Helping People Quit Tobacco Peter Selby MBBS, CCFP, MHSc, ASAM Associate Professor, University of Toronto Clinical Director, Addictions Program, CAMH Principal Investigator, OTRU Disclosures! Grants/research support: - CAMH, Health Canada, Smoke Free Ontario, MHP, CTCRI, CIHR - Alberta Health Services, Vancouver Coastal Authority - Pfizer Canada, OLA, ECHO, NIDA, CCS, CCO! Speakers bureau/honoraria: - Schering Canada, Johnson & Johnson Consumer Health Care Canada - Pfizer Inc. Canada, Pfizer Global, Sanofi-Synthelabo Canada, - GSK Canada, Genpharm Canada, Prempharm Canada, NABI Pharmaceuticals! Consulting fees: - Schering Canada, Johnson & Johnson Consumer Health Care Canada, - Pfizer Inc. Canada, Pfizer Global, Genpharm Canada, - Prempharm Canada, NABI Pharmaceuticals, V-CC Systems Inc., - ehealth Behaviour Change Software Co.! Research funding: Schering Canada (Buprenorphine training 2000)! No tobacco or alcohol or food industry funding 2 1
Disclaimer! Although I will be speaking about medications, the information presented is for educational purposes only! The decision to prescribe or administer a medication should be made by qualified and trained healthcare professionals! National and regional variations determine which professional groups might be authorized to prescribe these medications! No endorsement of any particular method should be inferred by the presenter or the sponsor 3 Why Do People Quit Tobacco?! Health effects! Cost! Social pressure 4 2
When Do People Quit?! Most quit in their 30s and 40s! Quit at 30 = normal life expectancy! Quit at 40 = 9 years QALY gained! Quit at 60 = 3 years QALY gained! Some don t quit at all and die from a smoking-related illness! Remind smokers that it is never too late to quit! Sources: Gellert et al. (2012). Arch Intern Med, 172(11): 837-844. (Invited Commentary); Doll et al. (2004). BMJ, 328(7455):1529 1533. 5 Two Frameworks for Effective Interventions! A = Ask all smokers about their use of tobacco in the last six months! A = Advise every smoker to quit as soon as possible! A = Assess their readiness to quit! A = Assist them by counseling and/or prescribing medications! A = Arrange for follow-up Source: United States Department of Health and Human Services. (2008). Clinical Practice Guideline: Treating Tobacco Dependence Update. Retrieved from, http://www.ahrq.gov/clinic/tobacco/treating_tobacco_use08.pdf 6 3
Two Frameworks for Effective Interventions! A: Ask about smoking! W: Warn your smoking patients that with continued smoking, the chance of death from smoking-induced diseases is 50%! A: Advise that by quitting, risk is greatly reduced (25% at old age and much more before the age of 40)! R: Refer to a cessation clinic or hotline! D: Do it again until they quit 7 How Do People Quit Tobacco?! Policies lead to increased motivation to quit! Spontaneous quitting! Self-help! Behavioral therapy (brief to intensive) - Quitlines - Support groups - Individual interventions! Pharmaceutical quit aids Image source: istockphoto.com 8 4
Natural History of Quitting 9 Quit Attempts 10 5
Levels of Interventions Text sources: Piper et al. (2009). Archives of General Psychiatry, 66: 1253-1262; USDHHS, Clinical Practice Guidelines. (2008); Image source: Daniel Bachhuber. Creative Commons BY-NC-ND. http://www.flickr.com/photos/ danielbachhuber/3228358059/in/photostream/ 11 Self-Help Interventions! Systematic review of 68 trials - Statistically significant pooled effect in self-help versus no intervention (RR=1.21; 95%CI=1.05-1.39) - No effect found when control condition involved other written materials - No added benefit of self-help materials to face-to-face counseling or NRT - Some benefit of tailoring materials to individual (RR=1.31; 95% CI=1.20-1.42) May be due to additional contact between the patient and the clinician Source: Lancaster & Stead. (2009). Cochrane Database of Syst Rev (3):CD001118. 12 6
