Alcohol history and smoking cessation in nicotine replacement therapy, bupropion sustained release and varenicline trials: a review

AIMS: We conducted a review of published reports of smoking cessation pharmacotherapy trials in order to address the following: (i) the generalizability of findings to smokers with a history of alcohol problems; (ii) the extent to which alcohol use affects smoking cessation overall and the efficacy of pharmacotherapy specifically and (iii) the effect of smoking cessation on alcohol use. METHODS: We located published reports of nicotine replacement therapy (NRT), bupropion sustained release (SR) and varenicline clinical trials using an approach based on prior Cochrane reviews. The reports were searched for alcohol-related inclusion/exclusion criteria and for findings related to alcohol. RESULTS: The present review included 212 published reports from 149 trials. Alcohol-related exclusion criteria appeared frequently (41.6% of trials)--45/125 NRT trials (36%), 15/22 bupropion SR trials (68.2%) and 3/3 varenicline trials--and most commonly involved exclusion of participants with either current or recent alcohol problems. Most studies failed to provide any baseline alcohol-related characteristics. Eleven trials reported on the relationship between alcohol history and likelihood of smoking cessation. In the majority of these studies, smokers with a past history of alcohol problems were not at a disadvantage, although contrary findings exist. Only two studies examined the potential influence of smoking cessation on alcohol use. CONCLUSIONS: Smokers with alcohol problems, particularly those with current or recent problems, are underrepresented in studies of approved pharmacotherapy for smoking cessation. Future trials should assess alcohol use at baseline and during treatment and examine reciprocal influences between alcohol consumption and smoking cessation.     

Ethnic Differences in Smoking Rate, Nicotine Dependence, and Cessation-Related Variables Among Adult Smokers in Hawaii

This study tests hypotheses concerning ethnic disparities in daily cigarette smoking rates, nicotine dependence, cessation motivation, and knowledge and past use of cessation methods (e.g., counseling) and products (e.g., nicotine patch) in a multiethnic sample of smokers in Hawaii. Previous research has revealed significant differences in smoking prevalence among Native Hawaiians, Filipinos, Japanese, and Caucasians in Hawaii. However, no study has examined differences in dependence and cessation-related knowledge and practices among smokers representing these ethnic groups. Participants were recruited through newspaper advertisement as part of a larger smoking cessation intervention study. Participants (N?=?919; M age?=?45.6, SD?=?12.7; 48?% women) eligible to participate provided self-report data through mail and telephone. Participants included 271 self-identified Native Hawaiians, 63 Filipinos, 316 Caucasians, 145 “East Asians” (e.g., Japanese, Chinese), and 124 “other” (e.g., Hispanic, African-American). Pair-wise comparisons of means, controlling for age, gender, income, education, and marital status, indicated that Native Hawaiian smokers reported significantly higher daily smoking rates and higher levels of nicotine dependence compared to East Asians. Native Hawaiian smokers reported significantly lower motivation to quit smoking than Caucasians. Further, Filipino and Native Hawaiian smokers reported lesser knowledge of cessation methods and products, and less frequent use of these methods and products than Caucasians. The results suggest that Native Hawaiian and Filipino smokers could be underserved with regard to receiving cessation-related advice, and may lack adequate access to smoking cessation products and services. In addition, cessation interventions tailored for Native Hawaiian smokers could benefit from a motivational enhancement component.     

Smoking cessation in women concerned about weight.

BACKGROUND. Weight gain after smoking cessation is often cited by women smokers as a primary reason for not attempting to quit smoking or for relapsing after a cessation attempt. METHODS. A randomized trial of 417 women smokers was conducted to test the addition of two weight control strategies to a smoking cessation program. Participants received the standard smoking cessation program, the program plus nicotine gum, the program plus behavioral weight control, or the program plus both nicotine gum and behavioral weight control. Weight and smoking status were measured at the end of treatment and at 6 and 12 months posttreatment. RESULTS. Smoking cessation rates were highest in the group receiving the smoking cessation program plus nicotine gum. Weight gain did not vary by treatment condition, so its effect on relapse could not be examined by group. There was no significant relationship between weight gained and relapse in individuals. CONCLUSIONS. The added behavioral weight control program was attractive to the participants and did not reduce smoking cessation rates. However, it did not produce the expected effect on weight, thereby restricting our ability to examine the effect of weight control on smoking cessation and relapse.     

