tobacco.html
…and you should consider whether you are going to use a pharmacological aid to smoking cessation, like nicotine replacement therapy:Which nicotine replacement therapy? 6/19/07 http://www.healthline.com/blogs/smoking_cessation/2007/06/which-nicotine-replacement-therapy.html

It may also be worthwhile checking out some of the best websites for helping people quit smoking. These are discussed at: “Become an Ex”: (April 30, 2008)
http://www.healthline.com/blogs/smoking_cessation/2008/04/become-ex.html

It is also a good idea to be thinking about what has tripped you up on any prior quit attempts, and what you can do differently this time in order to succeed. In particular, its worth anticipating specific things coming up in your life in the next week or two that may be a risk for relapse. Make a plan of how you will manage these situations without smoking.

I’d be interested to hear from anyone out there who is currently planning to quit smoking at New Year. Use the “comment” option on the blog to tell us how you are planning to quit, and let us know of your progress.

Labels: 2009, cessation, cigarette smoking, jonathan foulds, preparation

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UK National Smoking Cessation Conference

Probably the best conference on smoking cessation over recent years has been the UK National Smoking Cessation Conference. The UK is probably the only country to have a national and fairly comprehensive smoking cessation service involving widespread access to trained smoking cessation counselors, access to low cost smoking cessation medicines (via the UKs National Health Service), as well as telephone and internet help. As a result, this conference is the largest gathering of smoking cessation counselors in the world, and also attracts many attendees and speakers from other countries.

It consistently has very lively speakers and many of the presentations are available online with the full slides and audio recording. The 2008 conference just became available online and includes many interesting presentations. For example, an interesting slide show by Rachna Kasliwal describing results of a study of adverse events in patients using Chantix is available at: http://www.uknscc.org/2008_UKNSCC/speakers/rachna_kasliwal.html

An interesting debate on the topic;
“Debate: This house believes that hypnotherapy and acupuncture should be treatments provided by NHS Smoking Services” is also available with full audio and slides at:
http://www.uknscc.org/2008_UKNSCC/speakers/debate.html

I also thought the presentation by Dr Paul Eveyard on “Does stopping smoking mean putting on weight?” was very interesting. The audio recording and his slides are available at:
http://www.uknscc.org/2008_UKNSCC/speakers/paul_aveyard.html

The full archive of each conference from 2005-2008 is now available online at:
http://www.uknscc.org/index.html

It provides an excellent source of information from leading experts on all aspects of stopping smoking.

Labels: cessation, cigarette smoking, conference, jonathan foulds, UK

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Extended treatment for some addicted smokers

The brand new US Public Health Service Guideline on the Treatment of Tobacco Use and Dependence was written after an extremely thorough review of all the randomized controlled smoking cessation trials in the literature with at least 6 months follow-up.

http://www.surgeongeneral.gov/tobacco/

The guideline was also written by a large group of experts on tobacco treatment and healthcare. That guideline stated:

“For some patients it may be appropriate to continue medication treatment for periods longer than is usually recommended. Although weaning should be encouraged for all patients using medications, continued use of such medications is clearly preferable to a return to smoking with respect to health consequences.” (p126).

So what is meant by extended or “long term” treatment for tobacco dependence?

Most pharmacological tobacco dependence treatments (e.g. bupropion/Zyban, nicotine patch, nicotine gum) last for 7-12 weeks. Most non-pharmacological treatment is even shorter, e.g. the number of counseling sessions reimbursed by Medicare is 4 (>10 minutes) and group treatment most commonly consists of 6 weekly sessions. So in the field of tobacco dependence treatment, any treatment lasting longer than 12 weeks is considered “long term”. So is there any evidence that treatment lasting longer than 12 weeks may be safe and effective?

Williams et al (1) randomized patients to 52 weeks of varenicline (Chantix) or placebo. They found that varenicline was safe for a year of treatment and produced significantly higher quit rates at one year than placebo.

Tonstad and colleagues (2) treated 1927 smokers with the typical 12 weeks of varenicline and the 1236 who were not smoking at 12 weeks were then randomized to a further 12 weeks of varenicline or placebo (double blind). The question was, “does longer term treatment with varenicline prevent relapse over the next 12 weeks? By week 24, 30% of those who had varenicline had smoked, compared with 50% of those who had placebo for the last 12 weeks. So longer term varenicline resulted in more people succeeding in quitting smoking. When the participants were followed up at 12 months (i.e. at least 6 months off-drug for everyone) there were still more non-smokers among those who had varenicline for 24 weeks as compared to those who had it for 12 weeks.

