Getting the most out of current

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Getting the most out of current  treatments

• Peter Hajek

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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

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Possible improvements

• Do not provide ineffective treatments
• Keep up-to-date and use new treatment variations
  when available
• Participate in research

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Ineffective treatments Examples from secondary
care
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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

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Method

• 19,520 abstracts screened
• 179 papers included

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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

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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

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Secondary care services Proctor survey

• Service funding, staffing, staff training
• Sources of referral
• Throughput and outcome
• Post-discharge care
• Barriers and facilitators
• Needed for other services too (primary care,
  workplace, pregnancy, youth, pharmacy, specialist
  providers)

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To join the Secondary Care Services Network

• E-mail Barnie Proctor on
• b.proctor_at_qmul.ac.uk

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Are quitlines still effective in the UK?

• An earlier study showed no effect of a pro-active
  UK Quitline (9.5 vs 9.3 at 6M)
• A new study compared reactive and pro-active,
  both with and without posted NRT
• Gilbert et al. Addiction 2006, 101, 590-598
• Ferguson et al., BMJ 2012, 344,e1696

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CO-validated abstinence at 6 month (7-days only)

• Proactive vs reactive support 7.4 vs 8
• No difference
• NRT vs no NRT vouchers 6.2 vs 9.2
• No NRT did better! (p0.006)
• Authors conclusion Neither pro-active calls nor
  NRT improves on reactive line
• Harsher interpretation Quitline was not
  effective, with or without these extras

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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

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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

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Can we do better with medications we have?
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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

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Old NRT products

• UK is more liberal with NRT than other countries
• Our licensing allows
• Extended use
• Pre-loading
• Combinations and increased dosing

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Using NRT for longer
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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

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Using NRT prior to quitting
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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
• ShiffmanFerguson (2008) Addiction 103557-563
• LindsonAveyard (2011) Psychopharmacology
  214579-592.

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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

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Tailor NRT dose to response
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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

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E-cigarettes (EC)
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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

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Good nicotine delivery and craving relief
(Vansickel et al, Addiction 2012)

• 20 smokers
• 6 x 10-puff

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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
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Helps smokers unwilling to quit (Polosa et al BMC
Public Health 2011)

• 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

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• 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

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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

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Champix
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Champix pre-loading
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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

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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

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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

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Effect on cotinine prior to TQD
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Enjoyment of cigarettes
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Abstinence
Placebo pre-loading (n48) Varenicline pre-loading (n53) Significance
12 weeks Sustained abstinence 21 47 p0.005
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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)
  13831390

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Champix plus NRT
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Champix NRT

• N116, 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 11140

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Abstinence ()

• self-reported

Period after TQD Placebo Patch (n59) Nicotine patch (n58) 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
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Tailor Champix dose to response
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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

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Annual Update and Supervision Day 2013

• 2. December
• Details from Janice Rossabi, sctrp_at_yahoo.co.uk

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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

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