Transcript Evolving Paradigms of smoking cessation

New Paradigms for Smoking
Cessation and Tobacco Harm
Reduction
Edward Anselm, MD
Medical Director,
Health Republic Insurance of New Jersey
Assistant Professor of Medicine,
Icahn School of Medicine at Mount Sinai
Per capita consumption of different
forms of tobacco in the United States,
1880–2011
A Major Public Health Success
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Taxes
Smoke-free environments
De-normalization of smoking
Paid advertising against smoking
Graphic Warning Labels
Evidence-based clinical interventions
Trends in prevalence (%) of current cigarette smoking among adults,
18 years of age and older, by gender; National Health Interview Survey
(NHIS) 1965–2012; United States
Tobacco use in NYC increases
Smoking and Mental Illness
55
60
50
41
35
40
30
59
39
42
37
31
23
20
10
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Current
Lifetime
Smoking Rates Smoking Rates
Quit Rates
JAMA 2000 Nov 22-29; 284 (20):
2606-10
No Mental Ilness
Anytime in Lifetime
Current
Smoking and Mental Illness
NSDUMH 2009 to 2011; Adults over 18
Overall prevalence of smoking
Prevalence of Any Mental Illness
Prevalence of smoking among people w AMI
21.4%
19.9%
36.1%
• AMI was highest among men, adults aged <45 years, and those
living below the poverty level;
• Smoking prevalence was lowest among college graduates.
• During 2009–2011, adults with AMI smoked 30.9% of all cigarettes
smoked by Adults.
MMWR / February 8, 2013 / Vol. 62 / No. 5
Smoking Prevalence and Income 1997 to 2012:
Overall smoking declined from 24.7% to 20.0%
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30
25
20
Below Poverty
Above Poverty
15
Well above Poverty
10
5
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1997
2012
Smoking Proves Hard to Shake Among the Poor
New York Times March 25, 2014
Tobacco Use and Mental Health
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Episodic mood management
Nicotine and self medication
Depression
Substance abuse
Obsessive-Compulsive Disorder
Attention Deficit/Hyperactivity Disorder
Schizophrenia
LGBT
• Studies consistently show LGBT smoking
prevalence is 35‐200% higher than the
general population.
• New general population data show LGBT
people smoke cigarettes at rates 68%
higher than other groups
• 60% of poor lesbians of color in the Bronx
were current smokers.
Quitting
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Interested in Quitting
Attempted Quitting last year
Ready to change
Successful
– 5-8 Previous attempts
– Process over several years
– Majority quit on their own
• Not willing to try
• LARGE TREATMENT GAP
• Natural history of cessation
68.9%
42.7%
Self Medication
• Nicotine; MAO I Conditioned relaxation
• Withdrawal Symptoms
– Craving
– Dysphoria
• Situational mood modulation
– Triggers for relapse
• Chronic mood modulation
What is being self-medicated?
• The role of antidepressants in smoking
cessation: Bupropion, Nortryptiline
• Weight gain after discontinuation of nicotine
or bupropion therapy
• Improved cognition for people with
schizophrenia, ADDHD, and OCD
Harm Reduction
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Needle exchange
Methadone
Low Tar/Low Nicotine Cigarettes
Truvada
NICE Guidelines 2013
NICE Public Health Guidance:
Tobacco: harm-reduction approaches to smoking
Stopping smoking, but using one or more licensed nicotine-containing products as
long as needed to prevent relapse
Cutting down prior to stopping smoking (cutting down to quit)
-with the help of one or more licensed nicotine-containing products (the
products may be used as long as needed to prevent relapse)
-without using licensed nicotine-containing products.
Smoking reduction
-with the help of one or more licensed nicotine-containing products (the
products may be used as long as needed to prevent relapse)
-without using licensed nicotine-containing products.
Temporary abstinence from smoking
-with the help of one or more licensed nicotine-containing products
-without using licensed nicotine-containing products.
Considerations in the NICE Guidance
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Long term safety of nicotine replacement
Did not consider buproprion or varenicline
Did not consider patients with Mental Illness
Safety of electronic cigarettes
Unintended consequences
Fig. 2. Overall weighted scores for each of the products. Cigarettes, with an overall harm score of 99.6, are judged to be most
harmful, and followed by small cigars at 67. The heights of the colored portions indicate the part scores on each of the
criteria. Product‐related mortality, the upper dark red sections, are substantial contributors to those two products, and they
also contribute moderately to cigars, pipes, water pipes, and smokeless unrefined. The numbers in the legend show the
normalized weights on the criteria. Higher weights mean larger differences that matter between most and least harmful
products on each criterion.
Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, Fagerstrom K, Letlape K, Milton A, Polosa R, Ramsey J,
SweanorD. Estimating the harms of nicotine‐containing products using the MCDA approach. European Addiction Research.
2014 April; 20:218‐225 link: http://www.karger.com/Article/FullText/36022
What is in an E-cigarette?
• Battery
• Atomizer
• Cartridge
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Propylene glycol, or
Glycerin
Nicotine
Flavoring
Identification of toxicants in cinnamon-flavored electronic cigarette refill
R.Z. Behar Toxicology in Vitro
Volume 28, Issue 2, March 2014, Pages 198–208
Electronic Nicotine Delivery Systems:
E-Cigarettes
• Regulatory Perspectives
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Variation in products -over 300 products
Safety to smokers-very limited data
Safety to bystanders-no data
Accidental poisoning to children
Use by adolescents; flavored
• Aid in behavior change
– Efficacy in smoking cessation-unproven
– Efficacy in harm reduction-unproven
• Alternative to smoking
E-Cigs and Cessation
Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study
Jamie Brown et, al Addiction Accepted May 2014
Background And Aims
Electronic cigarettes (e-cigarettes) are rapidly increasing in popularity. Two randomised controlled trials have suggested that ecigarettes can aid smoking cessation but there are many factors that could influence their real-world effectiveness. This study
aimed to assess, using an established methodology, the effectiveness of e-cigarettes when used to aid smoking cessation
compared with nicotine replacement therapy (NRT) bought over-the-counter and with unaided quitting in the general population.
Design And Setting
A large cross-sectional survey of a representative sample of the English population.
Participants
The study included 5863 adults who had smoked within the previous 12 months and made at least one quit attempt during that
period with either an e-cigarette only (n=464), NRT bought over-the-counter only (n=1922) or no aid in their most recent quit
attempt (n=3477).
Measurements
The primary outcome was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including
nicotine dependence.
Findings
E-cigarette users were more likely to report abstinence than either those who used NRT bought over-the-counter (odds ratio 2.23,
95% confidence interval 1.70 to 2.93, 20.0% vs. 10.1%) or no aid (odds ratio 1.38, 95% confidence interval 1.08 to 1.76, 20.0% vs.
15.4%). The adjusted odds of non-smoking in users of e-cigarettes were 1.63 (95% confidence interval 1.17 to 2.27) times higher
compared with users of NRT bought over-the-counter and 1.61 (95% confidence interval 1.19 to 2.18) times higher compared
with those using no aid.
Conclusions
Among smokers who have attempted to stop without professional support, those who use e-cigarettes are more likely to report
continued abstinence than those who used a licensed NRT product bought over-the-counter or no aid to cessation. This difference
persists after adjusting for a range of smoker characteristics such as nicotine dependence.
Smokers Who Try E-Cigarettes to Quit Smoking:
Findings From a Multiethnic Study in Hawaii
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Pallav Pokhrel, Pebbles Fagan, Melissa A. Little, Crissy T. Kawamoto, and Thaddeus A. Herzog. Smokers Who Try E-Cigarettes
to Quit Smoking: Findings From a Multiethnic Study in Hawaii. American Journal of Public Health: September 2013, Vol. 103,
No. 9, pp. e57-e62.
doi: 10.2105/AJPH.2013.301453
Objectives. We characterized smokers who are likely to use electronic or “e-”cigarettes to quit smoking.
Methods. We obtained cross-sectional data in 2010–2012 from 1567 adult daily smokers in Hawaii using a paperand-pencil survey. Analyses were conducted using logistic regression.
Results. Of the participants, 13% reported having ever used e-cigarettes to quit smoking. Smokers who had used
them reported higher motivation to quit, higher quitting self-efficacy, and longer recent quit duration than did
other smokers. Age (odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.97, 0.99) and Native Hawaiian
ethnicity (OR = 0.68; 95% CI = 0.45, 0.99) were inversely associated with increased likelihood of ever using ecigarettes for cessation. Other significant correlates were higher motivation to quit (OR = 1.14; 95% CI = 1.08,
1.21), quitting self-efficacy (OR = 1.18; 95% CI = 1.06, 1.36), and ever using US Food and Drug Administration
(FDA)–approved cessation aids such as nicotine gum (OR = 3.72; 95% CI = 2.67, 5.19).
Conclusions. Smokers who try e-cigarettes to quit smoking appear to be serious about wanting to quit. Despite lack
of evidence regarding efficacy, smokers treat e-cigarettes as valid alternatives to FDA-approved cessation aids.
Research is needed to test the safety and efficacy of e-cigarettes as cessation aids.
