Clinical Strategies to Enhance the Efficacy of Nicotine Replacement Therapy for Smoking Cessation: A Review of the Literature

Abstract

A number of smoking cessation pharmacotherapies have led to increases in quitting and thus to significant benefits to public health. Among existing medications, nicotine replacement therapy (NRT) has been available the longest, has the largest literature base in support, and is the only option for over-the-counter access. While the short term efficacy of NRT is well documented in clinical trials, long term abstinence rates associated with using NRT are modest, as most smokers will relapse. This literature review examines emerging clinical strategies to improve NRT efficacy. After an initial overview of NRT and its FDA-approved indications for use, we review randomized trials in which clinical delivery of NRT was manipulated and tested, in an attempt to enhance efficacy, through a) duration of use (pre-quit and extended use), b) amount of use (high dose and combination NRT), c) tailoring to specific smoker groups (genotype and phenotype), or d) use of NRT for novel purposes (relapse prevention, temporary abstinence, cessation induction). Outcomes vary within and across topic area, and we highlight areas that offer stronger promise. Combination NRT likely represents the most promising strategy moving forward; other clinical strategies offer conflicting evidence but deserve further testing (pre-quit NRT or tailored treatment), or offer potential utility but are in need of further, direct tests. Some areas, though based on a limited set of studies, do not offer great promise (high dose and extended treatment NRT). We conclude with a brief discussion of emergent NRT products (e.g., oral nicotine spray, among others), which may ultimately offer greater efficacy than current formulations. In order to further lower the prevalence of smoking, novel strategies designed to optimize NRT efficacy are needed.

Outcomes of a Tailored Intervention for Cigarette Smoking Cessation Among Latinos Living With HIV/AIDS

“…[16][17][18][19] Despite high levels of interest in quitting, 11 only a small proportion of PLWH smokers who participate in clinical trials that include nicotine replacement therapy (NRT) sustain abstinence at 6 months, 20 compared to 20%-30% quit rates seen with similar treatments in the general population of smokers. 21 To date, only two adequately powered smoking cessation trials have been conducted with PLWH smokers, and abstinence outcomes at 6 months have not exceeded 12%. 20,22 An exception is a recent 3-arm study comparing intensive individual counseling, static web-based tobacco treatment, and a minimal contact control that reported high 3-month quit rates in all three conditions (26%, 29%, and 24%, respectively) with no significant between-group differences.…”

Nicotine Replacement Therapy

“…Evidence supporting the role of nicotine replacement therapy in adolescent and pregnant smokers is sparse, and different countries have conflicting recommendations on its use (8). Studies comparing nicotine replacement therapy regimens beginning 2 or 4 weeks before a quit attempt with therapy beginning at smoking cessation yield conflicting results and deserve further research (8,19). Extended duration or maintenance treatment and high-dose nicotine replacement therapy (e.g., 42 mg daily transdermal vs. 21 mg daily transdermal) applied to study populations have only weak evidence of benefit (8).…”

“…Despite efficacy of treatment, up to two-thirds of smokers attempting to quit do not use any evidence-based treatment (8). Psychiatrists have the under-recognized opportunity and obligation to provide patients lifesaving and life-improving treatments for tobacco use disorder that are safe, effective, affordable, and often well received.…”

Alternative Sampling Strategies for Cytochrome P450 Phenotyping

“…The role of nicotine metabolites and corresponding metabolic ratios in various matrices, including oral fluid, as biomarkers of exposure to tobacco smoke, smoking cessation or to guide treatment of nicotine dependence has been thoroughly explored, as indicated in several studies and recent review papers [105][106][107][108][109][110]. Here, we will discuss studies that specifically evaluated the usefulness of nicotine metabolic ratios in oral fluid for CYP2A6 phenotyping.…”