But the added effects of longer duration treatment do not just apply to varenicline, or even just pharmacotherapy. Hall and colleagues (2004) (3) randomized smokers to standard 12 weeks of counseling and 8 weeks of nicotine patches plus either another 9 months of counseling, or 12 months of nortriptyline (an antidepressant that helps people quit smoking) or 12 months of placebo. At the one year follow-up, those who had nortriptyline and counseling for a year had a quit rate of 50%, as compared with only 18% for those who had nortiptyline but only 12 weeks of counseling, 30% for those who had 12 weeks of counseling and placebo, and 42% for those who had a year of counseling and placebo. The authors concluded that, “Comprehensive extended treatments that combine drug and psychological interventions can produce consistent abstinence rates that are substantially higher than those in the literature.” But as can be seen from the numbers, it was primarily the extended counseling that contributed to the unusually high one-year quit rates.

This study by Hall and colleagues was one of the first to really adopt the “chronic disease” model for smoking cessation, and it is also the one study to achieve the highest one year quit rates (50%).

The reality is that most smokers are not seeking extended (i.e. over 12 weeks) counseling or extended pharmacotherapy as a way to stop smoking. And many will not need it. The point is that those patients who have made a choice that they are willing to do whatever is necessary to save their life and become healthier by stopping smoking, and who appear likely to benefit from it, should be provided with extended treatment that appears likely to increase their chances. When 12 weeks of treatment have not succeeded in controlling hypertension, diabetes or asthma, we don’t expect our doctors to say, “oh well, never mind, it didn’t work and I won’t try to help you any more.” The same should go for tobacco dependence treatment. And when a patient has had 12 weeks of treatment but still feels vulnerable to relapse then there is evidence to suggest that the extended treatment may help them to remain smoke-free. The evidence is certainly not clear enough to recommend this to all patients, but it is sufficient to support it as an option for some.

(1) Williams KE, Reeves KR, Billing CB Jr, Pennington AM, Gong J. A double-blind study evaluating the long-term safety of varenicline for smoking cessation. Curr Med Res Opin. 2007 Apr;23(4):793-801.

(2) Tonstad S, Tønnesen P, Hajek P, Williams KE, Billing CB, Reeves KR;Varenicline Phase 3 Study Group. Effect of maintenance therapy with varenicline on smoking cessation: a randomizedcontrolled trial. JAMA. 2006 Jul 5;296(1):64-71.

(3) Hall SM, Humfleet GL, Reus VI, Muñoz RF, Cullen J. Extended nortriptyline and psychological treatment for cigarette smoking. Am J Psychiatry. 2004 Nov;161(11):2100-7.

Note: Jonathan Foulds has done paid work for pharmaceutical companies (Novartis, GSK, Celtic Pharma and Pfizer). This has included advising on potential new medicines, training health professionals, advising on clinical trial design, discussing barriers to quitting and reviewing applications for research grants. His main funding sources are mentioned in a funding statement on the bio page.

Labels: cessation, cigarette smoking, dependence, extended, jonathan foulds

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Are Americans Switching to Smokeless Tobacco?

A recent paper by Professor Brad Rodu of University of Louisville, School of Medicine and Dr Carl Phillips if the University of Alberta suggested that switching to smokeless tobacco is a viable smoking cessation option for American smokers.

The paper, published in the online Harm Reduction Journal, used data from the year 2000 National Health Interview Survey (NHIS) which asked 3622 male smokers and 3653 male former smokers about the methods used and outcome of their most recent attempt to quit smoking. Because the NHIS survey is administered to a fairly representative sample of the US population, Rodu and Phillips then used the results of the survey to estimate the total number of male smokers in the US using each quit rate and quitting smoking in the United States. So far this all sounds fairly sensible. However, the authors then took that fairly simple data and made rather far-reaching claims without critically examining the quality (and quantity) of data.

