VI Brazilian Congress on AsthmaII Brazilian Congress on COPD

II Brazilian Congress on SmokingBelo Horizonte, August 22-25, 2007

DURATA: 1 ORA

Giovanni Viegi, MD. Director of Research, Italian National Research Council,

Head, Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Pisa – Italy

. Professor of “Health Effects of Pollution”, School of Environmental Sciences, University of Pisa - Italy

. 2006-07 Past-President, European Respiratory Society (ERS)

Future pharmacological treatments on stopping smoking

7. Psychological and behavioural interventions8. Pharmacological treatment for smoking cessation9. Other interventions10. Smoking reduction11. Organisational anchorage and education12. The costs of smoking and economics of smoking cessation13. Research prospects14. References

7. Psychological and behavioural interventions

Three interventions can be included as psychological and behavioural strategies to aid smoking cessation: self-help interventions, brief advice and counselling.

7.1. Self-help programmes

Self-help is defined as structured programming for smokers trying to quit, without intensive contact with the therapist.

tailored self-help materials can be recommended for smoking cessation (Evidence A).

7.2. Brief advice

Brief advice given by physicians or nurses can be defined as routinely providing smokers with brief information to help them quit smoking and increase their motivation to make quit attempts.

It can be recommended that physicians give brief advice on smoking cessation to smokers, including respiratory patients who smoke. Nurses should do the same (Evidence A).

However, when dealing with most pulmonary patients brief advice cannot stand alone, and much more intensive intervention is required.

7.3. Counselling

There are three types of counselling - individual, group and telephone – which vary in terms of the manner of providing counselling and the time taken.

Individual counselling is defined as a face-to-face encounter between a patient and a trained smoking cessation counsellor.

There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions (Evidence A).

7.3.1. Group counselling

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation and to provide each other with mutual support.

Using this kind of support allows more people to be treated by one therapist and could be more cost-effective than individual counselling.

Part I of II

There is no evidence about the efficacy of group therapy in respiratory patients.

Group counselling is effective for smoking cessation (Evidence A). It is unclear whether group counselling is more or less effective than individual counselling (Evidence A).

Part II of II

7.3.2. Telephone counselling

In the proactive approach, the counsellor initiates the calls to provide the smoker with support to make an attempt at quitting (OR 1.41; 95% CI 1.27-1.57).

Reactive counselling is provided via help-lines or hotlines that take calls from smokers (OR 1.33; 95 % CI 1.21-1.47) [129].

The findings suggest that proactive telephone counselling is effective compared to other minimal interventions (Evidence A).

7.4. Behavioural therapy

7.4.1. Aversive smoking

Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus.

There is insufficient evidence to support the use of aversive smoking to quit [133].

7.4.2. Exercise therapy

There is insufficient evidence to support exercise for smoking cessation. [138].

7.5. Procedures for psychological and behavioural interventions in smoking cessation

The following visit schedule can be recommended: Weeks 1, 2, 4, 8, and 12 and 6 and 12 months after quit day.

Some considerations should be taken into account in order to provide the smoker with the best help during the follow-up period:

- At times, ex-smokers feel that they need to smoke again even more than during the first days after quitting.

Part I of II

- Sometimes abstinent smokers can suffer from withdrawal symptoms for long periods. - Coinciding with special situations (social occasions, eating and drinking, meeting friends, etc.), smokers can feel confident enough to try smoking just one cigarette.- Smokers who continue smoking daily 2-3 weeks after receiving adequate treatment for their addiction should be considered unsuccessful.

Part II of II

8. Pharmacological treatment for smoking cessation

8.1. First-line treatment

Nicotine replacement therapy and/or sustained-released bupropion, in conjunction with behavioural intervention, are recommended as first-line pharmacotherapy in current guidelines for smoking cessation [10,146-149].

Except in the presence of contraindications, these drugs should be used in almost all patients attempting to quit smoking.

Part I of II

Smokers of 10 or more cigarettes a day who are ready to stop should be encouraged to use NRT or bupropion to aid cessation.

Health professionals who deliver smoking cessation interventions should give smokers accurate information and advice on these products.