Using extended cognitive behavioral treatment and medication to treat dependent smokers

Objectives. We evaluated smoking-cessation efficacy of an extended course of sustained-release bupropion (bupropion SR) and cognitive-behavioral treatment (CBT).Methods. Participants who smoked at least 10 cigarettes per day and who smoked within 30 minutes of arising (n = 406) completed a 12-week smoking-cessation treatment including group counseling, nicotine-replacement therapy, and bupropion SR. Participants were then randomly assigned to 1 of 5 conditions: (1) no further treatment, (2) active bupropion SR for 40 weeks, (3) placebo for 40 weeks, (4) active bupropion SR and 11 sessions of CBT for 40 weeks (A-CBT), or (5) placebo and 11 sessions of CBT for 40 weeks. Participants were assessed at baseline and at weeks 12, 24, 52, 64, and 104.Results. A-CBT was not superior to the other 3 extended treatments. From weeks 12 through 104, all extended treatment conditions were superior to standard treatment. At weeks 64 and 104, the 2 CBT conditions produced significantly higher abstinence rates than did the other 3 conditions.Conclusions. Brief contact with providers can increase abstinence during treatment. CBT may increase long-term abstinence after extended treatment is terminated.Researchers and clinicians have come to expect low rates of long-term cigarette abstinence subsequent to tobacco-dependence treatment—usually 25% or less at 1 year, even with combination therapy.^1,2 These low rates may be attributable to a failure to conceputalize tobacco dependence as an addiction with a chronic, relapsing course. The implications of a chronic-disease model suggest that longer, more extended courses of tobacco-dependence treatment may result in higher long-term cigarette abstinence rates.Three studies have examined the efficacy of extended administration of sustained-release bupropion (bupropion SR). Hays et al. treated participants for 7 weeks with open-label bupropion SR and then randomly assigned only cigarette-abstinent participants (59% of the sample) to active or placebo bupropion SR for an additional 45 weeks. Cigarette abstinence was significantly higher in the active drug condition (55.1%) than in the placebo drug condition (42.3%) after 1 year of therapy, but the conditions did not differ at 2-year follow-up (41.6% for active drug; 40.0% for placebo).³ In a second study, smokers were treated with nicotine patches calibrated to individual cigarette intake. Abstinent participants (31% of the sample) were then randomly assigned to either active or placebo bupropion SR for 6 months. Abstinence rates did not differ between conditions at 6 months (25% for placebo; 28% for active drug).⁴ Cox et al.⁵ randomized abstinent smokers who had been treated with 7 weeks of bupropion SR to either continued bupropion SR for the remainder of 1 year or to placebo. Active drug produced greater cigarette abstinence at the end of treatment when compared with placebo (55.89% vs 43.58%), but there were no differences at 1-year follow-up (42.34% vs 42.95%). Thus, it appears that extended bupropion SR provides an increase in abstinence rates while being administered, but this effect is lost after medication termination.Extended administration of varenicline has also been studied. Williams et al. administered either varenicline or placebo over 1 year and found that varenicline was superior to placebo at both 12 weeks (76.5% to 72.2%) and 52 weeks (37.8% to 34.1%).⁶ Tonstad et al.⁷ randomized abstinent smokers who had been treated with 12 weeks of varenicline to either continued varenicline or to placebo for an additional 12 weeks. Continuous cigarette abstinence rates were higher for the varenicline group than for the placebo group for weeks 13 through 24 (70.5% to 49.6%) and for weeks 13 through 52 (43.6% to 36.9%). Thus, the therapeutic effects of extended varenicline may last past the period of administration.In earlier work, our group studied extended administration of nortriptyline. We assigned smokers to 1 of 4 treatment conditions in a 2 × 2 factorial design (nortriptyline vs placebo by brief treatment vs extended treatment). Participants in extended treatment continued taking drug or placebo and received monthly individual counseling sessions through week 52. At week 52, abstinence rates were 56% for extended nortriptyline and 57% for extended placebo. Both conditions produced abstinence rates that exceeded those of short-term treatment.Three studies have investigated the effects of extended cognitive-behavioral treatment (CBT). Killen et al.⁸ treated smokers for 12 weeks with open-label bupropion SR, nicotine patch, and weekly relapse-prevention training. All participants, independent of smoking status, were then offered 4 relapse-prevention sessions and continued on either active or placebo drug for an additional 14 weeks. There were no differences in abstinence rates between conditions at 1 year. In a second study⁹ participants received bupropion SR, nicotine patch, and CBT for 8 weeks and were then randomly assigned to receive either 12 weeks of CBT plus voicemail monitoring and telephone counseling or telephone-based general support. The investigators reported significant differences at 20 weeks (45% vs 29%) but not at 52 weeks (31% vs 27%).Recently, we studied 402 people who smoked at least 10 cigarettes per day and who were 50 years old or older.¹⁰ All completed a 12-week treatment that included group counseling, nicotine gum, and bupropion SR, and all were then randomly assigned to 1 of 4 follow-up conditions: (1) standard treatment (no further treatment), (2) extended nicotine-replacement therapy (NRT) with 40 weeks of nicotine gum availability, (3) extended CBT (11 cognitive behavioral sessions over a 40-week period), or (4) extended CBT plus extended NRT (11 CBT sessions plus 40 weeks of nicotine gum availability). The extended CBT condition produced high cigarette-abstinence rates that were maintained throughout the 2-year study period (week 24 = 58.3%; week 52 = 55.0%; week 64 = 54.6%; week 104 = 54.8%). The extended CBT condition was significantly more effective than extended NRT and standard treatment across that period. No other treatment condition was significantly different from standard treatment. These findings suggest that extended CBT can produce high and stable cigarette abstinence rates. Medication does not appear to play a major role in maintaining abstinence when combined with CBT.In the current study, we evaluated a CBT intervention similar to that described by Hall et al.¹⁰ We also evaluated the efficacy of long-term bupropion SR versus placebo. We proposed the following hypotheses: (1) at all assessments after baseline, the active bupropion extended CBT (A-CBT) condition would produce higher point prevalence abstinence rates than placebo with extended CBT (P-CBT), placebo alone, active bupropion alone, or standard treatment (our primary hypothesis); and (2) at all assessments after the end of extended treatment, the 2 conditions that included CBT (combined with active or placebo bupropion) would produce abstinence rates superior to those produced by the 3 conditions that did not include CBT.     

