Transcript Slide 1

Smoking cessation
and COPD
Philip Tønnesen, M.D., dr.med.
Dept. Pulm. Medicine
Gentofte Hospital
Copenhagen, Denmark
Disclosure
I have received consulting and
speaking fees and research
grants from many companies
who develop smoking cessation
medications, products and
services
Disclosure
First line drugs: Efficacy figures
from the Cochrane register
Sustained quit rates for 1-year (Risk Ratio)
NRT versus placebo1
1.58
(111 studies)
(95 % CI, 1.50-1.66)
Any type of NRT
Bupropion SR versus placebo2
1.85
(31 studies)
1.
2.
3.
Varenicline versus placebo3
2.33
(9 studies)
(95% CI, 1.95-2.80)
Silagy et al. Cochrane Database Syst Rev. 2008;jan 23(0):CD000146.
Hughes et al. Cochrane Database Syst Rev. 2008;(3) CD000031
Cahill et al. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD006103.
First line drugs: Efficacy figures from US
clinical guidelines
OR (95%CI)
Abstinence
rate
a
13.8
PLACEBO
1.0
MONOTHERAPIES
Varenicline
High dose nicotine patch
Nicotine gum (>14 weeks)
BupropionSR
COMBINATION THERAPIES
Patch + ad lib NRT
Patch + BupropionSR
Patch + inhaler
“
3.1 (2.5-3.8)
2.3 (1.7-3.0)
2.2 (1.5-3.2)
2.0 (1.8-2.2)
33.2
26.5
26.1
24.2
2
3.6 (2.5-5.2)
2.5 (1.9-3.4)
2.2 (1.3-3.6)
36.5
28.9
25.8
Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline.Treating Tobacco use and Dependence.: 2008 Update. Rockville, MD: U.S. Department
of Health
Smoking prevalence among COPD pt’s
in large RCT trials with ICS/LABA
Study
N
 INSPIRE
1,323
 ISOLDE
751
 TORCH
5,343
 TRISTAN
1,465
 EUROSCOP
647
 VESTBO
290
Age FEV1(%)
Smokers
65
1.3 (39%)
38%
64
1.4 (50%)
38%
65
1.2 (45%)
45%
63
1.4 (45%)
51%
53
2.5 (80%)
54%
59
2.4 (86%)
77%
Network meta-analysis of RCT’s in COPD (1)
8 trials included
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Lung Health Study
Hilberink
Tønnesen
Taskin
Wagena
Pederson
Crowley
Brandt
(Taskin
COPD
N=7,372
(N=5,887)
(N=392)
(N=370)
(N=404)
(N=255)
(N=64)
(N=49)
(N=56)
(N=499)
Prolonged abstinence rate
12 M: 34 % versus 9 % (NRT)
6 M: 16 % versus 9 % (NRT)
12 M: 14 % versus 5 % (NRT)
6 M: 16 % versus 9 % (BUP)
6 M: 30 % versus 19 %(BUP)
6 M: 27 % versus 16 %
6 M: 14 % versus 14 %
12 M: 32 % versus 16 %
12 M: 19 % versus 6 % (VAR))***
Efficacy of smoking cessation in COPD (2)
Odds ratio
Nothing/ usual care
Counselling alone
1.82 (0.96-3.34), P=0.07
Counselling +antidepres.
3.32 (1.53-7.21), P=0.002
Counselling + NRT
5.08 (4.32-5.97), P<0.001
Counselling + varenicline
4.04 (2.13-7.67) P<0.001
(1 study only) (CHEST, 2011)
Eur Respir J 2009;34:634-40
COPD cont.
Smoking cessation in COPD
Tønnesen et al, Chest 2006:
Nurse-conducted smoking cessation in patients with
COPD, using nicotine sublingual tablets and behavioral
support
Smoking cessation/reduction in COPD
(Tønnesen et al. Chest, 2006)
 370 COPD patients
 Age :62 years
 FEV1: 1.57 (56 % predicted)
 Cigarettes/day: 20
 FTND: 6.4
 High – low support, NRT – placebo 12 weeks
Smoking cessation in COPD
NRT versus placebo:
6 months quit rate: 23 % vs 10 %
12 months quit rate: 17 % vs 10 % (OR 2.0)
2 week to 12 months: 14 % vs. 5 %
SGRQ in COPD (12 Months)
Quitters
Reducers
Smokers
Symptoms
-28
-21
-2
Activity
-6
-8
-2
Impact
-8
-5
-4
Total score -10.9
-8.5
-2.9
Varenicline and COPD (mild-moderate)
Chest 2010, Tashkin et al
12 weeks
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Varenicline
Placebo
Numbers
250
254
Age
57
57
FEV1 %
71 %
69 %
Cig/day
25
24
18.6 %
5.6 %
Quitters
3-12 Months
Effect of smoking cessation interventions
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GPs short advice:
2%
Intensive behavioural support:
7%
Self-help material
1%
Proactive telephone counseling
2%
Nicotine products
7%
Bupropion
9%
Varenicline
11 %*
Intensive support+NRT/bupropion
13 -19 %
Intensive support + varenicline
18 - 22 %*
Modified from West et al, Thorax 2000; *Cochrane Library 2007-2008
Lung Health study 1
(1)
 10 clinical centers in US
 12 group sessions during the first 10 weeks
 4 sessions in the first week
 Target quit day
 Counselling
 Aggresive use of Nicotine 2-mg chewing gum
 Follow-up program with focus on relapse prevention,
stress mangement, weight gain
 Formal re-treatment when relapsed
Lung Health Study: Point prevalence
8 weekly individual visits with 2 mg nico-gum (2)
40
35
% quitters
30
25
20
S-I
U-C
15
(N=5587)
10
5
0
1-year
2-year
3-year
4-year
5-year
Recycling of smokers every 4 months in 5 years! NRT:2mg-GUM
Anthonisen NR, Connett JE, Kiley JP,et al. Effects of smoking intervention and the use of an inhaled anticholinergic
bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA 1994; 272: 1497-1505.