Part II of II

8.1.1. Nicotine replacement therapy (NRT)

This treatment aims to replace the nicotine obtained from cigarettes, thus reducing withdrawal symptoms when stopping smokingThe recommended dosages of NRT vary depending on the degree of dependence.Use should normally be restricted to the licensed duration, but may continue for up to and beyond 3 months in instances of continuing nicotine dependency.

Part I of V

Nicotine replacement therapy should be discontinued if the user restarts smoking [150,151,153].There is little direct evidence that one NRT product is more effective than another, so the decision about which product to use should be guided by individual preferences.Combination NRT has been reported to improve outcome but long-term results are conflicting.

Part II of V

Part III of V

No differences have been found between 16‑hour and 24‑hour nicotine patches and prolongation of treatment for more than 3 months did not increase quit rateHigher doses of nicotine patches have resulted in modest increases in success rates.Tapering of patch dosage is not more effective than abruptly ceasing use.

Relative contraindications given for NRT are cardiovascular disease, hyperthyroidism, diabetes mellitus, severe renal or hepatic impairment and peptic ulcer.NRT has been shown to be safe in patients with coronary heart disease and it should be used in these patients for whom quitting smoking is one of the most important factors influencing prognosis.

Part IV of V

Part V of V

A risk-benefit assessment should be made as to using NRT in breastfeeding or pregnant women taking into account the fact that continuing smoking will deliver more nicotine than NRT.Nicotine replacement is generally well tolerated. The most common adverse effects are localised irritation from nicotine, such as local skin irritation with the patch, or with oral preparations mucous menbrane irritation in the mouth and throat, that generally lessen or disappear due to development of local tolerance after a few days.

Formulation Marketed product

Nicotine transdermal patches

5 mg, 10 mg, 15 mg/16 h (Nicorette, Pfizer)7 mg, 14 mg, 21 mg/24 h (Nicotnell TTS 10, TTS 20, TTS 30, Novartis)7 mg, 14 mg. 21 mg/24 h (NiQuitin CQ, GlaxoSmithKline (GSK)

Table 4. Available nicotine replacement therapy (NRT) formulations

Part I of II

Nicotine chewing gum 2 mg, 4 mg (Nicorette, Pfizer; Nicotinell, Novartis)

Nicotine oral tablets 2 mg sublingual tablet (Nicorette Microtab, Pfizer)1 mg lozenge (Nicotinell, Novartis)2 mg and 4 mg lozenge (NiQuitin CQ, GSK)

Nicotine “oral” inhaler 10 mg inhalation cartridge, plus mouthpiece (Nicorette Inhalator, Pfizer)

Nicotine nasal spray 0.5 mg per spray into each nostril (Nicorette Nasal Spray, Pfizer)

Table 4. Available nicotine replacement therapy (NRT) formulations

Part II of II

Table 5. Cochrane meta-analysis of effect of NRT formulations as odds ratio of abstinence with NRT versus controls. A total of 39,503 subjects were included in the analysis [139]

Smoking cessation therapy

NRT vs. placeboOdds ratio (95% CI)

Abstinence rate NRT

Abstinence rate Control

All NRT formulations

1.77 (1.7-1.9) 17% 10%

Nicotine gum 1.66 (1.5-1.8) 17%

Nicotine patch 1.81 (1.6-2.0) 14%

Nicotine inhaler 2.14 (1.4-3.2) 17%

Nicotine nasal spray

2.35 (1.6-3.4) 24%

*Data from ref 140 Part I of II

Table 5. Cochrane meta-analysis of effect of NRT formulations as odds ratio of abstinence with NRT versus controls. A total of 39,503 subjects were included in the analysis [139]

Smoking cessation therapy

NRT vs. placeboOdds ratio (95% CI)

Abstinence rate NRT

Abstinence rate Control

Nicotine sublingual tablet/lozenge

2.05 (1.9-3.3) 17%

4 mg gum vs. 2 mg gum

2.20 (1.5-3.3)

Fixed gum vs. ad libitum gum

1.29 (0.90-1.9)

Combination of two NRT vs. single NRT

1.42 (1.1-1.8)

Bupropion SR* 2.06 (1.8- 2.4)

*Data from ref 140Part II of II

8.1.2. Efficacy of NRT in smokers with respiratory diseases

Table 6. One-year success rates from smoking cessation studies in patients with respiratory diseases who smoke. Modified from reference 163.