Exploring the Relationship Between Mental Health and Smoking Cessation: A Study of Rural Teens

This study examined the association between mental health and smoking cessation among rural youth. Participants were 113 male and 145 female adolescents ages 14-19 from rural West Virginia and North Carolina. Participants were enrolled in the American Lung Association's 10-week Not On Tobacco (N-O-T) program or a 15-min single-dose brief intervention. Baseline and postprogram measures were completed on smoking status (i.e., quit, reduction), nicotine dependence, smoking history, and depression and anxiety. Results showed that more N-O-T participants quit and reduced smoking than did brief intervention participants. Intervention group, baseline smoking rate, and the Group x Gender, Group x Anxiety, and Group x Depression interactions were significant predictors of change in smoking behavior from baseline to postprogram. In conclusion, more N-O-T participants demonstrated favorable changes in smoking than did brief intervention participants. Approximately 1/3 of youth exhibited mental health pathology; more females than males. Levels of depression and anxiety improved from baseline to postprogram, overall. Although the extent of the impact of mental health on cessation outcomes was inconclusive, findings suggest that rural youth who smoke may be at risk for pathological depression and anxiety. Future cessation programming with rural youth should consider the inclusion of coping and stress management skills and mental health referral protocols as significant program components.     

Modeling heaping in self-reported cigarette counts

In studies of smoking behavior, some subjects report exact cigarette counts, whereas others report rounded-off counts, particularly multiples of 20, 10 or 5. This form of data reporting error, known as heaping, can bias the estimation of parameters of interest such as mean cigarette consumption. We present a model to describe heaped count data from a randomized trial of bupropion treatment for smoking cessation. The model posits that the reported cigarette count is a deterministic function of an underlying precise cigarette count variable and a heaping behavior variable, both of which are at best partially observed. To account for an excess of zeros, as would likely occur in a smoking cessation study where some subjects successfully quit, we model the underlying count variable with zero-inflated count distributions. We study the sensitivity of the inference on smoking cessation by fitting various models that either do or do not account for heaping and zero inflation, comparing the models by means of Bayes factors. Our results suggest that sufficiently rich models for both the underlying distribution and the heaping behavior are indispensable to obtaining a good fit with heaped smoking data. The analyses moreover reveal that bupropion has a significant effect on the fraction abstinent, but not on mean cigarette consumption among the non-abstinent.     

