A randomized trial of a family physician intervention for smoking cessation

We assessed the impact of three conditions on one-year smoking cessation rates. Physicians in 70 community general practices were randomly allocated by practice to one of three groups: In the usual care group, smoking patients were to receive the care they normally would receive. In the gum only group, physicians were asked to speak to patients about smoking cessation and offer nicotine gum. In the gum plus group, physicians were trained in the experimental intervention. This intervention involved advice to stop smoking, the setting of a quit date, the offer of nicotine gum, and four follow-up visits. Smoking cessation was measured by self-report after one year and validated using saliva cotinine measures. Using a criterion of at least three months of abstinence, 8.8% of the patients of the trained physicians had stopped smoking at the one-year follow-up compared with 4.4% and 6.1% of the patients in the usual care and gum only groups, respectively.     

Chewing nicotine gum for 3 months: what happens to plasma nicotine levels?

Techniques that help patients stop smoking should also reduce their exposure to agents such as nicotine. The mean plasma nicotine levels in 50 subjects while they were still smoking and then while they were chewing pieces of gum containing either 2 or 4 mg of nicotine over a 12-week period of abstinence were 35, 9 and 23 ng/mL (217, 56 and 143 nmol/L) respectively. A small number of subjects given an unlimited supply of gum used 14 to 24 pieces of 4-mg gum daily and had plasma nicotine levels exceeding the levels achieved while smoking. There were no acute symptoms necessitating medical intervention associated with these excessive levels. Side effects were uncommon and usually controllable. When simple dosage rules are followed people who chew nicotine gum for a few months to stop smoking lower their exposure to nicotine.     

Nicotine vs placebo gum in general medical practice

Three hundred fifteen smokers who attended a family practice clinic and wished to quit smoking were assigned in a random, double-blind manner to receive either nicotine (2 mg) or placebo gum. Smokers initially received brief advice from a physician and nurse, a slide presentation and written materials (29 to 35 minutes), and a single follow-up visit (12 to 20 minutes) one week after cessation. After corrections for marital status and income, 10% of those who received nicotine gum and 7% of those who received placebo gum reported continuous abstinence for 11 months and passed observer and biochemical verification (this difference was not statistically significant). We conclude that, when used in a nonselected group of smokers along with a brief intervention in a general medical practice, the pharmacologic effects of nicotine gum to increase cessation are either small or nonexistent.     

Randomised controlled trial of nicotine chewing-gum

The effectiveness of 2 mg nicotine chewing-gum as an aid to stopping smoking was compared with a placebo containing 1 mg nicotine, but unbuffered, in a double-blind randomised trial. Of 58 subjects given the active gum, 27 (47%) were not smoking at one-year follow-up compared with 12 (21%) of the 58 subjects treated with placebo (p less than 0.025). By the most stringent criterion of outcome, 18 (31%) subjects in the active treatment group and eight (14%) in the placebo group had not smoked at all from the start of treatment to follow-up at one year (p less than 0.05). Subjects receiving the active gum experienced less severe withdrawal symptoms and rated their gum as more helpful than did the placebo group. Minor side effects were common but only gastric symptoms were more frequent with the active gum. Subjects receiving active gum used it for longer than those receiving placebo but most stopped using it within six months and only four (7%) developed longer-term dependence. The number of gums used daily correlated significantly with pretreatment blood nicotine concentrations in the active treatment group and with pretreatment cigarette consumption in the placebo group. A lower pretreatment blood nicotine value was the best predictor of success at one year (p less than 0.001) but there was no significant relation to cigarette consumption, sex, and social class. The results clearly confirm the usefulness of nicotine chewing-gum as an aid to stopping smoking and imply a definite role for nicotine in cigarette dependence and withdrawal. Successful use of the gum requires careful attention to subjects' expectations and clear instructions on how to use it.     

Internists and nicotine gum

Nicotine gum may be a useful aid to help patients quit smoking. The effectiveness of the gum and incidence of side effects may depend on using the gum properly. To describe internists' current practices of prescribing nicotine gum and other drugs for smoking cessation, we surveyed randomly selected internists. Most internists prescribe nicotine gum to fewer than 25% of patients who try to quit smoking. Contrary to current recommendations, nearly half of internists would suggest gum to help patients cut down on smoking, and a majority would limit its use to less than three months. There is no evidence that sedatives are useful for smoking cessation, but one fourth of internists had recently prescribed them for that purpose. There is a widespread need for physician education about how to use nicotine gum more effectively.     

