Opioid Antagonists Other Pharmacotherapies

11.3.11 Silver Acetate

Silver฀acetate฀in฀the฀form฀of฀chewing฀gum฀or฀mouth฀spray฀has฀been฀compared฀with฀placebo฀ in฀four฀aversive฀smoking฀studies฀ [149] ,฀but฀no฀signiicant฀results฀were฀reported.฀In฀one฀ triple-arm฀study,฀silver฀acetate฀and฀the฀2-mg฀nicotine฀chewing฀gum฀formulation฀were฀com- pared฀with฀placebo฀OR฀=฀1.05;฀CI:฀0.63–1.73฀ [150] .฀An฀additional฀4฀gain฀after฀2฀months฀ is฀too฀small฀to฀be฀deemed฀a฀success฀ [17] .

11.3.12 Nicotine-Vaccination

There฀are฀three฀different฀companies฀presently฀that฀have฀completed฀Phase฀II฀clinical฀studies฀ of฀their฀anti-nicotine฀vaccines.฀They฀are฀all฀rushing฀to฀obtain฀regulatory฀approval฀and฀to฀ bring฀their฀vaccine฀candidates฀to฀the฀market฀ [151] . In฀general,฀nicotine฀vaccines฀are฀composed฀of฀a฀linkage฀between฀the฀nicotine฀molecule฀ and฀an฀adjuvant฀with฀a฀carrier฀protein.฀Preliminary฀results฀of฀the฀three฀Phase฀II฀clinical฀ studies฀are฀encouraging.฀In฀this฀respect,฀subjects฀who฀have฀a฀high฀anti-nicotine฀antibody฀ level฀also฀present฀high฀quit฀rates฀ [152] .฀However,฀the฀data฀available฀are฀by฀far฀too฀prelimi- nary฀to฀extrapolate฀for฀long-term฀quit฀rates.฀It฀can฀be฀expected฀that฀vaccines฀may฀appear฀on฀ the฀market฀in฀2011.

11.4 Therapeutic Monitoring in Smoking Cessation

Most฀physicians฀use฀the฀self-report฀SR฀conirmed฀by฀carbon฀monoxide฀CO฀readings฀as฀the฀ method฀usually฀employed฀in฀clinical฀practice฀to฀determine฀whether฀“ex-smokers”฀are฀smok- ing฀tobacco฀during฀and฀following฀treatment.฀The฀combination฀of฀SR฀and฀CO฀was฀evaluated฀ in฀some฀studies,฀and฀a฀close฀relationship฀between฀CO฀readings฀and฀SR฀was฀found฀in฀ex- smokers฀who฀had฀been฀informed฀beforehand฀that฀CO฀reading฀would฀be฀taken฀ [153,฀154] .฀A฀ relatively฀low฀average฀false-negative฀rate฀of฀6฀was฀reported฀in฀an฀analysis฀of฀12฀additional฀ intervention฀studies฀using฀CO฀conirmation฀ [107] .฀Data฀such฀as฀these฀have฀been฀taken฀as฀ evidence฀that฀CO฀evaluation฀can฀detect฀under-representation฀of฀smoking฀in฀self-reports.฀If฀the฀ patient฀has฀been฀informed฀that฀CO฀reading฀will฀be฀taken,฀then฀the฀inconsistent฀smoking฀patient฀ may฀stop฀smoking฀for฀several฀hours฀before฀CO฀reading.฀On฀the฀other฀hand,฀the฀measurement฀ of฀CO฀in฀expired฀air฀may฀be฀problematic฀because฀increased฀values฀10฀ppm฀have฀been฀ recorded฀in฀ex-smokers฀or฀in฀smokers฀who฀quit฀smoking฀several฀days฀prior฀to฀measurement. A฀second฀possibility฀to฀control฀smoking฀cessation฀is฀the฀analysis฀of฀cotinine฀in฀plasma,฀ urine,฀or฀saliva.฀In฀a฀sample฀of฀hospital฀outpatients฀self-report,฀CO฀and฀cotinine฀analyses฀ were฀used฀to฀validate฀the฀eficacy฀of฀smoking฀cessation฀ [155] .฀Up฀to฀20฀of฀claimed฀ex- smokers฀were฀classiied฀as฀smokers฀by฀each฀test.฀The฀cotinine฀analyses฀were฀superior฀to฀CO฀ readings,฀although฀CO฀also฀worked฀relatively฀well฀ [155] .฀Because฀of฀cost฀considerations,฀ the฀cotinine฀analysis฀should฀not฀be฀used฀routinely฀ [155] .฀In฀only฀one฀1-year฀study,฀the฀CO฀