Comparing Smoking Cessation Interventions for Work-Site Disease Management

Smoking cessation continues to be one of the most cost-effective preventive measures for work-site disease management. The US Public Health Service Clinical Practice Guideline, entitled ‘Treating Tobacco Use and Dependence,’ provides guidance for evaluating and choosing smoking cessation programs for work sites.Smoking cessation interventions can be characterized by the resource intensity of the effort, the format and methods of interacting with patients and the focus and objectives of the content. These features are compared with typical group, phone and Internet-based program options. Pharmacotherapy treatment recommendations are reviewed as well as characteristics of first-line nicotine replacement therapy (NRT) medications (e.g. nicotine patch, gum, spray and inhaler) and bupropion.It is suggested that work-site recruitment and participation campaigns may fail for a variety of reasons including: (i) too narrowly cast recruitment messages; (ii) inadequate exposure to campaign messages; (iii) lack of immediate and accessible enrollment mechanisms; and (iv) passive rather than active outreach. Four broad issues to consider when comparing outcomes data from potential smoking cessation programs are: (i) at what follow-up point(s) is the quit rate measured?; (ii) is there a comparison group?; (iii) how was quit status determined?; and (iv) how is the status of participants who are lost to follow-up calculated in the outcomes data?     

Predictors of smoking cessation among African-Americans enrolled in a randomized controlled trial of bupropion

OBJECTIVES: Identification of individual characteristics that predict successful smoking cessation treatment has been limited to studies with mostly white participants. This study identifies factors that predict successful quitting among African-Americans participating in a smoking cessation trial. METHODS: Twenty-one baseline variables were analyzed as potential predictors from a double-blind placebo-controlled, randomized trial that used bupropion SR for smoking cessation among 600 African-American smokers. Chi-square tests, two sample t tests, and multiple logistic regression procedures were employed to identify predictors of 7-day abstinence among the 535 participants who completed the 7-week medication phase. RESULTS: Univariate predictors of cessation were receiving bupropion (P < 0.0001), not smoking menthol cigarettes (P = 0.0062), smoking after 30 min of waking (P < 0.0001), older age (P = 0.0085), smoking fewer cigarettes per day (P = 0.0038), and lower cotinine levels (P = 0.0002). Logistic regression identified three significant independent predictors. Participants who received bupropion treatment were more than twice as likely to quit smoking at the end of treatment compared to participants who received placebo (OR = 2.62; 95% CI = 1.77-3.88, P < 0.0001), while smoking within 30 min of waking (OR = 0.40; 95% CI = 0.25-0.62, P < 0.0001) and higher salivary cotinine levels at baseline (OR = 0.799; 95% CI = 0.629-0.922, P < 0.0001) reduced the likelihood of quitting. CONCLUSIONS: This is the first report identifying predictors of smoking cessation among African-Americans participating in a clinical trial. Results indicate that, aside from bupropion treatment, various indicators of addiction were the strongest predictors. While this is similar to findings among white smokers, thresholds of addiction may need to be adjusted for African-American smoking patterns. Additional studies focused on diverse populations are needed to improve treatment approaches and to identify population-specific factors that are important for treatment-matching approaches.     

Cigarette smoking and mortality. MRFIT Research Group.