Three year evaluation of a programme by general practitioners to help patients to stop smoking

A controlled study was undertaken to measure the effectiveness of general practitioners' use of an intensive programme to help patients to stop smoking. Two hundred cigarette smokers who attended a general practice were allocated to either a treatment (n = 100) or a non-intervention control (n = 100) group. After the initial visit treatment consisted of an educational consultation and four follow up visits. Smoking state was assessed biochemically at six months and three years. Thirty five patients in the treatment group were abstinent at three years compared with eight in the control group (p less than 0.001). Sixty four patients attended the educational consultation and first follow up visit; of these, 45 were not smoking at the first follow up visit, 30 maintained abstinence up to six months, and 22 were still not smoking after three years. Among the 37 patients who completed the treatment programme and attended all the follow up visits 57% were abstinent at three years. The results of this study suggest that general practitioners can help patients to stop smoking.     

Minimal contact treatment for smoking cessation. A placebo controlled trial of nicotine polacrilex and self-directed relapse prevention: initial results of the Stanford Stop Smoking Project

To determine the effectiveness of nicotine polacrilex combined with self-administered relapse prevention materials in maintaining smoking cessation, we conducted a randomized, double-blind, placebo controlled trial. Volunteers aged 18 to 65 years responding to media announcements were required to quit smoking for 48 hours without assistance. Of 1844 potential participants, 136 were medically excluded, 535 declined to make a quit attempt, and 573 were unable to quit, leaving 600 participants (35%) who were randomized. Eight self-help relapse prevention modules were mailed weekly. Gum was used either ad lib for smoking urges or on a fixed, hourly schedule (12 pieces per day). Only 15% of the subjects in each gum group stopped using the gum altogether because of side effects, but only 20% of the ad lib groups and 40% of the fixed-dosage group used at least eight pieces of gum per day during the first week. The abstinence rates (for at least seven days) at the six-month follow-up were 31% in both active gum groups and 22% in the placebo and no gum groups. Relapse rates in the two active gum groups were about half those in the placebo and no gum groups. Nicotine polacrilex may be a useful adjunct to minimal contact smoking cessation formats, which have broad appeal. Also, minimal contact relapse prevention programs may assist physicians in helping patients to maintain smoking cessation using nicotine polacrilex.     

Antismoking products

Nicotine is the addictive substance in tobacco and its withdrawal is responsible for a range of unpleasant symptoms after smoking cessation. Although it produces acute physiological effects, nicotine alone is not carcinogenic and does not appear to cause the vascular disease associated with smoking. Nicotine replacement has been shown to be a safe and effective pharmacological treatment for tobacco dependence in certain smokers. Its efficacy is greatest when prescribed for those who are motivated and highly nicotine-dependent. It is probably not indicated for smokers with a low degree of nicotine dependence. Studies of nicotine chewing gum conducted in special referral clinics have generally produced positive results, whereas those conducted in community practice settings have shown a smaller benefit when compared with placebo. When the results of all published placebo-controlled trials are pooled the typical improvement in smoking cessation rate is 40% (odds ratio continued smoking 0.6; 95% confidence interval 0.5-0.71; P less than 0.00001). The best results with nicotine chewing gum have been obtained with multicomponent programmes which have included some counselling and ongoing follow up and support. Early reports of success with a transdermal nicotine preparation suggest that it may have similar efficacy to nicotine gum. Clonidine administered orally or transdermally has also been shown to reduce tobacco withdrawal symptoms but requires more convincing evidence of long-term efficacy before it can be recommended for routine use. Currently available over-the-counter products, apart from nicotine chewing gum, have not been shown to be effective.     

A smoking cessation intervention program for family physicians.

Family physicians are able to approach many patients who smoke but are often hesitant to help them quit. Lack of knowledge about effective interventions is a major reason for this hesitancy. The important components that have been tested in physician-initiated smoking cessation interventions are advice to quit, information about the risks of smoking and techniques for quitting, nicotine gum, setting a date for quitting and offers of supportive follow-up visits. We describe a cessation program developed for family physicians that incorporates these factors into three types of visits over a 2-month period: the challenge visit, which occurs during a regular office visit and focuses on advice and setting a date to quit; the quit-date visit, which involves instructing patients on the proper use of nicotine gum, if applicable, and confirming their desire to quit; and four supportive follow-up visits, which provide continuing encouragement for 2 months and allow physicians to monitor withdrawal symptoms, relapses and other problems. Such a program can be effectively incorporated into a general practice.     

