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Smoking reduction. Philip Tønnesen, M.D., Department of Pulmonary Medicine Copenhagen, Denmark. Tobacco control. Prevention Smoking cessation Smoking reduction. Nicotine replacement. 17 % of NRT is used for other than smoking cessation! i.e.

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Smoking reduction

Smoking reduction

Philip Tønnesen, M.D.,

Department of Pulmonary Medicine

Copenhagen, Denmark

P Tonnesen.2009


Tobacco control
Tobacco control

Prevention Smoking cessation

Smoking reduction

P Tonnesen.2009


Nicotine replacement
Nicotine replacement

  • 17 % of NRT is used for other than smoking cessation! i.e.

  • 60 % use NRT < 2 weeks

  • 40 % no instruction (GP or pharmacit)

  • Temporary abstinence: during work, travel

  • Smoking reduction

P Tonnesen.2009


Smokers in the netherlands
Smokers in the Netherlands

100%

New smokers to reach with Reduction to Stop

Happy smokers

34%

80%

Wants to reduce

16%

Smokers

60%

Reduces now

17%

Unhappy (ambivalent) smokers66%

40%

Wants to stop

29%

20%

Stops today 4%

0%

P Tonnesen.2009


Smoking reduction1
Smoking Reduction

Rationale

  • Aimed for smokers low in motivation to quit / unable to quit

  • Induction of permanent change in smoking habit

  • Compensation not 100%

  • Will not interfere with smoking cessation

P Tonnesen.2009


Smoking reduction2
Smoking Reduction

  • Cigarettes  + NRT use

    Definition: “arbitrary”

    Cigarettes/day < 50 % of entry numbers

    plus any decrease in CO (1 ppm or >)

P Tonnesen.2009


Cessation induction
Cessation-induction

Ready to reduce smoking

NRT increases reduction

Self-efficacy increased

Intentionto quit increased

Increasedprobabilityof a quit attempt

Reducingprior to quittingdecreases relapse

NRT prior to quittingdecreases relapse

Increasedabstinence

P Tonnesen.2009


Clinical studies
Clinical Studies

P Tonnesen.2009


Gum and inhalator increase the likelihood of successful sustained reduction 2 inhaler 4 gum studies
Gum and Inhalator Increase the Likelihood of Successful Sustained Reduction (2 Inhaler, 4 Gum studies)

%

*

* p<0.001

*

*

*

Sustained Smoking Reduction From Week 6 (at least 50% reduction, verified by a lowered CO)

P Tonnesen.2009


Gum and inhalator increase the likelihood of successful cessation 2 inhaler 4 gum studies
Gum and Inhalator Increase the Likelihood of Successful Cessation (2 Inhaler, 4 Gum studies)

%

* p<0.001

*

*

*

*

Point Prevalence Cessation Rates (complete cessation, verified by a CO < 10 ppm)

P Tonnesen.2009


Smoking reduction wennike t nnesen et al addiction 2003
Smoking reduction Cessation Wennike, Tønnesen et al. Addiction 2003

  • 411 smokers

  • 24 cigarettes/day

  • Motivation to reduce on 10-cm VAS: 9

  • Motivation to quit on 10-cm VAS: 5

  • Nicotine gum for up to 12 months

P Tonnesen.2009


Smoking reduction wennike t nnesen et al addiction 20031
Smoking reduction Cessation Wennike, Tønnesen et al. Addiction 2003

Reduction (sustained):

Active Placebo

4-months 14 % 5 % (p<0.002)

1-year 8.8 % 1.5 % (p<0.001)

2-years 6.3 % 0.5 % (p<0.001)

P Tonnesen.2009


Smoking reduction wennike t nnesen et al addiction 20032
Smoking reduction Cessation Wennike, Tønnesen et al, Addiction 2003

Cessation (point):

Active Placebo

4 months 6.3 % 0.5 % (p<0.001)

1-year 11.2 % 3.9 % (p<0.005)

2-years 9.3 % 3.4% (p<0.01)

P Tonnesen.2009


Motivation to quit
Motivation to quit Cessation

P Tonnesen.2009


Smoking cessation reduction in copd t nnesen et al in press
Smoking cessation/reduction in COPD Cessation (Tønnesen et al.In press)

  • 370 COPD patients

  • Age :62 years

  • FEV1: 1.57 (56 % predicted)

  • Cigarettes/day: 20

  • FTND: 6.4

  • High – low support, NRT – placebo 12 weeks

P Tonnesen.2009


Smoking reduction in copd
Smoking reduction in COPD Cessation

NRT versus placebo:

6 months reduction rate: 21 % vs 15 %

12 months reduction rate: 12 % vs 13 %

P Tonnesen.2009


Smoking cessation in copd
Smoking cessation in COPD Cessation

NRT versus placebo:

6 months quit rate: 23 % vs 10 %

12 months quit rate: 17 % vs 10 % (OR 2.0)

P Tonnesen.2009


Reduction to quit with nrt otc
Reduction to quit with NRT OTC Cessation

  • 3297 smokers in US

  • 2-mg, 4-mg nicotine gum or placebo

  • The first 8 weeks gardually reduce number of CPD and increase number of pieces of gum

  • Abstinent 24 hours use gum as FDA recom

  • Shiffman et al. Am J Prev Med 2009

P Tonnesen.2009


Reduction to quit with nrt otc1
Reduction to quit with NRT OTC Cessation

  • Results: Odds ratio for quitting vs. placebo

  • 1 Month 6 Months

  • 2-mg gum 2.01 1.80

  • 4-mg gum 4.66 5.90

  • Reducers more likely to quit

  • Shiffman et al. 2009

P Tonnesen.2009


Adverse events Cessation

  • A review of 11 studies of NRT used for smoking reduction found no unexpected adverse events, while side effects that may possibly be related to nicotine overdose (such as nausea and vomiting) were evenly distributed between active and placebo treatment groups (Fagerström & Hughes 2002)

  • No increase in cardiovascular events (Murray et al 1996) in concurrent use of NRT and smoking for up to five years

P Tonnesen.2009


Adverse events cont Cessation

  • Use of nicotine 4 mg gum and smoking every hour (in order to attain unusually high plasma nicotine levels) revealed no evidence of adverse cardiac effects, even during exercise tests (Stahl et al 2001).

  • The total nicotine intake remains broadly stable when smokers use NRT to reduce their cigarette smoking (Benowitz et al 1998)

P Tonnesen.2009


Conclusion smoking reduction
Conclusion : Smoking reduction Cessation

  • Reduction possible long-term

  • Reduction leads to cessation

  • NRT increase ”success rates”

  • Motivation to quit not decreased, but actually increased (55-80%)

  • Recruitment of new segment of smokers

  • Effect on health ? (if < 6 cig/day ?)

P Tonnesen.2009


Nrt and smoking reduction
NRT and smoking reduction Cessation

  • Fast acting NRT:

    gum or inhaler,

    sublingual, loozenge

    (nasal spray) (mouth spray)

    2. Use for 2-3 months: If reduced to less than 50 % then continue with NRT

P Tonnesen.2009


Treatment of most smokers is possible
Treatment of most smokers is possible Cessation

Motivated to quit Motivated to reduce

Smoking

cessation

Smoking

Reduction

Agressive smoking cessation with NRT: Combinations of 2 NRT’s;

bupropionSR; varenicline;

Recycling

NRT for 3-(18) months

P Tonnesen.2009


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