Smoking Cessation: Summary

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Smoking CessationSummary

• G. Michael Allan,
• Associate Professor, Dept of Family Med,
• Medical Director, TOP
• Jennifer Dunkin Candra Cotton
• PCN Ed North

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Objectives

• To put into context risk vs benefit of smoking
  cessation
• To review the literature regarding various
  medications for smoking cessation

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For Whom the Bell Tolls,

• A 54 year old male, recently discharged from
  hospital after a MI. Received a stent, some
  heart damage ejection fraction of 50.
• He has always been a bit of time bomb
• BMI 33 ( big waist) - elevated BP
• low HDL - non-compliant
• smoker (almost 2 packs a day)
• He is still smoking. He knows he should quit but
  he is clearly under the impression that smoking
  is not as big a risk as his cholesterol.

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For Whom the Bell Tolls,

• A new LOE 1 study shows that intense efforts
• in smoking cessation in high risk pts results in
• Smoking cessation of rates lt40
• Decreased hospitalization
• Decreased mortality
• More smoking in movies
• More tobacco advertising to teenagers

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For Whom the Bell Tolls,

• Weekly counseling x 3 months /- Bupropion/NRT
• Comparing intensive intervention vs usual
• 2 yr continued abstinence 39 vs 9 (NNT 4)
• Normal cessation rates in highest risk pts. is 9
• Even a low cessation rate (30) is better than
  nothing!
• Hospitalization 23 vs 41 (NNT 6)
• Mortality 3 vs 12 (NNT 11)
• Chest 2007 131 44652

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For Whom the Bell Tolls

• But I dont have time for intensive intervention!
• About 2-3 of people quit without anything per
  year.
• In 3 minutes you can
• Ask permission in non-threatening way
• Advise to quit smoking
• Refer (Assist)- link them to services
• Brief intervention ? cessation rates 2.3 (NNT
  44)
• Cochrane Database Syst Rev. 2008 Apr
  16(2)CD000165

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For Whom the Bell Tolls

• NRT works!!!
• Nicotine gum
• 16 cessation rates at one year
• Nicotine patch
• 19 cessation rates at one year
• Safe to use patch prior to quitting

Cochrane Database of Systematic Reviews 2008 (1)
CD000146
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Butt-Out Doc,

• Your 54 year old male with recent MI is now ready
  to quit.
• Over the last 3 months he has tried acupuncture,
  hypnotherapy, and NRT (rash) but none really
  helped him quit.
• Although not a fan of pills, he would like to
  talk about his options.

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Butt-Out Doc

• According to the evidence, you can tell him
• Any antidepressant will work
• Buproprion is the best antidepressant
• There is one other antidepressant just as good
• Varenicline is way better than antidepressants
• Varenicline may be better but questions
  remain
• Varenicline is part of a secret deal between the
  drug tobacco companies

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Butt-Out Doc.

• 6 trials with varenicline (5K pts)
• Varenicline 1mg bid x 12 weeks vs placebo or
  buproprion x 6 months
• Varenicline 21 vs placebo 8, NNT 8
• Varenicline 21 vs buproprion 14 NNT 14
• Nausea ? 3x but dropout rate was ?
• Weaknesses funding, serious SE are
  questionable, mainly 2 studies (80-90)
• Cochrane 2007 Iss 1. Art. No.CD006103

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Butt-out Doc

• FDA warning suicidality
• Concerns about safety remain
• In patients with history of depression, prescribe
  reduced quantities and monitor more frequently
  for suicidality

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Butt-Out Doc

• Antidepressants
• Nortriptyline buproprion (20 cessation, NNT
  11)
• Nortriptyline better tolerated
• 4-9 dropout vs 7-12 dropout
• Other antidepressants not effective

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Butt-out Doc

• Belief-the correct dose of buproprion is 150mg po
  BID
• 1 year RCT, 742 patients
• Placebo or buproprion SR 100, 150 or 300mg/day
  for 7 weeks
• 150mg as effective as 300mg dose!
• New Engl J Med 1997 3371195-202

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Smoking Cessation Options
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Cochrane 2008 1 CD000146 2004, 4
CD000031 2007, 1 CD006103.
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Smoking Cessation Agents