Cessation Groups! Allow the clinician to reach a larger number of people! More cost-effective than individual therapy! Clients have a forum to share experiences, accountability to the group, encouragement! Role models in other smokers who are further along in quit process! Opportunity to practice smoke-free social interactions 13 Cessation Groups Effectiveness! Systematic review of 53 trials! Chances of quitting are nearly doubled with group programs when compared to self-help (RR=1.98; 95% CI= 1.60-2.46)! Groups are more effective than no treatment! No significant outcome difference between individual and group counseling! Limited evidence for increased success of combining group with other treatments Source: Lancaster & Stead. (2009). Cochrane Database of Syst Rev (3):CD001118. 14 7
Individual Behavioral Therapy! Systematic review of 30 trials containing over 7,000 participants! Individual counseling was more effective than minimal behavioural intervention for long-term cessation (RR=1.39; 95%CI=1.24-1.57)! No effect of intensive versus brief counseling! No effect of different counseling methods of similar intensity! Some evidence of individual therapy as effective addition to NRT (RR=1.27; 95%CI=1.02-1.59) Source: Lancaster & Stead. (2005). Cochrane Database of Syst Rev (2):CD001292. 15 Intensity and Length of Contact Session length Estimated abstinence rate No contact 10.9% < 3 minutes 13.4% 3 10 minutes 16.0% > 10 minutes 22.1%! Need to treatment match! Not everyone needs intensive interventions! Doubling intensity does not double quit rates Source: United States Department of Health and Human Services. (2008). Clinical Practice Guideline: Treating Tobacco Dependence Update. Retrieved from, http://www.ahrq.gov/clinic/tobacco/treating_tobacco_use08.pdf 16 8
Intensity and Length of Contact Total contact time Estimated abstinence rate None 11.0% 1-3 minutes 14.4% 4-30 minutes 18.8% 31-89 minutes 26.5% 90-300 minutes 28.4% > 300 25.5%! Need to consider resources available Source: United States Department of Health and Human Services. (2008). Clinical Practice Guideline: Treating Tobacco Dependence Update. Retrieved from, http://www.ahrq.gov/clinic/tobacco/treating_tobacco_use08.pdf 17 Quitlines! Telephone quitlines can offer cessation support via: - Mail-outs - Recorded messages - Over-the-phone counseling - Call backs - Pharmacotherapy access Image source: istockphoto.com 18 9
Quitline Efficacy! Systematic review of 8 trials, pooled data from 18,500 participants! Call-back counseling found to be beneficial compared to control (OR=1.41; 95%CI=1.27-1.57)! Some dose-response effect (but may be due to higher motivation)! Not enough evidence to determine differences between support type Source: Stead et al. (2007). Tob Control, 16(1): 13-18. 19 Pharmacological Interventions! Can increase motivation to stop or make a quit attempt! Can increase confidence when making quit attempt! Deterrent to smoking! Reduce to quit (RTQ)! Maintenance, relapse prevention! Treatment type depends on patient 20 10
Approved Smoking Medications! First-line medications - Nicotine patch - Nicotine gum - Nicotine inhaler - Nicotine lozenge - Nicotine nasal spray - Bupropion - Varenicline Image source: istockphoto.com 21 Pharmacotherapy for Smoking Cessation Medication Nicotine replacement therapy Bupropion Varenicline Treatment length [1] Main side effects [2] Gum Lozenge Patch Inhaler 8-12 weeks (up to 1 year) Dizziness Dyspepsia Hiccups Mouth irritation Nausea/ vomiting Sore jaw/ throat 8-12 weeks (up to 1 year) Diarrhea Flatulence Heartburn Hiccups Mouth irritation Nausea Sore jaw 8-12 weeks (up to 1 year) Disturbed sleep (insomnia, abnormal/ vivid dreams) Headache Site irritation 8-12 weeks (up to 1 year) Coughing Irritation of