Neuronal nicotinic acetylcholine receptors as pharmacotherapeutic targets for the treatment of alcohol use disorders

Alcohol use disorders (AUDs) are complex and developing effective treatments will require the combination of novel medications and cognitive behavioral therapy approaches. Epidemiological studies have shown there is a high correlation between alcohol consumption and tobacco use, and the prevalence of smoking in alcoholics is as high as 80% compared to about 30% for the general population. Both preclinical and clinical data provide evidence that nicotine administration increases alcohol intake and nonspecific nicotinic receptor antagonists reduce alcohol-mediated behaviors. As nicotine interacts specifically with the neuronal nicotinic acetylcholine receptor (nAChR) system, this suggests that nAChRs play an important role in the behavioral effects of alcohol. In this review, we discuss the importance of nAChRs for the treatment of AUDs and argue that the use of FDA approved nAChR ligands, such as varenicline and mecamylamine, approved as smoking cessation aids may prove to be valuable treatments for AUDs. We also address the importance of combining effective medications with behavioral therapy for the treatment of alcohol dependent individuals.

Recent developments for smoking cessation and treatment of nicotine dependence

Nicotine is an addictive drug like heroin, amphetamine or cocaine. Addiction to tobacco leads to significant failure rates in programmes for smoking cessation. The alpha(4)beta(2) and alpha(7) nicotinic acetylcholine receptors (nAChRs) and CB1 cannabinoid receptors play an important role in nicotine addiction.

Smoking cessation

21. Smoking cessation 21.1 Epidemiology of cigarette smoking 21.2 Nicotine, addiction and pharmacokinetics 21.3 Nicotine replacement therapy 21.4 Varenicline 21.5 Bupropion

Effectiveness of a Multi-Component Smoking Cessation Support Programme (McSCSP) for Patients with Severe Mental Disorders: Study Design

Only a few studies have examined the efficacy and safety of smoking cessation programmes in patients with mental disorders. The aim of this paper is to describe in detail the methodology used in the study as well as the Multi-component Smoking Cessation Support Programme in terms of pharmacological treatments and psychological interventions. An open-label 9-month follow-up study was conducted in Spain. A total of 82 clinically stable outpatients with schizophrenia, schizoaffective or bipolar disorder were enrolled. Treatment consisted of a programme specifically developed by the research team for individuals with severe mental disorders. The programme consisted of two phases: (1) weekly individual motivational therapy for 4-12 weeks, and (2) a 12-week active treatment phase. During this phase, at each study visit patients received a one- or two-week supply of medication (transdermal nicotine patches, varenicline or bupropion) with instructions on how to take it, in addition to group psychotherapy for smoking cessation. Evaluations were performed: (1) at the time of enrolment in the study, (2) during the 12-week active treatment phase of the study (weekly for the first 4 weeks and then biweekly), and (3) after the end of this phase (two follow-up assessments at weeks 12 and 24). Evaluations included: (1) smoking history, (2) substance use, (3) psychopathology, (4) adverse events, and (5) laboratory tests. The importance of this study lies in addressing a topical issue often ignored by psychiatrists: the unacceptably high rates of tobacco use in patients with severe mental disorders.

Nicotine dependence and levels of depression and anxiety in smokers in the process of smoking cessation

