Nicotine addiction is a complex, chronic condition with physiological and psychological/behavioural aspects that make smoking cessation extremely difficult. This paper reviews current recommendations for smoking cessation and the efficacy of pharmacotherapy and behavioural modification techniques, used either alone or in combination, for smoking cessation.
Abstinence rates for pharmacotherapies range from approximately 16% to approximately 30% at 1-year follow-up, with efficacy odds ratios (ORs) compared with placebo of approximately 1.7 for nicotine replacement therapy (NRT), approximately 1.9 for bupropion sustained release and approximately 3.0 for varenicline. Behaviour modification therapies have achieved quit rates of between 8% and 43% for up to 1 year, with ORs in comparison to no treatment of between approximately 1.2 and approximately 2.2. No direct comparisons have been made between pharmacotherapy alone and psychological behaviour strategies alone. However, combining physiological approaches with counselling significantly increases the odds of quitting compared with either technique alone.
Applying multimodal techniques for the treatment of nicotine addiction is the recommended approach and has demonstrated the potential to improve rates of permanent abstinence in smokers attempting cessation. While the numbers of patients receiving help and advice regarding smoking cessation is increasing, the multimodal approach appears to be currently underutilised by clinicians and therefore smoking cessation strategies are not being optimised.
"Among agonist treatments, dronabinol seems most analogous to nicotine replacement, in that it provides the primary pharmacologically active plant compound, delivered with slow pharmacokinetics--slow absorption compared to the spike in nicotine or THC blood level after smoking, and the ability to sustain a steady blood level, opposing withdrawal. Nicotine replacement has only a modest effect size for sustaining abstinence in nicotine dependence, but its effect can be augmented by combination with other medications, such as bupropion (Shah et al., 2008) or behavioral treatments (Reus and Smith, 2008). This suggests that future studies should test combinations of dronabinol with other treatments with complementary mechanisms. "
[Show abstract][Hide abstract] ABSTRACT: Cannabis dependence is a substantial public health problem. Behavioral treatments have shown promise, but there are no effective medications for cannabis dependence. The purpose of this study was to evaluate the safety and efficacy of dronabinol, a synthetic form of delta-9-tetrahydrocannabinol, a naturally occurring pharmacologically active component of marijuana, in treating cannabis dependence. 156 cannabis-dependent adults were enrolled in a randomized, double-blind, placebo-controlled, 12-week trial. After a 1-week placebo lead-in phase, participants were randomized to receive dronabinol 20mg twice a day or placebo. Doses were maintained until the end of week 8 and then tapered off over 2 weeks. All participants received weekly motivational enhancement and relapse prevention therapy. Marijuana use was assessed using the timeline follow back method. There was no significant difference between treatment groups in the proportion of participants who achieved 2 weeks of abstinence at the end of the maintenance phase (dronabinol: 17.7%; placebo: 15.6%). Although both groups showed a reduction in marijuana use over time, there were no differences between the groups. Treatment retention was significantly higher at the end of the maintenance phase on dronabinol (77%), compared to placebo (61%) (P=.02), and withdrawal symptoms were significantly lower on dronabinol than placebo (P=.02). This is the first trial using an agonist substitution strategy for treatment of cannabis dependence. Dronabinol showed promise, it was well-tolerated, and improved treatment retention and withdrawal symptoms. Future trials might test higher doses, combinations of dronabinol with other medications with complementary mechanisms, or with more potent behavioral interventions.
Drug and alcohol dependence 02/2011; 116(1-3):142-50. DOI:10.1016/j.drugalcdep.2010.12.010 · 3.42 Impact Factor
"In contrast, the bupropion HCl-treated group showed areas of greater metabolic decreases than the PGC-treated group in several areas including the left amygdala and anterior cingulate cortex, a region we have previously shown to exhibit attenuated cigarette cue-induced activation following bupropion HCl treatment in heavy smokers (Brody et al, 2004). The difference between these active treatments, combined with increased effects at the shared sites (such as the posterior cingulate), may account for the increased efficacy of combined treatment with bupropion HCl and PGC (Reus and Smith, 2008). Owing to the relaxed threshold we used in this comparison (pp0.001, "
[Show abstract][Hide abstract] ABSTRACT: While bupropion HCl and practical group counseling (PGC) are commonly used treatments for tobacco dependence, the effects of these treatments on brain function are not well established. For this study, 54 tobacco-dependent cigarette smokers underwent resting (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning before and after 8 weeks of treatment with bupropion HCl, PGC, or pill placebo. Using Statistical Parametric Mapping (SPM 2), changes in cerebral glucose metabolism from before to after treatment were compared between treatment groups and correlations were determined between amount of daily cigarette usage and cerebral glucose metabolism. Compared with placebo, the two active treatments (bupropion HCl and PGC) had reductions in glucose metabolism in the posterior cingulate gyrus. Further analysis suggested that PGC had a greater effect than bupropion HCl on glucose metabolism in this region. We also found positive correlations between daily cigarette use and glucose metabolism in the left occipital gyrus and parietal-temporal junction. There were no significant negative correlations between daily cigarette use and glucose metabolism. Our findings suggest that bupropion HCl and PGC reduce neural activity much as the performance of a goal-oriented task does in the default mode network of the brain, including the posterior cingulate gyrus. Thus, this study supports the theory that active treatments for tobacco dependence move the brain into a more goal-oriented state.
Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology 10/2009; 35(3):605-12. DOI:10.1038/npp.2009.165 · 7.05 Impact Factor
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