ATTUD Journal Club Postings

Is it Best to Switch or Add to New Treatment When Trying to Quit Again?

A recent article based on very large prospective study reported that smokers who failed a quit attempt on one medication, tried again and used a different medication, had 3 times higher success rates than those who tried again and used the same medication (Heckman et al Am J Prev Med, in press). Although this is not an experimental study, it does suggest switching is better. The effect did not appear to be due to switching to a more effective medication (e.g. from single NRT to varenicline).

Decades ago I was a general psychiatrist at a tertiary care academic hospital in which almost all our patients had failed multiple prior treatments. Our standard practice was to review with the patient the prior treatments, especially compliance and adverse events from the treatments and, importantly, the patient’s own beliefs about which future treatments would work. Although a minority, sometimes patients would state they thought their prior treatment worked but that they were not compliant enough of some event happened (e.g. losing a girlfriend) that overwhelmed the treatment and thus they wanted to retry the treatment. But more often we tried either a new class of medications, a combination of medications, increasing the dose of medications.

Unfortunately, these efforts were often unsuccessful. There was sometimes a hunt for a “magic bullet” medication in which patients and physicians avoided “elephants in the room” such as a spouse who smokes and is not willing to quit or having to take care of a demanding or severely ill relative. I mention this because I think the study I cited above is important in that we can now tell patients that if they try a new treatment they still have a good chance of quitting. But, after a treatment failure, we sometimes need to have a heart-to-heart talk about what needs to change to be successful (e.g. asking the spouse not to smoke, getting outside help to deal with household stress, support groups, etc). Sometimes patients do not want to discuss these problems (“I came here to stop smoking not to lay down on a couch”) or see it as irrelevant, but simply bringing up the notion that one’s chance to stop smoking are unlikely to be good unless one deals with this problem may be important for the smoker to hear.

The above sounds like a cliché – best to use both meds and talking therapy. But here’s the rub- do we have any evidence that adding a treatment for non-drug related problems increases smoking cessation success? A Cochrane review (Van der Meer, 2013) concluded that mood management therapy in smokers with past or current depression increased quit rates by 40-50%. But I could not find data for other common disorders; e.g., does treatment focused on alcohol dependence comorbidity increase quitting smoking or how about treating adult ADD comorbidity. Plus there are timing questions. Should we ask patients to put off quitting smoking until they get 3-4 weeks of treatment of the comorbidity and hope they are still motivated at the end of it? Does the comorbidity treatment need to be “integrated” with smoking; ie. include discussions of how comorbidity influences smoking (which requires TTSs to be competent in treating the comorbidity) or could a TTS simply refer a smoker to a provider who has no expertise in smoking cessation?

In summary, although population data indicate hardening of remaining smokers is not occurring, there is empirical evidence that those entering treatment for smoking cessation are more and more having other problems. So I think we need to think both about switching to a new cessation treatment and about whether we need to address a comorbid problem (whether it is a psychiatric problem or a “problem in living”).