Efficacy of the therapies used at the Antismoking Center of Viterbo ASL in relation to gender, nicotine dependence and motivation in the period 2003-2023| Tabaccologia

Abstract

The data concern 2,471 smokers attending the Antismoking Center of Viterbo ASL in the twenty-year period 2003-2023. This heterogeneous cohort of patients differed in gender, age, degree of nicotine addiction, level of motivation and health status. Strategies for quitting smoking varied, mostly according to their availability on the market: nicotine substitutes, varenicline and cytisine, were used along with “brief counseling” [1]. The aim of the study was to verify the effectiveness of the different therapies in relation to gender, degree of addiction and motivation of smokers. Efficacy of the therapies was estimated with periodic checks, measurement of exhaled carbon monoxide (CO), up to one year after the last cigarette smoked (abstinence). The analysis proved that as the degree of addiction increased, the probability of success decreased. Furthermore, it was found out that as the degree of nicotine addiction increased, the success rate increased in those who had been treated with varenicline and cytisine. In recent years new therapies have been introduced, others have been withdrawn from the market but despite that, success rates have slightly varied, averaging around 25% to 30%. This means that, as demonstrated by other studies, there are further variables that contribute to the success of the process of quitting smoking: primarily the motivation of the smoking patient and the degree of nicotine addiction.

Introduction

The Viterbo ASL Antismoking Center has been engaged in tobacco control since 2003. During this twenty-year period, data were acquired on about 2,471 smokers (Figure 1) who began the process of quitting tobacco and nicotine smoking. In recent years there has been a revolution in the tobacco market due to the introduction of vaping products and non-burned Heated Tobacco Products (HTP) devices in which the common element is the presence of nicotine that is inhaled.

The Antismoking Center of Viterbo ASL has 3 locations located in the district with clinics equipped with the same instrumentation such as spirometer, scale, statimeter, CO meter, sphygmomanometer and pulse oximeter. Patients who attend the Antismoking Center are mostly referred by General Practitioners or by Hospital Specialist Units (pulmonology, diabetology, cardiology). In other cases, however, it is the smokers themselves who seek information to stop smoking on the Internet (search engines such as Google, ASL Viterbo website), by telephone (toll-free number). The Antismoking Center provides an email address and a telephone number to manage visits by appointment. Once an appointment has been booked, the first visit is carried out with the patient takeover, which will follow a series of meetings which are initially closer in time and then gradually less frequent for approximately 8-10 visits up to a year after the last cigarette smoked. During the visit, motivational counseling is carried out, the medical record is filled oud and the most suitable therapy is prescribed according to the patient’s clinical conditions and expectations.

The aim of the study is to verify the different success rates (number of abstinent smokers) based on the different therapies used (NRT, varenicline, cytisine) in relation to gender, degree of addiction and motivation, as well as to verify the number of abstinent smokers year by year from 2003 to 2023 in accordance to the treatments used (counseling + therapy) at the Antismoking Center of Viterbo ASL.

Materials and methods

During the first visit, the patient’s medical record is filled out with particular attention to smoking activity, age of onset, number and brand of cigarettes smoked over time, correlation with alcohol, coffee or recurring habits; personal data, education, work activity, physiological and pathological history are collected; any previous attempts to quit smoking are investigated; the degree of dependency is measured through the Fagerstrom questionnaire [2] and the degree of motivation through a motivational questionnaire [3]. The Fagerstrom questionnaire shows four different degrees of dependency: mild (0-2 points), medium (3-4 points), strong (5-6 points), very strong (7-10 points). The medical examination is carried out with particular attention to the physical examination of the chest and the cardiovascular system, the parameters relating to blood pressure, weight, height, blood oxygen saturation and carbon monoxide concentration in ppm (parts per million) in the air are recorded during expiration. The-quitting-smoking process also includes a respiratory function test with a spirometer at the beginning and at the end of the path (one year after the last cigarette smoked). During first visit, the most suitable therapy for the patient is prescribed and subsequent check-ups are scheduled, during which motivational counseling is resumed and compliance to the therapy is assessed by repeating the breath carbon monoxide test. This test has a double aim: on the one hand it provides the practitioner with the confirmation of the actual reduction in the number of cigarettes smoked (confirm of the smoking status) and on the other hand it reinforces the patient’s motivation to continue the quitting-smoking process (in a setting of smoking cessation) [4]. If it is not possible to carry out one of the several check-ups, the patient is contacted by telephone to conduct the interview. The therapies available have varied over the last 20 years: from 2003 to 2006 smokers were treated only with NRT (transdermal patches especially), in 2007 varenicline was introduced (administered according to standard 12-weeks treatment) and since 2016 there were 3 therapies available thanks to the spread of cytisine (administered according to induction-scaling scheme approved by SITAB).[5] Since 2021, following the withdrawal of Varenicline from the market, the available therapies were NRT and cytisine. For the definition of abstinence, a time laps of one year after last cigarette smoked was taken as reference. This was verified through a physical examination and exhaled CO measurement; when it wasn’t possible to conduct the last scheduled examination, patients were interviewed by telephone. All data obtained during the visits are entered into a special software, which was developed by the Workplace Health and Prevention Service. Chi-square test was carried out to evaluate the statistical significance of the abstinence proportions between different categories.

