The essentials of smoking cessation

1
The essentials of smoking cessation
Dr Alex Bobak GP and GPSI in Smoking Cessation
Wandsworth, London
2
Smoking the size of the problem

• Smoking is the largest preventable cause of
  disease and premature death in the world1
• More than 50 of long-term smokers die
  prematurely due to smoking-related diseases2

1. WHO Report on the Global Tobacco
Epidemicthe MPOWER package. Geneva, World
Health Organization, 2008 2. Doll R, et al. Br
Med J 2004328151927
3
Whats in a cigarette?
Nicotine
Tar
Arsenic
Ammonia
Toluene
Phenol
DDT
Nitrosamine
Naphthalene
Butane
HydrogenCyanide
Carbonmonoxide
Cadmium
Cigarette smoke contains more than 4,000
chemicals,including over 60 known carcinogens
and metabolic poisons
Ginzel KH. Whats in a cigarette? http//www.acsh.
org/publications/priorities/0102/nicotine.html
4
Why do people keep smoking?

• NICOTINE
• ADDICTION

HABIT
SOCIAL
5
The power of nicotine addiction

• 60 smoke again post MI (40 within 2 days)
• 50 smoke again post laryngectomy
• 50 smoke again post pneumonectomy
• 80 of women do not stop smoking during pregnancy

1. Bigelow GE et al. US DHHS 1986. 2. Himbury S
Br Med J 1995. 3. Davidson G et al. Thorax 1992.
4. ASH May 2004.
6
Mechanics of nicotine addiction
NucleusAccumbens(NAcc)
NIC
VentralTegmentalArea(VTA)
7
The dopamine triggered by inhaled nicotine
rapidly gets reabsorbed which leads to..
low mood and craving which leads to..
another cigarette..
8
Regular smoking leads to a 300 increase in
brain nicotine receptors
9
On stopping smoking

• It takes 24-48 hours for nicotine to leave the
  body
• It takes 8-12 weeks for the nicotine receptors to
  down-regulate

10
Smokers want to stop
All smokers
70 want to stop1
23 succeed in stopping each year3
30 try each year2
1. Bridgwood et al, General Household Survey
1998. 2. West, Getting serious about stopping
smoking 1997. 3. Arnsten, Prim Psychiatry 1996.
11
3 Keys to successful cessation

• Wanting to stop smoking
• Good quality support
• Evidence based treatments

12
Long term cessation rates
No Pharmacotherapy Pharmacotherapy (eg NRT)
Willpower alone 2-3 4-6
Support (trained adviser) 10-15 20-30
13
So what can we do about it?

• 1 BRIEF INTERVENTIONS
• Routine brief advice on HOW to stop from the
  whole practice team
• 2 IN HOUSE STOP SMOKING SERVICE
• Provide a good quality stop smoking service which
  is as accessible as possible

14
Keys to brief advice

• Brief! (or it wont be used)
• Positive (or you put them off trying)
• Not confrontational or nagging (not telling them
  to stop)
• Informative (saying how to stop)
• Evidence based
• Try to sell the service
• QOF with conscience!

15
Keys to a successful advisor

• Availability
• Flexibility
• Empathy
• Listening and communication skills
• Positive
• Motivational
• Realistic
• Knowledge of smoking cessation
• Cost effective

16
Keys to successful support

• Smoker owns the attempt
• Choice of support and treatment options
• Systems to make treatments easy to obtain
• Same advisor throughout
• Not telling smoker to stop but how to stop
• Routine use of CO monitoring
• Expect and normalise failure

17
Behavioural support

• Minimise motivation to smoke
• e.g. change routines, counter belief that smoking
  helps with stress
• Maximise motivation not to smoke
• e.g. foster desire not to let down the group or
  advisor, build sense of achievement
• Maximise self-regulatory capacity
• e.g. make a not a puff rule, give guidance on
  conserving mental reserves
• Optimise use of medication
• e.g. ensure adherence to dosing regimen, address
  concerns about side-effects

18
Nicotine replacement therapy

• Available in six different forms
• Based on nicotine weaning1
• Significantly reduces withdrawal symptoms and
  cravings vs placebo2
• Significantly increases smoking cessation rate
  vs placebo (odds ratio 1.77)3
• Treatment lasts 812 weeks with gradual withdrawal

1. Thompson GH, et al. Ann Pharmacother
199832106775 2. Henningfield JE, N Engl J Med
199533311962033. Silagy C, et al. Cochrane
Database Syst Rev 2004. CD000146
CNS central nervous system
19
NRT-Dosage and use

• Gum upto 15 or 25/day 2mg or 4mg
• Patch 16 or 24 hours 3 strengths
• S/L tabs upto 40/day 2mg
• Lozenges min 9 max 15/day 2mg or 4mg
• Inhalator 6-12 cartridges/day
• Spray upto 64 sprays/day

20
NRT

• All forms are effective
• Starting patch 2-weeks before quit date probably
  improves efficacy
• Combining patch and an acute NRT product (e.g.
  gum) improves efficacy
• NRT gum is effective in both gradual and abrupt
  cessation

Stead, L.F., et al., Nicotine replacement therapy
for smoking cessation. Cochrane Database Syst
Rev, 2008(1) p. CD000146.
21
Plasma nicotine levels contrast between
cigarettes and NRT
25 20 15 10 5 0
Cigarette
Spray
Plasma nicotine (ng/ml)
Gum/Inhalator/Tablet/lozenge
Patch
10
0
20
40
30
50
60
Time (minutes)
Adapted from Tobacco Advisory Group of the Royal
College of Physicians 2000.
22
Considerationsfor patients using NRT

• USE ENOUGH! Avoid under-dosing and irregular
  use.
• LONG ENOUGH! Dont stop early, continue 8-12
  weeks.
• NOT A PUFF! Slower and less efficient source
  of nicotine than cigarettes so can not compete.

