Smoking Cessation
Lauren Howell, PharmD
Combined nicotine replacement therapy (CNRT) and varenicline have been well established as first line options for smoking cessation. But which treatment regimen is best after an initial failure to abstain from smoking?
A study published in the May 28, 2024, issue of JAMA attempted to determine what pharmacotherapy may be most effective to fill the gap between those who are interested in quitting and those who are actually able to quit. The results showed that increasing the dose of CNRT or varenicline after an initial cessation failure provided the greatest benefit for patients.
Results
Participants in the trial were initially randomized to either receive CNRT or varenicline at a standard dose. The varenicline group followed a titration schedule of 0.5 mg for days 1 through 3; 0.5 mg twice a day for days 4 to 7; and 1 mg twice a day thereafter. The CNRT treatment consisted of a 21-mg patch plus 2-mg lozenges taken as needed, with a recommendation to use at least 6 a day.
After 6 weeks, individuals who were successful at abstaining from smoking continued the same regimen that they started with but nonabstainers were rerandomized to continue their current medication, increase the dose of their current medication, or switch to the alternate medication for another 6 weeks. The increased varenicline dose was 3 mg total per day and the increased CNRT dose was 42 mg from patches (2 patches instead of 1) plus the 2-mg lozenges, as in phase 1.
For those who had not abstained while receiving CNRT during the first 6 weeks, end of treatment abstinence probabilities at week 12 were 14% among those whose CNRT dose had been increased, 14% among those who had been switched to varenicline, and 8% among those who continued at the initial CNRT dose. For those who had not abstained during the first 6 weeks of the trial while taking varenicline, end of treatment abstinence probabilities were 0% among those who were switched to CNRT, 20% among those who increased their varenicline dose, and 3% among those who continued their initial varenicline dose.
For the individuals who were originally taking varenicline, increasing the dose led to the greatest benefit. For those who were originally receiving CNRT, the benefit was similar for both those that increased their dose and those that switched to varenicline.
One of the limitations of this study was that only 2-mg lozenges were used in the CNRT group. For people who smoke more heavily, 4-mg lozenges are available and could have proven to be more effective. Only the lower dose was used in this study to simplify the dosing strategy.
Researchers concluded that a study investigating the long-term benefits of these treatment strategies would add more insight into the results of the study. Additionally, they added, follow-up trials with more rescue therapy alternatives and treatment strategies, such as bupropion therapy, may be beneficial to help paint a full picture of the most effective smoking cessation strategies.
Application to pharmacy practice
Currently, only 4.7% of individuals who attempt to stop smoking receive evidence-based counseling and pharmacotherapy.
Pharmacists are uniquely positioned to change this statistic by asking patients about their smoking history, assessing readiness to quit, and making recommendations.
Most patients visit their pharmacy more often than their primary care office, allowing pharmacists to perform regular follow up and recommend changes to therapy as needed.
With many dosage forms of nicotine replacement therapy available over the counter, pharmacy staff can be trained to be aware of patients purchasing these products and make recommendations accordingly. ■