2007

Expanding Treatment Options at Mayo Clinic Nicotine Dependence Center

Points to Remember

• Nicotine is a potent addictive substance characterized by difficulty quitting use without medical support. Failure to break nicotine dependency fuels major public health problems.
• Because relapse is common, a broad array of treatment options is desirable to maximize the chance of designing effective individualized therapy.
• Two new drug options, varenicline and bupropion, have been used successfully in the context of medically managed residential treatment at the Mayo Clinic Nicotine Dependence Center.
• Motivating patients to make lasting behavior changes is the key to successful nicotine cessation, and patients benefit from the support and guidance of multiple specialists in addiction medicine.

The Challenge

Nicotine is a potent ganglionic and central nervous system stimulant mediated by neural nicotine receptors, and nicotine addiction remains a widespread public health threat. In general, 1% of patients who quit on their own remain nicotine-free at 12 months, while up to 50% of patients enrolled in a residential treatment program for nicotine addiction remain nicotine-free at 12 months. Other interventions have quit rates between these 2 extremes (Figure).

Relapse after an initial smoking cessation effort is common. New treatment options are always welcome because they strengthen and diversify a quit plan, thus increasing the likelihood of success. Data from clinical trials show that medications to manage withdrawal and cravings greatly improve outcomes, doubling the abstinence outcomes in people who take medications compared with those who don't.

Comparative effectiveness of tobacco cessation methods. Data show the percentage of patients able to achieve 6 to 12-month smoking cessation.

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New Medications

One of the most recent promising additions to nicotine addiction treatment options is the prescription drug varenicline (Chantix). Approved by the US Food and Drug Administration in 2006, varenicline is a partial nicotinic acetylcholine receptor agonist. It interacts with nicotine receptors in the brain in 2 ways:

• It partially stimulates the receptor to mimic the effect of nicotine while reducing withdrawal symptoms.
• It blocks the receptor from further stimulation, so even if a person on varenicline relapses and smokes, the experience is not satisfying because the nicotine is not available to the body.

Varenicline is not to be taken in combination with nicotine replacement therapies such as the patch, unless a supervised short-term plan is followed. This approach is often indicated at the onset of varenicline therapy because the drug's effects are not felt for the first 3 or 4 days after initiation of treatment.

Bupropion (Wellbutrin SR) is a drug that has been used for years to treat depression, but now it has been found to be effective in helping patients who are not depressed manage their cravings and withdrawal symptoms of nicotine addiction. Its site of action in the brain is different from the one targeted by varenicline. Instead of working at the receptor level, bupropion mediates responses of the reward system pathways where it stimulates release of the neurotransmitter dopamine.

Keys to Success

As helpful as these pharmaceutical approaches may be in managing cravings and helping build new behaviors, addiction medicine specialists emphasize that patient motivation and commitment to a plan remain the keys to achieving and maintaining abstinence.

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In both outpatient and residential inpatient treatment services, researchers at the Mayo Clinic Nicotine Dependence Center are involved in identifying and improving new treatment approaches that help motivate patients to make these lasting behavior changes. These range from novel pharmaceutical therapies, to alternative and complementary approaches, to clinical trials of an immunotherapeutic nicotine vaccine, to expanded use of specially trained tobacco treatment specialists who can help patients achieve tobacco-free lifestyles.