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Ask the Experts: How do I chose the right smoking cessation medication?

Using an Adaptive Treatment regimen to guide tobacco use pharmacotherapy


by Rachael Joyner, NP, FNP-BC, APRN | Nurse Practitioner


With several medication options for treatment of tobacco dependence, I am often asked by patients and other healthcare providers, “How do I pick the right medication?”


High quality evidence shows that varenicline (generic Chantix) and combination nicotine replacement therapy (NRT), such as nicotine patch plus nicotine gum or lozenge, are the most effective smoking cessation medications. These are thought of as “standard-of-care” medication treatment.


Of course, we treat patients in the real world where other considerations such as patient preferences, medication cost, other medical conditions, and medication side effects or interactions play a role in our medication decisions. This is why being flexible in our treatment of individuals trying to quit tobacco is key to success.

“For some reason, medication treatment for smoking cessation is often rigid or prescriptive. The core idea in Adaptive Treatment is to check in with your patient and change direction if your patient is not responding to treatment.--James Davis, MD

There is now new information showing that “Adaptive Treatment” is more effective than non-adaptive treatment when using smoking cessation medications. Adaptive treatment simply refers to a process of starting a medication regimen and then changing it based on patient response. Adaptive treatment is the norm for most medical problems, but it has not been explored for smoking cessation until recently.


Photograph of Dr. James Davis, Director, Duke Smoking Cessation Program
Dr. James Davis, Director, Duke Smoking Cessation Program

“For some reason, medication treatment for smoking cessation has historically not allowed for adaptation,” explains Dr. James Davis, MD, Medical Director of the Duke Center for Smoking Cessation. “Most patients are started on a medication and asked to quit smoking. We just hope the medication will work for them.”


Dr. Davis is the lead author of a recent study published in JAMA that compared adaptive pharmacotherapy to current conventional medication treatment for smoking cessation. Of the 188 patients included in the study, those randomized to the adaptive treatment group were three times more likely to be quit than those in the standard care group.  These findings were statistically significant, and smoking abstinence was confirmed with biochemical measures, instead of only relying on patient report.



“The core idea in Adaptive Treatment is to check in with your patient after starting the medication, and then change the medication regimen if your patient is not responding well to treatment,” Dr. Davis said.


Biochemically Verified 30-Day Point Prevalence Smoking Abstinence 12 Weeks After Target Quit Date (Primary Outcome), Graphic Courtesy Dr. James Davis
Biochemically Verified 30-Day Point Prevalence Smoking Abstinence 12 Weeks After Target Quit Date (Primary Outcome), Graphic Courtesy Dr. James Davis


So what does adaptive treatment look in real-life practice? You start a patient on their smoking cessation medication, for example varenicline, and then see them in 2 weeks. If they are unable to decrease the amount of cigarettes they are smoking daily by 50% (non-responders), then you would add an additional medication, such as nicotine gum.

 

These adjustments are ideally made prior to the patient’s quit day, as they did in the study. As Dr. Davis explains, “This allows us to optimize medication treatment before a person does that hard work of making a quit attempt.” 


It is important to remember that standard-of-care treatment for tobacco use is to use both pharmacotherapy and behavioral treatments.


There are currently seven FDA-approved medications for smoking cessation—varenicline, bupropion, nicotine patch, and short-acting nicotine replacement (gum, lozenges, inhaler, nasal spray)—plus other medications—clonidine and nortriptyline—supported by research as effective for treating tobacco use.

 

To learn more about adaptive treatment and other evidence-based smoking cessation pharmacotherapy strategies, don’t miss our upcoming Tobacco Dependence Pharmacotherapy 1-day virtual CE Short Course – May 9th, 2024. Visit https://www.dukeunctts.com/shortcourses to learn more.


About the Author


Rachael Joyner, DNP, FNP-BC, APRN, is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.

 

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