Background: Depression and anxiety are psychiatric disorders that are related to tobacco use and associated with dependence, the process of cessation, lapses and relapses after quitting smoking. Objective: To analyze the association of nicotine dependence with the level of anxiety and depression in patients who are in the process of smoking cessation. Methods: Cross-sectional study conducted with patients who sought the smoking cessation program in Cuiabá/MT. All the smokers enrolled from May to August 2012, participated in this study. Four instruments were applied: Socio-demographic Questionnaire, Fagerstrom test, Beck Anxiety Inventory and Beck Depression Inventory. Following bivariate analysis, using the crude prevalence ratio, with level of significance lower than 5% (p < 0.05), having as variable outcome the nicotine dependence >= 5 (Fagerstrom). The associations with p < 0.20 were selected for robust Multiple Poisson Regression (RPa). Results: Associations of Fagerstrom >= 5 with the male sex (RP = 1.15 CI 95% 1.03-1.28); number of cigarettes/day (RP = 1,33; CI 95% 1.19-1.48); and moderate/severe level of depression (RP = 1.15; CI 95% 1.04-1.28) were found. In the final model (RPa), the following variables remained associated: male gender (RPa 1.12; CI 95% 1.01-1.24), number of cigarettes/day (RPa 1.28; CI 95% 1.15-1.43) and high level of depression (RPa 1.12; CI 95% 1.01-1.23). Discussion: High level of nicotine dependence was associated significantly with the level of depression, emphasizing the association between smoking and psychiatric comorbidities.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND: Quitting smoking improves prognosis after a cardiac event, but many patients continue to smoke, and improved cessation aids are urgently required. OBJECTIVES: To assess the effectiveness of psychosocial interventions such as behavioural therapeutic intervention, telephone support and self-help interventions in helping people with coronary heart disease (CHD) to quit smoking. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (issue 2 2003), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to August 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. SELECTION CRITERIA: Randomised controlled studies (RCTs) in patients with CHD with a minimum follow-up of 6 months. After initial selection of the studies three trials with methodological flaws (e.g. high drop out) were excluded. DATA COLLECTION AND ANALYSIS: Abstinence rates were computed according to an intention to treat analysis if possible, or if not on follow-up results only. MAIN RESULTS: We found 16 RCTs meeting inclusion criteria. Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors. The trials mostly included older male patients with CHD, predominantly myocardial infarction. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (odds ratio (OR) 1.66, 95% confidence interval (CI) 1.25 to 2.22), but substantial heterogeneity between trials. Studies with validated assessment of smoking status at follow-up had lower efficacy (OR 1.44, 95% CI 0.99 to 2.11) than non-validated trials (OR 1.92, 95% CI 1.26 to 2.93). Studies were clustered by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The ORs for different strategies were similar (behavioural therapies OR 1.69, 95% CI 1.33 to 2.14; telephone support OR 1.58, 95% CI 1.28 to 1.97; self-help OR 1.48, 95% CI 1.11 to 1.96). More intense interventions showed increased quit rates (OR 1.98, 95% CI 1.49 to 2.65) whereas brief interventions did not appear effective (OR 0.92, 95% CI 0.70 to 1.22). Two trials had longer term follow-up, and did not show any benefits after 5 years. AUTHORS' CONCLUSIONS: Psychosocial smoking cessation interventions are effective in promoting abstinence at 1 year, provided they are of sufficient duration. Further studies, with longer follow-up, should compare different psychosocial intervention strategies, or the addition of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone.

Effectiveness of hospital-based smoking cessation

Study objectives: Smoking cessation for current smokers is a health-care imperative. It is not clear which approaches to smoking cessation are the most effective in the hospital setting and which factors predict long-term abstinence. We hypothesized that a hospital-based smoking cessation program involving behavioral modification and support would provide an effective intervention for smoking cessation. Design: Prospective cohort study. Setting: Smoking cessation clinics in a tertiary referral, cardiothoracic hospital. Patients or participants: Two hundred forty-three smokers and 187 never-smoker control subjects. Interventions: Smokers underwent specific sessions of individual counseling on behavioral modification, including written information, advice about quit aids, and support during the quit attempt. Abstinence was confirmed by exhaled carbon monoxide measurements. Measurements and results: Compared to never-smoker control subjects, smokers were more likely to have grown up with a smoking father or siblings, and to currently live or socialize with other smokers. Two hundred sixteen smokers attended at least two sessions of the smoking cessation program. Of these, 25% were unavailable for follow-up at 12 months and were assumed to be smoking. The point prevalence abstinence rate at 12 months was 32%. Independent factors associated with abstinence at 12 months were self-belief in quitting ability, having a heart condition, growing up without siblings who smoked, and increasing number of pack-years. Conclusions: This prospective study has demonstrated that this hospital-based smoking cessation program was as effective as programs in other settings. Social and psychological factors were associated with a greater chance of abstinence.

'It had to be my choice' Indigenous smoking cessation and negotiations of risk, resistance and resilience

While Australia is considered a world leader in tobacco control, smoking rates within the Aboriginal and Torres Strait Islander population have not declined at the same rate. This failure highlights an obvious shortcoming of mainstream anti-smoking efforts to effectively understand and engage with the socio-cultural context of Indigenous smoking and smoking cessation experiences. The purpose of this article is to explore the narrative accounts of 20 Indigenous ex-smokers within an urban community and determine the motivators and enablers for successful smoking cessation. Our findings indicated that health risk narratives and the associated social stigma produced through anti-smoking campaigns formed part of a broader apparatus of oppression among Indigenous people, often inspiring resistance and resentment rather than compliance. Instead, a significant life event and supportive relationships were the most useful predictors of successful smoking cessation acting as both a motivator and enabler to behavioural change. Indigenous smoking cessation narratives most commonly involved changing and reordering a person’s life and identity and autonomy over this process was the critical building block to reclaiming control over nicotine addiction. Most promisingly, at an individual level, we found the important role that individual health professionals played in encouraging and supporting Indigenous smoking cessation through positive rather than punitive interactions. More broadly, our findings highlighted the central importance of resilience, empowerment, and trust within health promotion practice.

