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NICOTINE REPLACEMENT THERAPY IN
SMOKING CESSATION
SCOTT SLEDGE, MD
FEBRUARY 2, 1999
CIGARETTE SMOKING RELATED MORTALITY
• Cigarette Smoking is the single most preventable cause of premature death in the United States.
• >400,000 deaths in the U.S. / year
• > 10 million deaths attributed directly to smoking since 1964; about 2 million from lung CA
MMWR. Nov ‘98
SMOKING ATTRIBUTABLE HEALTH CARE COSTS:
• In 1993, estimated at $50 billion– $27 billion for hospitals
– $15.5 billion for physician expenditures
– $4.9 billion for nursing homes
– $1.8 billion for prescription drugs
– $900 million for home health care MMWR ‘94
IN 1995...
• 25% of adults in U.S. - current smokers
(47 million adults)
• Of these, 32 million wanted to quit (68%)
• And 17 million (45%) had stopped for > one day
MMWR. Dec ‘97
INCIDENCE of SMOKING: NORTH CAROLINA
• 26% of those > 18 years smoke; compared with 23% for all states
• Gender– 30% of males smoke
– 22% of females smoke
CAN PHYSICIANS HELP SOLVE THIS PROBLEM?
• >70% smokers see MD yearly
• ~70% report wanting to quit
• Physician’s advice -- an important motivator
UNFORTUNATELY...
• 50% smokers-- report being asked about smoking or urged to quit
• Fewer report specific advice on quitting
OBSTACLES TO HELPING PATIENTS QUIT SMOKING
• Time constraints
• A perceived lack of skills to be effective
• Frustration due to low success rates
• Belief that smoking cessation is not an important part of professional responsibility
METHODS TO HELP PATIENTS STOP SMOKING:
• HEALTH CARE PROVIDER ADVICE AND FOLLOWUP
• BEHAVIOR MODIFICATION PROGRAMS
• PHARMACOTHERAPY
• ALTERNATIVE THERAPIES (e.g.. ACCUPUNCTURE, HYPNOSIS)
NICOTINE REPLACEMENT THERAPY
• NICOTINE POLACRILEX “NICOTINE GUM”
• NICOTINE PATCH
• NICOTINE NASAL SPRAY
• NICOTINE INHALER
NICOTINE GUM
NICOTINE GUM
• Available in two strengths
• 2 mg form was approved by the FDA in 1984 and 4 mg form approved in 1992
• Both strengths became over the counter in April 1996
EFFICACY of NICOTINE GUM
• Hjalmarson, et al published RCT on effectiveness of 2 mg nicotine gum
• 205 subjects in smoking cessation clinic randomized to nicotine gum or placebo gum
• At one year, 29% of nicotine gum subjects were abstinent vs. 16% of the placebo group --JAMA ‘84
HIGHER DOSING OF NICOTINE GUM
• In 1995, Herrera N, et al showed “highly dependent” smokers need 4 mg gum
• Highly dependent smokers given 4 mg gum or 2 mg gum. *
• Lowly dependent smokers given 2 mg gum or placebo.*
*(Randomized at “quit phase”)
-Chest ‘95
AT 2 YEAR FOLLOW-UP...
• Highly dependent group--
Abstinence rates :
– 34% for 4 mg and 16% for 2 mg
• Lowly dependent group--
Abstinence rates:
– 39% for 2 mg and 17 % for placebo
--Chest ‘95
WHAT ABOUT PATIENTS IN A PRIMARY CARE SETTING?• Hughes, et al published RCT performed at
2 family practice clinics in suburbs
• 315 smokers assigned 2 mg gum or placebo
• Patients shown 13 minute video on gum and instructed to use prn for craving
• Brief follow-up visit at 1 to 2 weeks
-JAMA ‘89
RESULTS AT ONE YEAR:
• 10% of active gum users passed observer and biochemical verification
• 7% of placebo users passed observer and biochemical verification
• NOT STATISTICALLY SIGNIFICANT
• *31 dropouts and 24 noncontacts counted as smokers
PROPER USE OF NICOTINE GUM
• NICOTINE GUM IS NOT CHEWED LIKE OTHER CHEWING GUM– COMPRESS with teeth until peppery– “PARK” between the cheek and gum.– REPEAT every minute or so for ~ 30 minutes
per dose
EATING AND DRINKING:
• Avoid 15 minutes prior to and during use of the gum
• Acidic beverages (e.g. coffee, fruit juices) reduce nicotine absorption
DOSING:
• Specify a fixed dosing schedule.
