Pre-cessation nicotine treatment Jean-Franois ETTER Dr polit. sci,

Pre-cessation nicotine treatment Jean-Franois ETTER Dr polit. sci,

Pre-cessation nicotine treatment Jean-Franois ETTER Dr polit. sci, privat docent Institute de Mdicine Sociale et Prventive Facult de Mdecine, Universit de Genve Berne, September 13, 2006 Competing interests statement The Institute of Social and Preventive Medicine of the University of Geneva has received: - trial medications (nicotine) from Pfizer, - grants from Novartis and Pfizer to develop computer-tailored smoking cessation counseling programs, led by JFE. Nicotine replacement therapy for smoking cessation

Cochrane: 105 studies, n=32000, 6-12 months Modest success rates (7% over placebo) In the long term, this effect is decreased by 30% 60% of studies were funded by pharma industry Industry-funded studies are twice as likely to find p>.05 results 20 Nicotine placebo % abstinents

17 15 10 10 5 0 105 tudes

Smoking reduction prior to quitting Easier to quit if one smokes fewer cigarettes Successful reduction may increase the feeling that stopping is possible Many smokers prefer gradual vs. abrupt cessation Spontaneous reduction + NRT use in smokers Ambivalence, special group Smokers must be treated like other addicts: have all of them do stg, either quit or reduce Those not motivated to stop should not be excluded from treatment New: Cut down to stop NRT now licensed for cut down to stop (Pfizer term) in several countries reducing the amount you smoke until you decide to give up completely. You should aim to do this in 6 months. (Nicorette website)

New customers: smokers who use NRT for several months before they stop smoking UK: NARS report (ASH: M. Raw, A. McNeill, R. West) UK: NICE report in preparation Where does the evidence come from ? Long-term NRT-aided reduction in smokers not willing to quit Review 19 studies (Hughes, Addiction 2005;100:1074) NRT for 2-12 months (25 th-75th percentiles) ActiveControl RR

CPD reduced: 8-23 3-8 1.3-2.5 % reduced: 13-26% 25-56% Achieved 50% reduc: 8-27% 2-22% 1.6-4.6

NARS report, NRT license for CDTS Based on long-term NRT-aided reduction studies in smokers not motivated to stop ...but CDTS is licensed as a strategy to stop gradually Recommendation CDTS for 6 months is arbitrary CDTS not based on short-term pre-cessation NRT in smokers motivated to quit because 2-4 additional weeks of treatment not worth the effort of getting this approach licensed? Short-term (1-2 weeks) pre-cessation NRT in smokers willing to quit: 3 studies N Product Placebo FollowDurat up pre-tx

Quit rate pre-tx vs control RR P-value Herrera Chest 1995 200 Gum 1 week

No 6 weeks 61% vs 52% 1.2 NS Schuurman s Addiction 2004

234 Patch 2 weeks Yes 6 months 22% vs 9% in 16+ cig 2.4

0.01 Rose Nicotine Tob Res 2006 96 Yes 6 months 20.8%

vs 12.5% 2.3 0.3 Patch 2 weeks 3 studies NRT for 1-2 weeks pre-cessation 70 60 61

52 % abstinents 50 40 30 22 20.8 20 9 10

12.5 0 Herrera Schuurmans 16+ cig Rose Shiffman 2006 study Gradual cessation with NRT N=3200 2 or 4 mg gums or placebo for 4-8 weeks pre quit NRT for 12 weeks post quit, up to 12 months Results at 6 months (4 mg):

OR = 6 (over placebo) Presented at WCTOH, Washington, July 2006 Ongoing study in Geneva Easier to quit if one smokes fewer cigarettes / day 4 mg: strong taste Poor compliance Hypothesized mechanisms of pre-cessation NRT: - reduce cigarette consumption - increase N gums during first crucial days a after cessation - break automatic association nicotine = cigarette Geneva study Aim: test if treatment with 4 mg nicotine gums is more

effective if it starts 4 weeks before the quit date 2 groups compared: 1) gums 1 month before + 2 months after 2) gums 2 months after quit date Randomized trial No placebo Geneva study Gums sent by mail No face-to-face counseling Advice to use clinics, quitlines, web 15+ cig./day. GE + VD Follow-up 4 times

Quit date, end of treatment (2 mo), 1 yr, 5 yrs Saliva cotinine after 12 months CO at 12 months if quit and cotinine >10 ng/ml 215 participants (September 13, 2006) Follow-up rate: - 98% at quit date - 94% at end of treatment Conclusions Long term NRT reduction increases quit rates in smokers not trying to quit Short-term (1-2 weeks) pre-cessation NRT increases quit rates in smokers trying to quit (RR = 1.2 2.4) Paradoxically, NRT is licensed pre-cessation (CDTS) for smokers who do not want to stop, but not for those who do

Implications Smokers should be reminded that quitting is best All smokers should receive treatment + support Smokers who prefer gradual quitting may use NRT Possibility that it may weaken the not a puff message ? Population impact ? To increase quit rates we need to: - increases taxes - ban smoking in public places - advocacy - evidence-based media campaigns Get these slides on

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