throat and nasal passages Stomatitis 8 weeks (up to 1 year) Dry mouth GI disturbance Insomnia Jitteriness Nausea Seizure 12 weeks (up to 24 weeks) Bad taste Constipation Flatulence Nausea Sleep disturbances Dosage 2mg 4mg 2mg 4mg 5, 10, 15mg or 7, 14, 21mg 6-12 cartridges per day 150-300 mg/ day 0.5mg qd to 1mg bid Efficacy at six months or later (RR [95% CI]) [3],[4],[5] 1.43 [1.33-1.53] (53 trials) 2.00 [1.63 to 2.45] (6 trials) 1.66 [1.53 to 1.81] (41 trials) 1.90 [1.36-2.67] (4 trials) 1.69 [1.53-1.85] (36 trials) 2.31 [2.01-2.66] (10 trials) Sources: [1] Le Foll & George. (2007). CMAJ, 177(11): 1373-1380; [2] e-cps [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2007, cited on September 14, 2011, from: http://www.e-cps.ca; [3] Stead et al. (2008). Cochrane Database of Syst Rev (1): CD000146; [4] Hughes et al. (2007). Cochrane Database of Syst Rev (1):CD000031; [5] Cahill et al. (2011). Cochrane Database of Syst Rev (2):CD006103 22 11
Nicotine Replacement Therapy! Nicotine replacement therapy - Provides the body with nicotine to help minimize withdrawal symptoms and cravings - Eliminates toxic substances one gets from cigarettes - Shown to almost double quit rates - Most effective when combined with counseling - Can be used to help reduce smoking Can start before quit date - A behavioral intervention may be more effective for those who smoke 10 cigarettes or less or for non-daily smokers Source: Stead et al. (2008). The Cochrane Collaboration, (1):CD000146 23 Pharmacotherapy! Bupropion - Antidepressant - Nearly doubles chances of quitting (RR=1.69; 95%CI=1.53-1.85) - No evidence that adding bupropion to NRT increases effectiveness - Shown to minimize weight gain associated with quitting smoking - Contraindications include: seizure history, active eating disorder, MAOI medications, sensitivity to bupropion Source: Hughes et al. (2007). Cochrane Database of Syst Rev (1):CD000031. 24 12
Pharmacotherapy! Varenicline - Reduces withdrawal and craving - Prevents pleasurable effects of smoking - α4β2 nicotinic acetylcholine receptor partial agonist - Long-term effectiveness - Some debate regarding safety - Systematic review of 14 trials determined more effective than placebo (R=2.27; 95%CI=2.02-2.55) - Some benefit over NRT (RR=1.13, 95%CI=0.94-1.35) and bupropion (RR=1.52; 95% CI=1.22-1.88) Sources: Cahill et al. (2011). Cochrane Database of Syst Rev (2):CD006103; Cahill et al. (2012). Cochrane Database of Syst Rev (4):CD006193. 25 Second-Line Medications! Use at physician s discretion (first-line medications unsuccessful)! Not approved as smoking cessation aids! Clonidine - Antihypertensive - Helps to reduce withdrawal! Nortriptyline - Antidepressant - Two studies demonstrated increased abstinence rates 26 13
What About Chewing Tobacco?! Behavioral interventions appear to increase quit rates! Some additional benefit from telephone counseling and oral examination! Negative findings regarding NRT patch and bupropion for long-term cessation but some short-term benefit! Varenicline might benefit Swedish snus users* *Source: Ebbert et al. (2011). Cochrane Database of Syst Rev (2):CD004306. 27 What About Shisha?! No studies done to demonstrate the efficacy of any particular intervention! Trial of behavioral therapy 28 14
The Future! Vaccines prevent nicotine from reaching the brain! Transcranial magnetic stimulation! Cytisine Text sources: Ottney. (2011). Pharmacotherapy, 31(7): 703-713; Brody & Cook. (2011). Biol Psychiatry, 70: 702-703; West et al. (2011). New England Journal of Medicine, 365: 1193-1200; Image source: istockphoto.com 29 Helping Patients to Quit Tobacco If you have helped two smoking patients quit, you have saved at least one life. Text source: Gellert et al. (2012). Arch Intern Med, 172(11): 837-844. (Invited Commentary); Image source: istockphoto.com 30 15