ReferenceNo of patients Sustained success (%) P value

Intervention Control / Usual care

Hospitalised patients

Campbell (1990) 111 20 (+NRT/placebo) 20 NS

Campbell (1996) 234 21 (+NRT/placebo) 14 NS

Miller (1997) 1,4021 14 (+NRT) 13 NS

1,4822 19 (+NRT) 13 <0.01

Lewis (1998) 1853 6.5 (+Placebo) 4.9 NS

9.7 (+NRT) 4.9 NS

1Low intervention and 2high intervention in same study36‑month success rate4 5 mg nicotine patch used as ‘placebo’

Part I of II

Table 6. One-year success rates from smoking cessation studies in patients with respiratory diseases who smoke. Modified from reference 163.

ReferenceNo of patients Sustained success (%) P value

Intervention Control / Usual care

Ambulatory patients

BTS I (1983) 1,550 9.8 (+NRT/placebo) 8.9 NS

Lung Health Study (1994)

5,887 28 (+NRT) 7 <0.001

Tønnesen I (1996)

446 5.6 (+NRT/placebo4) 1.8 <0.01

Taskin (2001) 4043 23 (bupropion/placebo) 16 <0.01

Hand (2002) 245 15 (+NRT) 14 NS

Tønnesen II (2006)

370 17 (+NRT/placebo) 10 <0.001

1Low intervention and 2high intervention in same study36‑month success rate4 5 mg nicotine patch used as ‘placebo’ Part II of II

• Smoking reduction indication is approved in:

• Europe: Austria, Belgium, Czech Rep., Denmark, France, Iceland, Italy, Netherlands, Russia, Switzerland, Sweden, UK.

• Rest of the world: Brazil, Malaysia, New-Zealand, Philippines.

Indication for smoking reduction

8.1.3. Bupropion SR

Bupropion hydrochloride is an antidepressive drug (an aminoketone) which has been shown to be an effective aid to cessation in smokers who smoke more than 10 cigarettes/day and who are motivated to stop.

Bupropion inhibits neuronal reuptake of noradrenaline and dopamine, with minimal effect on the re-uptake of serotonin and no inhibitory effect on monoamine oxidase.

Part I of V

It has been shown to reduce the activity of these dopamine-releasing neurones and thereby may deactivate the reward circuit and reduce craving. Sustained-release (SR) bupropion is considered a useful option for smokers attempting to stop smoking for the first time, especially those who cannot tolerate NRT, who prefer non-nicotine treatment or who have failed to quit with NRT [2-6,16-19].

For smoking cessation the recommended dose of bupropion SR is 150 mg/day for the first week, thereafter increasing to 300 mg/day (150 mg twice daily).

Part II of V

Smokers using bupropion SR are advised to continue to smoke until the target quit day which usually is set after 1 week of treatment.

A reduced maintenance dose—that is, 150 mg daily—is recommended in elderly smokers, or those with liver or renal impairment or below 45 kg in body-weight.

The recommended duration of treatment for smoking cessation is 7–12 weeks.

Part III of V

Bupropion SR is a prescription-only medicine.

The most common side effects are sleep disturbances and dry mouth.

A serious but rare side effect is seizures (<1:1000).[140]. The drug is contraindicated in patients with current or past epilepsy, and should be used with extreme caution in smokers with conditions predisposing to a low threshold for seizure, such as history of head trauma, or alcohol abuse.

Part IV of V

Caution is needed regarding the dose in patients with diabetes treated with hypoglycaemic agents or insulin, and in patients taking drugs that lower the seizure threshold (e.g, antipsychotics, antidepressants, theophylline and systemic corticosteroids).

Bupropion is also contraindicated in patients with a history of anorexia nervosa and bulimia, severe hepatic necrosis, or bipolar disorder.

