Promoting second quit attempts right after relapse may improve rates of smoking abstinence

A randomized trial found that patients who wanted to quit smoking but relapsed after a first attempt were more likely to succeed if their primary care physicians encouraged them to try quitting again immediately.

Encouraging patients to try to quit smoking again immediately after relapse might be the best way to improve long-term quit rates, a recent study found.

Researchers at 18 primary care clinics in Wisconsin performed a sequential three-phase randomized trial to compare the effects of three postrelapse interventions on smoking abstinence. In the first phase of the study, patients received cessation counseling and eight weeks of a nicotine patch. In the second phase, those who relapsed were randomly assigned to one of three recovery groups: smoking reduction counseling plus nicotine mini-lozenges plus encouragement to quit starting one month after randomization (the preparation group), repeated encouragement to quit starting immediately after randomization (the recycling group), or advice to call the tobacco quitline (the control group).

In the third phase, patients assigned to the first two groups could choose to receive eight weeks of nicotine patches plus mini-lozenges plus randomization to skill training or supportive counseling. The second and third phases of the study lasted 15 months or less. Each active treatment in the second phase was compared with control for the primary outcome of biochemically confirmed seven-day point-prevalence abstinence 14 months after the treatment was started. The results were published Jan. 29 by Addiction.

Overall, 1,154 primary care patients (53.6% women, 81.2% White) who were interested in quitting smoking enrolled in the trial from 2015 to 2019. Of these, 582 relapsed and were randomized to recovery treatment. Those assigned to the preparation group in the second phase of the trial did not have significantly higher abstinence rates at 14 months than the control group (3.6% vs. 2.1%; risk difference, 1.5% [95% CI, −1.8 to 5.0%]; odds ratio, 1.8 [95% CI, 0.5 to 6.9]), but those assigned to the recycling group did (6.9% vs. 2.1%; risk difference, 4.8% [95% CI, 0.7% to 8.9%]; odds ratio, 3.5 [95% CI, 1.0 to 12.4]). Those assigned to the recycling group were also more likely to enter the third phase of the study and receive new treatment than those assigned to the preparation group (83.4% vs. 55.9%; P<0.0001).

The authors noted that they offered more intensive pharmacotherapy in the third phase of the study and that fewer patients might have chosen to enter that phase if the same treatment from the first phase had been offered. Among other limitations, 47% of the participants reporting abstinence at the 14-month phone call did not attend a visit for biochemical verification, the authors said. They pointed out that more than half of the participants who ultimately entered cessation treatment did so within nine days of entering recycling and that recycling is easier and less expensive to deliver than preparation. "In conclusion, this study found that when people relapse while trying to quit smoking, it appears especially effective to immediately and repeatedly encourage them to quit again using evidence-based cessation treatment," the authors wrote.

In related news, a randomized trial published Jan. 29 by JAMA Internal Medicine found that e-cigarettes were noninferior to varenicline and superior to nicotine gum for smoking cessation.

Patients in China who smoked at least 10 cigarettes per day and wanted to quit were assigned to 12 weeks of e-cigarettes (409 patients, 30 mg/mL nicotine salt for two weeks and 50 mg/mL thereafter), varenicline (409 patients, 0.5 mg once daily for three days, 0.5 mg twice daily for four days, and 1 mg twice daily thereafter), or nicotine gum (250 patients, 2 mg for those who smoked ≤20 cigarettes daily or 4 mg for those who smoked >20 cigarettes daily). Minimal behavioral support was provided.

At six months, rates of biochemically validated abstinence were 15.7%, 14.2%, and 8.8%, respectively. The quit rate in the e-cigarette arm was noninferior to the varenicline arm (absolute risk reduction, 1.47%; 95% CI, −1.41% to 4.34%) and higher than in the nicotine gum arm (odds ratio, 1.92; 95% CI, 1.15 to 3.21). A total of 62.8% of patients in the e-cigarette arm were still using e-cigarettes at six months.

The authors of an accompanying editorial noted that the study did not compare combinations of nicotine replacement therapy and that the dose of nicotine gum may have been suboptimal, among other limitations. They stressed the greater addiction potential of e-cigarettes, as evidenced by the high rate of continued use at six months in this trial. Guidance for clinicians on e-cigarettes is limited, the editorialists said; they noted that recommending only FDA-approved products and encouraging cessation of all tobacco products is the most conservative approach, while providing evidence-based information on the pros and cons of all approved medications and e-cigarettes and helping the patient make an informed decision is the least.

"A moderate approach would be to recommend approved medications as the first step and, if that fails, then inform the patient of the evidence regarding the use of ECs [electronic cigarettes] as a possible approach, acknowledging all its caveats," they wrote. "Describing the evidence for ECs as a means to stop smoking might also be suggested if the patient has already tried approved medications and found them ineffective." In all cases, the editorialists said, patients should be told that using both cigarettes and e-cigarettes together has not been shown to be beneficial and that stopping e-cigarettes should be the ultimate goal.