Varenicline and Motivational Advice for Smokers With Substance Use Disorders

People with substance use disorders (SUD) have a high prevalence and rate of smoking with
little success in quitting, so stronger approaches are needed to encourage attempts to quit
smoking. Brief advice (BA), to motivate cessation, produced some benefit but low abstinence
rates for smokers with SUDs while adding free transdermal nicotine replacement therapy (NRT)
improved short-term cessation rates. Varenicline has been found to produce higher rates of
short and long-term abstinence than bupropion or placebo. However, a comparison between the
efficacy of varenicline and NRT has not yet conducted with people with SUDs. Given the lack
of effectiveness for standard smoking treatments for this population, what needs to be known
is whether varenicline would increase the smoking abstinence rates relative to NRT when all
receive motivational counseling.

The primary aim of this study is to evaluate the effects of 12 weeks of varenicline as
compared to NRT, using a two-group randomized placebo-controlled design on smoking cessation
rates for 12 months among 274 outpatients in treatment for SUD. The counseling incorporates
BA (adapted slightly for sobriety settings by directly addressing barriers and concerns
expressed by substance abusers), skills training and medication management. Confirmed
point-prevalence and sustained abstinence will be assessed at 3 and 6 a months after the
start of treatment. Secondary aims will examine potential mediators of effect including
within-treatment abstinence, craving, and nicotine withdrawal levels.

The potential significance is to add to knowledge about the most effective ways to maximize
smoking cessation among substance abusers, important given that no methods are known to work
with this difficult population. No study published to date has compared varenicline to NRT
for efficacy with patients with SUD.

Inclusion Criteria:

- Diagnosis of substance abuse or dependence by DSM-IV criteria

- Currently smoking at least 10 cigarettes per day for the past 6 months

Exclusion Criteria:

- Active psychosis or marked organic impairment according to medical records, or
evidence of hallucinations or delusions

- Current use of any nicotine replacement, or other smoking cessation treatment

- Medical contraindications for NRT (including pregnancy, nursing, women not using birth
control during heterosexual sex, history of unstable angina, history of severe
congestive heart failure, uncontrolled hypertension, lung cancer, supplemental oxygen,
allergy to adhesive, severe skin disease that requires treatment)

- Medical contraindications for VAR (including pregnancy, nursing, severe renal
impairment by laboratory test, history of intolerance of varenicline, history of
serious suicidal ideation or attempts in the past 5 years)