Bupropion should not be used with a monoamine oxidase inhibitor, and at least 14 days should elapse between stopping such treatment and starting bupropion [9,139, 167-170].

Part V of V

8.1.4. Efficacy of bupropion in patients with COPD who smoke

Very few studies have used bupropion SR for smoking cessation in patients with chronic diseases such as COPD.

These abstinence rates are much lower than those observed in similar studies with bupropion SR in healthy subjects, suggesting that COPD patients may be relatively “hard core.”

8.2. Second-line smoking cessation treatments

Nortriptyline, a tricyclic antidepressant, is the only other antidepressant that has demonstrated evidence of efficacy for smoking cessation.

The dose of nortriptyline for smoking cessation is 75–150 mg daily.

There are many contraindications with nortriptyline, including common anticholinergic side effects and particularly cardiac conduction disturbances and orthostatic blood pressure drop.

Part I of II

Clonidine, has been recommended as a second-line therapy in US smoking cessation guidelines [10].

Adverse effects associated with clonidine, such as drowsiness, fatigue and dry mouth, may limit its use [177], and we consider it to be obsolete today.

Part II of II

SMOKING CESSATION

New Medication

Treatment

Ch GratziouCh GratziouAss.Prof Pulmonary and Crit CareAss.Prof Pulmonary and Crit Care Medical Schools,Medical Schools,Athens UniversityAthens University

Nicotine Addiction

Blood Nicotine

Blood Brain Barrier

Nicotine AchetylocholineBrain receptorsDopamine

release

AddictionAddiction

REWARD

Nicotine in Blood

Blood brain Barrier

Nicotine Ach Receptors Dopamine release

Addiction Addiction

XXReward

XX XX

Medication Treatment

New Medications for Smoking Cessation

Cannabinoid Receptor

Antagonists

Cannabinoid Receptors CB1

CB1

Rewarding stimulies (including palatable food ) and other abuse substances produce dopamine release

in the nucleus accumbens

Glu GABA DA

CB1

CB1 plays an important role in Nac dopamine release

by inhibition of GABA release

Cannabinoid Receptors

• The primary psychoactive

constituent of marijuana, is

related to the action on two

cannabinoid receptors :

CB(1) and CB(2)

THE NECTAR OF DELIGHTTHE NECTAR OF DELIGHT

Cannabinoids Receptors CB1-receptor CB2-receptor

Appetite

Pain

Brain +++ ++

Lung + ++

• CB1 are associated with the intake of food and smoking addiction

• Blocking the CB1 may reduce food craving . • Blocking the CB1 may reduce tobacco depedence by less

motivation to take nicotine possibly due to impairment of dopamine release by the nucleus accumbens

Rimonabant :a CB1- cannabinoid receptor

antagonist

Pharmacological Characteristics • T ½ : 8-15 days

• Metabolised by oxidation in the liver

Why Rimonabant has a place for Smoking Cessation

Animal Studies

• Endocannabinoids are released by chronic nicotine administration (Gonzalez et al, 2002)

• Rimonabant blocks nicotine –induced reinforcement and nicotine self -administration(Cohen et al, 2002)

• Rimonabant produces loss of weight

Weight and Smoking !!

Rimonabant

Clinical trials phase ΙΙΙ ( 7 studies)

Dose 20mg /day for 10 w

Weight ControlDiabetics, Hyper cholesterolemia

Multicentre International study (RIO Europe)

Rimonabant 5 or 20 mg/dayProlonged Abstinence (10 weeks)

n=261 n=261n=262

16.1 15.6

27.6

0

5

10

15

20

25

30

35

40

ITT

Ab

stin

ent

(%)

P=.004

OR=2.0 - 95% CI=[1.296; 3.046]

PlaceboRimonabant 5 mgRimonabant 20 mg

USA study

American College of Cardiology 2004

Rimonabant 5 or 20 mg/dayProlonged Abstinence (10 weeks)

2024 25

0

5

10

15

20

25

30

35

40

ITT

Ab

stin

ent

(%)

P= NS

PlaceboRimonabant 5 mgRimonabant 20 mg

European study

1.Lancet 2005; 365: 1389‑1364.

