Smoking reduction

1
Smoking reduction

• Philip Tønnesen, M.D.,
• Department of Pulmonary Medicine
• Copenhagen, Denmark

2
Tobacco control

• Prevention Smoking cessation
• Smoking reduction

3
Nicotine replacement

• 17 of NRT is used for other than smoking
  cessation! i.e.
• 60 use NRT lt 2 weeks
• 40 no instruction (GP or pharmacit)
• Temporary abstinence during work, travel
• Smoking reduction

4
Smokers in the Netherlands
100
New smokers to reach with Reduction to Stop
Happy smokers 34
80
Wants to reduce 16
Smokers
60
Reduces now 17
Unhappy (ambivalent) smokers 66
40
Wants to stop 29
20
Stops today 4
0
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Smoking Reduction

• Rationale
• Aimed for smokers low in motivation to quit /
  unable to quit
• Induction of permanent change in smoking habit
• Compensation not 100
• Will not interfere with smoking cessation

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Smoking Reduction

• Cigarettes ? NRT use
• Definition arbitrary
• Cigarettes/day lt 50 of entry numbers
• plus any decrease in CO (1 ppm or gt)

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Cessation-induction
Ready to reduce smoking
NRT increases reduction
Self-efficacy increased
Intention to quit increased
Increased probability of a quit attempt
NRT prior to quittingdecreases relapse
Reducing prior to quittingdecreases relapse
Increased abstinence
8
Clinical Studies
9
Gum and Inhalator Increase the Likelihood of
Successful Sustained Reduction (2 Inhaler, 4 Gum
studies)


plt0.001



Sustained Smoking Reduction From Week 6 (at
least 50 reduction, verified by a lowered CO)
10
Gum and Inhalator Increase the Likelihood of
Successful Cessation (2 Inhaler, 4 Gum studies)

plt0.001




Point Prevalence Cessation Rates (complete
cessation, verified by a CO lt 10 ppm)
11
Smoking reductionWennike, Tønnesen et al.
Addiction 2003

• 411 smokers
• 24 cigarettes/day
• Motivation to reduce on 10-cm VAS 9
• Motivation to quit on 10-cm VAS 5
• Nicotine gum for up to 12 months

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Smoking reductionWennike, Tønnesen et al.
Addiction 2003

• Reduction (sustained)
• Active Placebo
• 4-months 14 5 (plt0.002)
• 1-year 8.8 1.5 (plt0.001)
• 2-years 6.3 0.5 (plt0.001)

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Smoking reductionWennike, Tønnesen et al,
Addiction 2003

• Cessation (point)
• Active Placebo
• 4 months 6.3 0.5 (plt0.001)
• 1-year 11.2 3.9 (plt0.005)
• 2-years 9.3 3.4 (plt0.01)

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Motivation to quit
15
Smoking cessation/reduction in COPD (Tønnesen et
al.In press)

• 370 COPD patients
• Age 62 years
• FEV1 1.57 (56 predicted)
• Cigarettes/day 20
• FTND 6.4
• High low support, NRT placebo 12 weeks

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Smoking reduction in COPD

• NRT versus placebo
• 6 months reduction rate 21 vs 15
• 12 months reduction rate 12 vs 13

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Smoking cessation in COPD

• NRT versus placebo
• 6 months quit rate 23 vs 10
• 12 months quit rate 17 vs 10 (OR 2.0)

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Reduction to quit with NRT OTC

• 3297 smokers in US
• 2-mg, 4-mg nicotine gum or placebo
• The first 8 weeks gardually reduce number of CPD
  and increase number of pieces of gum
• Abstinent 24 hours use gum as FDA recom
• Shiffman et al. Am J Prev Med 2009

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Reduction to quit with NRT OTC

• Results Odds ratio for quitting vs. placebo
• 1 Month 6 Months
• 2-mg gum 2.01 1.80
• 4-mg gum 4.66 5.90
• Reducers more likely to quit
• Shiffman et al. 2009

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Adverse events

• A review of 11 studies of NRT used for smoking
  reduction found no unexpected adverse events,
  while side effects that may possibly be related
  to nicotine overdose (such as nausea and
  vomiting) were evenly distributed between active
  and placebo treatment groups (Fagerström Hughes
  2002)
• No increase in cardiovascular events (Murray et
  al 1996) in concurrent use of NRT and smoking for
  up to five years

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Adverse events cont

• Use of nicotine 4 mg gum and smoking every hour
  (in order to attain unusually high plasma
  nicotine levels) revealed no evidence of adverse
  cardiac effects, even during exercise tests
  (Stahl et al 2001).
• The total nicotine intake remains broadly stable
  when smokers use NRT to reduce their cigarette
  smoking (Benowitz et al 1998)

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Conclusion Smoking reduction

• Reduction possible long-term
• Reduction leads to cessation
• NRT increase success rates
• Motivation to quit not decreased, but actually
  increased (55-80)
• Recruitment of new segment of smokers
• Effect on health ? (if lt 6 cig/day ?)

23
NRT and smoking reduction

• Fast acting NRT
• gum or inhaler,
• sublingual, loozenge
• (nasal spray) (mouth spray)
• 2. Use for 2-3 months If reduced to less than
  50 then continue with NRT

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Treatment of most smokers is possible
Motivated to quit
Motivated to reduce
Smoking cessation
Smoking Reduction
Agressive smoking cessation with NRT
Combinations of 2 NRTs bupropionSR
varenicline Recycling
NRT for 3-(18) months