Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task ForceFREE
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Abstract
Background:
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Study Selection:
Data Extraction:
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Limitation:
Conclusion:
Primary Funding Source:
Methods
Data Sources and Searches
Study Selection
Data Extraction and Quality Assessment
Data Synthesis and Analysis
Role of the Funding Source
Results
Behavioral Interventions Among Adults
Health and Cessation Outcomes
Adverse Events
Pharmacotherapy Interventions Among Adults
Health and Cessation Outcomes
Adverse Events
Combined Behavioral and Pharmacotherapy Interventions Among Adults
Electronic Nicotine Delivery Systems
Behavioral Interventions Among Pregnant Women
Health Outcomes
Cessation Outcomes
Adverse Events
Pharmacotherapy Interventions Among Pregnant Women
Health Outcomes
Cessation Outcomes
Adverse Events
Discussion
References
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Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force. Ann Intern Med.2015;163:608-621. [Epub 20 October 2015]. doi:10.7326/M15-0171
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USPSTF incomplete review fails pregnant women and their doctors.
With its ‘review of reviews’ methodology, the normally respected US Preventive Services Task Force (1) failed to critically analyse a recent negative trial (2) and missed a major well designed trial on Nicotine Replacement Therapy (NRT).(3)
The authors included a trial of low dose nicotine patches alone (16 mg nicotine, 16 hours delivery) which hardly surprisingly failed to decrease withdrawal symptoms and craving vs. placebo, (2) as pregnant women are highly dependent on nicotine due to increased metabolism.(4)
Combining patches with faster acting forms of nicotine replacement therapy as a ‘belt and braces’ strategy works substantially better than patches alone, understandably related to the pharmokinetics. A 2013 trial was overlooked that showed this strategy is also evidence-based during pregnancy where it doubles the odds ratio of quitting.(3)
People should not fear nicotine more than carbon monoxide and the deleterious products of combustion: plasma nicotine levels are steady and lower with a 21 mg patch than with smoking, and peaks are avoided. Typical steady-state plasma nicotine concentrations with nicotine patches range from 10 to 20 ng/ml while smoking a cigarette results in a mean arterial plasma concentrations of about 30 ng/ml, not accounting for the peaks.(5) Moreover, as NRT greatly suppresses craving, occasional cigarette smoking with a patch is less deleterious than smoking without a patch because there is no compensatory smoking (ie more intense smoking) but a decreased uptake.
Healthcare professionals who want to truly help pregnant smokers and their expected children need better training in basic pharmacology (dose effects, pharmacokinetics, toxicology), basic support and cognitive behavioural therapies.
1 Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, Whitlock EP. Behavioral counseling and pharmacotherapy interventions for tobacco cessation in adults, including pregnant women: A Review of reviews for the U.S. Preventive Services Task Force. Ann Intern Med 2015. Online Sep 22. doi: 10.7326/M15-0171.
2 Brose LS, McEwen A, West R. Association between nicotine replacement therapy use in pregnancy and smoking cessation. Drug and Alchohol Dependence 2013;132:660-4.
3 Berlin I, Grangé G, Jacob N, Tanguy ML. Nicotine patches in pregnant smokers: randomised,placebo controlled, multicentre trial of efficacy. BMJ 2014;348:g1622
4 Koren G, Blanchette P, Lubetzky A, Kramer M. Hair nicotine: cotinine metabolic ratio in pregnant women: a new method to study metabolism in late pregnancy. Ther Drug Monit 2008 ;30:246-8.
5 Benowitz NL, Hukkanen J, Jacob P 3rd. Nicotine chemistry, metabolism, kinetics and biomarkers. Handb Exp Pharmacol 2009;192:29-60.
Author's Response
Reference List
(1) Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, Whitlock EP. Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force. Ann Intern Med. 2015;163:608-21. [PMID: 26389650]
(2) Brose LS, McEwen A, West R. Association between nicotine replacement therapy use in pregnancy and smoking cessation. Drug & Alcohol Dependence. 2013;132:660-664. [PMID: 23680076]
(3) Berlin I, Grange G, Jacob N, Tanguy ML. Nicotine patches in pregnant smokers: randomised, placebo controlled, multicentre trial of efficacy. BMJ. 2014;348:g1622. [PMID: 24627552]