The effects of supplementary nicotine in regular cigarette smokers

Blood nicotine levels were measured in eight subjects over a 5-week period, while smoking normally, while smoking and chewing gum containing 2 mg nicotine, and while smoking and chewing placebo gum. Despite a small but significant rise in blood nicotine levels during the period of the nicotine gum chewing (mean 35.3 ng/ml) compared with placebo (mean 28.9 ng/ml) and control (mean 26.3 ng/ml), cigarette consumption butt lengths, filter nicotine and blood carboxyhaemoglobin levels did not change indicating that there had been no significant changes in smoking patterns. The reasons for this failure to demonstrate an effect are discussed. It is concluded that the dose of nicotine used was probably not adequate to produce an effect.     

A smoking cessation programme for use in general practice

The effectiveness of a smoking intervention programme based in general practice was evaluated at six months by a randomized controlled trial. In the programme, general practitioners achieved a 33% success rate compared with 3% in a control group. Reported abstinence was checked by blood tests for cotinine, carboxyhaemoglobin and thiocyanate. The majority of patients considered that their chances of success were greater if a doctor administered the programme, and that having the results of lung function and blood tests explained in relation to the risks of cardiovascular and respiratory diseases constituted a strong incentive to stop smoking. Two cases illustrating a successful and a failed outcome of the programme are described. If one quarter of general practitioners in Australia adopted this programme in their practice, approximately 150,000 new abstainers could be expected each year.     

Cost-effectiveness of nicotine gum as an adjunct to physician's advice against cigarette smoking

A nicotine chewing gum has recently become available for use as an aid in giving up cigarette smoking. Although its efficacy has been demonstrated in clinic-based smoking cessation programs, its value in a primary care setting is uncertain. We examined the cost-effectiveness of nicotine gum as an adjunct to physician's advice and counseling against smoking during routine office visits. Our findings indicate that the cost per year of life saved with this intervention ranges from $4113 to $6465 for men and from $6880 to $9473 for women, depending on age. This compares favorably with other widely accepted medical practices, eg, treatment of hypertension or hyperlipidemia. Our study, therefore, suggests that nicotine gum is a cost-effective adjunct to physician's advice against cigarette smoking in a primary care setting.     

Nasal nicotine solution: a potential aid to giving up smoking?

A nasal solution was developed containing 2 mg nicotine for use as a kind of liquid snuff. Its absorption was studied in three subjects. An average peak of plasma nicotine concentrations of 86.9 nmol/l (14.1 ng/ml) was reached seven and a half minutes after taking the solution. This compared with an average peak of 158.4 nmol/l (25.7 ng/ml) one and a half minutes after completing (but seven and a half minutes after starting) a middle tar cigarette (1.4 mg nicotine) and an average peak of 52.4 nmol/l (8.5 ng/ml) after chewing nicotine gum (2 mg nicotine) for 30 minutes. The more rapid and efficient absorption of nicotine from the nasal nicotine solution than from nicotine chewing gum suggests that it might prove a useful aid to giving up smoking. Nasal nicotine solution might be particularly useful in smokers for whom the gum is less suitable on account of dentures or peptic ulcers or who experience nausea and dyspeptic symptoms from the gum.     

Practice nurses and antismoking education

A questionnaire on antismoking activities and education was sent to 369 nurses in general practice. The response rate was 80%. Although most of the nurses sometimes advised patients about smoking, routine antismoking education occurred less frequently. Only a few regularly referred smokers to other agencies for help, recommended aids to stop smoking, or used antismoking literature. Although the nurses thought that they had an important role in helping smokers to give up, they expressed little confidence in their effectiveness, believing that advice from the general practitioner and the smoker's personal determination to give up have more impact. The nurses expressed a need for training in antismoking education. Seventy seven per cent were interested in attending seminars and listed information about smoking, techniques for stopping, and counselling skills as priorities. If practice nurses are to use opportunities in primary care to help smokers there is clearly a need to provide further training and to establish the effectiveness of nurses in their role as smoking educators.     

