الفهرس 
Tobacco addictionOnly 14 pages are availabe for public view
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Abstract
Tobacco remains one of the leading causes of death worldwide, despite efforts to control its use. The framework convention on tobacco control has initiated worldwide efforts for tobacco control, one of which is offering treatment options for tobacco use disorder. Currently, available treatment options offer results that are barely satisfactory, with the best results yielding quit rates in up to 36% using the cessation services (Fiore et al., 2008). The search for novel, more effective treatment tools is mandatory.
Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation (NIBS) treatment modality that has gained approval in treatment resistant major depressive disorder (MDD) and Obsessive Compulsive Disorder (OCD), and recently received an FDA clearance for smoking cessation. Its potential in addiction treatment has been explored and research is underway to refine an optimum protocol for treatment that could yield more satisfactory cessation rates.
This study hypothesized that combining a course of 10 Hz rTMS of the left DLPFC with an evidence-based cognitive-behavioral intervention will support abstinence. It was a double-blinded randomized controlled trial carried out in real life conditions to assess the role of using rTMS for smoking cessation on a scalable level. It aimed to determine whether rTMS at this site would increase the likelihood of abstinence from smoking and have a decremental effect on cravings 6 months after the treatment sessions in comparison to counseling alone.
Fifty-four subjects were recruited through word of mouth, the tobacco dependence treatment clinic at the Okasha Institute of Psychiatry and social media announcements. Current cigarette and/or waterpipe smokers of both genders between the ages of 18 and 60 who were willing to quit smoking and comply with the study procedures were included. To control for confounders, subjects with history of mental illness such as: Bipolar disorder, Psychotic illness, Major Depression with psychotic features, OCD or eating disorders were excluded. Subjects with contraindication to rTMS (history of neurological disorder or seizure, increased intracranial pressure, brain surgery, or head trauma with loss of consciousness for > 15 minutes, implanted electronic device, metal in the head, or pregnancy), history of autoimmune, endocrine, viral, or vascular disorder affecting the brain; history or MRI evidence of neurological disorder that would lead to local or diffuse brain lesions or significant physical impairment, or unstable cardiac disease, uncontrolled hypertension, severe renal or liver insufficiency also were excluded.
After an informed consent and eligibility by the Mini International Neuropsychiatric Interview (M.I.N.I.) and electroencephalography, 70 subjects were randomized to both study arms and were further tested for level of dependence using Fagerstrom Test for Nicotine dependence- Arabic version (FTND)(Kassim et al., 2012) and Lebanese Waterpipe Dependence Scale-11 (LWDS-11)(Salameh et al., 2008) when indicated. Further assessment included a medical and smoking history, a physical examination and carbon monoxide (CO) monitoring using piCO+ Smokerlyzer®(CoVita Bedfont, n.d.). Baseline craving was measured and followed up during study visits using the Arabic Tobacco Craving Questionnaire-12 (ATCQ-12)(Albrithen and Singleton, 2015). Ten minutes of smoking cessation counselling, based on the 2008 update of the US Public Health Service guidelines (Fiore et al., 2008), were provided to all participants at each visit. Target quit date (TQD) was set within 10 days of starting rTMS sessions, typically after the 3rd session. The rTMS procedure involved using the Magventure R 30 (Magventure, n.d.) stimulator with a figure-eight coil. A protocol was chosen on the assumption that stimulation at such site would produce neuromodulation effects on the dopamine (DA) system with a number of sessions that may be acceptable for a scalable implantation treatment. The active rTMS protocol involved stimulation at a frequency of 10 Hz in 20 trains/day, 50 pulses/train, and inter-train interval of 15s done at 100% of the motor threshold (after identification of the resting Motor Threshold Potential (rMTP)) at the left dorsolateral prefrontal cortex, determined by moving the TMS coil 6 cm anterior to M1 along a parasagittal line. Subjects received 6 sessions over 2 weeks (3 sessions/week). Sham rTMS involved tilting the coil over left dorsolateral pre-frontal cortex touching the scalp with the same stimulation parameters. Participation was to be terminated upon request or in case of intolerable adverse events including intolerable headache and seizures.
At the end of the follow-up period, 54 subjects completed the trial. Subjects were followed up at weeks 2, 4, 12 for cravings using ATCQ-12 (telephonic after end of sessions) and Nicotine Use Inventory (NUI)(Koegelenberg et al., 2014) Subjects were additionally followed up using NUI at week 24 for continuing abstinence. Point prevalence of abstinence was defined as self-report of no smoking or other tobacco use the preceding 7 days. Continuous abstinence was defined as abstinence between quit day and follow-up time. Treatment response was defined as a 50% or more reduction in cigarette consumption per day at the end of the treatment trial.
Main findings indicated that 6 sessions of rTMS on the left DLPFC were not superior to sham treatment as regards 6-month abstinence or craving parameter reduction, however, there was a statistically significant reduction in exhaled carbon monoxide readings during the sessions and a statistically insignificantly higher treatment response in the active rTMS group. This finding, along with findings from other studies indicates that rTMS has a role as a smoking cessation aid, yet a more refined protocol has yet to be discovered to set a standard for treatment using this modality.