Increasing smoking cessation in the United States: Expanding the availability of over-the-counter medications
Cet article présente les défis liés à l'augmentation de la cessation tabagique aux Etats-Unis en suggérant notamment d'améliorer les traitements pour l'abandon du tabac et d'augmenter leur disponibilité en vente libre
US Centers for Disease Control and Prevention recently reported that cigarette smoking (defined as smoking every day or only on some days) reached a record low in 2017 with a decline to 14% among US adults.1 Tobacco-associated morbidity has likewise declined steadily in the United States, but remains the leading preventable cause of death for an estimated 480 000 individuals each year.1 This continued decline in smoking prevalence is an outstanding public health success, but the United States can do better with modest, evidence-driven changes in tobacco treatment practice and policy.
Two-thirds of smokers want to quit, but less than one-third make a quit attempt using evidence-based approaches.2 Improving treatment options and access are essential for improving quit rates. As the recent CDC report1 indicated, “barrier-free access to tobacco cessation counseling and approved medications, along with [Food and Drug Administration] FDA regulation of tobacco products, can accelerate progress toward reducing tobacco-related death and disease in the United States.”
Improving Tobacco Treatment Rates
Two related practice and policy changes have the potential to significantly increase the use of the most effective treatments to help smokers quit. The first is adoption of recommendations from a new evidence-based practice guideline that varenicline or combination nicotine replacement (eg, patch and lozenge) plus behavioral support be used as the first-line treatment for tobacco addiction for most smokers. The second is consideration of converting varenicline (and possibly other treatments for smoking cessation) from a prescription medication to an over-the-counter (OTC) medication.
First-Line Smoking Cessation Treatments
Every smoker in the United States has access to free behavioral support to assist in quitting via state tobacco quit lines.1 Many persons use smoking cessation medications approved by the FDA, primarily OTC nicotine replacement therapy (gum, patch, or lozenge). However, 2 meta-analyses of smokers trying to quit3,4 and a more recent meta-analysis including smokers not ready to quit5 reported that varenicline was associated with higher quit rates than other single cessation medications, with cessation rates at 6 months of 33.2% compared with 23.4% for the nicotine patch and 24.2% for bupropion.3
The EAGLES trial6 compared varenicline, bupropion, the nicotine patch, and placebo in 8144 smokers with (n = 4116) and without (n = 4028) a history of psychiatric conditions and found rates of abstinence from smoking at 24 weeks that were significantly higher in the varenicline group (21.8%) vs the bupropion (16.2%) and nicotine patch (15.7%) groups. Whether these rates would be maintained at 1 year or longer is not known. The most common adverse events from varenicline included nausea, insomnia, and abnormal dreams. Neuropsychiatric adverse events were comparable across medications, and patients with psychiatric conditions were more likely to report psychiatric adverse events across study medications including placebo.
Meta-analyses also have found that combining 2 different nicotine replacement products (such as the nicotine patch and lozenge) was associated with quit rates similar to varenicline alone.3,4 Combination therapy requires consistent adherence to both medications to achieve the higher quit rate; however, the adherence rate is less than 2% for combination nicotine replacement therapy.7
Given the available evidence, clinicians and health care systems should recognize different tiers of tobacco treatment and ensure that smokers are offered either varenicline or combination nicotine replacement therapy as a first-line treatment option. Combination therapy should be encouraged if there is reason to believe that the smoker will adhere to use of both medications. A smoker may require up to 30 quit attempts before successful smoking cessation is achieved. Therefore, each attempt should involve an individualized approach so that the most effective treatment is offered to afford the best opportunity to achieve sustained abstinence from tobacco. (...)
JAMA , article en libre accès, 2018