The partial agonist varenicline (Chantix, Pfizer), which is commonly used as a smoking cessation treatment, may also be effective in treating cocaine dependence, new research suggests. In a small, randomized study of 37 cocaine-dependent adults, those treated with varenicline experienced significantly lower levels of reward effect from cocaine compared w their counterparts treated with placebo.

Participants receiving varenicline also had lower odds of cocaine use, which was the study’s primary outcome measure, but this finding was not statistically significant.

“Because it’s a small-scale study, it was underpowered. But the fact that we did see these effects with such low power suggests that there might really be something there,” lead author Jennifer G. Plebani, PhD, research assistant professor in the Department of Psychiatry and director of the Human Behavior and Pharmacology Laboratory in the Treatment Research Center at the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Medscape Medical News.

Dr. Plebani noted that there are currently no established, proven medications for treating cocaine dependence.

“We have medications for treating opiate or alcohol dependence but nothing for this condition. So we’re cautiously optimistic. Anytime we have an additional tool that might help some patients, it’s worth considering” she said.

“I would tell clinicians that if they have someone who is cocaine dependent, and they are not responding to the treatment options that are currently available, it might be worth thinking about using varenicline. And I would recommend using it in combination with psychotherapy.”

The study is published in the February issue of Drug and Alcohol Dependence.

Cardiovascular, Neuropsychiatric Concerns

A recent meta-analysis published in the Canadian Medical Association Journal in July 2011 and reported at the time by heartwire, a sister publication of Medscape Medical News, raised concerns about varenicline and cardiovascular risk.

Researchers from Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. told heartwire at the time that the results highlighted “how dangerous this drug is” and that it only offers “a very modest benefit.”

On the other hand, another investigator who has conducted research with the medication, Taylor Hays, MD, from the Mayo Clinic, wrote in an accompanying editorial that “the small absolute risk of cardiovascular events associated with varenicline treatment is outweighed by the enormous benefit for reducing cardiovascular morbidity and mortality that can be achieved with successful smoking abstinence.”

In addition, a study published in PLoS One in November 2011, investigators from Wake Forest also reported that varenicline was associated with a significantly increased risk for suicidal behavior and depression compared with other smoking cessation medications.

This was in marked contrast to a review by the US Food and Drug Administration (FDA) published the month before that examined 2 epidemiological studies that showed no differences in risk for neuropsychiatric adverse events between varenicline and nicotine replacement therapy.

However, the FDA also reported that these studies had a number of limitations and that clinicians should continue following the recommendations listed on the physician label and in the patient medication guide — and to carefully monitor use.

Nevertheless, “based on FDA’s assessment of currently available data, the Agency continues to believe that the drug’s benefits outweigh the risks and the current warnings in the Chantix drug label are appropriate,” the organization noted in a release at the time.

The study was published online on January 10, 2012, in the journal Tobacco Control. The title of the study is “A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation”. And, the study is authored by Hillel R. Alpert and Gregory N. Connolly (both from the Center for Global Tobacco Control, Harvard School of Public Health) and Lois Biener (Center for Survey Research, University of Massachusetts).

The objective of the study by these three researchers was to determine the effectiveness of nicotine replacement therapies (NRTS) – what is commonly called nicotine patches and other such smoking cessation devices such as gum, inhalers, and nasal sprays.

The NRTs were used, within this study, either with or without professional smoking cessation counselors.

The study used 787 adult smokers from the state of Massachusetts who had quit smoking cigarettes within the past two years.

The Massachusetts researchers found that nearly 1 out of 3 participants had relapsed with the use of NRTs.

And, they also found that the chances of relapsing were “unaffected” by whether the participants used professional counseling or not.

By most estimates and polls, the number of teens who light up is on the decline, however, with an average ranging between 12 and 19 percent lighting up by grade 12, a new campaign is aiming to speak their la nguage. University of Michigan’s Llyod Johnston says that “This is very good news for the health and longevity of these young people,” pointing out that a decline of even 1 percent can equal the prevention of thousands of deaths related to smoking.

