Smoking Cessation: Recent Developments in Behavioral and Pharmacologic Interventions

Tobacco use, as Drs. Cinciripini and McClure point out, exacts an enormous toll on our society. Consider the following statistics:

• Tobacco kills over 430,000 Americans each year, more than alcohol, cocaine, heroin, homicide, suicide, car accidents, fire, and AIDS combined.
  
  
• During the 1990s, tobacco will cost the lives of more than 4.5 million Americans—the equivalent of killing every man, woman, and child in Portland, Oregon; Fargo, North Dakota; Flint, Michigan; Buffalo, New York; Greensboro, North Carolina; Miami, Florida; Baton Rouge, Louisiana; Austin, Texas; Denver, Colorado; Berkeley, California; Salt Lake City, Utah; and Cleveland, Ohio; combined.
  
  
• The annual US death toll from tobacco use is equivalent to having three fully loaded 747s crash every day of the year, with no survivors.
  
  
• Each day in the United States, nearly 3,000 children under the age of 18 will start smoking. Approximately 18 of them will some day die from homicide and 35 in a car accident, but more than 1,000 will die prematurely from a smoking-related disease.
  
  
• Five million children alive in the United States today will die prematurely due to their tobacco use, losing an average of 15 years of life.
  
  
• The annual direct and indirect cost of tobacco use in the United States is more than $100 billion, or about $4 for each pack of cigarettes sold.
  
  
• Worldwide, more than 1 out of every 10 people now alive will die prematurely from a tobacco-related disease.

This list could go on, but the point is clear—action must be taken immediately to end the tobacco epidemic. In the face of the overwhelming evidence of tobacco’s destruction, to do otherwise would invite both the astonishment and the animosity of future generations.

Fortunately, various actions can be taken to stem tobacco’s tide. Many are outlined in the pending tobacco “settlement” arrived at through negotiations between US state attorneys general and the tobacco industry. These actions include: sharply increased tobacco taxes, indexed to inflation; FDA authority to regulate nicotine as it would any other dangerous drug; a ban on tobacco advertising aimed at children; reducing youth access to tobacco; new, more explicit tobacco package warning labels; nationwide standards to minimize exposure to environmental tobacco smoke; an increased and broader research base; and—of specific relevance to the paper by Drs. Cinciripini and McClure—greatly expanded treatment options and an effective health-care delivery system for the treatment of nicotine dependence.

Current Treatment of Nicotine Dependence

Drs. Cinciripini and McClure provide a superb overview of available treatments for nicotine dependence. They summarize the rationale for treatment; note the lack of clinical utility of standard self-help approaches; identify the combination of behavioral and pharmacologic treatment as the strategy most likely to be successful in helping patients stop smoking; and review both existing and emerging pharmacologic adjuncts to the behavioral treatment of nicotine dependence.

The authors acknowledge the relatively low success rates of efforts to stop using tobacco, both among those who try to quit on their own and those who are treated by a health-care provider, usually a physician. Yet, the public health implications of an increase in the cessation rate to even 5% of all smokers, for example, would be enormous, resulting in nearly 2-1/2 million new nonsmokers per year. The ultimate effects would be fewer cancers (both primary and recurrent), increased survival time for those already diagnosed, and less heart and chronic obstructive lung disease.

Drs. Cinciripini and McClure thoroughly cover the potential for significant treatment advances through pharmacologic adjuncts to traditional treatments. They describe the data supporting the treatment effectiveness of nicotine replacement products (nicotine gum, transdermal nicotine patches, and, more recently, nicotine nasal spray, and nicotine vapor inhaler), and then correctly and succinctly point out both the modest successes and limitations of these adjuncts.

The authors are more optimistic about the new class of nonnicotine medications, including nicotine antagonists, such as mecamylamine (Inversine); antihypertensives, such as clonidine; anxiolytics, such as buspirone (BuSpar); and antidepressants, such as bupropion (Zyban), which recently received FDA approval for use in the treatment of nicotine dependence. They are careful to caution, however, that much of the research on these medications is preliminary and that, to date, the best advice remains that they be used in combination with behavioral therapy, even if that therapy is nothing more than simple advice to quit and brief follow-up.