For example, the main conclusions drawn in the paper and its abstract (summary) were that a reasonably large number of smokers in the US (261,000) have quit smoking by switching to smokeless tobacco on their latest quit attempt. It is also claimed that the quit rate among those trying to quit smoking by switching to smokeless tobacco is higher than among those trying other methods (e.g. nicotine replacement therapy). However, examination of the data tables in the paper revealed that a total of only 33 people in the survey claimed to have quit smoking by switching to smokeless tobacco. Unfortunately this is too small a number to provide reliable estimates of numbers using this as a quit method nationally. The ubsurdity of using such very small samples to estimate national numbers is even clearer when one looks at the figures for those using the nicotine nasal spray (NNS). Only 3 people in the survey claimed to have used the nicotine nasal spray on their last quit smoking attempt, and none remained free of smoking at the time of the survey. Despite this extremely small sample, the authors went ahead and used it to estimate that at a national level,14,000 smokers used the NNS on their latest quit attempt and none (0%) succeeded.

One other issue with this study stems from the fact that the various smoking cessation aids differed in the time periods in which they were available. For example, while smokeless tobacco has been available for over 100 years, the pharmacological aids only became available in the 1980s and 1990s. So 48% of those who quit by using smokeless tobacco quit at least 10 years ago, compared to 11% of those who quit with the patch. In some ways this may make those quits on smokeless more impressive in that they are longer term quits, but it also serves to underline that in some ways these comparative figures are not comparing like with like. Smokers who quit 20-20 years ago may differ from those trying to quit in recent years, and memory for more distant events maybe less accuarate.

But overall, the biggest weakness of this study was the very small sample of participants who used smokeless tobacco in their quit attempt and then the inappropriate use of these very small numbers to estimate national numbers. Perhaps the main thing that can be concluded from this study report is that the vast majority of smoking cessation attempts in the United States do not involve the use of a proven smoking cessation aid, and a small but measurable proportion of smokers succeed in quitting smoking by switching to smokeless tobacco. If the NHIS survey uses similar questions in future it may be interesting to see how the pattern of use of smoking cessation aids changes over time.

I’d encourage smokers to use smoking cessation treatments that have been demonstrated to be safe and to increase your chances of success. These include counseling from a trained healthcare provider, nicotine replacement therapy, bupropion and varenicline.

The paper by Rodu and Philips is available at:
http://www.harmreductionjournal.com/content/5/1/18

Labels: cessation, cigarette smoking, comprehensice tobacco control, jonathan foulds, nicotine regulation reduction smoking smokeless

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Chantix (varenicline) Safety

Last week a report was released by an organization called the “Institute for Safe Medication Practices” (ISMP) which claimed to have safety concerns about Chantix (varenicline, also marketed as Champix outside the United States). The Executive Summary of the report made two main recommendations:

1. Chantix should be avoided or used with caution by persons operating aircraft, motor vehicles or other machines (e.g. power stations) where a lapse in alertness or motor control could have serious consequences.
2. Patients and doctors should excercise caution in the use of Chantix (generally) and “consider the use of alternative approaches to smoking cessation.”

Given that most of us drive a vehicle, the report is basically suggesting that varenicline is such an unsafe drug that it should be avoided. These are strong recommendations, and have immediately resulted in the Federal Aviation Authority (FAA) and Federal Motor Carrier Safety Administration (FMCSA) adding varenicline to their list of drugs that should not be used by pilots or truck drivers. The report itself has not been published in a peer-reviewed journal and so it is reasonable to assess the quality of the data on which it was based, and to evaluate whether the recommendations are warranted on the basis of that data.

The ISMP report was based on an analysis of the frequency and type of serious adverse events that have been reported to the US Food and Drug Administration (FDA) about Chantix, in comparison to other drugs. In particular, the report noted that by the 4th quarter of 2007 Chantix “accounted for more reports of serious adverse events in the United States than any other drug.” This amounted to 988 reports about Chantix in the 4th quarter, as compared with 372 (Oxycodone) to 640 (Interferon Beta) reports about the next 5 most reported drugs.

The report then selected a sample (3063) of the total reports (excluding foreign or unclear reports) for slightly more detailed analysis. It noted that a much larger proportion of the reports about Chantix came from consumers (57%) than is typical of other drugs (26%) for which health professionals are the predominant source. The report also noted that a lower proportion of the reports about Chantix (2.5%) reported deaths, as compared with 17% of reports about other drugs.

The report summarized the most frequent medical terms included in the reports about Chantix. By far the most common term used was nausea (593), which was more than twice as common as any other reported symptom. It was also noteable that among the most commonly reported medical symptoms mentioned in the adverse event reports, many are also recognized nicotine withdrawal symptoms (i.e symptoms known to increase when smokers quit smoking, particularly without any treatment medication), such as depression (287), insomnia (242), anxiety (217), and weight increase (141).

