ATTUD Journal Club Postings

Combined Pharmacotherapy and Behavior Therapy for Smokeless Tobacco Cessation

Although there has much press about e-cigarettes recently, we should not forget that smokeless tobacco use is increasing in the US. For example, in a very recent survey, 2.4% of Americans were currently using smokeless vs 2.3% using e-cigarettes (Lee et al, Preventive Med 62:14-19). A recent Cochrane review concluded that person-to-person counseling was helpful for cessation of smokeless tobacco. However, neither NRT nor bupropion was consistently effective. One study of varenciline in Swedish snus users did find an effect (OR = 1.6).

Now comes a large study comparing nicotine lozenge only, telephone counseling only or the combo (Severson HH, et al Nicotine Tobacco Research on line, in press). The percent abstinent at 6 month followup (i.e., point prevalence) was 38% in the counseling only, 42% in the lozenge only and 49% in the lozenge plus counseling only conditions. All of these quit rates are higher than typically found in cigarette smokers and are consistent with other lines of evidence that smokeless users are less dependent and find quitting less difficulty than smokers. But more importantly, the study suggest that it really takes a two-pronged approach with addressing withdrawal and craving via a medication and addressing coping skills and motivation with counseling to obtain a high rate of success. Unfortunately, this rationale is not always completely endorsed in medicine. For example, my experience is that, when it comes to treatment of major depressin, many patients and clinicians see the pharmacological and behavioral treatments as competing with this sometimes resulting in turf battles. In contrast almost all TTSs don’t see pharmacotherapy as a substitute for counseling or visa versa, but see that counseling has a role in helping medications work and visa versa. If this complementary role is correct, then when someone fails an OTC treatment, the next treatment many not be a different OTC or a medication alone treatment but the addition of a behavioral treatment. If you cannot quit because of the stress of raising a mentally ill kid and living with a smoker who is not interested in quitting, no medication is going to help that.