Finally, Drs. Cinciripini and McClure summarize the recent clinical practice guidelines for the treatment of nicotine dependence published in 1996 by the Agency for Health Care Policy and Research (AHCPR).[1] This is the most comprehensive review and set of treatment recommendations available and is a superb companion to the brief treatment protocol recommended by the National Cancer Institute (NCI), reproduced in Table 1.[2]

Following the protocols recommended by the AHCPR and NCI can substantially increase the success rates for the treatment of nicotine dependence.

Future Needs in the Treatment of Nicotine Dependence

If we are to be successful in treating nicotine dependence, two primary needs must be met: (1) the development of effective means for delivering proven treatment methods and (2) research into the development of new and more effective treatment protocols.

Delivery Issues—In order for the treatment of nicotine dependence to become a routine, accepted part of medical practice, health-care providers must first believe that they can be effective in treating their patients[3]; third-party payors and managed-care organizations must establish reimbursement systems for the treatment of nicotine dependence[4]; and the AHCPR, NCI, and similar practice guidelines must be widely disseminated and training opportunities in their adoption offered.[5]

Research Issues—Numerous questions remain concerning the most effective means of treating nicotine- dependent patients: What are the minimal elements of behavioral therapy necessary to achieve any given threshold level of treatment success? Is there, as Benowitz and Henningfield[6] have suggested, a nicotine threshold at which dependence does not develop? How is the over-the-counter availability of nicotine gum and nicotine patches affecting cessation success? What is the most effective role for primary-care staff other than physicians in the delivery of treatment for nicotine dependence? What are the most effective nonnicotine medications (as reviewed by Drs. Cinciripini and McClure)? What new medications, or combinations of existing medications, can contribute to effective treatment? Can an effective treatment for nicotine-dependent youth be developed?

A number of these treatment research issues have begun to be addressed in a series of seven clinical trials funded in 1996 by the NCI and the National Institute on Drug Abuse. The overall goal of the investigators, collectively known as the Pharmaco-Behavioral Treatment of Nicotine Dependence Research Group, is the identification of the most effective, generalizable, cost-efficient, and durable behavioral treatment that can be used as an adjuvant to pharmacologic therapy for nicotine dependence. Patient accrual is now in progress, and preliminary results of this trial should begin to become available in late 1999.

Summary

In summary, Drs. Cinciripini and McClure have provided an excellent overview of the current status of treatment for nicotine dependence. Their thorough review of pharmacologic treatment options should be especially useful to primary-care providers, as well as any provider who wishes to help a patient overcome nicotine dependence. Doing so, as former Surgeon General Koop said over a decade ago, “...may be the most important thing you can do for your patient.”

References:

1. Agency for Health Care Policy Research: Smoking Cessation. Clinical Practice Guideline. no. 18, AHCPR publication no. 96-0692. Rockville, MD, US Department of Health and Human Services, 1996.

2. Glynn TJ, Manley MW: How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. NIH Publication No. 90-3064. Bethesda, MD, US Department of Health and Human Services, 1990.

3. Orleans CT, George LK, Houpt JL, et al: Health promotion in primary care: A survey of family practitioners. Prev Med 14:636-647, 1985.

4. Logsdon DN, Lazaro CM, Meier RV: The feasibility of behavioral risk reduction in primary care. Am J Prev Med 5:249-256, 1989.

5. Kottke TE, Solberg LI, Brekke ML, et al: A controlled trial to integrate smoking cessation advice into primary care practice: Doctors helping smokers, round III. J Fam Pract 34:701-708, 1992.

6. Benowitz NL, Henningfield JE: Establishing a nicotine threshold for addiction: The implications for tobacco regulation. N Engl J Med 331:123-125, 1994.