METHODS. The relationship of cigarette smoking and smoking cessation to mortality was investigated among men screened for and also among those randomized to the Multiple Risk Factor Intervention Trial (MRFIT). RESULTS. Among the 361,662 men screened for the MRFIT, cigarette smoking was an important risk factor for all-cause, coronary heart disease (CHD), stroke, and cancer mortality. These risks, on the log relative scale, were strongest for cancers of the lung, mouth, and larynx. The excess risk associated with cigarette smoking was greatest for death from CHD. Overall, approximately one-half of all deaths were associated with cigarette smoking. Among the 12,866 randomized participants, weak positive associations with duration of cigarette smoking habit and tar and nicotine levels were found with all-cause mortality. For both SI and UC men, substantial differences in subsequent CHD (34-49%) and all-cause (35-47%) mortality were evident for men who reported cigarette smoking cessation by the end of the trial compared with those continuing to smoke. There was no evidence that lung cancer death rates were lower among cigarette smokers who quite compared with those who continued to smoke in this 10-year follow-up period. CONCLUSION. The data are consistent with results of previous epidemiologic studies indicating that the benefits of smoking cessation on CHD are rapid, while for lung cancer, the benefit is not evident in a 10-year follow-up period.     

2015-2018年央补项目戒烟门诊患者首诊后1个月随访时戒烟率影响因素分析

目的 评估中央补助地方戒烟门诊项目实施效果,探索影响吸烟者戒烟成功的因素,以指导戒烟服务的提供和戒烟门诊工作的开展。方法 采用人群现场干预研究,由经过项目培训的医务人员,对吸烟者进行面对面访谈,完成调查问卷,并进行心理行为干预。已配备戒烟药物的医院,为患者开具相应药物。首诊1个月后开展随访干预,获得1个月随访7 d时点戒烟率。结果 1个月随访7 d时点戒烟率为34.1%。多元logistic回归结果显示, ≥60岁患病人群戒烟可能性最大;自身患病、首诊非每天吸烟、准备在30 d内戒烟、使用酒石酸伐尼克兰和盐酸安非他酮的患者,戒烟成功的可能性更大;未就业者相对于就业者更不利于戒烟;每日吸烟量越大、吸烟年限越长、晨起后第一支烟越急迫的患者,戒烟的可能性越小;是否有戒烟史对戒烟可能性没有影响。结论 从1个月随访时7 d时点戒烟率看,央补戒烟门诊项目戒烟干预有效。应加大对吸烟者的宣传,戒烟越早越有效。使用酒石酸伐尼克兰和盐酸安非他酮等药物能增加戒烟的可能性,应加强戒烟门诊有效药物的配备率。戒烟门诊医务人员帮助患者在戒烟过程中克服戒断症状很重要。     

Over-the-counter nicotine patch therapy for smoking cessation: results from randomized, double-blind, placebo-controlled, and open label trials.

OBJECTIVES: The purpose of this study was to determine the efficacy and safety of the nicotine patch for smoking cessation in an over-the-counter environment. The years of study were 1994 to 1995. METHODS: Parallel 6-week trials were conducted: a placebo-controlled trial of no-cost 22-mg, 24-hour nicotine patch therapy and an open label trial of the same therapy with patches purchased by subjects. Participants (n = 958) were 18 years or older, had smoked at least 15 cigarettes daily for at least 6 months, and were enrolled at 3 study sites. The main outcome measure was self-reported smoking abstinence confirmed by expired carbon monoxide measurements. RESULTS: Smoking cessation rates in the placebo-controlled trial were 16.8% and 9.6% at week 6 and 8.7% and 4.3% at week 24 for the active patch and placebo groups, respectively. Smoking cessation rates in the open label-pay trial were 19.0% and 10.8% at weeks 6 and 24, respectively. A slight increase in adverse cardiovascular events was noted only in the open label-pay group in comparison with the placebo group. CONCLUSIONS: In an over-the-counter environment, the 22-mg, 24-hour nicotine patch is effective and safe for smoking cessation treatment.     

Graphic Canadian cigarette warning labels and adverse outcomes: evidence from Canadian smokers

OBJECTIVES: We assessed the impact of graphic Canadian cigarette warning labels. METHODS: We used a longitudinal telephone survey of 616 adult smokers. RESULTS: Approximately one fifth of participants reported smoking less as a result of the labels; only 1% reported smoking more. Although participants reported negative emotional responses to the warnings including fear (44%) and disgust (58%), smokers who reported greater negative emotion were more likely to have quit, attempted to quit, or reduced their smoking 3 months later. Participants who attempted to avoid the warnings (30%) were no less likely to think about the warnings or engage in cessation behavior at follow-up. CONCLUSIONS: Policymakers should not be reluctant to introduce vivid or graphic warnings for fear of adverse outcomes.     

