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Smoking cessation and COPD

Smoking cessation and COPD. Philip Tønnesen, M.D., dr.med. Dept. Pulm. Medicine Gentofte Hospital Copenhagen, Denmark. Disclosure. I have received consulting and speaking fees and research grants from many companies who develop smoking cessation medications, products and services .

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Smoking cessation and COPD

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  1. Smoking cessation and COPD Philip Tønnesen, M.D., dr.med.Dept. Pulm. MedicineGentofte Hospital Copenhagen, Denmark

  2. Disclosure I have received consulting and speaking fees and research grants from many companies who develop smoking cessation medications, products and services

  3. Disclosure

  4. First line drugs: Efficacy figures from the Cochrane register Sustained quit rates for 1-year (Risk Ratio) NRT versus placebo1 1.58 (111 studies) (95 % CI, 1.50-1.66) Any type of NRT Bupropion SR versus placebo2 1.85 (31 studies) Vareniclineversus placebo3 2.33 (9 studies) (95% CI, 1.95-2.80) • Silagy et al. Cochrane Database Syst Rev. 2008;jan 23(0):CD000146. • Hughes et al. Cochrane Database Syst Rev. 2008;(3) CD000031 • Cahill et al. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD006103.

  5. First line drugs: Efficacy figures from US clinical guidelines OR (95%CI) Abstinence rate PLACEBOa 1.0 13.8 MONOTHERAPIES “ Varenicline 3.1 (2.5-3.8) 33.2 High dose nicotine patch 2.3 (1.7-3.0) 26.5 Nicotine gum (>14 weeks) 2.2 (1.5-3.2) 26.1 BupropionSR 2.0 (1.8-2.2) 24.2 COMBINATION THERAPIES 2 Patch + ad lib NRT 3.6 (2.5-5.2) 36.5 Patch + BupropionSR 2.5 (1.9-3.4) 28.9 Patch + inhaler 2.2 (1.3-3.6) 25.8 Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline.Treating Tobacco use and Dependence.: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

  6. Smoking prevalence among COPD pt’s in large RCT trials with ICS/LABA Study N Age FEV1(%) Smokers • INSPIRE 1,323 65 1.3 (39%) 38% • ISOLDE 751 64 1.4 (50%) 38% • TORCH 5,343 65 1.2 (45%) 45% • TRISTAN 1,465 63 1.4 (45%) 51% • EUROSCOP 647 53 2.5 (80%) 54% • VESTBO 290 59 2.4 (86%) 77%

  7. Network meta-analysis of RCT’s in COPD (1) 8 trials included COPD N=7,372Prolonged abstinence rate • Lung Health Study (N=5,887) 12 M: 34 % versus 9 % (NRT) • Hilberink (N=392) 6 M: 16 % versus 9 % (NRT) • Tønnesen (N=370) 12 M: 14 % versus 5 % (NRT) • Taskin (N=404) 6 M: 16 % versus 9 % (BUP) • Wagena (N=255) 6 M: 30 % versus 19 %(BUP) • Pederson (N=64) 6 M: 27 % versus 16 % • Crowley (N=49) 6 M: 14 % versus 14 % • Brandt (N=56) 12 M: 32 % versus 16 % • (Taskin (N=499) 12 M: 19 % versus 6 % (VAR))*** • Eur Respir J 2009;34:634-40

  8. Efficacy of smoking cessation in COPD (2) Eur Respir J 2009;34:634-40

  9. COPD cont.

  10. Smoking cessation in COPD Tønnesen et al, Chest 2006: Nurse-conducted smoking cessation in patients with COPD, using nicotine sublingual tablets and behavioral support

  11. Smoking cessation/reduction in COPD (Tønnesen et al. Chest, 2006) • 370 COPD patients • Age :62 years • FEV1: 1.57 (56 % predicted) • Cigarettes/day: 20 • FTND: 6.4 • High – low support, NRT – placebo 12 weeks

  12. Smoking cessation in COPD NRT versus placebo: 6 months quit rate: 23 % vs 10 % 12 months quit rate: 17 % vs 10 % (OR 2.0) 2 week to 12 months: 14 % vs. 5 %

  13. SGRQ in COPD (12 Months) Quitters Reducers Smokers Symptoms -28 -21 -2 Activity -6 -8 -2 Impact -8 -5 -4 Total score -10.9 -8.5 -2.9

  14. Varenicline and COPD (mild-moderate)Chest 2010, Tashkin et al 12 weeks Varenicline Placebo • Numbers 250 254 • Age 57 57 • FEV1 % 71 % 69 % • Cig/day 25 24 • Quitters 3-12 Months 18.6 % 5.6 %

  15. Effect of smoking cessation interventions • GPs short advice: 2 % • Intensive behavioural support: 7 % • Self-help material 1 % • Proactive telephone counseling 2 % • Nicotine products 7 % • Bupropion 9 % • Varenicline 11 %* • Intensive support+NRT/bupropion 13 -19 % • Intensive support + varenicline 18 - 22 %* Modified from West et al, Thorax 2000; *Cochrane Library 2007-2008

  16. Lung Health study 1 (1) 10 clinical centers in US 12 group sessions during the first 10 weeks 4 sessions in the first week Target quit day Counselling Aggresive use of Nicotine 2-mg chewing gum Follow-up program with focus on relapse prevention, stress mangement, weight gain Formal re-treatment when relapsed

  17. 40 35 30 25 % quitters 20 S-I U-C 15 10 5 0 1-year 2-year 3-year 4-year 5-year Lung Health Study: Point prevalence 8 weekly individual visits with 2 mg nico-gum (2) (N=5587) Recycling of smokers every 4 months in 5 years! NRT:2mg-GUM Anthonisen NR, Connett JE, Kiley JP,et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA 1994; 272: 1497‑1505.

