Smoking cessation is a common topic that comes up in both the outpatient and inpatient setting. In the hospital we often prescribe nicotine replacement therapy, however as an outpatient there are many more options for smoking cessation. A recent paper in NEJM got me thinking, what works best?
The starting point:
This all got started when I was listening to The Curbsiders (highly recommend, check it out to listen to on your drive into work or on the treadmill) where they were discussing a NEJM published a study in June 2018. In this study, they looked at the success of a variety of smoking cessation strategies. All patients received counseling on smoking cessation and motivational interviews however patients were further randomized to one of the following groups for additional aid including, 1) free cessation aids when the above measures failed including nicotine replacement therapy (NRT), pharmacotherapy, e-cigarettes, 2) free electronic cigarettes, 3) free above cessation aids + $600 in rewards for sustained abstinence, 4) free above cessation aids + $600 in redeemable funds deposited incrementally with sustained cessation. Results showed that redeemable deposits and rewards resulted in higher rates of sustained cessation, 6 months out and confirmed with urine testing, compared to free cessation aids. Furthermore, sustained cessation rates with free electronic cigarettes were not superior to free cessation aids alone. I was particularly surprised at the effect that monetary incentives had with smoking cessation and the dearth of results with more typical smoking cessation aids. So what does the literature say about these other strategies?
A Cochrane review from 2014 assessed for the efficacy of antidepressants for smoking cessation. Antidepressants are hypothesized to help with smoking cessation because of the depressive symptoms smoking cessation causes, the antidepressant effects of nicotine, and the suspected neural pathways that are involved in nicotine addiction. The most commonly prescribed medications include buproprion and varenicline. The Cochrane review covered 90 trials noting the significantly increased long-term smoking cessation in patients that took buproprion compared to other antidepressants. Little to no evidence exists for SSRIs, venlafaxine, diet, or herbal remedies. Varenicline shows superior rates of long-term cessation compared to buproprion. Important things to keep in mind: 1) buproprion carries a risk of seizures and thus is contraindicated in patients with a seizure history, 2) varenicline carries a risk of suicide and thus mood should be assessed before and after starting.
What about electronic cigarettes?
A Cochrane review from 2016 reviewed the efficacy of electronic cigarettes for smoking cessation. Much like the recent trial from NEJM, there was minimal evidence that showed increased rates of long-term smoking cessation and thus the recommendation was “low confidence.”
As e-cigarettes become more popular, another important consideration is the side effects of these devices. The Cochrane review’s most common side effects included throat and mouth irritation with little mention of long-term effects. The NEJM published a review article on e-cigarettes in 2016 with some interesting information. First multiple cited studies did not show a benefit of electronic cigarettes for smoking cessation, in fact one showed no reduction in the number of tobacco cigarettes smoked between those trying to quit smoking with e-cigarettes compared to those not. Furthermore the contents of the liquids and aerosols are not benign. Inhaled e-cigarette contents have been analyzed to show some of the same carcinogens found in cigarette smoke including formaldehyde, acetaldehyde and reactive oxygen species, though notably at decreased concentrations. Mouse models exposed to e-cigarettes have increased lung inflammation, increased pulmonary oxidative stress, and alterations in the functioning endothelial barrier and clearance of the lung. While studies of the long-term effects are still pending, electronic cigarettes have certainly been proven that they are not benign.
Many other therapies exist for smoking cessation not included in this post. One of the more commonly encountered is hypnotherapy. A Cochrane review in 2010 looked at the efficacy of hypnotherapy for smoking cessation and showed largely heterogeneous results with no consistent evidence in literature to support it as a cessation tool.
Reflection / Learning Points:
So where are we left with all this information? The first study showed us the power of incentivizing patients, particularly with money. While physicians are unlikely to be handing out cash in clinic any time soon, perhaps this information could be used in different ways. As the NEJM study suggests, the results should be considered by employers to use monetary rewards for smoking cessation as part of their health insurance plans. As internal medicine doctors, perhaps it suggests that we should be motivating our patients to quit smoking in order to save money. In Ohio a pack of cigarettes costs about $6.50. If a patient is a pack-a-day smoker, quitting would save $195/month and $1170 in 6 months, almost two times the incentives offered in the NEJM study. Its powerful, but something tells me the idea of getting money from a third party is the key to the motivation. It may take patients setting aside the cost of cigarettes to a trusted friend (or physician?) who will pay them with confirmed abstinence to properly motivate them.
Secondly medications for smoking cessation can be helpful but should be limited to buproprion and varenicline and should be considered in highly motivated patients.
Finally, I’m not a believer in the electronic cigarettes. Overall the data is not convincing for smoking cessation. Furthermore it continues to expose patients to similar carcinogens found cigarette smoke and causes proven injury to the lungs. Are they less harmful than cigarettes? Perhaps. But it seems that long-term use will likely have negative effects as well. After review, I will certainly advise patients on the lack of evidence for smoking cessation with e-cigarettes, the risks of their use, and recommend use for shortest amount of time possible.
What do you all think? Leave a comment.
- Halpern, S et al. “A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation.” NEJM, vol. 378, no. 24, 23 May 2018, 2302-10.
- Hughes, J et al. “Antidepressants for smoking cessation.” Cochrane Database of Systemic Reviews, 8 Jan 2014.
- Hartmann-Boyce, J et al. “Electronic cigarettes for smoking cessation.” Cochrane Database of Systemic Reviews, 13 Sept 2016.
- Dinaker, C et al. “The Health Effects of Electronic Cigarettes.” NEJM, vol. 375, no.14, 6 Oct 2016, 1372-81.
- Barnes, J et al. “Hypnotherapy for smoking cessation.” Cochrane Database of Systemic Reviews, 6 Oct 2010.
Authored by: GREGORY WIGGER, MD