Side effects with Rimonabant

Placebo 5-mg rimonbant 20-mg rimonabant 2.3 % 1.5 % 2.7 %

Dropouts due to Adverse Events 3.8 % 5.7 % 6.9 %

Cardiovascular Safety ProfileNo safety issue has been detected through laboratory, vital signs, or ECG data

The most frequent side effects reported with rimonabant were nausea, diarrhoea, vomiting, urinary tract infections, anxiety and upper respiratory tract infections.

Rimonabant

Not APPROVED for Smoking Cessation Treatment

Drug for a specific target group ?

• Hypertension , cardiovascular diseases

• Diabetes,

• Hypercholesterolemia,

• Overweight

Rimonabant

• Relative low abstinence rate

• Long term results?

• Prevention of weight gain .

Modification to the molecule might give better efficacy

New Medications for Smoking Cessation

Nicotine Acetylcholine Receptors

n-ACh antagonists

Nicotine Addiction and n ACh Receptors

Cholinergic action

Pre-synaptic

Meta-synapsic membrane Cellular Body of

Dopaminergic neuron

Synapsis

nACh –Receptor

Endogenous nACh Rs are found throughout the central and peripheral nervous system.

The most abundant form of nACh receptors is a pentameric made of a4b2 units

Leonard & Bertrand

Nicotine Tob Res 2001;3

The a4b2 receptor is critical for self administration of nicotine Picciotto et al 1998, Tanner et al 2004

• Developed specifically for targeting the main nicotinic receptor responsible for nicotine addiction : a4b2 n ACh receptors

• Not a substitute for nicotine • Not an antidepressant

Varenicline

Varenicline: New Molecule

H

NH

N

N

N

N

S-(-)-Nicotine

Varenicline New mechanism of Action

Varenicline was developed as Partial

agonist of 42 nicotinic acetylcholine

recptors combining agonist and

antagonist properties in one compound

Varenicline : New Mechanism of Action

0

50

100

Response level(%)

Full agonist

(nicotine)

Antagonist(meca-

mylamine)

Full agonist

+antagonist

Partialagonist

Partialagonist

+nicotine

A selective nicotinic receptor partial agonist evokes a reducedlevel of response, while antagonizing the response of a full agonist

The nicotinic AcHR is aThe nicotinic AcHR is aligand-gated pentamericligand-gated pentamericion channel; downstreamion channel; downstream

effects include DATOeffects include DATO

Dopamineturnover(DATO)

Dose, exposure

Effect

Maximum effect

0%

100%

50%

Partial agonist

Full agonist

Varenicline: A Partial Agonist

Craving; withdrawal relief

Blocks reward

Varenicline a Partial Agonist

How Varenicline helps to overcome nicotine addiction

As Partial agonist

minimises the withdrawal symptoms ( agonist effect)

blocks the pathway that is associated with reward system after nicotine intake ( antagonist effect )

Varenicline Pharmacological Characteristics

Low Protein binding

Absorption Absorption

DistributionDistribution

MetabolismMetabolism

Excreted as unchanged in the urine Renally cleared >90 %

Excretion Excretion

No interaction with Food No interaction with other Medications

Highly absorbed 99 %

Half life 17h

Non metabolised No drug interaction with c Ρ450

Varenicline: Clinical Studies

JAMA July 2006 : 3 randomised trials

1. Gonzales D, Rennard SI, Nides M, et al. Varenicline, an a4b2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA. 2006;296:47-55.

2. Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an a4b2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA. 2006;296:56-63.3.

Treatment PhaseTreatment Phase Nontreatment PhaseNontreatment Phase

Varenicline 1mg bidVarenicline 1mg bid

Bupropion 150 mg bidBupropion 150 mg bid

Placebo Placebo

ScreeningScreeningVisitVisit BaselineBaseline

RandomizationRandomization

1212 5252

Varenicline Clinical Studies: Design

Primary Endpoint:Primary Endpoint: CO- confirmed 4-wk continuous CO- confirmed 4-wk continuous quit rate wks quit rate wks 9-129-12

Secondary Endpoint:Secondary Endpoint:CO-confirmed continuous abstinence CO-confirmed continuous abstinence rate wks rate wks 9-529-52

99WkWk

TargetTargetQuit DateQuit Date

11

Continuous abstinence rates (confirmed by CO )

P.001

(P=.007),

(P=.057),

(P=.001)

P.001

Gonzales et al. JAMA. 2006;296:47-55.

