47 96
Clinical
Consultation Guide
Tobacco
Cessation:
A
Guide
for
Clinicians
Laura
Brandt
a , * ,Gabriele
Fischer
ba
Medical University
of
Vienna,
Center
for
Public Health,
Vienna,
Austria;
b
Medical University
of
Vienna, Department
of
Psychiatry
and
Psychotherapy
and
Center
for
Public Health,
Vienna,
Austria
1.
Introduction
Substance
use
disorders
(SUDs),
including
tobacco
use
disorder
(TUD;
Diagnostic
and
Statistical Manual
of Mental
Disorders
,
fifth
edition
[DSM]
code
305.1),
are
defined
as
chronic
relapsing
disorders
with
underlying
altered
brain
regions
that
control
decision making
and
judgment,
influ-
encedbypolygenetic, environmental, and cultural factors
[1] .About
69%
of
current
smokers
reportedly want
to
quit
smoking,
and
52% make
an
unassisted
quit
attempt,
but
only
6%
successfully
quit
smoking
within
a
given
year
[2]. The vast majority of
smokers making an attempt
to quit
relapse
to smoking, with up
to 76%
relapsing within
the
first
week
[3] .Most patients with SUDs, however, are able
to quit
substance use over
time
[4] .Lifetime dependence
remission
rates
(ie,
successful
cessation)
are
estimated
at
84%
for
nicotine
compared with
91%
for
alcohol,
97%
for
cannabis,
and 99%
for
cocaine
[5]. The nicotine-dependence
time
frame
to
remission
is approximately 26 yr compared with 14 yr
for
alcohol, 6
yr
for
cannabis,
and 5
yr
for
cocaine, highlighting
the
high
addiction
potential
of
nicotine
and
the
difficulty
entailed
in
achieving
long-term
smoking
cessation
[5].
2.
Methods of
smoking cessation: What works well?
Treatment
interventions
for
smoking
cessation
available
in
Europe
are
separated
into
those
that
are
clearly
beneficial
(proven efficacy by
randomized controlled
trials, documen-
ted
in systematic
reviews, and suitable
for most patients) or
likely
to be beneficial
(limited proven efficacy, recommended
only with
caution
or with
limitations
in
guidelines)
[6].
2.1.
Interventions with
proven
efficacy
Nicotine
replacement
therapy
(NRT)
increases
smoking quit
rates
by
50–70%,
independent
of
therapeutic
setting,
NRT
form
(gum,
transdermal
patch,
nasal
spray,
inhaler,
or
sublingual
tablets
or
lozenges),
or
additional
provision
of
support
[7].
Varenicline
is
a
partial
agonist
on
the
nicotinergic
receptor
a
4
b
2
that
aims
to
reduce
both
withdrawal
symptoms and perceived
rewards associated with smoking.
Applying
the
recommended dose of 1 mg
varenicline
twice
daily
produces
a
two-
to
threefold
increase
in
abstinence
rates
(over 6 mo and even
longer
in some studies) compared
with placebo
[8]. Treatment success
rates
range
from 14%
to
47%
compared with
4%
to
23%
in
placebo
groups
at
52-wk
follow-up
[8].
Varenicline
also
has
proven
efficacy
in
patients with
psychiatric
comorbidities
[9].
The
dopaminergic
antidepressant
bupropion has
shown
efficacy
in
increasing
long-term
smoking
cessation equal
to
NRT
[10].
Its
effect
on
smoking
cessation
is
independent
of
the
antidepressant
effect,
and
the
side
effects
seem
acceptable
because
they
rarely
lead
to
treatment
dropout.
Moreover,
the
use
of
bupropion
in
addition
to
NRT might
increase
long-term
beneficial
effects
[10].
A
treatment
success
rate
of
16%
has
been
reported
at
52-wk
follow-up,
compared with 22%
for varenicline and 8%
for placebo
[11] .Notably,
pharmacologic
smoking
cessation
therapy
is
not
fully
reimbursed by health
insurance
in most European
countries despite
its proven
efficacy
and
cost-effectiveness
[12].
Full
reimbursement
of
smoking
cessation
therapy
could
significantly
increase
its
use
and,
subsequently,
the
number
of
successful
quitters
[13–15] .2.2.
Interventions with
limited
efficacy
A
psychosocial
treatment
option
known
as
contingency
management
(CM)
seems
promising
to
promote
smoking
cessation
in
high-risk
populations
such
as
adolescents
or
pregnant women
and
has
low
drop-out
rates
[16,17] .It
is
based
on
principles
of
operant
conditioning
that
offer
E U R O P E A N U R O L O G Y F O C U S 1 ( 2 0 1 5 ) 4 7 – 4 9ava il abl e
at
www.sc iencedirect.comjourna l
homepage:
www.europeanurology.com* Corresponding
author. Medical University
of Vienna,
Center
for
Public Health, Kinderspitalgasse
15,
1090 Vienna, Austria.
Tel.
+43
1
4040035000.
address:
laura.brandt@meduniwien.ac.at(L.
Brandt).
http://dx.doi.org/10.1016/j.euf.2014.10.0042405-4569/
#
2015
European
Association
of Urology.
Published
by
Elsevier
B.V.
All
rights
reserved.