MONTREAL, QC — Pharmacotherapy and individual or telephone counseling are safe, effective ways to help motivated patients with cardiovascular disease (CVD) quit smoking, researchers report. The finding from a large meta-analysis of randomized trials contrasts with some earlier research[2–4] that found such interventions ineffective in such patients.
Drug and behavioral smoking-cessation interventions have been shown effective at increasing quit rates in healthy individuals, but whether they work in patients with CVD has been unclear, the researchers, led by Karine Suissa (McGill University, Montreal, QC), write in a study published online January 16, 2017 in Circulation: Cardiovascular Quality and Outcomes.
“While there were several studies on the efficacy and safety of smoking-cessation therapies in the general population, there are important differences between the general population and patients with cardiovascular disease, and it wasn’t clear to us how information from these trials could be generalized to CVD patients who are motivated to quit,” Suissa told heartwire from Medscape.
“Cardiac patients have a higher risk for cardiovascular events compared with the general population. This would result in a greater motivation to quit in the time following an event. That moment is a teachable moment, a time window when the nurses and physicians can offer spontaneous counseling to make the cardiovascular patient want to quit smoking. Since these events occur less often in the general population, the motivation to quit tends to be quite different. It’s not surprising to see differences in smoking-cessation treatment effects between the cardiovascular patient and the general population,” she said.
Suissa and her team did a network meta-analysis of 24 randomized trials comprising more than 6700 patients with CVD who were motivated to quit smoking. They found seven such trials encompassing 2095 patients that assessed pharmacological interventions with varenicline (Chantix, Champix, Pfizer), bupropion, and nicotine-replacement therapy, and 17 with 4666 patients that assessed behavioral interventions, including in-hospital counseling, telephone therapy, and individual counseling.
The pharmacotherapy trials assessed continuous abstinence at 12 months, with six of them validating abstinence with a blood test. All included three to 25 sessions of personal counseling in addition to drug therapy.
Of the 17 behavioral-intervention trials, five assessed 12-month continuous abstinence, with 15 using a blood test to validate abstinence. There was no form of adjunctive pharmacotherapy in seven of these trials; five provided adjunctive pharmacotherapy for both control and intervention arms, and three trials provided it only for the intervention group.
The most common behavioral intervention was motivational support (in 10 trials). Only three behavioral intervention trials provided cognitive behavioral therapy.
In-hospital counseling trials offered an average of 44 minutes of intervention; telephone counseling trials offered 99 minutes, and individual counseling trials offered an average of 233 minutes.
Results of the network meta-analysis showed that varenicline was more than two and a half times more effective than placebo in helping CVD patients quit smoking (relative risk [RR] 2.64, 95% CI 1.34–5.21) and that bupropion was 42% more effective than placebo (RR 1.42, 95% CI 1.01–2.01). But nicotine-replacement therapy didn’t appear effective (RR 1.22, 95% CI 0.72–2.06).
Among the behavioral interventions, individual counseling was the most effective in helping CVD patients quit smoking (RR 1.64, 95% C: 1.17–2.28), followed by telephone therapy (RR 1.47, 95% CI 1.15–1.88). In-hospital behavioral interventions didn’t appear to be effective (RR 1.05, 95% CI 0.78–1.43).
“This study gives physicians information to work together with their patients to make informed decisions about smoking-cessation treatment,” Suissa said.
“Clinicians should have a discussion with their patients and take everything into account, including the benefits of the different smoking-cessation treatments, the uncertainty of their success, and also issues of polypharmacy. This is a shared decision-making process. We are just putting it all together and showing that these are the drugs and these are the counseling techniques that came out of our analysis as being more efficacious,” she said.
The study was supported by the Canadian Institutes of Health Research. Suissa reports no relevant financial relationships. Disclosures for the coauthors are listed in the paper.
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