Randomised double blind

19 centres

in USA

1025 smokers

Treatment 12w

Follow-up 40 w

44%

29.5%

17.7%

21.9%

16.1%

8.4%

20.7%

29.5%

10.5%

Continuous abstinence rates (confirmed by CO )

P.001

Jorenby et al. JAMA. 2006;296:56-63.

43.9%

17.6%

29.8% 29.7%

13.2%

20.2%

23%

10.3%

14.6%

Randomised double blind

14 centres

1413 smokers

Treatment 12wFollow-up to 52 w

Side effects

Jorenby et al. JAMA. 2006;296:56-63.

Maintenance treatment with

varenicline Tonstad S, Tønnesen P, Hajek P, et al. Effect of maintenance therapy with varenicline on smoking cessation: a randomized controlled trial. JAMA. 2006;296:64-71.

To determine whether smokers who quit after 12 weeks of treatment with varenicline, maintain greater continuous abstinence rates than placebo controls during an additional 12 weeks of treatment and until 52 weeks after treatment initiation.

Maintenance of Abstinence:Study Design

Secondary Endpoint:CO-confirmed continuous abstinence rate wk 13–52

Wk12Wk12 2424 5252

NONTREATMENTNONTREATMENTFOLLOW-UPFOLLOW-UP

DOUBLE-BLIND DOUBLE-BLIND OPEN-LABELOPEN-LABEL

Primary Endpoint:CO-confirmed continuous abstinence rate wk 13–24

Varenicline 1mg bidVarenicline 1mg bid Varenicline 1mg bidVarenicline 1mg bid

PlaceboPlacebo

Quitters randomizedQuitters randomized

12 weeks

Maintenance treatment :7 day point prevalence abstinence

Tonstad et al .et al . JAMA. 2006;296:64-711st phase Open study 12w2nd phase Randomised double blind additional 12w

14 centres 1927smokers 63 % participate in 2nd phase

49,8

70,6

0

20

40

60

80

100

Res

ponse

Rat

e (%

)Maintenance of Abstinence Study:

CO-confirmed Continuous Abstinence Rates

N=602

Varenicline N=604

Placebo N=602

Varenicline N=604

Placebo

Wks 13–24

OR=2.47OR=2.47(95% CI 1.95, 3.15) p<0.0001

1.351.35

Wks 13–52

37,144,0

OR=

OR = odds ratio

(95% CI 1.07, 1.70) p=0.0126

Wks 24-52

Side effects

Tonstad et al .et al . JAMA. 2006;296:64-71

Varenicline: Published Studies

Gonzales et al. JAMA. 2006;296:47-55.

Varenicline is an efficacious, safe, and well-tolerated smoking cessation pharmacotherapy.

Varenicline’s short-term and long-term efficacy exceeded that of both placebo and bupropion SR.

Jorenby et al. JAMA. 2006;296:56-63.

Extended use of varenicline helps recent ex-smokers to

maintain their abstinence and prevent relapse

Tonstad et al .et al . JAMA. 2006;296:64-71

Part I of II Cahill et al, Cochrane Database of SR, 2007

Part I of II Cahill et al, Cochrane Database of SR, 2007

New Medications for Smoking Cessation

Modifiers of

nicotine metabolism

Modifiers of nicotine metabolism

• Inhibitors of CYP2A6

Nicotine Cotinine

3-hydroxycotinine

CYP2A6

CYP2A6

Cytochrome CYP2A6

• CYP2A6 Polymorfism (26 alleles) is Related with

• Nicotine metabolism • Lower smoking initiation rate and lower

smoking dependence • Lower smoking habit • Reduced risk for lung cancer

CYP2A6 Inhibitors

• Enhance the action and effectiveness of

NRTs.