In an effort to continue the decline, the National Cancer Institute has launched a new initiative, including a special website, and Smartphone application, all with the goal of helping teens quit smoking before they become adults.

Finding the message that will resonate with adolescents isn’t always easy, according to the National Cancer Institute’s, Erik Auguston, as he feels they are not “receptive to messages about diseases they won’t develop for decades.” According to Auguston, often times when teens try to quit, they go at it alone and fail.

Citing that anti-smoking messaging is often speaking to adults, and excludes teens, the NCI’s Smokefree Teen Program has a different approach, with messaging that empower teens, such as “We’re NOT going to tell you what to do.” Other parts of the program include materials that are targeted at teen specific triggers, including mood, social life, and peer pressure.

The NCI will also speak their language by including social media and text messaging, where teens can turn to others for support and motivational messaging. The Smokefree T-X-T program offers 24 hour encouragement, advice, tips, all through texts and social media. Once they sign up, they pick an expected quit date, and supportive text messages are also sent for up to 6 weeks, providing further support and motivation.

USA Today reports that behavioral scientist Alexander Prokhorov feels the new program is a “gigantic step in the right direction.” Prokhorov has also developed a website that utilizes messages such about smoking staining teeth, creating bad breath, and being harmful to the environment.

We would like to know what you think about the National Cancer Institute’s new initiative to communicate directly with teens? In your mind is teen smoking still a big problem, or are you more concerned about other drug use?

Smokers who suffer a stroke that causes a lesion at the insular cortex are more than 5 times more likely to stop their nicotine habit than those whose stroke did not result in such a lesion, according to a new study. In addition, the researchers found that preparedness to change also influenced successful smoking cessation poststroke.

The study results were not surprising, given that research has already shown that biological and psychological factors help explain smoking cessation in patients with stroke, said the study’s lead author, Rosa Suňer Soler, PhD, from the Neurology Department, Josep Trueta Hospital, Girona, Spain.

Biologically, the insular cortex may play an important role in emotional decision-making, and in terms of psychology, smoking behavior may be explained by stages, processes, and levels of change, Dr. Suňer told Medscape Medical News. “Before you stop smoking, you must be aware that you have a problem and take the decision to stop smoking.”
The analysis included 110 patients who were smokers when they suffered an acute stroke and were admitted to a stroke unit between January 2005 and July 2007. Researchers recorded sociodemographic and other variables, as well as information on smoking, including number of cigarettes smoked per day and level of nicotine dependence. In addition, they categorized patients according to their stage of preparedness to quit smoking before the stroke: precontemplation, contemplation, preparation, action (stopped smoking for less than 6 months), or maintenance (smoke-free for at least 6 months)

From computed tomography or magnetic resonance imaging scans, investigators classified lesions affecting the insular cortex by hemisphere (right or left side) and subtype (ischemic or hemorrhagic) and measured the volume of the cerebral infarct or hemorrhage.

Patients were evaluated at 3, 6, and 12 months after the stroke. Smoking abstinence was confirmed by recording expired carbon monoxide levels. Patients also assessed their difficulty in giving up smoking and their urge to restart the habit.

Patients smoked on average 27.6 cigarettes per day, had a mean score of 6.1 points in the Fagerström Test of nicotine dependence, and had started smoking at a mean age of 17.1 years. Of the sample, 85.5% said that before the stroke, they were not considering stopping smoking in the near future.

In 24.5% of the patients, the stroke-related lesion affected the insular cortex. At discharge, 69.1% of patients indicated they had given up smoking during hospitalization, including 88.9% of the patients with an insular cortex lesion and 62.7% of those without (P = .05).

At 1 year, 70.4% of participants with insular cortex lesions had stopped compared with 30.1% of those without (P < .001).

Having a lesion at the insular cortex was associated with significantly increased odds of quitting smoking (odds ratio, 5.42; 95% confidence interval, 1.95 – 15.01; P = .001).