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Read More: http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2013.301453
Advances in Treatment I
• Natural History of smoking cessation
– The successful Quitter makes 5-8 efforts
– Each quit attempt is longer than the previous
– Process over several years
• Reasons for relapse
– Nicotine withdrawal symptoms
– Minor life stress
– Major life stress
Advances in Treatment II
• Correct use of medication
– Longer duration of treatment
– Increased use of behavioral interventions
• Combination Therapy
– Nicotine plus bupropion
– Combination of Nicotine products
• Treatment of Craving
– Clonidine
– Naltrexone
– Topiramate
• Weight gain does not occur until medication is discontinued
• Use telephonic counseling
• Referral to psychiatry
Opportunistic interventions
Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice
to quit and offer of assistance
Paul Aveyard, Rachna Begh, Amanda Parsons, and Robert West2 Article first published online: 28 FEB
2012DOI: 10.1111/j.1360-0443.2011.03770.x © 2011 The Authors, Addiction © 2011 Society for the Study of
Addiction
Aims This study aimed to assess the effects of opportunistic brief physician advice to stop smoking and offer of
assistance on incidence of attempts to stop and quit success in smokers not selected by motivation to quit.
Methods We included relevant trials from the Cochrane Reviews of physician advice for smoking cessation,
nicotine replacement therapy (NRT), varenicline and bupropion. We extracted data on quit attempts and quit
success. Estimates were combined using the Mantel–Haentszel method and heterogeneity assessed with the I2
statistic. Study quality was assessed by method of randomization, allocation concealment and follow-up blind
to allocation.
Results Thirteen studies were included. Compared to no intervention, advice to quit on medical grounds
increased the frequency of quit attempts [risk ratio (RR) 1.24, 95% confidence interval (CI): 1.16–1.33], but not
as much as behavioural support for cessation (RR 2.17, 95% CI 1.52–3.11) or offering NRT (RR 1.68, 95% CI:
1.48–1.89). In a direct comparison, offering assistance generated more quit attempts than giving advice to quit
on medical grounds (RR 1.69, 95% CI: 1.24–2.31 for behavioural support and 1.39, 95% CI: 1.25–1.54 for
offering medication). There was evidence that medical advice increased the success of quit attempts and
inconclusive evidence that offering assistance increased their success.
Conclusions Physicians may be more effective in promoting attempts to stop smoking by offering assistance to
all smokers than by advising smokers to quit and offering assistance only to those who express an interest in
doing so.
View Full Article with Supporting Information (HTML) Get PDF (98K)
Nicotine sampling
Nicotine Therapy Sampling to Induce Quit Attempts Among Smokers Unmotivated to Quit: A Randomized
Clinical Trial
Matthew J. Carpenter, PhD; John R. Hughes, MD; Kevin M. Gray, MD; Amy E. Wahlquist, MS; Michael E. Saladin,
PhD; Anthony J. Alberg, PhD, MPH
Background: Rates of smoking cessation have not changed in a decade, accentuating the need for novel
approaches to prompt quit attempts. methods: Within a nationwide randomized clinical
trial (N=849) to induce further quit attempts and cessation, smokers currently unmotivated to quit were
randomized to a practice quit attempt (PQA) alone or to nicotine replacement therapy (hereafter referred to as
nicotine therapy), sampling within the context of a PQA. Following a 6-week intervention period, participants
were followed up for 6 months to assess outcomes.
The PQA intervention was designed to increase motivation, confidence, and coping skills. The combination of a
PQA plus nicotine therapy sampling added samples of nicotine lozenges to enhance attitudes toward
pharmacotherapy and to promote the use of additional cessation resources. Primary outcomes included the
incidence of any ever occurring selfdefined quit attempt and 24-hour quit attempt. Secondary measures
included 7-day point prevalence abstinence at any time during the study (ie, floating abstinence) and at the
final follow-up assessment.
Results: Compared with PQA intervention, nicotine therapy sampling was associated with a significantly higher
incidence of any quit attempt (49% vs 40%; relative risk [RR], 1.2; 95% CI, 1.1-1.4) and any 24-hour quit attempt
(43% vs 34%; 1.3; 1.1-1.5). Nicotine therapy sampling was marginally more likely to promote floating
abstinence (19% vs 15%; RR, 1.3; 95% CI, 1.0-1.7); 6-month
point prevalence abstinence rates were no different between groups (16% vs 14%; 1.2; 0.9-1.6).
Conclusion: Nicotine therapy sampling during a PQA represents a novel strategy to motivate smokers to make a
quit attempt.
Proactive Tobacco Treatment and
Population-Level Cessation
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Steven S. Fu, MD, et al
JAMA Intern Med. 2014;174(5):671-677.
Importance Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate
smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that
include both behavioral counseling and pharmacotherapy.
Objective To assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco
cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and
do not use treatment) compared with usual care among a diverse population of current smokers.