• Reduce the number of cigarettes consumption

• Control the desire for smoking

• Reduce the activation of pre-carcinogens to

carcinogens

• Reduce the risk for Lung Cancer

CYP2A6 Inhibitors

• Μethoxsalen 10mg , 30 mg • Tranylcypromine (MAO inhibitor)

– 2.5mg, 10mg

Increase plasma level of nicotine

Reduce smoking desire and cigarette consumption

Sellers et al.Research focus2003Zhang et al. Drug Metab. Dispos.2001

Other New Approaches for

Smoking Cessation

Vaccination ????

Nicotine in Blood

Blood brain Barrier

Nicotine Ach Receptors Dopamine release

Addiction Addiction

XXReward

Vaccine : Mechanism of Action

Nicotine in Blood

Blood brain Barrier

Nicotine Ach Receptors Dopamine release

Addiction Addiction

XXReward

Vaccine : Mechanism of Action

XX

Possible place for Vaccine

• Relapse prevention

Advantages

No daily use

No action in CNS

Combination with other therapies

• Preparation of heavy smokers for smoking abstinence

• Early prevention of Smoking Dependence ??

Vaccines against Smoking

• ΤΑ-ΝΙC (Xenova research Ltd, UK)• NicVAX ( Nabi , USA)• Nicotine –Qbeta ( Cytos, Switzerland)

Successful clinical trials phase Ι and II Few Side Effects

More ongoing studies

1: Curr Opin Investig Drugs. 2007 Jan;8(1):71-7.

Drug evaluation: CYT-002-NicQb, a therapeutic vaccine for the treatment of nicotine addiction.Heading CE.The Open University in the North, Faculty of Science, Eldon House, Regent Centre, Gosforth, Newcastle upon Tyne NE3 3PW, UK. moore11@globalnet.co.uk

Cytos Biotechnology AG is developing an intramuscular therapeutic vaccine, CYT-002-NicQb (also known as nicotine-Qbeta), based on its Immunodrug (formerly known as alpha vaccine) nicotine-specific antibody-generating technology, for the potential treatment of nicotine addiction. A phase II trial was initiated in Switzerland in January 2005 and in February 2006, Cytos Biotechnology announced that it planned to begin a phase IIb/III trial in 2007.

Vaccines against Smoking Questions !!

• More clinical studies in smokers• Safety ( long term use)• Cost of Therapy• Duration of action and effectiveness• Use Frequency• Ethical issues

– Prevention of tobacco use in adolescents , – Use in pregnancy ??

Further Questions on New Treatments

More clinical trials and real phase studies to assess :

• Effectiveness

• Long term use

– Relapse Prevention

– Weight gain

• Combined use

8.3. New medications

8.3.1. Varenicline

Varenicline is a partial agonist at the subtype of neuronal nicotinic receptors composed of α4 and β2 subunits.

Varenicline initially stimulates the α4β2 receptors that mediate the effects of the nicotinic agonist on dopamine release in the nucleus accumbens (the agonist function).

If nicotine is added to varenicline treatment no increase in dopamine response is seen (the antagonist function).

Part I of II

As varenicline combines both agonist and antagonist function it can reduce nicotine dependence and can also attenuate the effects of nicotine withdrawal [179,180]. Smokers are asked to up-titrate their dose to varenicline 1 mg twice daily during the first 7 days of treatment, the stop smoking on day 8, and continue treatment for 12 weeks.We expect that with more documentation and experience varenicline will be a first-line drug in smoking cessation.

Part II of II

Table 7. Continuous quit rates, in percent, from week 9 to 52 in two phase III trials of varenicline for smoking cessation

Study Placebo Varenicline 2 mg/day

Bupropion SR 300 mg/day

P value

Gonzalez [179]Study 1

8.4 22.1 16.4 varenicline vs placebo p<0.001varenicline vs bupropion p<0.07bupropion vs varenicline p<0.001

Jorenby [180]Study 2

10.3 23.0 15.0 varenicline vs bupropion p<0.001bupropion vs placebo p<0.001varenicline vs placebo p<0.001

8.3.2. Rimonabant

The stimulation of CB1 receptors by endocannabinoids within the brain plays an integral role in the development and maintenance of nicotine and tobacco dependence, and rimonabant exerts its effects in addicted individuals by inhibiting this role of the endocannabinoid system [182].