Problems with the ISMP report and its conclusions

There are a number of fundamental problems with the quality of the data, analysis and interpretation in the ISMP report. Before discussing some of these, it is worth discussing the way that reports of serious adverse events are delivered to the FDA. There are 4 main sources of reports.

1. Members of the public can send reports directly to FDA, either by mail or via an on-line reporting system (and I have provided the link on previous posts on this blog about Chantix to ensure that reports reach FDA).
2. Health professionals can report adverse events to FDA.
3. Lawyers sometimes report adverse events to FDA.
4. The manufacturer is required to report to FDA any reports that are brought to its attention directly. Those adverse events that are already mentioned on the product labeling are reported on a quarterly basis, and novel symptoms must be reported within 15 days (expedited).

Reports from the first 3 of these sources are entirely voluntary and are made in a rather haphazard way. The ISMP report estimated that typically between 1 and 10% of serious adverse events are actually reported to FDA. It is commonly found that AE reports peak around two years after the launch of a drug, even if the drug becomes used more often thereafter. The purpose of the FDA’s reporting and monitoring system is to facilitate post-marketing surveillance and enable detection of patterns of adverse events that could potentially be caused by a medicine but were not detected in the initial placebo-controlled trials leading to drug approval. The main point here is that these reports are not made in a systematic way, and the frequency of reports can be influenced by factors such as (a) the frequency of use of the drug (b) the novelty of the drug (c) media coverage of the drug and (d) efforts by the company to interact with users in a manner that will lead to them hearing of and therefore being required to report on AEs.

With these factors in mind, here are some of the problems with the ISMP report:

1. The report fails to consider the frequency of the use of the drug when considering the number of adverse events being reported. Since its launch in August 2006 (i.e. less than 2 years), Chantix has been used by an estimated 5.5 million smokers in the United States. In 2007 alone it was used by 3.8 million new patients in the U.S. (6.2 million prescriptions). This is many times more than the other drugs listed in the ISMP report. For example, Etanercept (Enbrel, the drug with the 3rd largest number of adverse event reports to FDA) was launched in 1998, and has been used by a total of 450,000 patients WORLDWIDE in those 10 years. Comparing frequency of adverse events without adjusting for the frequency of drug use is so obviously inappropriate as to cast doubt on the reliability of the report as a whole.
As mentioned briefly in the ISMP report, many factors can affect the frequency of reporting of adverse events to FDA. In the case of Chantix, the widely publicized death of a rock musician (who was tragically shot by a neighbor in Texas) which his partner felt could have been related to Chantix, sparked off widespread media speculation about potential side effects. The manufacturer also offers a number of direct to consumer quit smoking services, including a free telephone hotline called “Get Quit”. Because this hotline is run by the manufacturer, whenever a caller mentions a symptom, they are immediately transferred to the medical department, the details are noted and the information reported to FDA. These events and procedures can have a large effect of increasing the number of serious adverse events reported and this was not adequately considered in the ISMP report. It is noteworthy that 92% of the events analyzed in the ISMP report came via the manufacturer.

2. The report fails to adequately consider the possibility that some of the reported adverse events may have been caused by nicotine withdrawal. The vast majority of those using Chantix were attempting to quit smoking, which itself is known to cause a range of nicotine withdrawal symptoms, including many of the symptoms most commonly reported to FDA and mentioned in the ISMP report (depression, insomnia, anxiety, weight increase). It is entirely plausible that many of these reported symptoms were caused by nicotine withdrawal rather than Chantix. In fact in the placebo-controlled trials of Chantix, withdrawal symptoms were REDUCED in those using Chantix.

3. The report doesn't adequately consider the serious health effects of tobacco dependence. The ISMP report characterizes the other comparison drugs as being “intended for serious illness in patients and have benefits that are accompanied by substantial risks. In comparison, varenicline is intended for use in healthy people to help stop smoking.” Unfortunately this statement indicates a misunderstanding of the nature of tobacco dependence as a serious illness causing the premature death of 50% of continuing smokers, and of the fact that a high proportion of patients using smoking cessation medications are already suffering from or at very high risk for smoking-caused illnesses, including some mentioned as adverse events in the report (e.g. cardiac arrhythmias).

4. The report inaccuratley characterizes the relative efficacy of varenicline versus other treatments. The ISMP report states that Chantix has similar long term quit rates to nicotine gum. This statement contradicts the findings of the new US Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence, which found a mean quit rate of 13.8% with placebo, 19% with nicotine gum and 33.2% with varenicline (p109) and that quit rates with varenicline are significantly greater than with the nicotine patch (p121). This Guideline, written after the recent labeling changes for varenicline, concluded that, “Varenicline is an effective smoking cessation treatment that patients should be encouraged to use.” (p113).

