Triple Treatment for Smokers

On June 22, 2009 President Obama signed a tobacco control act which allows the Food and Drug Administration (FDA) to regulate certain types of cigarettes. This will be helpful in improving tobacco avoidance in children and in adults. It will, in addition, be an important path for discussions between parents and their children, discussions between physicians and their patients, and discussions within families about the helpfulness of tobacco control.

Tobacco usage produces many adverse effects, including cardiovascular disease, respiratory disease, cancer, and symptoms such as shortness of breath and cough. Because of this, trying to reduce tobacco dependence and cigarette addiction is extremely important. Any advance in this area is beneficial to over 25% of the American population.

A recent article by Dr. M. Steinberg and co-authors from the Robert Wood Johnson Medical School in New Jersey (Annals of Internal Medicine, Volume 150, page 447, 2009) has set a new standard for helping people to stop smoking. The study was a small one, with only 127 smokers who were entered into the program between 2005 and 2007. These individuals were randomized to receive either a nicotine patch alone in a standard 10-week course which involves tapering over time, or a combination of the nicotine patch (in the same fashion), with the addition of a nicotine oral inhaler and a medication which reduces tobacco desire and is an anti-depression medication called bupropion. These smokers were tested 26 weeks after the date they decided to stop smoking to determine how often they were free of smoking, and then were followed without any treatment (no patches, no inhalers, no pills) until the time of relapse. Of course, in general usage, many such individuals would continue to use medications intermittently depending upon their smoking drive, but this was not permitted in this particular study.

The individuals in the study were all over 18 years of age, and about 5-10% were over age 65. Two-thirds were females. They included Caucasian as well as African American and Hispanic individuals. Although a few patients had previously had cancer, approximately 10-20% had heart disease, stroke, or vascular disease, and almost 25% had evidence of emphysema. About 15% previously had diabetes, 33% of the patients were troubled by depression, and about 25% had anxiety. Evidence of other substance abuse was seen in 7-14% and about 20% had alcohol abuse as well. Two-thirds were smoking more than one pack per day at the initiation of this study.

The results were impressive. At the end of 26 weeks, only 19% of the patients on the nicotine patch alone were free of smoking. However, 35% of the individuals given triple combination therapy were free of smoking.

In following these patients for the duration of their smoking cessation, those individuals who were free of smoking at 26 weeks were watched carefully to determine how long it was until they began smoking again. In individuals who had just the patch, the average time to beginning smoking again was only 23 days. However, in individuals who had triple therapy, smoking free status was continued an average of 65 days. Importantly at 6 months, 40% of smokers who had received the triple combination treatments were free of smoking compared to only 20% of individuals on patch alone.

These results are important. In addition to having discussions with your physician about smoking cessation, and in addition to getting recommendations for a patch, if you are a smoker you should also receive a prescription for a nicotine oral inhaler with instructions on its use, and instructions for taking bupropion as well. The triple combination therapy should not only be continued for the period of 26 weeks as used in the study, but continued afterwards as well to make certain that smoking relapse does not occur.

Triple medication in this circumstance was important in producing a smoking free life. However, it did produce slightly more insomnia (25% in the triple combination versus 9% in smokers with just the patch), and slightly more anxiety (22% with triple therapy versus 3% with patch) but very few people discontinued these treatments because of any side-effects.

If you or a family member is a smoker, discuss smoking cessation with your doctor and set a date to start your smoking free life. Ask for use of the triple combination therapy rather than just a single medical aid to help you. Enlist the support of family and friends to help you through the times you will want to get the habit back. Be certain you work as a team with your physician and your family to stop smoking and avoid the terrible consequences of cigarette addiction.