Rates of attendance at a smoking cessation clinic within a cardiac rehabilitation service

Objectives: Smoking cessation has been shown to be an important intervention for preventing cardiovascular events and improving the health of patients with heart disease. However, unaided quit attempts in these patients often leads to high rates of failure and a return to smoking. Outpatient smoking cessation clinics using face-to-face counseling, ongoing behavioral support, advice on smoking pharmacotherapy and objective monitoring, have been found to be one of the most effective interventions for improving quit smoking rates. An outpatient smoking cessation clinic was trialed within a cardiac rehabilitation service in order to explore its effects on smoking rates for patients with or at risk of heart disease. Attendance rates to the clinic were also monitored. Methods: A descriptive exploratory design was used for this newly developed clinic. Patients who currently smoked tobacco and who had a history of either coronary artery disease, heart failure, atrial fibrillation or those seen under a chest pain assessment service were invited to an outpatient ‘Cardiac Patients Smokers Clinic’. Initially patients were offered up to 10 clinic visits over a 3 month period. Follow-up clinic visits were conducted at 3, 6 and 12 months. A portable carbon monoxide meter was used to objectively measure levels of smoking and validate smoking abstinence. Primary outcomes included rates of attendance. Results: Preliminary findings showed 24 per cent of participants (N = 6) completed all their clinic visits and remained smoke free as measured by their ongoing expired carbon monoxide readings. Clinic attendance rates appeared lowest for those with significant mental health issues such as schizophrenia or substance abuse. However, rates of attendance were improved by having an administration officer make reminder telephone calls prior to clinic visits. Conclusions: Early findings indicate the feasibility of providing a specialist smoking cessation clinic within a cardiac rehabilitation service. Further, that reminder telephone calls prior to appointments improved attendance rates in patients with heart disease to this type of clinic. However, future investigations are warranted.

A smoking cessation intervention for people with chronic Hepatitis C : a randomised controlled trial

Purpose The purpose of this study was to examine the validity of current practice in smoking cessation for the general population i.e., a telephone counselling and nicotine replacement therapy (NRT) intervention and its applicability to people with chronic hepatitis-C. Methods A randomised controlled trial was conducted over twelve weeks. Following consent, ninety-two smokers (outpatients) with chronic hepatitis-C were recruited by the Nurse Practitioner hepatology, randomly assigned and stratified by number of cigarettes smoked (i.e., 15 and greater; <15) into the intervention group (telephone counselling and NRT) and control group (telephone counselling). Outcomes measured included socio-demographics, nicotine dependence, depression, anxiety and stress and quality of life (QOL). All statistical data were analysed using SPSS. Results After 12 weeks, the intervention group showed a sustained reduction of smoking i.e., 5.8(CI: 2.4,9.3) cigarettes less per day, whereas the control group showed 1.6(CI:-1.9,5.2) cigarette reduction. Although not statistically significantly different (F=2.9, p=0.090) the intervention group on average smoked 4.2 fewer cigarettes compared to the control group. After twelve weeks, seven patients in the intervention group and three patients in the control group reported quitting. Whilst not statistically significant (Fisher’s Exact, p=0.311) this was a clinically significant result. No differences were found for nicotine dependence or depression, anxiety and stress. The intervention group experienced no change in QOL (-0.1,CI:-0.9, 0.6), however, the environmental score for the control group decreased by 1.8(CI:1.0, 2.6,p= 0.001). This was statistically significant. Conclusion A telephone counselling and nicotine replacement therapy intervention from the nurse practitioner, hepatology reduced smoking in patients with chronic hepatitis-C. The intervention group showed a sustained reduction over the 12 weeks. A total of 10 patients quit smoking at the end of the study. QOL deteriorated in the environmental subscale for the control group. These results informed a nurse practitioner model of care for approaches to smoking cessation.