Probably the most basic problem with the ISMP report is its failure to consider the frequency of use of the medicines as a factor influencing the interpretation of the frequency of adverse events reported. It therefore remains unclear whether any of these serious adverse events were caused by varenicline. When added to the other problems of interpretation mentioned above, I prefer to rely on the recommendation of the US Clinical Practice Guideline, which resulted from a very thorough review of the available scientific evidence.

So what does this mean for patients considering quitting smoking? As always, rely on the advice of your own doctor rather than on reports in the media or the internet (including this one!).

The complete ISMP report can be found at:
Strong Safety Signal Seen for New Varenicline Risks
http://www.ismp.org/docs/vareniclineStudy.asp

Previous posts on this blog that are relevant to this issue are:
What is nicotine withdrawal syndrome? 3/6/07http://www.healthline.com/blogs/smoking_cessation/2007/03/what-is-nicotine-withdrawal-syndrome.html
Ten tips for coping with nicotine withdrawal. 3/7/07http://www.healthline.com/blogs/smoking_cessation/2007/03/ten-tips-on-coping-with-tobacco.html
Chantix: how does this new stop smoking medicine work? 4/15/07http://www.healthline.com/blogs/smoking_cessation/2007/04/chantix-how-does-this-new-quit-smoking.html
Can quitting smoking trigger depression? 6/16/07http://www.healthline.com/blogs/smoking_cessation/2007/06/can-quitting-smoking-trigger-depression.html
Chantix and mental illness. 08/12/07http://www.healthline.com/blogs/smoking_cessation/2007/08/chantix-and-mental-illness.html
Two new studies of Chantix (varenicline). 08/19/07http://www.healthline.com/blogs/smoking_cessation/2007/08/two-new-studies-of-chantix-varenicline.html
Does Chantix cause mental health problems? 9/20/07http://www.healthline.com/blogs/smoking_cessation/2007/09/does-chantix-cause-mental-health.html
Chantix (varenicline) safety being reviewed by FDA. 11/21/07http://www.healthline.com/blogs/smoking_cessation/2007/11/chantix-varenicline-safety-being.html
New study of Chantix in comparison with NRT. 11/28/07http://www.healthline.com/blogs/smoking_cessation/2007/11/new-study-of-chantix-in-comparison-with.html
Smoking and suicide. 4/22/08 http://www.healthline.com/blogs/smoking_cessation/2008/04/smoking-and-suicide.html

Full reports on the largest placebo-controlled trials of varenicline can be found via:
http://jama.ama-assn.org/cgi/content/full/296/1/47

Labels: cessation, champix, Chantix, cigarette smoking, jonathan foulds, Nicotine Replacement, safety, varenicline

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Become an Ex

On previous posts I’ve talked about good websites for helping smokers quit:

Can smoking cessation internet sites help you to quit? 4/21/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/can-smoking-cessation-internet-sites.html

There are quite a few good ones, and so far my favorite is at www.quitnet.com .

But I recently checked out a fairly new one and was very impressed. Its at www.becomeanex.org . It has been funded by a coalition on public health agencies, and appears to have been really well put together and is really easy to use. One of its main selling points is its emphasis on quitting smoking as a process, and its recognition that it is not all over in a month. So this site presents quitting as a process, provides loads of useful tips and advice, and is particularly good at helping you link with networks of other smokers for added support. The site makes good use of new technologies to make it easy to register, easy to communicate with other smokers trying to quit, and fairly easy to ask a question not just of others trying to quit, but also of recognized experts, like Dr Richard Hurt of the Mayo Clinic.

I found it very simple to register. You can set up your own profile, add your photo and details if you want (or not if you don’t), and there are plenty of subgroups you can join, made up of people with a particular thing in common (e.g. living in Texas, or using Chantix). The only slight problem I had was that when I clicked on some of the video components they didn’t all run smoothly. That may have just been a problem with my PC as I’m a bit technologically challenged. I believe this site is fairly new, (launched March, 2008) but I think it looks like it could be very helpful to tobacco users thinking about quitting.

Check it out and let me know what you think.
www.becomeanex.org

Labels: becomeanex, cessation, cigarette smoking, jonathan foulds, website

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