BOSTON — Smokers who have been unsuccessful to date in trying to kick the nicotine habit may be able to stop smoking by combining two smoking cessation approaches, according to a report published in the Oct. 17 issue of JAMA.  

"Many smokers believe they have tried and failed all treatments because they — and their physicians — have not used existing treatments in the most effective way," noted Nancy Rigotti, director of the Tobacco Research and Treatment Center of the Massachusetts General Hospital Department of Medicine. "Outdated product labeling by the Food and Drug Administration for nicotine replacement therapy contributes to this problem, as does the fear of possible side effects of FDA-approved medications. As a result, some smokers consider using newer, untested and unregulated products like electronic cigarettes."

In her paper, based on a grand rounds presentation at Northwestern University Feinberg School of Medicine, Rigotti presents a hypothetical smoking patient: a 50-year old man who is discouraged because previous quit attempts — one with nicotine replacement, the other with the antidepressant bupropion — did not succeed. He is reluctant to try varenicline, another FDA-approved smoking cessation medication, because of concern about possible serious side effects. Feeling that he has "tried everything," he asks his physician whether he should consider electronic cigarettes.

Rigotti noted that many quit attempts fail because smokers do not use existing treatments or, like the smoker in the example, don't use them in the most effective way. Only one-third of smokers who try to quit use behavioral support or medication — both of which have been proven to be effective. Even fewer smokers combine both types of assistance, even though this further improves a smoker's chance of success.

Smokers who do use nicotine replacement therapy may not do so in the most effective way. Though many products are available — including over-the-counter patches, gums and lozenges, and prescription-only inhalers and nasal spray — many smokers only use one product when studies have shown that combining two is safe and more effective, Rigotti wrote. The patch provides steady, prolonged relief of nicotine withdrawal symptoms but cannot help with sudden cravings that may be triggered by environmental cues like watching someone light up. Shorter-acting products like gums or lozenges can help smokers handle those cravings. Despite evidence that combining NRT products is more effective than using single agents and support for combined therapy in the 2008 U.S. Public Health Service Clinical Practice Guideline, the labels currently approved by the FDA caution smokers not to combine different nicotine replacement products.

Some smokers may be discouraged from using two other FDA-approved smoking cessation drugs, bupropion and varenicline, because of reports of behavioral changes in patients taking those drugs, even though they double a smoker's odds of success when making a quit attempt. Rigotti noted that in any individual it can be difficult to distinguish a side effect from the effects of nicotine withdrawal, which can include nervousness and depression. She stressed that both drugs are among the few effective options for treating tobacco dependence, and noted that physicians and patients need to weigh the potential risk of side effects against the certain risk of continuing to smoke. In most cases, Rigotti concluded, these drugs' benefits would outweigh their risks, but she cautioned that physicians do need to monitor patients who start on these drugs for behavior changes.

"Tobacco use kills approximately half of regular smokers, and treatment for tobacco use is one of the most cost-effective actions that physicians and healthcare systems can take," Rigotti said. "Those of us who provide health care need to recognize tobacco dependence as the chronic condition that it is and give tobacco treatment as high a priority as we do other chronic diseases like diabetes or high blood pressure."

Rigotti's work was supported by a grant from the National Heart, Lung and Blood Institute.