Smoking Quit Rate Rose With Longer Therapy

BY SHERRY BOSCHERT
Elsevier Global Medical News

SAN FRANCISCO — An intensive smoking-cessation program helped 33% of 202 patients in drug treatment quit smoking, an intent-to-treat analysis found.

A high proportion of patients in treatment for substance use also smoke cigarettes and generally have a hard time quitting, with previous studies suggesting quit rates of 5%-12%, Dr. Milan Khara said at the annual meeting of the American Society of Addiction Medicine.

The study enrolled 252 patients who were in drug treatment programs in 8 weeks of group therapy for smoking cessation plus free pharmacotherapy for smoking cessation during the group therapy and for up to an additional 18 weeks, for a total program length of 26 weeks. Fifty patients who participated for 2 weeks or less were dropped from the analysis, said Dr. Khara of the University of British Columbia, Vancouver.

The overall quit-smoking rate of 33% in the intent-to-treat analysis was exceeded by a quit rate of 43% among 152 patients who completed the program, meaning they had at least 6 weeks of contact with smoking-cessation group counseling, individual counselors, or health care professionals in the program.

Among these completers, the quit rate was 51% in those who attended the 8 weeks of smoking-cessation group therapy and participated in after-care, compared with 18% of completers who only attended the 8 weeks of group therapy, reported Chizimuzo T.C. Okoli, Ph.D., also of the university, who conducted the study with Dr. Khara.

About 80% of people in drug treatment programs smoke tobacco. “We often believe that these patients don’t want to quit smoking,” Dr. Khara said. But other studies have shown that 44%-80% of patients in drug treatment express interest in quitting.

Previous results for smoking-cessation programs during drug treatment range from quit rates of 23% at 1-week followup to 5% at 6-month follow-up, or 12% in a meta-analysis of 18 studies, he noted. “It may be that we need a more intensive approach than an 8- or 10-week program,” Dr. Khara said.

The current study enrolled patients at three sites who were aged 19 years or older, who had a history of a substance use disorder and/or mental illness, and who were financially disadvantaged. A 1-hour intake assessment included measurement of the carbon monoxide content in expiration.

After each of the structured, syllabus-based group therapy sessions, patients had one-on-one assessments with a physician or nurse and received smoking-cessation medication if needed, using one or more of the six first-line medications available in Canada. Clinicians were allowed to consider off-label prescribing, including higher doses, drug combinations, and extended durations of use. In all, 82% of patients received nicotine replacement therapy alone, 6% received oral medication alone, and 12% received both.

Most patients (89%) had a primary substance use disorder, primarily involving alcohol (33%) or cocaine (27%), with 12% dependent on heroin or other opiates, 11% dependent on marijuana, and 6% dependent on methamphetamine or related drugs. Primary mental health disorders in 65% of patients included mood disorders in 45%, anxiety disorder in 14%, and psychotic disorder in 6%.

The 11% of patients diagnosed with mental illness but not substance dependence were less likely to quit smoking than were patients with both disorders or with substance dependence alone. Those patients with lower expiratory carbon monoxide levels at baseline were more likely to complete the program and to quit smoking. Using both nicotine replacement therapy and an oral medication increased the likelihood of completing the program, and attending more of the program sessions increased the odds of quitting.

The study defined smoking cessation as patients reporting having not smoked tobacco in the previous 7 days, confirmed by a carbon monoxide level of less than eight parts per million in expired air.

Patients averaged age 48 years and said they had started smoking at a mean age of 14 years. They smoked an average of 22 cigarettes per day at baseline, with a mean expiration carbon monoxide level of 23 parts per million.

Dr. Khara has received funding from or been a consultant for Pfizer and Johnson & Johnson, which make smoking-cessation medications. Johnson & Johnson and divisions of the Canadian government funded provision of the medications in the study.

Dr. Philip Marcus, MPH, FCCP, comments:
This study shows that even “hardcore” smokers can stop smoking. However, it remains to be seen if the results at 7 days can persist for a longer period of time consistent with sustained abstinence and a better marker of success. This study also reinforces the relationship between substance abuse, mental illness, and cigarette smoking.