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Getting the most out of current treatments Peter Hajek
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
19,520 abstracts screened
179 papers included
Method
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
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 remarkablyconservative
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 allowsExtended usePre-loadingCombinations 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
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
Helps smokers unwilling to quit (Polosa et al BMC Public Health 2011)
‘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 pre-quit 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
Enjoyment of cigarettes
Abstinence
Placebo pre-loading
(n=48)
Varenicline pre-loading
(n=53)
Significance
12 weeksSustained 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 (%)
* self-reported
Period after TQD
Placebo Patch (n=59)
Nicotine patch (n=58)
Significance
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
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
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
