Transcript Understanding smoking behaviour

Getting the most out of
current treatments
Peter Hajek
Do we need to get more out of
current treatments?

Treatments we have are effective, but
with a large scope for improvement

Stop-smoking services have some 15%
long-term quit rate, much better than 5%
for unaided quit attempts, but still
helping only a minority of clients
Possible improvements

Do not provide ineffective treatments

Keep up-to-date and use new treatment
variations when available

Participate in research
Ineffective treatments:
Examples from secondary care
Stop-smoking interventions in
acute and maternity services:
Review of effectiveness
Report for the
National Institute for Health and Clinical Excellence
Katie Myers, Hayden McRobbie, Peter Hajek
25 April 2012
Method

19,520 abstracts screened

179 papers included
Summary of results
Brief interventions and interventions with
follow-up under 4 weeks are not effective,
with or without meds
 Interventions providing support for over 4
weeks in combination with medications are
effective
 Front-line healthcare staff should focus on
referring smokers to SSS

And yet
Some services still focus on training
front-line staff to deliver brief
interventions known to be ineffective
 Referrals to SSS from hospitals remain
low. Lack of organisational support,
unclear referral pathways, obsolete
training templates
 See survey of UK services by B. Proctor

To join the Secondary Care
Services Network

E-mail Barnie Proctor on
[email protected]
Changing profile
of UK smokers
When smoking rates are high, there are
many smokers who benefit from brief
interventions
 When ‘low-hanging fruit’ is gone, remaining
smokers are increasingly ‘treatment
resistant’ (mental health problems, re-attenders, etc.)
 New priorities: Intensive treatments and
harm-reduction approaches

Conclusions

Smokers seeking help should be referred
for specialist intensive treatment rather
than for brief interventions

Such treatment should be the core focus
of stop-smoking services
Can we do better with
medications we have?
The field has been remarkably
conservative
NRT did not improve for over 30 years !!!
 Varenicline: no change since launch 7
years ago

 The
curse of medicinal licensing
 stops
product development
 stops variation in use
Old NRT products
UK is more liberal with NRT than other
countries
 Our licensing allows

 Extended
use
 Pre-loading
 Combinations and increased
dosing
Using NRT for longer
Using NRT for longer
Cochrane: Use for 8 or cca 12 weeks, NS
 New(ish) study: Patches for 2 or 6 months

 2M
nicotine patches + 4M placebo in controls
Effect at 6 months (continuous abstinence
13% vs 19%)
 No effect at 1 year: 1% vs 0.7% (14% vs
15% 1-week abstinence)

 Different
from use for RP
Schnoll et al. Ann Intern Med 2010,152,144-151
Using NRT prior to quitting
Using NRT prior to quitting (?)
First review +++ *; second review: little
effect **
 NIHR study (Aveyard et al) on-going;
patch or no patch for 4 weeks pre-quit
 Used by some with priority groups to
facilitate quitting or reduce harm
 Anecdotally useful, licensing allows it

* Shiffman&Ferguson (2008) Addiction 103:557-563
** Lindson&Aveyard (2011) Psychopharmacology 214:579-592.
Should you ask smokers to cut
down when pre-loading?

In theory, this could be counterproductive.
The aim is to make cigarettes less
rewarding via extinction process, cutting
down is likely to make remaining cigs
more rewarding
Tailor NRT dose to response
Tailor NRT dose to response (?)
Increase dose during pre-loading until cig
consumption and enjoyment are affected
 (‘Non-reactor’ into ‘reactors’)
 Licensing allows it (to a degree)
 Anecdotally effective
 Studies needed with high dosing
 Services willing to help – e-mail me

E-cigarettes (EC)
E-cigarettes (?)
The most promising development by far,
needs time to evolve to kill off cigarettes
 Recent UK ruling will prevent that after 2016
 But EC are almost certainly good enough
already as treatment, though
 No RCTs yet
 Already used in priority groups, service
guidance needed

Good nicotine delivery and
craving relief (Vansickel et al, Addiction 2012)