Mean FEV1 quitters and smokers (diff. 11-yrs: (3)
380 ml; diff smokers and interm: 100 ml;
3,5
3
FEV-1
2,5
2
Quitters
Smokers
1,5
1
0,5
0
Entry 1-year 2-year 3-year 4-year 5-year
11years
Smoking Cessation: Effects on
Mortality (4)
Sustained Quitter
Intermittent Quitter
Continuing Smokers
Rate of Death per 1000
Person-Years
4
3
2
1
0
CHD
CVD
Lung
Cancer
Other Respiratory Other
Cancer Disease
Unknown
Causes of Death
CHD=coronary heart disease; CVD=cardiovascular disease.
Athonisen et al. Ann Intern Med. 2005;142(4):233-239.
Weight change in the Lung Health Study (5)
10
9
Mean weight change
8
7
Male smokers
Male quitters
Female smokers
Female quitters
6
5
4
3
2
1
0
0
1
2
3
Year
4
5
Intensity of intervention
Minimal (<3 minutes) is effective (A)
Dose-response effect (person-to-person) (A)
Four or more sessions are especially effective (A)
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Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline.Treating Tobacco
use and Dependence.: 2008 Update. Rockville, MD: U.S. Department of Healthand
Human Services. Public Health Service. May 2008.
Brief intervention = 2 questions
 ”Do you smoke?” and if yes
 ” Have you considered to quit?”
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Very simple and short:
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Arrange referal to smoking cessation: a new
appointment, smoking cessation clinic, etc.
It’s the patients project to quit but your obligation to
support the smoker in the quitting attempt
 Good idea to have a card with address and phone
number
Smoking cessation by hospitalization (1)
 COPD patients: Hospitalization (N=247) vs. Usual care (N=231)
FEV1 % pred.:75 % Age: 52 years
 Hospitalization in Åre Hospital in Northern Sweden
 11 days, third day: target quit day, NRT; exercise, 1 hour daily meeting
with trained cessation nurses, educational program followed by weekly
telephone calls by nurses
After 2-3 months 2-4 days in hospital
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Sundblad, Larsson K, Nathell L, Nic Tob Res 2008;10:883-890
Smoking cessation by hospitalization (2)
Smoking cessation group
Usual care
1-year quit rate: 52 %
1-year quit rate: 7 %
3-year quit rate: 38 %
3-year quit rate: 10 %
Used NRT: 28 %
Used NRT: 14 %
Used BUP: 5 %
Used BUP: 5 %
Sundblad, Larsson K, Nathell L, Nic Tob Res
2008;10:883-890
What are we doing today in smoking
cessation?
Cost-effectiveness
Meta-analysis of cost effectivness of smoking
cessation after 25 years
Quit rate Cost per QUALY
Usual care
1.4 %
Minimal counselling
2.6 %
Intensive counselling 6.0 %
Intesive c. + pharma. 12.3 %
Hoogendoorn M et al. Thorax 2010;65:711-718
16.900 Euros
8.200 Euros
2.400 Euros
The US experiment
 Re-imbursement
 Insurance coverage of smoking cessation resulted in:
1. Higher rates of use of evidence-based therapies
2. Higher overall quit rates
3. Smoking cessation coverage in US 25 % (1997) to 90 %
(2003)2
1. Kaper et al 2006 Pharmacoeconomics 24(5): 453-64
2. McPhillips-Tangum et al. Prev Chronic Dis 2006 3; 1-11. Available from:
http://www.cdc.gov/pcd/issues/2006/jul/05_0173.htm
ERS Guidelines
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Aggressive smoking cessation is recommended i.e.
varenicline, NRT, bupropionSR, and counseling and
recycling
Data from NIV-COPD national register in
Denmark for 2010
 Ambulatory COPD patients in DK
 Asked about smoking habit
Oct.-Dec.
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(N=6167)
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Adviced to quit smoking
(1467)
75 %
91 %
July-Sept.
Jan.-June
75 %
66 %
92 %
88 %
Conclusion smoking cessation in COPD
 Counselling + NRT increases quit rate
 Counselling + BupropionSR increases quit rate
 Counselling + Varenicline increases quit rate
(study under publication)
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Retreatment after relapse increases long-term quit rate
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Tønnesen et al. ERS guidelines. ERJ 2008
Expect a 1-year quit rate of 15-35 % (point prevalence)
Take home meassage: Smoking cessation
in COPD
 Counselling + NRT/ BupropionSR or Varenicline for 6
months should be perscribed to COPD smokers
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Retreatment if the COPD patient relapse
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Tønnesen et al. ERS guidelines. ERJ 2008
“Last Request: Please Don’t Smoke” My step-father asked me to take
this picture of him after he regained consciousness in ICU. He lost the
fight with lung disease (Asbestosis, COPD, and Pnuemonia) Friday
morning. I will be away for a little while