New study shows that longer duration nicotine replacement leads to better quit rates

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A new study was published in Annals of Internal Medicine this week, showing that having access to nicotine patches for 24 weeks leads to higher quit rates at 24 weeks (32%) that using the patch for the more typical duration (8 weeks), which led to only 20% being quit at 24 weeks. This study, by Dr Robert Schnoll and colleagues at University of Pennsylvania, recruited 568 healthy adult smokers (smoked an average of 21 cigarettes per day). They were all given a standard treatment consisting of 8 counseling sessions over 6 months, and a 24 week supply of patches. Half of the participants had full strength 21mg nicotine patches for 24 weeks (extended duration) and half had full strength nicotine patches for 8 weeks, and 16 weeks of placebo patches that were packaged to be identical to the nicotine patches. The study was conducted in a double-blind manner meaning neither the researchers not the participants were aware of who received the extended duration treatment, until after the study was completed.

This study examined a range of outcome measures, and produced some interesting findings. For example, while the quit rates were similar between the two groups up to week 8, , from weeks 9 to 24, the relapse rate was slower among those still using the nicotine patches. Then from weeks 24 to 52 (when all participants had ceased patch use), the relapse rates were again similar, although slightly higher in those who had extended duration nicotine patches up to week 24. From weeks 9 through 24, those smokers who continued to have access to nicotine patches but had a lapse cigarette were more likely to recover abstinence, than those using placebo patches.
The authors defined abstinence as either “point prevalence” (no tobacco use in prior 7 days at a point in time) “prolonged abstinence” (allows some smoking during first 14 days, then a period of abstinence, ending with 7 consecutive days of smoking…a relapse) and “continuous abstinence” (not a puff from the quit date to a follow-up point). Extended duration patch treatment led to higher rates of prolonged abstinence at one year (29% v 21%). It was noteworthy that only 1% of each group achieved continuous “not a puff” abstinence for 52 weeks!

There were a few odd aspects to this study. The researchers attempted to estimate the costs of the treatment as well as the additional medical costs incurred by participants as a result of participation in the study. It seems very unlikely that these were fully and/or accurately measured. For example, the total estimated cost for counseling was $120. No details were provided on how this estimate was arrived at, but its hard to see how the TOTAL cost of the behavioral part of the intervention would be so low. Even if only the 8 counseling sessions were included, that would imply that a counseling session costs $15. This is clearly an underestimate of true staff costs, and of course doesn’t take into account the potential impact/cost of the additional recruitment/assessment and follow-up procedures, which although strictly a part of the research process, likely influenced outcome.

One other thing that was slightly odd was that the discussion section of the paper began with the statement that “smokers who received extended therapy with transdermal nicotine were about twice as likely as those who received standard therapy to achieve abstinence 24 weeks after their quit date.” Given that the point prevalence quit rates were 32% vs 20%, neither this nor any other outcome measure was twice as likely in those receiving extended duration patches. Presumably the authors were referring to the “odds ratio” (1.8) but that is not a straightforward “likelihood” in the sense that most people understand it.

One other weakness of the study was that only healthy smokers were included in the study. For example, all volunteers who were already taking any medication or had a psychiatric disorder were excluded. As a result, of 3276 smokers who were screened, only 575 (18%) were included in the study. However, although that limits generalizability of the findings, I have some confidence in the result, partly because here at UMDNJ a research study by Dr Michael Steinberg and colleagues focusing on smokers with medical illness obtained a similar finding (extended duration treatment with patch plus bupropion plus nicotine inhaler gave better outcomes at 6 months than standard duration nicotine patch).

However, despite these minor quibbles, this was an excellent study yielding some very interesting results. These results are consistent with the view we that tobacco dependence is best treated as a chronic illness, and for some smokers, that means continuing the medication for as long as is necessary.

Reference
Schnoll et al (2010). Effectiveness of extended-duration transdermal nicotine therapy: a randomized trial. Annals of Internal Medicine, 153: 144-151
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About the Author


MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.

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