In smokers who lapse during nicotine patch treatment, continued patch use increases the likelihood of recovering abstinence
- Division of Primary Care, UK Centre for Tobacco Control Studies, University of Nottingham, Nottingham, UK
- Correspondence to: Tim Coleman
, Division of Primary Care, UK Centre for Tobacco Control Studies, University of Nottingham, Nottingham NG72RD, UK;
Commentary on Ferguson SG, Gitchell JG, Shiffman S. Continuing to wear nicotine patches after smoking lapses promotes recovery of abstinence. Addiction 2012;107:1349–53.
Implications for practice and research
Quitting smokers who use nicotine replacement therapy (NRT) are often advised to stop using this if they restart smoking; quitters often discontinue NRT after brief smoking lapses.
Quitters who continue using NRT during brief lapses may be more likely to return to abstinence.
Treating lapses with NRT probably encourages short-term cessation; research should investigate this further and test the impact on smokers’ long-term abstinence and health gain.
Smoking is the greatest reversible cause of morbidity and mortality; cessation is the most important lifestyle change for improving future health. NRT is the most widely used cessation treatment, but 75% of those who attempt cessation will restart smoking within 1 year.1 Treatments which stop brief lapses from becoming chronic relapse to smoking could increase treatment success.
Ferguson and colleagues conducted subgroup analyses of data from a placebo-randomised controlled trial (RCT) which tested the effectiveness of 21 mg/24 h transdermal NRT patches when used as if obtained ‘over the counter’ and without behavioural support. Initially, a 6-week supply of patches was issued. At 6 weeks, smoking status was monitored and participants were given a further 4-week supply of NRT patches. In one analysis, abstinence at 6 weeks in placebo and NRT groups was compared for those participants who reported one or more smoking lapses occurring between 3 and 6 weeks after quitting; in another, abstinence rates at 10 weeks were compared among those who reported lapse(s) between 3 and 10 weeks. There were 567 participants in total, data from 492 participants were used in the 6-week analysis (75 reported no lapses) and from 509 participants at 10 weeks (58 reported no lapses). Use of patches after lapsing (ie, to treat lapses) was not reported.
At both 6 and 10 weeks after quitting, smokers who reported lapses were more likely to return to abstinence if they had been randomised to NRT. At week 6, 8.3% of smokers who reported a lapse and who were treated with NRT had regained abstinence whereas in the placebo group only 0.8% had done so (relative risk (RR) 11.0, 95 CI 2.6 to 46.7). At week 10, the corresponding figures were 9.6% and 2.6%, respectively (3.7 RR, 95% CI 1.6 to 8.43). The authors concluded that the findings supported their hypothesis that treatment of smoking lapses with NRT patches promotes recovery from lapses and increases cessation rates.
Analyses were of data from a RCT designed to assess the efficacy of ‘over-the-counter’ NRT patches for abstinence at 10 weeks; smokers randomised to placebo could only use placebo to treat smoking lapses, whereas those randomised to NRT could only use NRT. If lapses occurring during placebo treatment are more resistant to recovery, this aspect of the study design could exaggerate the observed impact of treating lapses with NRT. To test the effect of using NRT for treating lapses, irrespective of treatment used in a cessation attempt, would require assembling a cohort of quitters and randomising only those who lapse to NRT or placebo. However, conducting such a study would be a logistical challenge.
The paper does not report data on participants’ adherence with trial treatments and the timing of treatment discontinuation, so one cannot be certain whether or not they actually used patches or stopped them after lapsing. The main trial manuscript (a different paper2) reported high adherence with patches; however, it did not specify if patches were actually used to help recovery after lapses had occurred. This means that patches may not have been used during recovery from lapses. Consequently, although analyses show that quitters who lapse while using NRT are more likely to regain abstinence than those who lapse while using placebo; the role of NRT in recovery from lapses remains unclear.
Ferguson and colleagues’ analyses provide evidence which supports, rather than proves, the hypothesis that treating brief smoking lapses with NRT prevents chronic relapse to smoking. This notion warrants testing in a clinical trial which randomises quitters at the point of lapsing to either NRT or placebo and closely monitors how these treatments are used. In the interim, it seems reasonable to suggest to smokers who quit with NRT that they should continue to use this during lapses. Concurrent smoking and NRT use is very unlikely to harm smokers who are attempting to stop. A minor risk is that some smokers might experience symptoms of mild nicotine toxicity; however, symptoms from this are usually mild (eg, headache) and would be a small price to pay, if this briefly increased exposure to nicotine were to result in their permanent smoking cessation.
Competing interests In the last 5 years, TC has been paid to attend two expert symposia arranged by Pierre Fabre Laboratories who manufactures nicotine replacement therapy.