Integrating smoking cessation treatment into primary care: an effectiveness study

BACKGROUND: Lack of interest has been cited as a reason not to offer cessation assistance to smokers, but research suggests that smokers accept treatments offered proactively. This study assessed acceptability, utilization, and effectiveness of free smoking cessation treatment among diverse primary care patients. METHOD: Medical assistants invited 4174 adult smokers to participate. Enrollees (1869) self-selected or were assigned to receive free nicotine patch therapy alone or in combination with the Committed Quitters(R) program, and for some, individual counseling. RESULTS: In nearly 68% of cases, patients accepted a treatment invitation; 77% of eligible smokers enrolled; 85% of these picked up free patches. Given a choice of treatments, 75% of participants elected a psychosocial treatment in addition to patch therapy. Thirteen percent of treatment initiators achieved biochemically confirmed 7-day point-prevalence abstinence at 1 year, with no significant treatment effects. Minority patients showed greater initial interest but less utilization did than White patients. CONCLUSIONS: Free, readily accessible smoking cessation treatment offered in primary care settings was accepted and used by the majority of unselected smokers of diverse racial/ethnic origins. Psychosocial treatment components did not significantly increase abstinence rates. Barriers, rather than lack of interest, may keep minority smokers from using cessation treatments.     

Bupropion: an effective new aid for smoking cessation

Smoking is responsible for a substantial percentage of the total morbidity and mortality in western society. In the Netherlands 34% of the population smoke. A considerable part of the smokers tried to stop smoking, but did not succeed. Since December 1999 a new type of anti-smoke therapy is available; bupropion chloride (Zyban). With this treatment an improvement in success ratio in comparison with placebo is described of 11-15% after a year in a healthy population. Combined with nicotine patches this percentage was 20%. These percentages are higher than those of nicotine replacement therapy alone (3-13%). It is very important that effects of bupropion are tested in high-risk patients with asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular diseases as these groups may benefit most from cessation of smoking. Especially in the COPD group cessation of smoking makes a more substantial contribution to improvement of the disease process than the medication now available. Therefore, it might be considered to prescribe bupropion under strict control in this group even now, before definitive research results are obtained.     

Smoking cessation treatment by primary care physicians: An update and call for training

BACKGROUND: Public health and government organizations have invested considerably to increase physician adherence to smoking-cessation practice guidelines. METHODS: A random sample of 2000 U.S. primary care physicians was ascertained from the American Medical Association (AMA) in 2002. Respondents (n = 1120, 62.3%) provided self-reported data about individual and practice characteristics and smoking-cessation practices. Data were analyzed in 2005. RESULTS: Most primary care physicians (75%) advised cessation, 64% recommended nicotine patches, 67% recommended bupropion, 32% recommended nicotine gum, 10% referred to cessation experts, and 26% referred to cessation programs "often or always." Advising cessation was related to being older, having a faculty appointment, having trained staff for smoking counseling, and having confidence to counsel patients about smoking. Physicians who were internists, younger, and those with greater confidence to counsel patients about smoking recommended nicotine replacement more often. Prescribing bupropion was less common among older physicians, in the Northeast, with trained staff available for counseling, and with a greater proportion of minority or Medicaid patients. Prescribing bupropion was more common among AMA-member physicians and physicians with greater confidence to counsel patients about smoking. Providing a referral to an outside expert or program was more common among female physicians, and physicians in the Northeast or West, with larger clinical practices, and with trained staff for cessation counseling. CONCLUSIONS: Current physician self-reported practices for smoking cessation suggest opportunity for improvement. Targeted efforts to educate and support subsets of primary care physicians may improve physician adherence and smoking outcomes.     