According to Dr. Suňer, the insular cortex may regulate the experience of conscious urges and cravings with other specific brain areas. Disruption of hypocretin transmission in the insular cortex may also help explain decreased tobacco consumption in smokers with damage to this brain region, she added.

Having the intention to stop smoking before the stroke also increased the odds of successfully quitting the habit (odds ratio, 7.29; 95% confidence interval, 1.89 – 28.07; P = .004). In addition, patients who stopped smoking had a lessened perception of difficulty in stopping smoking.

“Considering our results, we must adjust therapeutic interventions to stages of change in patients” and help them to quit if they have raised a concern about smoking, said Dr. Suňer. She suggested that physicians systematically ask patients who smoke what stage they are at in terms of quitting.

Smoking Dangers

The study also showed that only a third of the patients associated stroke with their smoking habit. “It shows how little knowledge people have of the true dangers of smoking,” said Dr. Suňer. “We explain to our acute stroke patients the risk factors and the importance of prevention, but there must also be more information campaigns among the general population.”

As well as emphasizing this lack of awareness that smoking is a stroke risk factor, the study also highlights the fact that willingness and consideration to stop the habit before the stroke help patients quit afterward, said Joseph Broderick, MD, chair of neurology, University of Cincinnati, Ohio, and a member of the American Academy of Neurology, when asked to comment.

“It is also remarkable that despite a life-changing event such as a stroke, so many patients continue to smoke,” Dr. Broderick told Medscape Medical News.

Dr. Broderick questioned whether language disruption, which often accompanies insular damage in the dominant hemisphere, plays a role in smoking cessation.

“The volume of brain injury was similar for the smokers and those who successfully stopped,” he noted. “I wonder whether language impairment per se could be associated with increased likelihood of stoppage, rather than an effect upon emotional and reward processing in the brain.”

The U.S. Naval Hospital Okinawa’s Health Promotion Department, in conjunction with the Occupational Health Clinic, provides a tobacco cessation program to assist service members and their families with their battle against nicotine addiction. The program provides classes every Tuesday morning at the hospital for those who are interested in decreasing their tobacco intake or would like to quit, said Joanne Haynes, a health promotions specialist with the hospital.

The program is important because tobacco use is the number one preventable cause of premature deaths among Americans, said Haynes.

According to the Center for Disease Control and Prevention, about 45.3 million people currently smoke cigarettes, and approximately 443,000 deaths occur annually due to cigarette smoking.

“This is where the tobacco cessation program comes in,” said Shirley Beasley-Posey, a wellness educator with Marine Corps Community Services’ health promotion office. “The program aims to provide the service member with information and a plan on how to become, and remain, successfully tobacco free.”

Individuals may use tobacco products as social habits or coping mechanisms to deal with certain stressors or problematic situations in life.

“Nicotine is an extremely addictive substance, making addiction the number one reason why people smoke,” said Beasley-Posey. “Smoking can also be a social habit. When others around you are smoking, you may feel like you should be doing the same. This feeling is known as peer pressure. Most people have a natural tendency to conform, which is an additional reason why people may decide to begin smoking.”

Tobacco use affects service members’ performance because it decreases stamina, conditioning, motor controls, lung capacity and night vision. Tobacco users are also at an increased risk for injuries and slower healing times, which can affect personal and unit readiness.

The tobacco cessation class offers the user information about the harmful effects of tobacco use and methods available to break the addiction. The class works with behavior modification and assists individuals in obtaining any needed medications, patches or gum that they may need to help break their habit.

“This program can benefit service members because we make it easy and convenient by offering walk-in appointments,” said Haynes. “We assist them in every aspect of breaking the addiction.
This program also assists members with the depression and irritability that nicotine withdrawal can often times bring on.”

The program is available as a class or in individual sessions; however, preregistration is recommended for those looking to attend the class.

