Non-Pharmacological & Pharmacological Therapies in Tobacco Cessation

FDA-BW.jpg While smoking rates are at an all-time low in the United States, the need to assist those who do still smoke is of vital importance.

In a plenary on evidence-based strategies for tobacco cessation held at the 2018 CHEST Annual Meeting in San Antonio, TX, a holistic approach that includes both pharmacological and non-pharmacological treatment paths, including medications and psycotherapies, was presented by investigators from Brooke Army Medical Center, showing evidence for multidimensional tobacco cessation strategies.

Tyson Sjulin, DO, MAJ, MC, led the panel. His points focused on the burden of nicotine dependence, which bears a heavier weight in individuals with lower incomes, mental illnesses, and substance abuse.

Sjulin then delved into 3 of the different medications available to treat tobacco cessation—nicotine replacement therapy (NRT) (17%-21% efficacy), bupropion (22%-40%), and varenicline (23%-44%). Typical side effects associated with each medication were also mentioned (skin insomnia with NRT, weight gain and depression with bupropion, and nausea and insomnia with varenicline).

In an open question he then answered for the audience, Sjulin revealed that combination NRT treatment has the highest cessation rate at 6 months (31.5%) compared to single NRT (17.7%), bupropion (19.1%), and varenicline (27.6%).

Mentioned studies only further supported his claim for combination therapies’ possible superiority. One study from the randomized clinical trial (“Efficacy of Varenicline combined with Nicotine Replacement Therapy versus Varenicline Alone for smoking Cessation”) demonstrated that varenicline in combination with the NRT patch had greater efficacy than varenicline alone at 12 and 24 weeks (55% versus 40%).

Other studies touched on also showed patients with cardiovascular disease and psychiatric disorders are not limited with treatment options as no treatments need to be avoided.

Moving into the mysterious landscape of electronic nicotine delivery devices (e-cigarettes), Jackie A. Hayes, MD, FCCP, addressed the rumored risks and benefits of e-cigarettes by highlighting the latest evidence (or lack thereof) regarding the efficacy of e-cigarettes in tobacco cessation.

As smokers and former smokers compose the majority (about 50%) of e-cigarette users, Hayes turned to the importance of uncovering e-cigs health benefits compared to combustible cigarettes. Upon comparing several studies from both the US and UK that showed conflicting data at instances, he concluded there is still a significant lack of research on e-cigarettes to determine their safety profile, harms, and benefits as a healthier alternative to combustible cigarettes and as a means for tobacco cessation.

Hayes also added that he would not advise his own patients to try e-cigarettes as a means for tobacco cessation due to the lack of data from cohort studies that lack definitive findings. He stated that long term studies will be needed to determine the nature of e-cigarettes; however, those studies will not be available for a number of years.

Winding down the presentation, Michael Chatterton, PsyD, a clinical health psychologist, touched on the non-pharmacological treatment options available for tobacco cessation—primarily, psychotherapies.

He started with motivational interviewing first, which was found to results in abstinence at 12-month follow 5.2 times more than anti-smoking advice. Motivational interviewing encourages individuals to address and resolve the discrepancy between their current behavior and overall values by focusing on overcoming ambivalence and facilitating behavior change.

Cognitive behavioral therapy (CBT), a structured psychotherapy aimed at solving problems with modifications in dysfunctional and unhelpful thinking behaviors and patterns, has also shown benefits for tobacco cessation efforts. Compared to a control group, CBT self-help programs significantly reduced smoking.

Acceptance and commitment therapy (ACT) also demonstrated even higher abstinence rates at 12-month follow-ups compared to CBT. By utilizing acceptance, mindfulness, and commitment to living according to one’s values, ACT enhances psychological flexibility.

Chatterton closed with mindfulness meditation, or the taking of time to be aware or conscious of something without needing to change it. This act allows individuals to process experiences and manage expectations; Chatterton compared the greater abstinence rates observed with mindfulness meditation to other programs like the American Lung Associations (ALA’s) Freedom from Smoking program (31% versus 6%).

Together, Sjulin , Hayes, and Chatterton discussed how both pharmacological and non-pharmacological therapies could assist in tobacco cessation. Their presented ideas only further reflect circulating ideas and opinions on tobacco cessation combination approaches that include elements of psychological care and medications, like those of Albert Rizzo, MD, pulmonologist and senior medical advisor at the ALA.

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