Smoking Cessation
Clarissa Chan, PharmD
A randomized placebo-controlled single-center Finnish study published in JAMA Internal Medicine on June 17, 2024, showed that varenicline and e-cigarettes had similar rates of smoking cessation at 52 weeks. Study participants received 18 mg/mL of nicotine-containing e-cigarettes together with placebo tablets, varenicline with standard dosing together with nicotine-free e-cigarettes, or placebo tablets together with nicotine-free e-cigarettes, all combined with a motivational interview, for 12 weeks.
Results of the study showed that 40.4% of the e-cigarette group achieved 7-day conventional cigarette smoking abstinence as confirmed by the exhaled carbon monoxide level on week 26, compared with 43.8% in the varenicline group, and 19.7% in the placebo group. No serious adverse events were reported.
However, according to David Hill, MD, director of clinical research at Waterbury Pulmonary Associates, who was not part of the study, the researchers used a fixed and relatively low dose of nicotine-containing e-cigarettes compared with what is available in the United States.
He noted that varenicline was as effective as e-cigarettes with a good safety profile and no long-term adverse effects, and that patients who quit with varenicline were no longer nicotine-addicted and could stop medical therapy.
Curbing nicotine addiction is key
Patients who switch to e-cigarettes have ongoing nicotine addiction and risk unknown and potentially significant harmful long-term adverse effects, said Hill, who is also an assistant clinical professor of medicine at Yale University and Quinnipiac University.
Ongoing nicotine dependance is a continued problem with nicotine replacement and many patients are likely to have difficulty stopping their use of a highly addictive, readily available product, Hill said.
“Patients who stop smoking with varenicline are no longer nicotine-addicted whereas those continuing to use e-cigarettes have an ongoing issue,” he said.
Nicotine cessation should be the primary goal as those with continued addiction are at risk to continue using combustion products. A gradual quit method over 3 months has better efficacy in heavier smokers than choosing a set quit date, said Hill.
In addition, the long-term safety of e-cigarette use remains unknown. In the United States, youth and young adult use has become an epidemic, and dual use of e-cigarettes and combustion products is very common, he said.
Varenicline, however, has a good long-term safety profile, and adverse effects, primarily nausea and vivid dreams, can sometimes be mitigated with dose adjustment and do not lead to long-term harm, said Hill.
Smoking cessation is complex
Smoking cessation is difficult and multiple attempts, perhaps using different approaches, may be necessary, said Hill.
Quit rates when patients attempt to stop smoking cold turkey tend to be around 5%. With prescription nicotine replacement, rates can rise as high as 20%. Pharmacologic therapy with varenicline has higher rates of success, nearing 40% depending on the method and the addition of counseling, Hill said.
There are multiple pathways to pursue. “Unregulated addictive e-cigarettes are not a part of my clinical approach,” said Hill. “Varenicline, bupropion, regulated nicotine replacement, and sometimes combinations of oral pharmaceuticals with regulated nicotine replacement along with counseling are my standard methods.”
In addition, behavioral modifications and counseling through motivational interviewing set up patients for success, have additive benefits, and are key to improving cessation when patients are attempting to stop smoking, he continued.
“Although motivational interviews may have benefits, much of the literature suggests that this technique alone is unlikely to achieve success,” said Hill. “If I could achieve a 20% quit rate in my smokers with no pharmacologic intervention, that approach would be my first approach for every patient interested in stopping smoking.” ■