• > one pack per day begin on 4 mg dose.
• At least one piece per hour for 1 to 3 mos.
• MAX = 30 pieces of 2 mg gum/day
= 20 pieces of 4 mg gum/day
WATCH OUT...• It is possible to become addicted to
nicotine gum.
• Not recommended for more than 6 months.
• Gradual tapering IS recommended
ADVERSE EFFECTS
• THROAT BURNING
• DIZZINESS
• NAUSEA
• HICCUPS
• ABDOMINAL PAIN
• JAW ACHE
NICOTINE PATCH
FIVE FDA-APPROVED TRANSDERMAL PATCHES:
Habitrol Nicoderm Nicotrol
Nicoderm-CQ Prostep
• Available in US in December 1991
• Nicoderm CQ and Nicotrol-- available over the counter
• Nicotrol-- delivers nicotine for 16 hours
EFFICACY
• Fiore et al performed meta-analysis of RCTS of four weeks or longer that:– Had biochemical confirmation
– Subjects not selected on basis of specific diseases (e.g.. coronary artery disease).
- JAMA ‘94
META-ANALYSIS:
• Seventeen studies with total 5098 pts
• At 6 months...abstinence rates for active patch 22% vs 9% for placebo
• Included primary care settings and behavior modification programs.
• Combined ODDS RATIOS = 3.0 (6 mo.)
ANALYSIS ALSO FOUND...
• 16 hour and 24 hour patch--equally efficacious.
• Intensive counseling enhanced clinical success, but patch was effective with minimal adjuvant therapy.
• Extending patch treatment > 8 weeks did not increase efficacy.
• Weaning patients did not have an added beneficial effect in cessation rate.
REGARDING DOSING...
• Available patches = 5 to 22 mg/day of nicotine
• Pack per day smoker receives 25 to 40 mg of nicotine/day from cigarettes
Will higher patch doses be more effective in heavier smokers?
In 1995, Dale et al looked at percentage of nicotine replacement and
smoking cessation
• Subjects randomized to 11-, 22-, or 44- mg doses of patch
• At one year...higher abstinence rates with the 44 mg patch were not found.
• BUT 44 mg patch was safe & superior in relieving withdrawal symptoms.
-JAMA 1995
Current Dosage Recommendations:
• > 10 cigarettes per day--use highest available dose
• 10 cigarettes per day or fewer -- start with the mid-range dose
• Fewer than 5 cigarettes per day probably do not need nicotine replacement.
PROPER USE OF THE NICOTINE PATCH
• On the quit date-- apply to a hairless portion of skin after cleansing with soap and water.
• Apply new patch daily-- preferably at new site
• Use > 8 weeks is not proven beneficial, and weaning may be unnecessary.
ADVERSE EFFECTS:
• SKIN IRRITATION
• ITCHING
• NAUSEA
• INSOMNIA
• ABNORMAL DREAMS
NICOTINE NASAL SPRAY
NICOTINE NASAL SPRAY
• Available in the United States in 1996 as a prescription product
• Designed for rapid delivery of nicotine--mimicking the effects of cigarette smoking
EFFICACY
• Sutherland, et al. published RCT examining nicotine nasal spray in a smoking cessation clinic
• 227 smokers received 4 weeks of supportive group therapy + active nicotine nasal spray or placebo
--Lancet Aug. 92
Main end point was biochemically validated complete abstinence from
smoking
• At one year...26% of active group abstinent vs. 10% assigned placebo
• Greatest advantage in the heaviest smokers
• Withdrawal symptoms, craving for cigarettes, and weight gain were all reduced by active spray
WARNING!
