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Smoking Cessation Treatment: Helping Smokers Quit. Saul Shiffman, Ph.D. Research Professor Psychology, Psychiatry, Pharmaceutical Sciences Consultant: GlaxoSmithKline Interest in developing pharmacotherapy. Role of Treatment.

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smoking cessation treatment helping smokers quit

Smoking Cessation Treatment:Helping Smokers Quit

Saul Shiffman, Ph.D.

Research Professor

Psychology, Psychiatry, Pharmaceutical Sciences

Consultant: GlaxoSmithKline

Interest in developing pharmacotherapy

role of treatment
Role of Treatment
  • Quitting among current smoklesr key to achieving reduction in mortality in next 50 years
  • Public education and policy pressures unlikely to get all smokers to quit
  • Smoking is addictive, so many smokers have difficulty quitting
  • Treatment may be most needed by those most at risk for morbidity & mortality
  • Access to effective treatment may be regarded as a right

Behavioral treatment

Pharmacologic treatment

evaluating treatment efficacy
Evaluating Treatment Efficacy
  • Meta-analysis synthesis
  • Outcomes
    • Abstinence at 6 months +
    • Continuous or last 7 days
    • “Not even a puff”
    • Biochemically validated
    • Missing = failure
    • Research criteria stricter than public health criteria
behavioral treatment
Behavioral Treatment
  • Convergence on loose collection of cognitive-behavioral methods
  • Aim to provide tools and techniques for behavior change
    • e.g., avoiding triggering stimuli, planning rewards
  • Increasingly, differentiated by delivery modality
channels for delivery of behavioral treatment














Channels for Delivery of Behavioral Treatment
effect by treatment modality
Effect by Treatment Modality

Source: AHRQ analysis: 2000

dose response effect treatment sessions
Dose-Response Effect: Treatment Sessions

Source: AHRQ analysis: 2000

alternative treatments
“Alternative” Treatments

Source: AHRQ analysis: 2000

  • Primarily aim to reduce craving and withdrawal, to make behavior change easier
    • Other mechanisms being explored, particularly reduced reward from smoking
nicotine replacement therapy nrt
Nicotine Replacement Therapy (NRT)
  • Transition smoker off smoking by temporarily replaceing “lost” nicotine with low-dose medicinal nicotine, to minimizew craving and withdrawal
    • Patch
    • Gum
    • Lozenge
    • Inhalator
    • Nasal Spray
innovations in nrt not approved in the us
Innovations in NRTNot Approved in the US
  • Combinations
    • “Steady-state” patch + “as-needed” acute form
    • Incremental efficacy (OR = 1.9)
  • Pre-treatment
    • Use patch for 2-4 weeks before quitting
    • Incremental efficacy (OR = 2.2)
  • Reduce to Quit
    • Smokers interested in quitting gradually, use gum to reduce smoking over 8 weeks
    • Increases quit rate (OR = 2.7)
  • Reduce Until Ready to Quit
    • Smokers not interested in quitting use NRT to cut down over 6-9 months
    • Increases quit rate (OR= 1.6)
is behavioral intervention necessary for nrt to work
Is Behavioral Intervention Necessary for NRT to Work?
  • Myth: Medications / NRTs do not work unless accompanied by behavioral treatment
  • OTC NRTs demonstrated efficacy with NO formal behavioral treatment
  • Effects of behavioral treatment & medication are additive
    • Each works equally well without the other
    • The combination yields highest success rates
non nicotine medications prescription only
Non-Nicotine MedicationsPrescription Only
  • Bupropion
    • Zyban Wellbutrin
    • Atypical antidepressant
    • Effects not limited to depressed
  • Varenicline
    • Nicotine receptor partial agonist / antagonist
  • Nortriptyline
    • Tri-cyclic antidepressant
    • Tested in academic trials
  • Clonidine
    • Catapres
    • Antihypertensive, 2 agonist (reduces sympathetic tone)
    • Tested in academic trial
effective medications few differences demonstrated
Effective Medications;Few Differences Demonstrated



Products vary in number, age, & type of study;

Studies vary in dosing; populations, assessments, behavioral intervention, & length of follow-up


Source: AHRQ analysis: 2000 + Shiffman et al 2003 + Wu et al 2006

on the horizon
On the Horizon
  • Many novel CNS drugs and novel applications of existing CNS drugs
  • Nicotine vaccine
    • Sequester nicotine in periphery, to prevent entry into brain, block reinforcement
    • Clinical utility unknown
public health impact
Public Health Impact

Public Health Impact


Efficacy (% quit)


Utilization (# using method)

utilization of treatments
Utilization of Treatments
  • A treatment that is not used has no effect on quitting or public health
utilization of behavioral treatments
Utilization of Behavioral Treatments

Any behavioral = 8.8%

Shiffman et al, under review, based on CPS, 2003

utilization of medications
Utilization of Medications

Any medication = 32.2%



Shiffman et al, under review, based on CPS, 2003

impact of otc availability on utilization of nrt medications
Impact of OTC Availability on Utilization of NRT Medications

Estimated Assisted Quit Attempts(in thousands)

Burton et al, MMWR, 2000 + additional GSK data

use of treatment
Use of Treatment


Shiffman et al, under review, based on CPS, 2003

treatment use lower in minority populations
Treatment Use Lower in Minority Populations


Ethnic-group differences persist when controlling for income, education

Shiffman et al, under review, based on CPS, 2003

  • Unaided cessation yields 3% success rates
  • Variety of behavioral treatments & medications available
  • Modest absolute efficacy, good relative efficacy
  • New treatments over the horizon, but no breakthroughs
  • Low utilization, therefore modest public health impact
  • Short and medium-term gains most likely to come from increased utilization / reach
utilization of treatments29
Utilization of Treatments
  • A treatment that is not used adequately has less effect on quitting or public health
  • Most users don’t use enough medication for long enough to reap full benefit
compliance with medication
Compliance with Medication
  • Duration
    • Longer use = increased efficacy
    • NRT recommended for 10-12 weeks
    • Typical use < 4 weeks
  • Dosing
    • More use = increased efficacy
    • Gum & lozenges recommended 9+ pieces/day
    • Typical use 4-6 pieces / day