Design, Setting, and Participants The Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a
population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of
Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the
proactive care intervention.
Interventions Current smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and
(2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by
telephone outreach to motivate smokers to seek treatment with choice of services.
Main Outcomes and Measures The primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a
follow-up survey among all current smokers regardless of interest in quitting or treatment utilization.
Results A total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The
population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual
care (P = .02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month
prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based notmissing-at-random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]).
Conclusions and Relevance Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to
evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates.
Reimbursement for smoking cessation
• Medicare
• Medicaid
• ACA Plans
• A reimbursable intervention at every visit
• Tools for office transformation:
• http://www.nysmokefree.com/Subpage.aspx?P=0&P1=70
Fees generated by smoking cessation
interventions
• For a population of 10,000 office visits per
year across all lines of business (Medicaid,
Medicare and Commercial)
– With a cigarette smoking prevalence of 12%
• 1200 smokers
– With an average reimbursement of $12 per
session
• $14,400 reimbursement per year
New paradigms
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Ask about E-cigarettes
Screen for, and treat mental illness
Harm reduction discussion
Support cessation or harm reduction efforts if
already in progress, even if using e-cigarettes
• Structured quit attempt
• Opt to Quit program
Rationale for Health Republic of New
Jerseys’ Tobacco Harm Reduction Policy
• The majority of current smokers continue to smoke as they are for
whatever reason, unable to quit
• The majority of these smokers are concerned about their risk of
tobacco-related disease and are willing to take steps to reduce their
exposure
• Reduction of smoking, by whatever means, is a desirable outcome
• Medications used in smoking cessation can be used to lower the
amount
• Smokers and their doctors should have conversations about
smoking cessation and Tobacco Harm Reduction
• Smokers who engage in proactive interventions have a significant
likelihood of quitting cigarettes
• Some smokers trying to quit require longer courses of medication
than current health plan policies allow
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Benefit Design for Tobacco Harm Reduction in the context of
fully implemented smoking cessation initiatives
• Medications: all FDA-approved medications
– Zero copay
– Lift Quantity Limits
• Smoking Cessation Counselling, up to 8 sessions per
year
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Physicians
Intermediate clinicians
Certified counsellors
Quit-lines
• Monitor physician performance
• Role of Incentives
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Current Smoking Cessation
Interventions
Five “A”s
Ask about smoking
Advise tobacco users to quit
Assess readiness to quit
Assist with a plan for
quitting
Arrange follow-up
• Every patient quitting
cigarettes should be
offered a medication
Two “A”s + R
Ask about smoking
Advise tobacco users to quit
Refer to cessation services
Five “R”s
Relevance
Risks
Rewards
Roadblocks
Repetition
Smoking Cessation Interventions by
Physicians: How well are they working?
Advising Smokers and Tobacco Users to Quit.
a rolling average represents the percentage of adults 18 years of age and older who
are current smokers or tobacco users and who received cessation advice during the
measurement year.
Discussing Cessation Medication.
a rolling average represents the percentage of adults 18 years of age and older who
are current smokers or tobacco users and who discussed or were recommended
cessation medications during the measurement year.
Discussing Cessation Strategies.
a rolling average represents the percentage of adults 18 years of age and older who
are current smokers or tobacco users and who discussed or were provided cessation
methods or strategies during the measurement year.
NCQA CAHPS Questions
Over 75% of smokers recall having
been advised to quit smoking in 2012
Discussing Cessation Strategies
Commercial
HMO PPO
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2012
2011
2010
2008
2007
2006
2005
2004
2003
47.9
47.6
45.0
49.7
48.0
43.2
38.9
36.8
36.0
37.3
40.1
39.0
43.3
44.2
42.6
35.1
Discussing Cessation Medications
Medicaid
HMO
41.1
40.3
38.5
40.8
39.2
36.7
33.9
32.7
32.3
Commercial
HMO PPO
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2012
2011
2010
2008
2007
2006
2005
2004
2003
NCQA 2013 State of Health Care Quality
Report
52.9
53.1
52.4
54.4
50.9
43.9
39.4
37.8
37.6
44.6
47.9
47.2
50.9
49.6
43.8
36.7
Medicaid
HMO
45.8
44.3
42.7
40.6
38.7
35.1
31.8
31.3
31.5
Effectiveness of Medications
Odds ratio
Abstinence
Placebo
1.0
13.8
Varenicline
3.1
33.2
Nicotine nasal spray
2.3
26.7
Nicotine patch
2.3
26.6
Nicotine gum
2.2
26.1
Nicotine inhaler
2.1
24.8
Bupropion SR
2.0
24.2
Nicotine lozenge 2 mg
4 mg
2.0
2.8
24.2/14.2*
23.6/10.2