Feb 082012

One-third of smokers try to quit each year, but few stay quit. Even with varenicline (Chantix), the most effective smoking cessation aid to date, only 10% are abstinent at one year.

Anne Joseph, Steven Fu, Dorothy Hatsukami et al wonder if that's partly because our (fee-for-service-driven) intermittent-visit model of patient care and counseling leaves craving smokers in the lurch in between visits.

They gave 443 smokers nicotine replacement and frequent supportive telephone calls for 4 weeks. They then randomized them to get either continued intensive support and nicotine replacement, or the shaft (2 more phone calls).

At 18 months, 30% of those in the high-attention + nicotine group reported abstinence for 6 months, vs. 24% in the standard care group. These rates are surprisingly high in both groups, and some healthy skepticism is advisable, since there was no biochemical verification of abstinence (e.g., urine cotinine).

The intensive-counseling group used almost twice as much nicotine replacement therapy as the standard care group, which alone could explain their higher self-reported success. Still, extra counseling has a good evidence base. For example, U.K. investigators got a substantial number of people to quit just by text-messaging them. And the intensity of physician counseling has also been associated with higher quit rates.

Providing or subsidizing nicotine replacement to those wanting to quit could drastically reduce cigarette smoking, as a pilot study strongly suggested. Faced with such promising data, why has the U.S. government embarked on a bizarre campaign to outlaw e-cigarettes, instead of funding large-scale clinical trials on nicotine replacement for smoking cessation or reduction?

Joseph AM et al. Chronic Disease Management for Tobacco Dependence. Arch Intern Med 2011;171:1894-1900.

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Regular nagging + nicotine better than benign neglect for smoking cessation (RCT, Arch Intern Med)