Results

Data referring to 2,471 smokers included in the study (1,129 F, average age 52 years, average number of 22 cigarettes smoked per day; 1,342 M, average age 51 years, average number of 26 cigarettes/day), were analyzed. 593 patients were treated with NRT (279 F and 314 M), 942 with varenicline (389 F and 553 M) and 614 with cytisine (308 F and 306 M). Abstinents at one year were 618 (262 F and 356 M) (difference F vs M, chi-square statistic 3.60, p-value 0.0575), of which 143 used NRT (51 F abstinent-18.3% and 92 M abstinent-29.3%) (Figure 2), 309 varenicline (124 F abstinent-31.9% and 185 M abstinent- 33.4%) (Figure 3), and 141 cytisine (75 F abstinent 24.3% and 66 M abstinent 21.5%) (Figure 4) (chi-square statistic: heterogeneity in treatments 23.6, p-value < 0.001). Patients were stratified based on the degree of dependency (Fagerström test): mild 362 smokers (179 F and 183 M), medium 547 smokers (264 F and 283 M) and high 815 smokers (341 F and 474 M). Abstinent smokers with mild dependence were 132 (36.5%), those with medium dependence were 161 (29.4%) and those with high dependence were 207 (25.4%) (Figure 5) (chi-square statistic: heterogeneity in the degree of dependence 14.97, p-value < 0.001).

Among the male smokers, the therapy showed in those with a mild degree of addiction an efficacy of 27% with NRT, 58% with varenicline and 7% with cytisine. (Figure 6) In those with medium addiction the efficacy was 19.5% with NRT, 61% with varenicline and 15% with cytisine (Figure 7); in those with high addiction the efficacy was 17% with NRT, 62% with varenicline and 17% with cytisine (Figure 8).

Among the female smokers, the therapy showed, an efficay of 22% in those with a mild degree of addiction with NRT, 50% with varenicline and 18% with cytisine (Figure 6); in those with medium addiction the efficacy was 14.5% with NRT, 56.5% with varenicline and 23% with cytisine (Figure 7); in those with high addiction the efficacy was 15% with NRT, 58% with varenicline and 24% with cytisine (Figure 8).

Regarding the success rate based on motivation, the main ones were linked to current health problems (741 smokers with 192 abstinent equal to 25.9%), fear of future illnesses (435 smokers with 127 abstinent equal to 29.2%), and to the feelings of addiction (4w04 smokers with 148 abstinent equal to 36.6%).

In relation to the different treatments used over time (NRT, varenicline, cytisine together with counseling), the results obtained (as a percentage of abstinent smokers after one year) show: from 2003 to 2006, a period in which smokers were treated only with NRT (263 patients of whom 75 were abstinent) with success rates ranging between 28%-31%; from 2007 to 2015, with the introduction of varenicline therapy, 1263 patients were treated, 355 of whom (65 NRT, 272 varenicline, 18 counseling only) were abstinent after one year. Overall percentages of abstinent smokers ranging between 21% - 33% were observed, varying up to 36% with NRT and up to 40% with varenicline.

Since 2016, with the introduction of cytisine, 728 patients were treated,197 of whom were abstinent after one year (13 NRT, 40 varenicline, 133 cytisine, 11 counseling only) with success rates ranging from 22% to 33% overall, varying up to 27% with NRT, up to 45% with varenicline and up to 50% with cytisine. (Figure 9 and 10)

Since 2021, with the withdrawal of varenicline from the market, the available therapies are NRT and cytisine. The data obtained from the study on the effectiveness of the various therapies used to stop smoking appear to be in line with those observed in the PASSI national surveillance survey [6] and with those from the studies on the effectiveness of therapies published in journals of national and international interest [1,7].

Conclusions

The analysis conducted made it possible to evaluate the effectiveness of the different therapies in relation to gender and degree of dependence: as the degree of dependence increases, the probability of success is reduced. This trend is confirmed with the use of NRTs. Furthermore, it emerged that as the degree of dependence increases, the percentage of success increases in those who have been treated with varenicline and cytisine.

Furthermore, it emerged that over the various years, despite the introduction of new therapies and the withdrawal of others from the market, success rates have slightly varied, averaging between 25% to 30%. This derives from the fact that, as demonstrated by other analyzes carried out, there are further variables that contribute to the success of the process of quitting smoking: primarily the motivation of the smoking patient and the degree of nicotine addiction.

Figures and tables

Figure 1.Total smokers treated, divided by gender.

Figure 2.Percentage of abstinent with NRT, divided by gender.

Figure 3.Percentage of abstinent with varenicline, divided by gender.

Figure 4.Percentage of abstinent with cytisine, divided by gender.

Figure 5.Percentage of success in relation to degree of dependence.

Figure 6.Percentage of success in patients with mild dependence, divided by therapy and gender.

Figure 7.Percentage of success in patients with medium dependence, divided by therapy and gender.

Figure 8.Percentage of success in patients with high dependence, divided by therapy and gender.

Figure 9.Percentage of success over time.

Figure 10.Percentage of success over time.

References

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