The Roles of Primary Care and Pharmacotherapies in Smoking Cessation

1
The Roles of Primary Care and Pharmacotherapies
in Smoking Cessation

• Dr Alex Bobak
• GPSI (GP with Special Interest) in Smoking
  Cessation
• Wandsworth, London

2
3 keys to successful cessation

• Motivation to stop smoking
• Good quality support
• Evidence based treatments

3
Long term cessation rates
4
Role of Primary Care

• Identifying smokers
• Giving routine brief advice to direct them to
  good quality support and treatment (ie LSSS)
• Providing the support and treatment in house
  where possible

5
Keys to brief advice

• Brief! (or it wont be used)
• Positive (or you put them off trying)
• Not confrontational or nagging (not telling them
  to stop)
• Informative (saying how to stop)
• Evidence based
• Try to sell the service
• eg 30 Second Approach

6
Keys to good quality stop smoking service in a
General Practice

• The advisor
• The consultations

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Keys to a successful advisor

• Willing
• Available
• Flexible
• Empathetic
• Skilled listener and communicator
• Positive
• Motivational
• Realistic
• Knowledge of smoking cessation
• Cost effective
• ie. should be carefully selected, not just
  delegated

8
Keys to successful consultations

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

9
Pharmacotherapy for nicotine dependence

• Nicotine Replacement Therapy (NRT)
• Bupropion (Zyban)
• Varenicline (Champix)

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Nicotine replacement therapy
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Nicotine replacement therapy

• Available in six different forms- all effective
• Based on nicotine weaning1
• Significantly reduces withdrawal symptoms and
  cravings vs placebo2
• Significantly increases smoking cessation rate
  vs placebo (odds ratio 1.77)3
• Treatment lasts 812 weeks with gradual withdrawal

1. Thompson GH, et al. Ann Pharmacother
199832106775 2. Henningfield JE, N Engl J Med
199533311962033. Silagy C, et al. Cochrane
Database Syst Rev 2004. CD000146
CNS central nervous system
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NRT-Dosage and use

• Gum upto 15 or 25/day 2mg or 4mg
• Patch 16 or 24 hours 3 strengths
• S/L tabs upto 40/day 2mg
• Lozenges min 9 max 15/day 2mg or 4mg
• Inhalator 6-12 cartridges/day
• Spray upto 64 sprays/day

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Newer uses of NRT

• Combining patch and an acute NRT product (e.g.
  inhalator) improves efficacy 1
• NRT to aid reduction increases the rate of
  attempts to stop and long-term abstinence rates 2
• Starting patch 2-weeks before quit date probably
  improves efficacy 1

1 Stead, L.F., et al., Nicotine replacement
therapy for smoking cessation. Cochrane Database
Syst Rev, 2008(1) p. CD000146. 2 Moore, D., et
al., Effectiveness and safety of nicotine
replacement therapy assisted reduction to stop
smoking systematic review and meta-analysis.
Bmj, 2009. 338 p. b1024.
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• NRT
• Contra-indications
• NONE
• Cautions
• Tendency to local irritation
• Severe cardiovascular disease
• Uncontrolled hyperthyroidism
• Diabetes
• Hepatic and renal impairment
• Pregnancy and breast-feeding

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• NRT
• Adverse events
• Gastrointestinal disturbances
• Headache
• Dizziness
• Flu-like symptoms
• Dry mouth
• Rash and local irritation
• Insomnia
• MOST MAY ALSO BE DUE TO NICOTINE WITHDRAWAL

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Bupropion
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Bupropion SR

• Non-nicotine prescription tablet originally
  developed to treat depression1
• Modifies dopamine levels and noradrenergic
  activity1
• Significantly increases smoking cessation rate
  vs placebo (odds ratio 1.94)2

1.Bupropion (Zyban) prescribing information.
Available athttp//us.gsk.com/products/assets/us_
zyban.pdf 2.Hughes et al. Cochrane Database Syst
Rev 1996. CD000031
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Bupropion treatment regime

• Quit date in the second week or earlier if the
  patient feels ready to stop
• Treatment for 8 weeks

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• BUPROPION
• Contra-indications
• History of seizures, eating disorder or bipolar
  disorder
• A CNS tumour
• Acute alcohol or benzodiazepine withdrawal
• Pregnancy
• Breast -feeding
• Cautions
• Elderly
• Predisposition to seizures
• Hepatic or renal impairment
• Drug interactions eg antidepressants,
  antiepileptics

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Adverse events on bupropion in smokers with CVD.
McRobbie 2001
Bupropion
Placebo
25
24
20
18
15
13
12
11
11
10
10
6
5
0
Insomnia
Headache
Dry mouth
Nausea
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Varenicline
22
(No Transcript)
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Varenicline- partial nicotine agonist

• Part blocking
• Reduces the pleasurable effects of smoking and
  potentially the risk of full relapse after a
  temporary lapse1-4

• Part Stimulating
• Relieves craving and withdrawal symptoms1-3

1. Coe JW. J Med Chem 2005 483474-3477. 2.
Gonzales D et al. JAMA 2006 29647-55. 3.
Jorenby DE et al. JAMA 2006 29656-63. 4. Foulds
J. Int J Clin Pract 2006 60571-576.
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Recruitment to abstinence
Drug treatment
Varenicline (n352) Bupropion SR (n329) Placebo
(n344)
60 50 40 30 20 10 0
Point prevalence abstinence ()
0 4 8 12 16 20 24 28 32 36 40 44 48 52
Time (weeks)
Gonzales D, et al. JAMA 20062964755
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Dose of varenicline
Quit date

• Standard course 12 weeks
• Licensed for up to 24 weeks use

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• VARENICLINE
• Contra-indications
• Pregnancy
• Cautions
• Renal impairment
• History of psychiatric illness
• Breast-feeding
• Avoid abrupt withdrawal (3 withdrawal syndrome)

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Adverse events on varenicline compared with
placebo
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What about nausea?

• Warn before prescribing
• Usually self limiting
• Take with food or water
• Can use anti-emetics ?prochlorperazine
  (Stemetil)
• Adjust dose

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Varenicline- review evidence

• More effective than bupropion and NRT
• Suicide concerns but data from UK do not show
  increased rate compared with expected rates in
  smokers

Cahill, K., L.F. Stead, and T. Lancaster,
Nicotine receptor partial agonists for smoking
cessation. Cochrane Database Syst Rev, 2008(3)
p. CD006103.
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English Stop Smoking Services 2007/2008
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NICE Guidance on Stop Smoking Services Feb 2009

• The adviser should not favour one medication
  over another. The clinician and patient should
  choose the one that seems most likely to
  succeed.

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NHS Stop Smoking Services Guidance 09/10 Mar 2009

• Since all motivated quitters should be given
  the optimum chance of success in any given quit
  attempt, nicotine replacement therapy (NRT),
  Champix (varenicline) and Zyban (bupropion)
  should all be made widely available in
  combination with intensive behavioural support as
  first-line treatments.