For smoking cessation, increasing dose may help improve abstinence

Most people who smoke don’t quit on their initial attempt. What’s the best course of action, then, if an initial smoking cessation attempt fails? Results from a randomized clinical trial published in JAMA Network found that for individuals who did not quit after being treated with varenicline, increasing the dosage enhanced abstinence. For nonabstainers who were initially treated with combination nicotine replacement therapy, a dosage increase or a switch to varenicline enhanced abstinence.

Researchers randomly assigned 490 volunteers to first-line treatment with 2 mg of varenicline daily or combined nicotine replacement therapy consisting of a 21-mg patch and a 2-mg lozenge.

Just 54 participants in the combined nicotine replacement therapy cohort and 88 in the varenicline group achieved abstinence by 6 weeks.

Nonabstinent participants were reallocated to stay on their initial regimen, increase the dosage, or switch from one medication to the other. Participants failing to present for Phase II randomization were assigned to continue their original intervention.

Everyone, regardless of assignment, received brief weekly counseling. The primary endpoint was biochemically verified 7-day point prevalence abstinence after 12 weeks of treatment. For patients taking varenicline, increasing the dosage had the biggest benefit, while either raising the dosage or trying varenicline appeared to be equally effective strategies for smokers who tried combined nicotine replacement therapy first.

However, secondary outcomes of continuous abstinence at 6 months suggested that smokers who reach abstinence by 6 weeks may do better by sticking to their initial treatment and increasing the dosage as opposed to switching to a different cessation method.