How best to get your patients to stop smoking. Dr Alex Bobak GP and GPSI in Smoking Cessation Wandsworth, London

Transcription

1 How best to get your patients to stop smoking Dr Alex Bobak GP and GPSI in Smoking Cessation Wandsworth, London 1

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3 Smoking can cause at least 14 different types of cancer 3

4 Smokers want to stop All smokers ~70% want to stop 1 ~30% try each year 2 ~2 3% succeed in stopping each year 3 1. Bridgwood A et al. General Household Survey West R Getting serious about stopping smoking Arnsten RP. Prim Psychiatry

5 3 Keys to stopping successfully: l Wanting to stop smoking But for 95-97% of smokers, wanting to stop is not enough 1 they need: l Good quality support l Evidence-based treatments 1. Hughes JR et al. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004; 99(1):

6 Long-term cessation rates No Pharmacotherapy Pharmacotherapy Willpower alone 3-5% 4-6% Support (trained adviser) 10-15% 20-30% 6

7 Proven smoking cessation interventions l Brief advice from a healthcare professional (especially a GP) l Behavioural support l Pharmacotherapy Nicotine Replacement Therapy Bupropion (Zyban) Varenicline (Champix) 7

8 Giving advice to smokers Smoking advice from a healthcare professional (HCP), especially a GP, can be one of the most important triggers for a quit attempt 8

9 What is the most common advice which GPs give to smokers? Advice to stop smoking 9

10 Problems with advice to stop l Negative message l Nagging l Nothing new l Encourages conflict and denial l Frustrating for both doctor and smoker l Takes longer l Puts you off doing it again 10

11 Ideas for a better form of advice? Advice on HOW to stop smoking 11

12 Long-term cessation rates No Pharmacotherapy Pharmacotherapy Willpower alone Support (trained adviser) 3-5% 4-6% (46% of attempts 1 ) (49% of attempts 1 ) 10-15% 20-30% (3.6% of attempts 2 ) 1. West R, Brown J. Smoking and Smoking Cessation in England London. April West R, Brown J. Smoking in England London. 12

13 Concept of Very Brief Advice (VBA) for smokers 1. Establish and record smoking status (QOF): Do you smoke?/are you still smoking? 2. Advise how to stop: The best way to stop is with support and treatment 3. Offer support and treatment (QOF): When you are ready just make an appointment with who is great!

14 VBA DELIBERATELY DOES NOT: advise smokers to stop ask how much or what they smoke even ask if they want to stop

15 Benefits of very brief advice (VBA): l Brief! (<30 seconds or it won t be used) l Records smoking status (future VBA as 70%+ relapse) l Opportunistic (suitable for almost any consultation) l Positive (or you put them off trying) l Not confrontational or nagging (not telling them to stop) l Informative (saying how to stop) l Engaging (new information) l Evidence-based l Satisfies QOF l NOT a smoking cessation consult (that s for next time) l Very simple: MINIMUM EFFORT, MAXIMUM REWARD 15

16 Modules on VBA: l RCGP module: Behaviour change in cancer prevention l National Centre for Smoking Cessation and Training module: l BMJ Learning website search VBA

17 Support options in order of likely effectiveness: l Group l One-to-one l Telephone helpline l Text messaging programmes l Stop smoking websites l Stop smoking books l Smartphone apps 17

18 Keys to good quality support in a General Practice : l The advisor l The consultations 18

19 Keys to a successful advisor l Willing l Available l Flexible l Empathetic l Skilled listener and communicator l Positive l Motivational l Realistic l Knowledge of smoking cessation l Cost-effective l i.e. should be carefully selected, not just delegated 19

20 Keys to successful consultations l Minimal delay l Smoker owns the attempt l Choice of support and treatment options l Systems to make treatments easy to obtain l Same advisor throughout l Not telling smoker to stop but how to stop l Routine use of CO monitoring l Expect and normalise failure l Enough time l Good record keeping (Targets!) 20

21 Pharmacotherapy for nicotine dependence l Nicotine Replacement Therapy (NRT) l Bupropion (Zyban) l Varenicline (Champix) 21

22 Nicotine Replacement Therapy (NRT) 22

23 Nicotine replacement therapy l Available in nine different forms l Based on nicotine weaning 1 l Significantly reduces withdrawal symptoms and cravings vs placebo 2 l Significantly increases smoking cessation rate vs placebo (odds ratio = 1.58) 3 l Standard regime is to start NRT on quit date l Treatment lasts 8 12 weeks l Combination use now routine 1. Thompson GH et al. Ann Pharmacother 1998;32: Henningfield JE N Engl J Med 1995;333: Stead LF et al. Cochrane Database Syst Rev CD

