Approach nicotine addiction like a chronic disease, researchers say

Cigarette smokers who underwent a yearlong cessation intervention that incorporated the probability of relapse had significantly higher six-month abstinence rates than those who underwent a standard eight-week intervention, researchers found.

“This randomized controlled trial shows that a smoking intervention based on chronic disease management principles of care […] is approximately 75% more effective at accomplishing long-term abstinence than delivery of a discrete episode of care for smoking cessation,” Anne M. Joseph, MD, of the University of Minnesota in Minneapolis, and colleagues wrote in the Archives of Internal Medicine.

They recruited 443 smokers to receive five telephone counseling sessions and nicotine replacement therapy by mail for four weeks, and then randomly assigned patients to one of two treatment groups: two additional counseling calls (usual care) or continued counseling and therapy for an additional 48 weeks (longitudinal care).

Analysis revealed that 30.2% of patients assigned to the longitudinal care group achieved abstinence at six months vs. 23.5% of the usual care group (P=0.13). Furthermore, those in the longitudinal care group were more likely to remain abstinent at 18 months than those in the usual care group (OR=1.74; 95% CI: 1.08-2.80).

Other factors that predicted prolonged abstinence at 18 months were quit attempts during the prior year (OR=1.75; 95% CI: 1.06-2.890), baseline cigarettes smoked per day (OR=0.95; 95% CI: 0.92-0.99) and smoking during the 14- to 21-day post-quit interval (0R=0.23; 95% CI: 0.14-0.38).

The longitudinal care model involves several key principals, according to the researchers, including:

  • Targeting the goal of quitting smoking
  • Incorporating failures into treatment
  • Setting interim goals
  • Continuing care until the desired outcome is achieved

“A longitudinal care model not only reinforces the notion that cessation may necessitate an ongoing series of quit attempts but also allows counselors to adjust treatment in response to smokers ongoing experience with quitting,” they wrote.

Motivating smokers to quit

But getting smokers to attempt quitting is the first step and more effort may be needed to steer them in the right direction, according to the authors of a separate study published in the same issue of the journal.

Matthew J. Carpenter, PhD, of the department of psychiatry and behavioral sciences at the Medical University of South Carolina, and colleagues, noted that smoking cessation rates have not changed in more than a decade.

Although 75% of smokers say they hope to quit eventually, only 10% report planning to quit in the next month and approximately 40% try to quit each year, according to background information in the study.

"Committing to quit is difficult for many smokers because they have failed in the past and fear embarrassment if unsuccessful," Carpenter and colleagues wrote. "An alternative is to have smokers engage in less-threatening cessation-like activities, such as a practice quit attempt."

The researchers conducted a nationwide clinical trial to see if administering a brief course of nicotine therapy in addition to a behavioral intervention could help motivate smokers with no current plans to quit to make an attempt. They recruited 894 smokers and randomly assigned them to either behavioral therapy alone or behavioral therapy with nicotine replacement.

All patients smoked at least 10 cigarette's a day, had no history of nicotine therapy and had no quit smoking attempt that lasted longer than one week in the previous year.

The behavioral intervention consisted of three telephone-counseling sessions during a six-week period, in which participants were encouraged to initiate an attempt to quit smoking.

During the first two calls, counselors worked with patients to develop a customized practice-quit attempt and made efforts to eliminate the pressure of committing to permanently quitting. Those assigned to nicotine therapy received a box of 72 nicotine lozenges after each of these first calls. After the second call, all participants were mailed support information.

On the third call, counselors reviewed the patient's progress and shifted towards encouraging permanent smoking cessation. Follow-up calls were made at four, 12 and 26 weeks post-intervention to measure the primary endpoints of self-reported quit attempt incidence and 24-hour quit attempts.

Data indicated that 49% of smokers who received nicotine therapy followed through with their practice-quit attempt compared with 40% of those who received behavioral intervention alone. This translated into a 20% improved relative risk of any quit attempt (RR=1.2; 95% CI: 1.1 to 1.4) and a 30% increase in the rate of 24-hour quit attempts (43% vs. 34%; RR=1.3; 95% CI: 1.1-1.5).

“Considering the stagnant incidence of quit attempts in the past decade, this novel and easy-to-use cessation induction strategy holds promise for translation to primary care settings,” the researchers wrote.

However, nicotine therapy had only a modest effect on seven-day abstinence rates (19% vs. 15%; RR=1.3; 95% CI: 1.0-1.6) and six-month abstinence rates were not significantly different between the two groups (16% vs. 14%; RR=1.2; 95% CI: 0.9-1.6).

These two studies by Joseph et al and Carpenter et al reflect the growing recognition of tobacco and nicotine addiction as a chronic relapsing condition similar to hypertension and diabetes, Neal L. Benowitz, MD, of San Francisco General Hospital, wrote in an accompanying editorial.

"Cigarette addiction is a chronic relapsing disorder, and a chronic disease management approach should also become the standard of care for its treatment," Benowitz wrote. "More research is needed to establish the cost versus benefit for such an approach, so that such treatment will be considered for funding by insurers who make coverage decisions based on cost-effectiveness."

Joseph AM et al. Arch Intern Med. 2011;171:1894-1900.

Carpenter MJ et al. Arch Intern Med. 2011;171:1901-1907.

Benowitz NL. Arch Intern Med. 2011;171: 1907-1909.

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