20 smokers

6 x 10-puff
Matches cigs in experienced users
Vansickel & Eissenberg Nicotine & Tobacco Research 2012
8 experienced e-cig users,
abstained overnight
Used their own EC
10 puffs and then 1 hour of
ad-lib use
Helps smokers unwilling to
quit (Polosa et al BMC Public Health 2011)
 40
smokers who did not want to quit
 EC to reduce smoking

At 6-month
 23%
stopped smoking
 Another 46% reduced by 50% or more

‘If I had a brother, or a child, or friend
who smoked, I would try to get them
thinking about e-cigs’
Lynn Kozlowski, 2013
What we tell patients attending
our clinics and asking about EC?

Do you recommend using them to quit?


For now we prefer you to use NRT or Champix, but
fine to try EC in addition to this. They may help as an
extra aid. If you have a go, let us know next week if
you found them helpful
Are they safe?

They are much safer than cigarettes. More research is
needed to see whether they are completely safe
Champix
Champix pre-loading
Champix pre-loading

Varenicline acts in two ways
 Alleviates
withdrawal discomfort
 Reduces ‘reward’ associated with smoking

Current treatment starts 1-2 weeks prequit at low dose, makes little use of the
second mechanism
What happens if cigs give
less satisfaction?
The behaviour should start to
‘extinguish’ – gradual decrease
 The cues linked to the sight and smell of
cigarettes which normally elicit urges to
smoke may weaken as well
 After quitting smoking, cigarettes may
be missed less and so withdrawal
discomfort may be lowered

Champix pre-loading study

Placebo or Champix started 4 weeks
pre-quit

All on Champix from 1-week pre-quit
Hajek et al. (2011) Arch Intern Med. 171(8):770-7
Effect on cotinine prior to TQD
450
Salivary cotinine concentration (ng/ml)
400
350
300
250
200
150
100
50
0
Baseline
Week 3
Time
varenicline (n=47)
Quit Date
placebo (n=41)
Enjoyment of cigarettes
5
4
Rating
(1=much more
enjoyable;
3
3=same as
before; 5=much
less enjoyable)
2
1
Baseline
Week 1
varenicline (n=35)
Week 2
Time
placebo (n=36)
Week 3
Quit Day
Abstinence
Placebo
Varenicline Significance
pre-loading pre-loading
(n=48)
(n=53)
12 weeks
Sustained
abstinence
21%
47%
p=0.005
Conclusion

Varenicline pre-loading seems to facilitate
quitting
 Pre-quit
reduction now confirmed in 2 other
trials *

Product labelling allows pre-quit use for up
to 5 weeks before TQD
* Hawk et al. Clin Pharmacol Ther. 2012; 91(2):172-80
* Ashare et al. J Psychopharmacol 2012; 26(10): 1383–1390
Champix plus NRT
Champix + NRT
N=116, all on Champix
 From TQD nicotine or placebo patch
 No effect of withdrawal ratings or on
abstinence rates

 Effect
possibly on Champix non-reactors?
Hajek et al. (2013) BMC Medicine 11:140
Abstinence (%)
Period after
TQD
Placebo Patch
(n=59)
Nicotine patch
(n=58)
24 hours
80
79
NS, p = 0.96
1 week
59
69
NS, p = 0.28
4 weeks
59
60
NS, p = 0.91
12 weeks*
29
36
NS, p = 0.39
* self-reported
Significance
Tailor Champix dose
to response
Tailor Champix dose to
response
Increase dose during pre-loading until cig
consumption and enjoyment are affected
 (‘Non-reactors’ into ‘reactors’)
 Dose increase not licensed, so limited to
research
 Study completed, results to be reported
soon and clinical implications covered at
Annual Update

Annual Update and
Supervision Day: 2013
2. December
Details from Janice Rossabi,
[email protected]
Summary
Use the best treatments, not the second best
 Old NRT:

 Pre-loading:
Wait for trial results
 Dose-to-response: Trial needed

New NRT:
 E-cigs:

Use as supplement, follow trial results
Champix:
 Use
pre-loading
 Dose-to-response: Wait for trial results