Getting the most out of current treatments

1. Getting the most out of current  treatments Peter Hajek

2. 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

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

4. Ineffective treatments: Examples from secondary care

5. 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

6. Method • 19,520 abstracts screened • 179 papers included

7. 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

8. 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

9. To join the Secondary Care Services Network • E-mail Barnie Proctor on b.proctor@qmul.ac.uk

10. 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

11. 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

12. Can we do better with medications we have?

13. 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

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

15. Using NRT for longer

17. 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

18. Using NRT prior to quitting

20. 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.

21. 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

22. Tailor NRT dose to response

24. 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

25. E-cigarettes (EC)

27. 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

28. Good nicotine delivery and craving relief (Vansickel et al, Addiction 2012) • 20 smokers • 6 x 10-puff

29. 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

30. 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

31. ‘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

32. 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

33. Champix

34. Champix pre-loading

36. 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

37. 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

38. 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

39. Effect on cotinine prior to TQD

40. Enjoyment of cigarettes

41. Abstinence

42. 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. ClinPharmacolTher. 2012; 91(2):172-80 * Ashare et al. J Psychopharmacol 2012; 26(10): 1383–1390

43. Champix plus NRT

45. 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

46. Abstinence (%) * self-reported

47. Tailor Champix dose to response

49. 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

50. Annual Update and Supervision Day: 2013 2. December Details from Janice Rossabi, sctrp@yahoo.co.uk