• Blood nicotine levels achieved are higher and faster than with the patch or gum
• Approximately 43% of smokers started on the nicotine nasal spray will continue using for 12 months after smoking cessation
PROPER USE
• Instruct the patient on how to “prime the pump” to ready it for use
• After priming, patient tilts head back and sprays once in each nostril
• Do not intentionally inhale or sniff while spraying! (absorption is in the nasal mucosa not the sinuses)
DOSING...
• Each spray delivers 0.5 mg of nicotine (each dose = 1 mg)
• Recommend 1 to 2 doses per hour with a maximum of 5 doses per hour (40 mg per day max.)
• Treat for 4 to 6 weeks and then wean over an additional 4 to 6 weeks
SIDE EFFECTS
• Almost all patients report nasal and throat irritation, sneezing, and watery eyes during week 1
• Symptoms should diminish over the first week of use
• If not improving after week 1, consider diseontinuing nasal spray
NICOTINE INHALER
NICOTINE ORAL INHALER
• Introduced in mid-1998
• Prescription product
• Intended to mimic the smoker’s hand-to-mouth ritual
EFFICACY
• A one year RCT conducted by Tonnesen et al.
• 286 volunteers recruited through a newspaper ad (each smoked 10+ cigarettes/day)
• Subjects randomly assigned to nicotine inhaler or placebo inhaler
--JAMA, March 1993
RESULTS...
• At one year, smoking abstinence rate in the active inhaler group was 15% vs. 5% in the placebo inhaler group
• Minimal levels of advice and support were used in this study
• Treatment was well tolerated and no serious adverse effects were reported
NICOTINE DELIVERY
• Each cartridge delivers 4 mg of nicotine
• About 80 puffs on the inhaler equal nicotine from 8 to 12 puffs on a cigarette
• Nicotine absorbed in buccal and pharyngeal mucosa -- not the bronchi
• Nicotine plasma concentrations rise more quickly than with gum (slower nasal spray)
DOSING AND USE
• Use 6 to 16 cartridges per day
• Frequent, continuous puffing over 20 minutes yields the best effects
• Recommended duration of treatment is 3 months (max. 6 months)
SIDE EFFECTS
• Most common are irritation in the mouth and throat and coughing
• Generally improve with use
• In the Tonneson study, no subjects discontinued the inhaler secondary to side effects
SMOKING CESSATION CLINICAL PRACTICE
GUIDELINES
• Published by the Agency for Health Care Policy and Research (AHCPR) in 1996
• Approximately 3000 research articles and abstracts were reviewed for appropriateness
Inclusion criteria for each article:
• Concerned a randomized controlled trial
• Follow-up end point at least 5 months after the quit date
• Published in English in a peer-reviewed journal between 1975 and 1994
Panel Recommendations Address Three Audiences:
• Primary Care Clinicians
• Smoking Cessation Specialists
• Health Care administrators, insurers, and purchasers
STRATEGIES FOR IMPLEMENTATION
• Step1. ASK - Systematically Identify All Tobacco Users at Every Visit
• Step2. ADVISE - Strongly Urge All Smokers to Quit
• Step 3. Identify Smokers Willing to Make a Quit Attempt
• Step 4. ASSIST - Aid the Patient in Quitting
• Step 5. ARRANGE - Schedule Follow-up Contact
In Regard to Nicotine Replacement...• Identified as the only pharmacologic
therapy proven effective
• Panel recommended that all patients planning a quit attempt be offered NRT (unless contraindicated)
Panel opinion was that the patch was preferable to gum in routine
clinical use.
• Fewer compliance problems
• Less clinician time and effort to train patients in proper use
QUESTIONS YET TO BE ANSWERED
• Which form of nicotine replacement is the most effective?
• How effective are nicotine replacement combinations? (e.g. patch and inhaler)
CONCLUSIONS
• Nicotine Replacement Therapy is effective in helping patients to quit smoking
• At this time, patient preference may be the best guide in choosing a form of nicotine replacement
• Success rates for smoking cessation remain low even with the best interventions
AN UNSUCCESSFUL QUIT ATTEMPT SHOULD BE SEEN AS A LEARNING
OPPORTUNITY FOR THE NEXT TIME !
SPECIAL THANKSTO
RAMON VELEZ, MDAMANDA EBRIGHT, MD
HAPPYGROUND
HOG’SDAY!