Physical dependence on nicotine in gum. A placebo substitution trial

To test whether ex-smokers become physically dependent on nicotine in gum, we entered eight ex-smokers who were using nicotine gum into a randomized, double-blind, placebo-substitution trial. When placebo was substituted, seven of the eight subjects were observed to have withdrawal symptoms and two relapsed to smoking or nicotine gum. This result suggests that physical dependence (ie, withdrawal) may be a cause of behavioral dependence on nicotine gum (ie, use of gum beyond the recommended period) and physicians should emphasize the need for gradual reduction of nicotine gum.     

Nicotine replacement in smoking cessation. Absorption of nicotine vapor from smoke-free cigarettes

Nicotine replacement is a promising new approach to aid smoking cessation, and various methods of delivery are being developed. One new device is a smoke-free cigarette (Favor) that has been test-marketed in several US states. Without lighting up, it delivers nicotine vapor and is free of other harmful products of tobacco smoke. To examine its therapeutic potential, we measured plasma nicotine concentrations before, during, and after its use in eight male subjects. Very little nicotine was absorbed when it was puffed like a conventional cigarette. However, with an intensive schedule of puffing at four further smoke-free cigarettes over a 20-minute period, plasma nicotine concentrations were increased by an average of 17.3 ng/mL (107.3 nmol/L) (range, 10.9 to 30.4 ng/mL [67.6 to 188.5 nmol/L]). Heart rate and blood pressure also increased significantly. The rate of nicotine absorption was slow and resembled that obtained from nicotine chewing gum, suggesting that most of the nicotine was deposited in the mouth, throat, and large airways and did not reach the lung alveoli. Despite the slow absorption, the plasma nicotine levels produced could be of therapeutic value as an aid to smoking cessation.     

太原市区医院门诊男性患者吸烟状况调查分析

目的通过调查太原地区医院门诊就诊的男性患者的吸烟状况,为创造无烟医院、降低烟草相关性疾病发生率、制定有效的戒烟措施提供依据。方法采用自行设计的调查问卷,在门诊就诊的男性患者中抽取170名进行调查,有效问卷165份,并对吸烟者进行呼出气CO含量测试。结果问卷合格的165名男性,吸烟率为42.4%,吸烟人群以31～50岁居多,各职业中以农民吸烟率最高为54.2%,不同教育水平中以小学和文盲的吸烟率最高为53.3%;吸烟人群77.6%的人对尼古丁成高度依赖性;吸烟人群呼出气CO含量与日吸烟支数、吸烟年限、吸烟指数呈正相关,差异有统计学意义（P〈0.01）。结论太原地区门诊就诊的男性患者吸烟率仍较高,开展各种形式的健康教育,加大控烟力度,开设戒烟门诊,才能够有效降低门诊就诊男性的吸烟率及烟草相关性疾病的发生率。     

Effects of nicotine chewing gum on UPDRS score and P300 in early-onset parkinsonism

It has been reported that nicotine shows some beneficial effects on Parkinson's disease. The purpose of the present study is to assess the therapeutic effects of nicotine chewing gum in patients with early-onset parkinsonism (EOP). The subjects were 8 patients with early-onset parkinsonism (male/female = 4/4, mean age; 51.3 years). Four out of 8 patients had a history of smoking (smokers). To estimate the effects of nicotine gum, the scores on the Unified Parkinson's Disease Rating Scale (UPDRS) and auditory event-related potentials (ERPs) were studied before and after taking nicotine gum in the EOP patients. In smokers, UPDRS scores improved by more than 10% and the P300 latency of auditory ERPs was shortened by more than 30 msec. In contrast, nicotine had no remarkable effects on UPDRS scores or auditory ERPs in non-smokers. We suggest that nicotine chewing gum may be a possible choice for the treatment of patients with EOP, especially when they are smokers.     

Heavy smokers, smoking cessation, and clonidine. Results of a double-blind, randomized trial

Seventy-one heavy smokers who had failed in previous attempts to stop smoking participated in a randomized clinical trial to test the efficacy of clonidine as an aid in smoking cessation. The success rate in clonidine-treated subjects (verified by serum cotinine concentration) was more than twice that in the placebo-treated subjects. When the data were stratified by gender, a strong effect present in women was not apparent in men. After six months, cessation rates remained significantly higher among smokers treated with clonidine than those receiving placebo. The data also revealed an unexpectedly high prevalence (61%) of a history of major depression in this sample and a significant negative effect of such a history on cessation regardless of treatment. These findings, highly suggestive of an important role of clonidine in smoking cessation, warrant further studies to establish the long-term (greater than or equal to 12 months) efficacy of this drug and to replicate the association between nicotine dependence and depression.