“We are very flexible in where we offer our classes,” said Beasley-Posey. “We can travel to them, or they are free to come to our location on Camp Foster. We have even held classes in the barracks.”

The third Thursday in November has been designated as The Great American Smokeout Day by the American Cancer Society to encourage users to at least quit for a day, said Haynes. There will be an event held on Camp Lester for the Great American Smokeout for all status of forces agreement personnel Nov. 18.

For more information on tobacco cessation or the Great American Smokeout event, contact U.S. Naval Hospital Okinawa’s Health Promotion Department at 643-7906 or walk into any Occupational Health Clinic.

Practice administrator Glenn Jennings, M.B.A., lost both his parents to smoking-related illnesses and his father-in-law to lung cancer, so he and his wife, family physician Carrie Burns, M.D., already were advocates of not smoking well before their Baytown, Texas, practice participated in the AAFP’s Office Champions Tobacco Cessation Pilot Project.

“What the project did was raise our level of awareness in our office, give us some tools and make us do some thinking about how we could be more effective,” said Jennings, who served as the practice’s office champion. “We became more effective as an office in identifying people who needed to quit smoking and adding new procedures.”

Jennings’ experience with the pilot is far from unique. Forty-nine participating practices were asked to review patient charts before and after the 13-month pilot, which was based largely on the AAFP’s evidence-based Ask and Act program. The percentage of patient charts with documentation of tobacco use status increased from 82.1 percent to 90.2 percent during that period, while the percentage of charts with documentation that patients were offered cessation assistance increased from 47.8 percent to 72.1 percent.

Each practice was required to name an office champion to lead the project and a physician champion to ensure that the office champion had the support of staff. The office champions were required to complete a training program, identify and implement system changes to better integrate tobacco cessation activities into daily office routines, and create a culture that encourages cessation.

According to the pilot’s final report (19-page PDF; About PDFs), practices successfully implemented 85 percent of the changes identified in their implementation plans, and 98 percent of practices expressed confidence that the changes they did make could be sustained.

Many of the changes were based on a practice toolkit provided by the AAFP that includes the following resources:
quit-smoking posters;
a smoking cessation group visits guide;
billing and coding information for smoking cessation-related services;
patient education materials;
lapel pins; and
“prescription pads” that list helpful information for patients before, during and after they quit smoking.
Jennings said Burns’ office had patient education materials and quitline cards in the waiting room and every exam room. In addition, medical assistants reviewed a stop-smoking booklet with patients and gave copies to patients who indicated they were ready to quit. The medical assistants followed up with those patients a week after their appointments to check their progress.

A quitter is defined by Merriam-Webster dictionary as one who gives up too easily. Sometimes quitting isn’t as easy as it seems. Sometimes quitting isn’t always a negative thing. Army Staff Sgt. Latasha Wade, Headquarters and Headquarters Company, 3rd Maneuver Enhancement Brigade, knows how difficult it can be to quit. Quit smoking, that is. “I smoked for 16 years,” Wade said. “I quit smoking when I met my husband. At that time he had been cigarette free for two years and he didn’t want to relapse being around a smoker. So I quit smoking five months after we started dating.”

Wade quit gradually.

“I was hiding it from my husband while we were dating and eventually I got tired of hiding it and I quit,” Wade said. “The advice I would give someone who wants to quit smoking would be to find something to motivate them to quit. Be it for health reasons, saving money or their significant other.”

Among current U.S. adult smokers, 70 percent report that they want to quit completely, and millions have attempted to quit smoking, according to the Centers for Disease Control and Prevention.

“I consistently smoked for 10 years,” Army Staff Sgt. Kevin Hoffman of the 98th Maintenance Company said. “I thought, this isn’t helping me any, and I had a new son. It was also getting expensive anyways, so I quit. It took about six months.”

His first attempt to stop smoking cold turkey failed, so he took another approach and quit gradually.

“I started smoking again for a couple weeks and I was like, ‘naw, this is just wrong.’ So then I just started slowly stopping and then one day I just threw the pack of cigarettes I had left away and I refused to smoke from then on.”