23
Bupropion (Zyban)

• Non-nicotine prescription tablet originally
  developed to treat depression1
• Modifies dopamine levels and noradrenergic
  activity1
• Significantly increases smoking cessation rate
  vs placebo (odds ratio 1.94)2

1.Bupropion (Zyban) prescribing information.
Available athttp//us.gsk.com/products/assets/us_
zyban.pdf 2.Hughes et al. Cochrane Database Syst
Rev 1996. CD000031
24
Varenicline (Champix)

• Specifically designed
• Oral prescription medicine
• Targets the ?4?2 nicotinic acetylcholine
  receptor

1. Coe JW. J Med Chem 2005 483474-3477. 2. Dani
JA, Harris RA. Nature Neuroscience 2005
81465-1470.
25
(No Transcript)
26
Varenicline- partial nicotine agonist

• Part blocking
• Reduces the pleasurable effects of smoking and
  potentially the risk of full relapse after a
  temporary lapse1-4

• Part Stimulating
• Relieves craving and withdrawal symptoms1-3

1. Coe JW. J Med Chem 2005 483474-3477. 2.
Gonzales D et al. JAMA 2006 29647-55. 3.
Jorenby DE et al. JAMA 2006 29656-63. 4. Foulds
J. Int J Clin Pract 2006 60571-576.
27
Recruitment to abstinence
Drug treatment
Varenicline (n352) Bupropion SR (n329) Placebo
(n344)
60 50 40 30 20 10 0
Point prevalence abstinence ()
0 4 8 12 16 20 24 28 32 36 40 44 48 52
Time (weeks)
Gonzales D, et al. JAMA 20062964755
28
12 week quit rates
Continuous quit rate weeks 9 12 ()
n692
n669
n684
varenicline vs. bupropion OR 1.87 (95 CI 1.40,
2.34), plt0.0001 varenicline vs. placebo OR
3.69 (95 CI 2.88, 4.72), plt0.0001
Primary endpoint Pooled Analysis, comparator
studies 1 2 (n2,045)
1. Gonzales DH et al. Presented at 12th SRNT,
15-18th Feb, 2006, Orlando, Florida. Abstract
PA9-2.
29
52 week quit rates
Continuous abstinence rate weeks 9 - 52 ()
n692
n669
n684
varenicline vs. bupropion OR 1.56 (95 CI 1.19,
2.06) plt0.0013 varenicline vs. placebo OR 2.82
(95 CI e.06, 3.86), plt0.0001
Secondary endpoint Pooled Analysis Comparator
Studies 1 2 (n2,045)
1. Gonzales DH et al. Presented at 12th SRNT,
15-18th Feb, 2006, Orlando, Florida. Abstract
PA9-2.
30
End of treatment quit rate
31
52 week quit rate
32
English Stop Smoking Services 2007/2008
No. Setting Quit Date Quit at 4 Weeks Quit Rate
NRT 474,311 231,601 49
Zyban 22,348 11,923 53
Champix 97,259 60,864 63
33
Adverse events on varenicline compared with
placebo
34
What about nausea?

• Warn before prescribing
• Usually self limiting
• Take with food or water
• Can use anti-emetics ?prochlorperazine
  (Stemetil)
• Adjust dose

35
12 vs 24 Weeks Use Results
Varenicline 24 wks Varenicline 12 wks
P0.02 OR 1.34
70.5
of Patients
43.6
49.6
36.9
Week
Tonstad S, et al. JAMA. 200629664-71.
36
Use of varenicline

• INDICATIONS
• Adults motivated to stop smoking
• CONTRAINDICATIONS
• Hypersensitivity to varenicline
• INTERACTIONS
• No clinically meaningful drug interactions

37
Special Populations

• Renal failure
• End stage - not recommended
• Severe reduce dose to 1mg daily
• Psychiatric illness (eg depression)
• monitor closely as stopping smoking may
  exacerbate illness
• Pregnancy, Breastfeeding, Under 18s, Epilepsy
• not investigated

38
Dose of varenicline
Days 1 3 0.5mg once daily
Days 4 7 0.5mg twice daily
Days 8 14 1mg twice daily
Days 15 1mg twice daily
Quit date
39
NICE Guidance on Stop Smoking Services Feb 2009

• The adviser should not favour one medication
  over another. The clinician and patient should
  choose the one that seems most likely to
  succeed.

40
NHS Stop Smoking Services Guidance 09/10 Mar 2009

• Since all motivated quitters should be given
  the optimum chance of success in any given quit
  attempt, nicotine replacement therapy (NRT),
  Champix (varenicline) and Zyban (bupropion)
  should all be made widely available in
  combination with intensive behavioural support as
  first-line treatments.

41
Numbers Needed to Treat (NNT) to Obtain 1
Long-Term Quitter?

• Brief advice (lt5 mins) 40(1)
• Adding medication to behavioural support..
• NRT 20(2)
• Bupropion 15(2)
• Varenicline 8(2)

1. West (2006) 2. Cochrane Review. (2007)
42
Numbers Needed to Treat (NNT) to Prevent a
Premature Death?

• Brief advice (lt5 mins) 80
• Adding medication to behavioural support..
• NRT 40
• Bupropion 30
• Varenicline 16