24 NRT- Use and dosage l Gum up to 15 or 25/day 2mg, 4mg or 6mg l Patch 16 or 24 hours Variety, all of 3 strengths l S/L tabs up to 40/day 2mg l Lozenges min 8 max 15/day 2mg or 4mg l Mini lozs up to 15/day 1.5mg or 4mg l Inhalator 6-12 cartridges/day 10mg l Nasal Spray up to 64 sprays/day 1mg l Oral Spray up to 64 sprays/day 1mg l Oral Strips up to 15 oral films/day 2.5mg 24

25 Plasma nicotine levels contrast between cigarettes and NRT 25 Plasma nicotine (ng/ml) Cigarette Spray Time (minutes) Gum/Inhalator/Tablet/Lozenge/Mini Patch Adapted from: Tobacco Advisory Group of the Royal College of Physicians

26 Considerations for patients using NRT l USE ENOUGH! Avoid under-dosing and irregular use l LONG ENOUGH! Don t stop early, continue 8 12 weeks l NOT A PUFF! Slower and less efficient source of nicotine than cigarettes so cannot compete 26

27 Bupropion (Zyban) 27

28 Bupropion SR l Non-nicotine prescription tablet originally developed to treat depression 1 l Modifies dopamine levels and noradrenergic activity 1 l Significantly increases smoking cessation rate vs placebo (odds ratio = 1.94) 2 1.Bupropion (Zyban) prescribing information. Available at 2.Hughes et al. Cochrane Database Syst Rev CD

29 Patient assessment for bupropion l INDICATIONS: Adults motivated to stop smoking l CONTRAINDICATIONS History of seizures History of eating disorder History of bipolar disorder CNS tumour Acute alcohol or benzodiazepine withdrawal Severe hepatic cirrhosis l Buproprion should not be used in pregnancy l Buproprion and its metabolites are secreted in breast milk l For full details refer to the SPC at 1. Bupropion (Zyban) Summary of product characteristics,

30 Patient assessment for bupropion l INTERACTIONS Antidepressants Antiepileptics Antivirals Atomoxetine Dopaminergics Hormone antagonists l CAUTIONS Elderly Predisposition to seizures eg drugs which lower seizure threshold, head trauma, diabetes Hepatic impairment Renal impairment 30

31 Dose of bupropion Quit date Days 1 6: Days 7 14: Days mg once daily 150mg twice daily 150mg twice daily Standard course 7-9 weeks Can be used for longer off license 31

32 Adverse events on bupropion Bupropion Placebo Insomnia Headache Dry mouth Nausea Bupropion in smokers with CVD. McRobbie

33 Varenicline (Champix) 33

34 Varenicline partial nicotine agonist Part blocking Reduces the pleasurable effects of smoking and potentially the risk of full relapse after a temporary lapse 1-4 Part Stimulating Relieves craving and withdrawal symptoms Coe JW. J Med Chem 2005;48: Gonzales D et al. JAMA 2006;296: Jorenby DE et al. JAMA 2006;296: Foulds J. Int J Clin Pract 2006;60:

35 Recruitment to abstinence Point prevalence abstinence (%) Drug treatment Varenicline (n=352) Bupropion SR (n=329) * Placebo (n=344) # ** Time (weeks) * p<0.001 Varenicline vs Placebo # p<0.001 Varenicline vs Bupropion SR ** p=0.13 Varenicline vs Bupropion SR Gonzales D et al. JAMA 2006;296:

36 Patient assessment for varenicline: l INTERACTIONS No clinically meaningful drug interactions l CAUTIONS Breastfeeding History of mental illness No specific contraindications Monitor mental state 1. Varenicline (Champix) Summary of product characteristics,

37 Patient assessment for varenicline: l INDICATIONS: Adults motivated to stop smoking l Not recommended in patients with end stage renal failure l Should not be used during pregnancy 1. Varenicline (Champix) Summary of product characteristics,

38 What about nausea? l Up to a third get nausea l Warn before prescribing l Usually self-limiting l Take with food or water l Can use anti-emetics?prochlorperazine (Stemetil) l Adjust dose 1. Varenicline (Champix) Summary of product characteristics,

39 Dose of varenicline Quit date Days 1 3: Days 4 7: Days 8 14: Days mg once daily 0.5mg twice daily 1mg twice daily 1mg twice daily Standard course 12 weeks Licensed for up to 24 weeks use 39

40 349 English General Practices 1 st Sept Oct ,546 adult smokers 81,545 NRT 6,741 bupropion 31,260 varenicline 40

41 Results and Conclusions l No evidence that patients prescribed varenicline or bupropion had higher rates of fatal or non-fatal self harm or treated depression compared with those on prescribed nicotine replacement therapy l These findings should be reassuring for users and prescribers of smoking cessation medicines 41

42 8144 smokers 4028 non-psych; 4116 psych 16 countries, 6 continents 30 th Nov th Jan varenicline 2034 bupropion 2038 NRT 2035 placebo 42

43 Primary Outcome Measure: Neuropsychiatric AE Composite Endpoint Participants with Events n/n, % Cohort Varenicline Bupropion NRT Placebo Non-psychiatric 13/ % 22/ % 25/ % 24/ % Psychiatric 67/ % 68/ % 53/ % 50/ % Overall (both cohorts) 80/ % 90/ % 78/ % 74/ % 1. Anthenelli R et al Lancet 2016: 43