Cost-benefit analysis of sustained-release bupropion, nicotine patch, or both for smoking cessation

BACKGROUND: The nicotine transdermal patch (NTP) has been shown previously to be a cost-effective smoking cessation intervention. This is the first economic analysis comparing the NTP with the only non-nicotine-containing pharmacological intervention, bupropion HCl. METHODS: Decision-tree analysis, based on a previously published cost-benefit smoking-cessation model, was used to determine the optimal treatment from the standpoint of costs versus benefits, from the employer's perspective. Base-case probabilities of successful quitting in our model came from clinical trial point-prevalence data at the end of a 1-year follow-up study (N = 893) comparing placebo, bupropion, NTP, and bupropion/NTP in combination, administered along with minimal counseling. Sensitivity analyses were performed to determine the effects of variations in base-case assumptions regarding the monetary benefits that would accrue if an intervention were successful, probabilities of quitting, drug costs, cost of lost work time for a health care provider visit, and cost of the visit itself. RESULTS: The analysis showed that bupropion is more cost-beneficial than either NTP or bupropion/NTP, with a net benefit in the first post-quit year of up to $338 per employee who attempts to quit compared with $26 for NTP, $178 for the two in combination, and $258 for placebo. These results were robust to most plausible variations in the assumptions used in the model. One exception was the monetary benefit of successful intervention (assumed in the base-case to be $1,654). If this benefit were actually less than $1, 112, placebo (i.e., minimal counseling with no pharmacological intervention) would be more cost-beneficial than any of the active treatments. CONCLUSION: From an employer's perspective, bupropion 300 mg/day for 9 weeks is a more cost-beneficial smoking cessation intervention than the nicotine patch, and under most scenarios, bupropion is also more cost-beneficial than placebo.     

Smoking cessation: How compelling is the evidence? A review

ObjectivesTo provide a short review of the evidence base supporting smoking cessation interventions, including behavioral therapy and pharmacological treatment options.MethodsPublished meta-analysis was mainly used supplemented with a limited literature search.ResultsEffective smoking cessation consists of pharmacotherapy and behavioral support. Counseling increases abstinence rates parallel to the intensity of support. First-line pharmacological drugs for smoking cessation are nicotine replacement products (patch, gum, inhaler, nasal spray, lozenge/tablets), varenicline and bupropion SR with scientific well-documented efficacy when used for 2-3 months and mostly mild side effects. Alternative therapies such as hypnosis and acupuncture have no scientifically proven effects.ConclusionsWith the most optimal drugs and counseling today a 1-year abstinence rate of approximately 25% can be expected in smoking cessation. On-going research is examining the potential effects of nicotine vaccination as relapse prevention.     

Smoking cessation in a blue-collar population: results from an evidence-based pilot program

BACKGROUND: Taft Hartley Funds provide group health care coverage for 10 million union workers as well as their dependents in industries such as construction and transportation. The adult smoking rate in these populations is estimated at approximately 40%, therefore, these funds include 9 million adult smokers. The absence of evidence demonstrating the effectiveness of smoking cessation programs has kept Taft Hartley Funds from investing in smoking cessation benefits. METHODS: A prototype for Taft Hartley Funds consistent with the Federal Clinical Guidelines for Smoking Cessation was designed and implemented in a pilot demonstration in the Carpenters Health and Security Trust of Western Washington. Participants chose a 1-call or more intensive 5-call smoking cessation counseling plan provided by the Group Health Cooperative's Free and Clear program. Medications were limited to the nicotine patch, nicotine gum, and Bupropion. Assessment of outcomes was performed by Free and Clear through a telephone survey 12 months following the enrollment date. RESULTS: Nine hundred thirty-five smokers participated in the program. This pilot evaluation covers 325 participants with at least 12 months since enrollment; 75% were male, the average age was 41.4 and 63% had smoked at least one pack per day for more than 20 years. Sixty-one percent selected 5-Call Counseling; 39% 1-Call. Seventy-five percent also used smoking cessation medications: gum, 4%; patch, 32%; Bupropion 21.5%; patch plus Bupropion, 15.7%. The point-prevalence-quit rates were: overall, 27.5%; 1-Call, 25.5%; and 5-Call, 28.9%. The cost of the program was $1025.28 per smoker who quit, or $11.78 per full-time equivalent employee covered by the Fund per year. The compounded savings in reduced lifetime tobacco-related medical costs for the participants who quit are estimated to be 15 times the cost of the program, yielding an annual return on investment of 27.6%. CONCLUSIONS: These results strongly suggest that smoking cessation programs can be effective even in such hard-to-reach populations as itinerant building trades workers, provided that the program is designed to their needs and environment. Based on these findings, health plans need to consider whether they are at risk of violating their fiduciary duties if they fail to offer smoking cessation benefits.