Like bupropion, the tricyclic antidepressant nortriptyline has been investigated for its potential in tobacco cessation therapy. While a significant amount is known about plasma concentrations of nortriptyline needed to treat depression, levels required for effective tobacco cessation are less clear. Mooney et al29 found that therapeutic plasma concentrations of nortriptyline varied among subjects by race and smoking habits; although a lower concentration was usually required to assist smoking cessation than to treat depression, adverse effects were common even at lower concentrations. Thus, it was recommended that nortriptyline be reserved for second-line treatment.
This summer, researchers for the Cochrane Tobacco Addiction Review Group published a review of the literature (including phase II and phase III trials conducted by pharmaceutical companies—making the risk for bias “high or unclear”) pertaining to two nicotine vaccines in development.21 In two studies, the level of development of nicotine antibodies was associated with commensurate cessation rates; in two others, the outcome measure (12 months’ abstinence from smoking) was met in 11% of subjects, whether they received the vaccine or placebo. Thus, no strong evidence yet exists that nicotine vaccination supports smoking cessation in the long term; further research is needed.
NONPHARMACEUTICAL
INTERVENTIONS
Acupuncture
Variations and modifications of the traditional Chinese therapy of acupuncture, including acupressure and electrostimulation, have been examined in a number of clinical trials. Despite the supporting rhetoric, objective research of good quality in this area is limited. However, one systematic literature review showed acupuncture to be only slightly more effective than sham interventions and less effective than NRT.30 Insufficient evidence was reported on acupressure and laser stimulation, and acupressure was no more effective than psychological treatments. Considering questionable study quality and other limitations in the currently available research, practitioners should not consider acupuncture or related interventions as first-line options—nor should their potential be dismissed altogether.
Hypnotherapy
Conclusive research findings regarding hypnotherapy as an effective treatment for tobacco dependence are also limited. In 2010, Barnes at al31 reviewed 11 studies comparing hypnotherapy with various alternate methods and found little difference in effectiveness among hypnotherapy, psychological counseling, and rapid smoking therapy. Despite the limitations in these data, however, hypnotherapy may be appropriate for some patients.
CONCLUSION
Tobacco dependence is not the same for any two patients. Just as health care providers do not use the same treatment option for every patient with hypertension or diabetes, treatment for tobacco-dependent patients must also be individualized.
Our professional goal is to care for the health of patients. We clinicians must recommend cessation to our patients who smoke at every encounter—and offer support often. When we miss an opportunity to counsel a patient on the importance of quitting, the patient may interpret our silence as condoning the behavior. Empowering patients with an understanding of the options can contribute to their success—a significant move toward better health.
The authors of Healthy People 2020 hope that 80% of current smokers will have tried to stop smoking by that year. Have 80% of your patients been counseled and offered assistance to stop?
REFERENCES
1. CDC. Current cigarette smoking prevalence among working adults—United States, 2004-2010. MMWR Morb Mortal Wkly Rep. 2011;60(38):1305-1309.
2. CDC. Vital signs: current cigarette smoking among adults aged ≥ 18 years—United States, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(35):1135-1140.
3. Jamal A, Dube SR, Malarcher AM, et al; CDC. Tobacco use screening and counseling during physician office visits among adults—National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005-2009. MMWR Morb Mortal Wkly Rep. 2012;61 suppl: 38-45.
4. US Department of Health and Human Services. Healthy People 2020 summary of objectives: tobacco use. http://healthypeople.gov/2020/topicsobjectives2020/pdfs/TobaccoUse.pdf. Accessed October 18, 2012.
5. US Department of Health and Human Services. Healthy People 2010 archives. www.healthypeople.gov/2010. Accessed October 18, 2012.
6. Blumenthal DS. Barriers to the provision of smoking cessation services reported by clinicians in underserved communities. J Am Board Fam Med. 2007;20(3):272-279.
7. Fiore MC, Jaén CR, Baker TB, et al; Public Health Service, US Department of Health and Human Services. Clinical practice guideline: treating tobacco use and dependence: 2008 update. www.ahrq.gov/clinic/tobacco/treating_tobacco_use08.pdf. Accessed October 18, 2012.
8. Carson KV, Verbiest ME, Crone MR, et al. Training health professionals in smoking cessation. Cochrane Database Syst Rev. 2012 May 16; 5:CD000214.
9. Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. Cochrane Database Syst Rev. 2004;(3):CD000058.
10. Guirguis AB, Ray SM, Zingone MM, et al. Smoking cessation: barriers to success and readiness to change. Tenn Med. 2010;103(9):45-49.
11. Nørregaard J, Tønnesen P, Petersen L. Predictors and reasons for relapse in smoking cessation with nicotine and placebo patches. Prev Med. 1993;22(2):261-271.