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Electronic letters to:
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![[Read eLetter]](/icons/misc/sectionDOWN.gif){kind=icon}
Reply to e-letter ‘nicotine replacement therapy dosage’
Hypnosis in Treatment of Tobacco Dependence
Nicotine replacement therapy dosage
Collaboration with other health professionals in fighting tobacco use
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Bernard Le Foll Centre for Addiction and Mental Health
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bernard_lefoll{at}camh.net Bernard Le Foll
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B. Le Foll1 and T.P. George2 1 Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto. 33 Russell Street, Toronto, Canada. 2 Addiction Psychiatry Program, Centre for Addiction and Mental Health, University of Toronto. 33 Russell Street, Toronto, Canada. Reply to e-letter ‘nicotine replacement therapy dosage’ [the two authors respond:] We thank Mr. Erban and Dr. Dworkind for their comments on our table presenting the nicotine replacement dosing schedules for the treatment of tobacco dependence (1). They correctly point out that our recommendations for nicotine inhaler use were inaccurate. We agree that a smoker will benefit from 6 to 12 cartridges per day, instead of few puffs as incorrectly presented in our table. We apologize for this oversight. Moreover, we agree that for initial gum dosing, we endorse the use of up to 12-16 pieces a day of the 2 or 4 mg piece polacrilex gum, and up to 20- 24 pieces daily for breakthrough craving and withdrawal symptoms. Needless to say, the dose of NRT should be tailored to individual needs and adjusted when there are clinical signs of toxicity or insufficient dosage. In clinical practice, toxicity from NRT administration is exceedingly rare. Therefore, the number of gums or inhalers can be increased if there is evidence for insufficient NRT dosing. For patients with high nicotine needs (e.g. high dependence scores, cigarettes per day and baseline cotinine levels), we favor the use of the patch (or combinations of different nicotine replacement therapies such as patch and gum, or patch and inhaler) since it is often difficult to provide sufficient nicotine replacement with a single formulation. For heavily dependent smokers, the application of two patches is well tolerated and tolerance should be monitored closely (2, 3). We appreciate the interest in our article, and the opportunity to addresses these questions. Sincerely, Bernard Le Foll, MD, PhD, CCFP Tony P. George, MD, FRCPC 1. Le Foll B, George TP.Treatment of tobacco dependence: integrating recent progress into practice CMAJ 2007; 177: 1373-1380. 2. Tonnesen P, Paoletti P, Gustavsson G et al.Higher dosage nicotine patches increase one-year smoking cessation rates: results from the European CEASE trial. Collaborative European Anti-Smoking Evaluation. European Respiratory Society Eur Respir J 1999; 13: 238-246. 3. Silagy C, Lancaster T, Stead L et al.Nicotine replacement therapy for smoking cessation Cochrane Database of Systematic Reviews 2004: Art. No.: CD000146. DOI: 000110.001002/14651858.CD14000146.pub14651852. Conflict of Interest:None declared for Bernard Le Foll. Tony George has received consultant and speaker fees from Pfizer and consult fees from Evotec and Sanofi for the development of smoking cessation medications. |
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Donald C. Brown Dalhousie University - retired
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donandel{at}eastlink.ca Donald C. Brown
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I was very excited that your cover of the November 20, 2007 issue featured “Tobacco Dependence – Helping Patients Quit,;. I continued to feel excited when I read the abstract in the article “Treatment of tobacco dependence: integrating recent progress into practice” by B. Le Foll and TP George that mentioned non-pharmacologic interventions for the treatment of tobacco dependence. I read through the detailed information on the neurochemical determinants and various types of pharmacotherapy and nicotine replacement therapy that comprised over 80% of the article. I was very disappointed to see that less than four lines were used to address alternative therapies, and that all in one sentence. The sentence contained a sweeping statement that hypnosis and other modalities have not been found to present any favourable effect on smoking cessation outcomes. There are hundreds of articles on this topic, many reporting research on both single and group hypnosis sessions including self-hypnosis smoking cessation treatments. Just as there are more than 200 kinds of psychotherapy there are many kinds and forms of hypnosis management. Many of the randomized studies of hypnosis have examined minimal approach to hypnotherapy involving one or two sessions or group interventions. Gary Elkines et al (2006) reports findings regarding this minimal approach to hypnosis for smoking have indicated outcomes of about 2% to 25% cessation. In their literature review, Hunt and Bespalec (1974) compared six methods of modifying smoking behaviour. They concluded that hypnosis “perhaps gives us our best results” (p. 435), with repeated success rates varying between 15% and 88%”. More recently, Viswesvaran and Schmidt (1992) performed a meta-analysis of 633 studies of smoking cessation and examined 48 studies in the “hypnosis” category that encompassed a total sample of 6,020 participants. Hypnosis achieved a success rate of 36%, higher than virtually any of the other treatments it was compared with (e.g. nicotine chewing gum, smoke aversion, 5-day plans). A more recent prospective study of intensive hypnotherapy for smoking cessation by Elkins, Marcus, Bates, Rajob and Cook (2006) report quit rates of 20% at the end of treatment, 60% at 12 weeks, and 40% at 26 weeks (p<0.05). Their reported abstinence rates were confirmed by carbon-monoxide measurements for the intensive hypnotherapy group. We have been encouraging more physicans for many years to start using hypnosis in their practices by reporting what can be achieved by hypnosis use and self-hypnosis. Its use can prevent a lot of pain, suffering and expense. The Canadian Medical Association approved the use of hypnosis as a therapeutic modality in 1965. Still only a small percent of physicians use it in their practices to day. Physicians need to know what patients can achieve with hypnosis and self-hypnosis practice! References Elkins G, Marcus J, Bates J, Rajob MH and Cook T (2006): Intensive hypnotherapy for smoking cessation: A prospective Study. Int J Clin Exper Hypn 54:300-315. Hunt W and Bespalec D (1974): An evaluation of current methods of modifying smoking behaviours, J Clin Psychol 30:431-438. Viswesvaran C and Schmidt F (1992): A Meta-analytic comparison of the effectiveness of smoking cessation methods. J Applied Psychol 77:554- 561. Sincerely Yours. Donald C. Brown, M.D., C.C.F.P., F.C.F.P., A.B. F.P. Conflict of Interest:None declared |
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Joseph Erban SMBD-Jewish General Hospital
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jerban{at}onc.jgh.mcgill.ca Joseph Erban
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We wish to bring to your attention certain issues concerning treatment dosages of medication for tobacco dependence outlined in Table 1 in “Treatment of tobacco dependence: integrating recent progress into practice.” (1) Nicotine gum 2 mg or 4 mg should be 10 to 16 pieces per day as oppose to the state 8 to 10 pieces mentioned in the article. That dosage can be increased to 24 pieces per day for heavy smokers i.e., >20 cigarettes per day. (2,3) The usage of nicotine inhaler should read 6 to 12 cartridges per day for up to 6 months as patients gradually taper the use of the inhaler after the first 3 months (2,4) instead of “4-6 puffs per day.”(1) We also disagree with the authors’ recommendations that “… patients may benefit from the use of several patches applied simultaneously on the skin… However, clinicians should advise such patients not to start with more than 2 patches simultaneously to avoid overdose.” We believe that patients who smoke more than 20 cigarettes per day and who score 6 or more on the Fagerstrom's test for nicotine dependence should begin treatment with a single patch of 21 mg per day and either use nicotine gum or inhaler as breakthrough when the cravings to go back to smoke are severe.(2) We discourage the use of 2 patches applied simultaneously because of the concerns regarding potential overdose. The usages of either the gum or the inhaler instead of an additional patch reduces the chance of overdose as patients can control the dosage needed. Joseph Erban MA. Smoking cessation counselor, Cancer Prevention Centre, SMBD – Jewish General Hospital, Montreal, Canada Michael Dworkind MD. Director of the smoking cessation program, Cancer Prevention Centre, SMBD – Jewish General Hospital, Montreal, Canada. References 1. Le Foll B, George TP. Treatment of tobacco dependence: integrating recent progress into practice. CMAJ 2007; 177(11):1373-80. 2. Perkins KA, Conklin CA, Levine MD, Cognitive-Behavioral Therapy for Smoking Cessation, A Practical Guidebook to the Most Effective Treatments. New York: Routledge; 2008. 3. Silagy C. Lancaster T, Stead L, et. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004; (3): CD000146. 4. Fiore M. A clinical guideline for treating tobacco use and dependence: A US public health service report.JAMA 2000; 283: 3244-54. Conflict of Interest:None declared |
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Lorne Scharf Cornwall Community Hospital
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lorne_scharf{at}yahoo.com Lorne Scharf
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It is very difficult for patients to quit smoking, and I think that primary prevention is a better approach. Discouraging smoking and limitting the availability of tobacco (as well as places to smoke) are successful initiatives underway in Canada. I found it interesting to read in the article "Treatment of tobacco dependence: integrating recent progress into practice" that aside from doctors, "Other health professionals (e.g., counsellors, nurses, dentists and pharmacists) can also play an important role in encouraging people to quit." Have pharmacists in Canada all given up the sales of tobacco products? In Quebec this has been disallowed for many years but it is not clear to me what the policies are in BC and some maritime jurisdictions. Conflict of Interest:None declared |
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