Hoffman said the reasons to quit go beyond your own health.

“You need to quit for the people that you love if not for yourself,” he said.

Here on Joint Base Elmendorf-Richardson, for Soldiers, Airmen, civilians and family members who would like to quit using tobacco products, the opportunity to quit is locally available.

A great way to start is to attend a tobacco cessation class.

“If they are ready to quit smoking today, what we normally do is invite them to attend the class,” said Janice Fulton, a health educator, at the JBER Health and Wellness Center, or HAWC. “The research over time has shown that on doing tobacco cessation in a group setting with that kind of support just increases your chances for success.

“If you’re determined to absolutely, positively quit today, we will definitely sit down and talk with you. If you want to do medications, then we’ll refer you to one of the providers involved with the tobacco cessation program who are able to prescribe the tobacco cessation medications.”

“Sometimes the folks that attend the class bring a family member like a spouse who’s going to be their support system in their cessation efforts, so they’re perfectly welcome to come to the class also and hear the information,” Fulton said.

There needs to be an environment of support for people trying to quit, according to Rebecca Kleinschmidt, a Health Educator, who also works at the HAWC.

“If the environment they’re in doesn’t support those changes, it’s really difficult for people to stay tobacco free. There are a lot of different stages in the progress of change. Action is one of those, but if people are in the preparation stage and their not quite ready to change, but they’re thinking about it, they’re very welcome here. They don’t have to be actively quitting smoking in order to participate in our class.

“We get people who really need to build their confidence before they jump into trying to reduce or quit. This is a good place to learn some skills on how to build their confidence, how to set reasonable goals and learn tricks that will make them feel more powerful in this fight against tobacco.”

It’s normal for many tobacco users to try quitting several times before succeeding, according to Fulton.

“That’s typical,” Fulton said. “Most people will tell you they’ve tried 8-11 times before they finally quit and that’s ok. They can come back as often as they need to. That’s OK.

Kleinschmidt feels there is a decrease in smoking during the winter months.

“I think people, around the holidays and New Year’s, reflect upon changes that they want in their lives,” Kleinschmidt said. “In addition, because of policy changes and environmental changes, it’s more common that people have to smoke outside and in the cold winter months here, that’s sort of a barrier to people. So when they have to smoke outside when it’s so cold, it’s sort of a reminder too: ‘Do I really want to be doing this? Is this really worth it?’”

Smokeless tobacco is also addressed at the three-day class.

“Since I’ve been involved in the smoking cessation program I’ve seen an increase in smokeless tobacco use,” Fulton said. “There are a lot of folks who use both, smoke and use smokeless tobacco, and have a tendency to use smokeless tobacco when the weather prohibits them from going outside. We’ve seen those rates increasing over time.”

The first day of class covers methods of quitting, including pharmacotherapy. A medical staff member spends time with each participant talking about what medication they want to use, if any, and making sure there are no contraindications present.

The second day covers triggers of use, normal withdrawal symptoms, both physical and psychological, and addresses any issues the participants have experienced since the first class. This day also includes nutrition counseling. The HAWC dieticians address weight gain issues after tobacco.

Day three addresses stress management and techniques for dealing with daily stressors without resorting to tobacco use and relapse prevention.

“The training is not restricted to tobacco or nutrition,” Fulton said. “We can do other things like cold weather injury prevention, infectious disease, STDs or other health related training.

The HAWC can take that training to any unit, Army or Air Force, on JBER, according to Fulton.

“Our primary objective is to provide primary prevention, which is to help people with small lifestyle changes that reduce the risk of illness or disease,” Kleinschmidt said. “We also provide secondary prevention, which is for people who weren’t diagnosed with an illness or a disease, but their symptoms can be managed with lifestyle changes. For example, the diabetic patient can be given nutritional advice and be given help on becoming more active and they can really control their insulin levels and control their symptoms ultimately with lifestyle changes.