44 Efficacy: Continuous Abstinence Rates (CARs) Non-Psychiatric and Psychiatric Cohorts * Non-Psychiatric Cohort Psychiatric Cohort Continuous Abstinence Rate (%) Varenicline (n=1005) Bupropion (n=1001) NRT (n=1013) Placebo (n=1009) 29.2* Varenicline (n=1032) Bupropion (n=1033) NRT (n=1025) Placebo (n=1026) 26.1* 26.4* 25.5* *p< vs. placebo **p= vs. placebo 20.4* 18.8* 18.5* 19.3* 18.3* * 13.0** Weeks 9 12 Weeks 9 24 Weeks 9 12 Weeks Anthenelli R et al Lancet 2016: 44

45 EAGLES conclusions l No significant increase in neuropsychiatric AEs in varenicline or bupropion compared with NRT patch or placebo l Varenicline more effective than placebo, NRT patch and bupropion l Bupropion and NRT patch more effective than placebo 45

46 Costeffectiveness of NRT, bupropion and varenicline 46

47 Cost-effectiveness of NRT and bupropion l From NICE guidance, 2002 l Both bupropion and NRT are considered to be among the most cost-effective of all healthcare interventions l Estimates of cost-effectiveness are below 2000 per Life Year Gained 47

48 Cost-effectiveness of varenicline l From NCSCT guidance, 2012 l The incremental cost-effectiveness ratio of varenicline compared with no pharmacotherapy has been estimated at between 950 and 1,140 per QALY gained l Prolonging treatment duration from 12 to 24 weeks has also been shown to be cost-effective, resulting in an ICER of 622 per QALY Shahab L. Cost-effectiveness of pharmacotherapy for smoking cessation. National Centre for Smoking Cessation and Training, London,

49 Cost Per Quality Adjusted Life Year Gained 25,000 24,000 Cost per QALY 20,000 15,000 10,000 14,000 5, ,554 * Intensive statin therapy over standard dose therapy in patients with acute coronary syndrome 0 Statins - starting treatment at 60 years Statins - starting treatment at 70 years * * Smoking cessation interventions (estimate 1) Smoking cessation interventions (estimate 2) 1. Ward S et al. White Rose Research Monograph eprints.whiterose.ac.uk/10911/. 2. Shahab L. Cost-effectiveness of pharmacotherapy for smoking cessation. National Centre for Smoking Cessation and Training, London,

50 NHS Annual Expenditure ( millions) (approx. millions expenditure annually) Statins 1 2 Smoking cessation interventions 1. Gibson L. BMJ 2004;328: NHS smoking statistics (England), April 2012 to March

51 The real world! English NHS Stop Smoking Services Data 51

52 English Stop Smoking Services % 4 week quit rates (DoH) Varenicline Bupropion NRT (Single or Combined) Statistics on NHS Stop Smoking Services: England, April to March, / / / / / / ; April to September

53 NHS Stop Smoking Services Guidance 2014 As all smokers should be given the optimum chance of success in any given quit attempt, licensed pharmacotherapy, currently nicotine replacement therapy (NRT), varenicline (Champix) and bupropion (Zyban) should all be made available in combination with intensive behavioural support. Varenicline or combination NRT offers smokers the best chances of quitting, and unless clinically contraindicated, should be available as first-line treatments to all clients Local Stop Smoking Services. Service delivery and monitoring guidance

54 Numbers Needed to Treat (NNT) to Obtain 1 Long- Term Quitter? l Brief advice = 40 (1) l Adding medication to behavioural support.. l NRT = 23 (2) l Bupropion = 20 (2) l Varenicline = 10 (2) 1. West (2006) 2. Cochrane Review. (2011) 54

55 Numbers Needed to Treat (NNT) to Prevent a Premature Death? l Brief advice = 80 l Adding medication to behavioural support.. l NRT = 46 l Bupropion = 40 l Varenicline = 20 55

56 E-Cigarettes Summary l About 3 million users in the UK (2017) l times safer than smoking l High false perception of harm l At least as effective as NRT for smoking cessation l Unregulated so great variability l Unlikely to cause any risk from passive vaping l May be addictive l No specific brands can be recommended as no trial data l One product (e-voke from British American Tobacco) is licensed for smoking cessation though not yet on the market 56

57 E-cigarette recommendations l First recommend varenicline, combination NRT and bupropion for cessation and if smokers won t use these, only then should you sanction use of e-cigarettes l Advise complete cessation of smoking with e-cigarettes not smoking reduction (45% e-cig users continue to smoke) 1 l Always recommend support- NHS stop smoking advisors paid the same to support quit attempts with e-cigs 1. Use of e-cigarettes (vapourisers) among adults in Great Britain. Action on Smoking and Health. May