  18. Mean FEV1 quitters and smokers (diff. 11-yrs: (3)380 ml; diff smokers and interm: 100 ml;

  19. Smoking Cessation: Effects on Mortality (4) Sustained Quitter Intermittent Quitter Continuing Smokers 4 3 Rate of Death per 1000 Person-Years 2 1 0 Lung Cancer Other Cancer Respiratory Disease CHD CVD Other Unknown Causes of Death CHD=coronary heart disease; CVD=cardiovascular disease. Athonisen et al. Ann Intern Med. 2005;142(4):233-239.

  20. Weight change in the Lung Health Study (5)

  21. Intensity of intervention Minimal (<3 minutes) is effective (A) Dose-response effect (person-to-person) (A) Four or more sessions are especially effective (A) • Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline.Treating Tobacco use and Dependence.: 2008 Update. Rockville, MD: U.S. Department of Healthand Human Services. Public Health Service. May 2008.

  22. Brief intervention = 2 questions • ”Do you smoke?” and if yes • ” Have you considered to quit?” • Very simple and short: • It’s the patients project to quit but your obligation to support the smoker in the quitting attempt • Arrange referal to smoking cessation: a new appointment, smoking cessation clinic, etc. • Good idea to have a card with address and phone number

  23. Smoking cessation by hospitalization (1) COPD patients: Hospitalization (N=247) vs. Usual care (N=231) FEV1 % pred.:75 % Age: 52 years Hospitalization in Åre Hospital in Northern Sweden 11 days, third day: target quit day, NRT; exercise, 1 hour daily meeting with trained cessation nurses, educational program followed by weekly telephone calls by nurses After 2-3 months 2-4 days in hospital Sundblad, Larsson K, Nathell L, Nic Tob Res 2008;10:883-890

  24. Smoking cessation group 1-year quit rate: 52 % 3-year quit rate: 38 % Used NRT: 28 % Used BUP: 5 % Sundblad, Larsson K, Nathell L, Nic Tob Res 2008;10:883-890 Usual care 1-year quit rate: 7 % 3-year quit rate: 10 % Used NRT: 14 % Used BUP: 5 % Smoking cessation by hospitalization (2)

  25. What are we doing today in smoking cessation?

  26. Cost-effectiveness

  27. Meta-analysis of cost effectivness of smoking cessation after 25 years Quit rate Cost per QUALYUsual care 1.4 %Minimal counselling 2.6 % 16.900 EurosIntensive counselling 6.0 % 8.200 EurosIntesive c. + pharma. 12.3 % 2.400 EurosHoogendoorn M et al. Thorax 2010;65:711-718

  28. The US experiment • Re-imbursement • Insurance coverage of smoking cessation resulted in: • Higher rates of use of evidence-based therapies • Higher overall quit rates • Smoking cessation coverage in US 25 % (1997) to 90 % (2003)2 1. Kaper et al 2006 Pharmacoeconomics 24(5): 453-64 2. McPhillips-Tangum et al. Prev Chronic Dis 2006 3; 1-11. Available from: http://www.cdc.gov/pcd/issues/2006/jul/05_0173.htm

  29. ERS Guidelines • Aggressive smoking cessation is recommended i.e. varenicline, NRT, bupropionSR, and counseling and recycling

  30. Data from NIV-COPD national register in Denmark for 2010 • Ambulatory COPD patients in DK • Asked about smoking habit Oct.-Dec. July-Sept. Jan.-June • (N=6167) 75 % 75 % 66 % • Adviced to quit smoking • (1467) 91 % 92 % 88 %

  31. Conclusion smoking cessation in COPD Counselling + NRT increases quit rate Counselling + BupropionSR increases quit rate Counselling + Varenicline increases quit rate (study under publication) Retreatment after relapse increases long-term quit rate Expect a 1-year quit rate of 15-35 % (point prevalence) Tønnesen et al. ERS guidelines. ERJ 2008

  32. Take home meassage: Smoking cessation in COPD Counselling + NRT/ BupropionSR or Varenicline for 6 months should be perscribed to COPD smokers Retreatment if the COPD patient relapse Tønnesen et al. ERS guidelines. ERJ 2008

  33. “Last Request: Please Don’t Smoke” My step-father asked me to take this picture of him after he regained consciousness in ICU. He lost the fight with lung disease (Asbestosis, COPD, and Pnuemonia) Friday morning. I will be away for a little while

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