Tobacco cessation is just one area of emphasis for the HAWC. The center can build preventive health training programs for units on nutrition, fitness, cholesterol reduction, STD awareness and other issues upon request.

“We mainly go by what people want and what people need, but the top two causes of unintentional or preventable death are tobacco use and overweight due to poor nutrition and inactivity,” Kleinschmidt said. “Those are the two major things we focus on. So many people needlessly die because of those two issues that are lifestyle based.”

Add Ralph Semple to the list of critics of B.C.’s plan to fund therapy for smokers. The president of South Surrey-based Imagine Laserworks said the government will spend $15-$25 million per year – based on its own estimates – on drugs he claims are not only ineffective, but also pose documented health risks to the public. And he says he is taking his concerns to NDP health critic Mike Farnworth.

“His office is very keen to talk to us,” Semple said.

Imagine, which has operated locally for the last decade, offers laser acupuncture treatments to help clients stop smoking. But Semple said the B.C. smoking cessation program, set to start Sept. 30, ignores alternative therapies to focus exclusively on pharmaceuticals such as nicotine gum and patches, or prescription pills.

“It’s not just about us,” he said. “What about acupuncture, or all the hypnotherapists’ offices or counselling? Why is this focused on supporting one industry? The BC Liberal website says they support small business, but in reality they’re supporting the pharmaceutical industry.”

The Ministry of Health, however, maintains that its drug coverage decisions are the result of a “rigorous” review process.

In a statement, ministry spokesperson Brian Cotton said the process “considers clinical evidence, cost effectiveness, input from clinical experts, information from other jurisdictions, available resources and existing programs and policies.”

Semple said he tried to have Imagine’s services included among government-covered therapies after the program was announced in May.

“I got the basic runaround,” he said. “They reported back to me that Health Canada doesn’t recognize laser acupuncture as a therapy.”

But Cotton said additional evidence is required on the “efficacy, safety and cost-effectiveness” of laser acupuncture before it could be considered under the program. He noted that PharmaCare would not cover it in any case, as it’s not classed as a prescription drug or a medical supply.

“The ministry is pleased to continue discussions with the laser therapists, should additional evidence… become available,” he said.

Semple’s attack on the smoking-cessation program also extends to specific prescription drugs that will be covered under B.C.’s plan, including one that has been the subject of Health Canada warnings and another that is the subject of numerous class-action suits in Canada and the U.S.

“People will assume if the government is paying for it, the government is endorsing it – that it’s good for them,” he said, adding that physicians have been slow to warn patients of potentially fatal side effects of such drugs.

“Is (Premier) Christy Clark’s government going to assume responsibility for class-action lawsuits?”

Cotton said the health ministry is completing a review of drugs that will be covered.

“The final decision will need to measure safety concerns against clinical evidence that shows the benefit of the drug in patients trying to quit smoking,” he said.

In addition to safety issues, Semple said the government’s decision to fund over-the-counter nicotine- replacement therapies ignores studies that show they have a success rate of less than eight per cent.

“It’s like telling an alcoholic, ‘if you want to quit drinking, switch from Scotch to Vodka’,” said Semple, who claims Imagine’s success rate is between 85 and 94 per cent.

In business for 13 years, Semple says his criticism is not simply sour grapes for having his therapy passed over for government support.

“People come to us as a last resort anyway… because the other things don’t work,” he said.

A free clinic aims to help smokers kick the habit. Via Christi Pulmonary Rehabilitation is hosting a free information session as they prepare to present the American Lung Association’s “Freedom From Smoking” program. The clinic will offer a wide range of strategies to quit smoking including: Lectures, group discussion, skills and practice.

Patients will receive the latest nicotine replacement therapy, smoking cessation medications, and learn tips to stay tobacco free.

The clinic will be held at Via Christi Hospital on St. Francis, 929 N. St. Francis, Monday, August 29. It will take place in conference room “C,” on the second floor. The program starts at 6 p.m.