The most frequent side effects reported with rimonabant were nausea, diarrhoea, vomiting, urinary tract infections, anxiety and upper respiratory tract infections.

Part I of II

Rimonabant’s effects do not seem to be significantly better than currently available cessation treatments.

With its better-documented efficacy on obesity treatment [184], one might speculate that rimonabant could be useful in overweight smokers for whom weight gain is a major barrier to quitting.

Part II of II

8.4. Key points: Pharmacotherapy and smoking cessation

- NRT and bupropion SR are first-line treatments for smoking cessation (Evidence A)

- Smokers attempting to quit should be encouraged to use these drugs to aid cessation, except in the presence of contra-indications (Evidence A).

- NRT (gum, patch, inhaler, nasal spray, lozenge and sublingual tablets) are equally effective as smoking cessation treatments (Evidence A).

Part I of II

Combining the nicotine patch with a self-administered form of NRT can be more effective than a single form of NRT (Evidence B).- NRT should be used to aid cessation in all smokers with COPD, regardless of disease severity and number of cigarettes smoked (Evidence B).- Combined treatment with bupropion SR and NRT might be more effective in heavy smokers (Evidence C)

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- Both NRT and bupropion SR are effective and well tolerated in smokers with stable cardiovascular disease and in COPD patients.(Evidence A)

- Nortriptyline may be used as second-line medication to treat tobacco dependence (Evidence B).

- There is no evidence that selective serotonin reuptake inhibitors (SSRIs) have any effect in smoking cessation.

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- Varenicline might have additional therapeutic effect as smoking cessation treatment and are considered a second-line agent until more documentation and experience occur (Evidence B)

- Regular follow-up visits are important and are linked with longer-term successful outcome (Evidence B).

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Yes No

Yes

No

Figure 2. An illustration of the recommended smoking cessation steps and approved first-line interventionsFigure 2. An illustration of the recommended smoking cessation steps and approved first-line interventions

Part I of II

Successful quitter

Relapse

NRT= nicotine replacement therapyPart II of II

9. Other interventions

9.1. Acupuncture and laser therapy

9.2. Hypnotherapy

There is no evidence that hypnosis, acupuncture or laser therapy has any effect in smoking cessation

11. Organisational anchorage and education

Smoking cessation services should be an integral part of a chest unit, offering advice and help to all smokers with respiratory diseases independently of the smoker’s motivation, but focusing primarily on those who want to try to quit.

As a minimum, chest departments should offer smoking cessation support, NRT and/or bupropion SR and at least four follow-up visits to all smokers.

The precise details of each service are likely to depend on local factors and national differences, taking into account the fact that individual clinicians fail to intervene with more than one-third of smokers [9].

11.1. Systematic identification of smokers

Focusing on hospitals - either inpatients or outpatients – there should be an organisational plan for identifying smokers, documenting smoking data in patients’ records, and delivering brief advice with an offer of referral to the smoking cessation service [9,198].

11.2. Equipment and staffing

Certain requirement and expertise should be available in each clinic unit to perform the assessments described previously. It should be possible to assess CO level, nicotine dependence and motivation to quit [80,199,200].

If the clinic cannot offer smoking cessation there should be written flow-charts stating where to refer the patients.

It is also important to engage GPs in smoking cessation, as many COPD patients consult their GP frequently.

11.3. Education

The following tools have been shown to alter physicians’ behaviour [202]:

- Education by physician “opinion leaders”

- Computerised concurrent feedback on clinical decisions,

- Academic detailing i.e. one-on-one education, often by a pharmacist,

- Physician incentives, but also patient education or information and patient incentives.

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Guidelines should be simple, pragmatic, usable and flexible with an increasing focus on implementation [201,203].

Smoking cessation should be part of the core curriculum of the undergraduate and postgraduate education and training of physicians.

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As smoking plays so large an aetiological role for a majority of pulmonary disorders, the pulmonary clinician must know about smoking cessation at a level similar to the knowledge about other respiratory therapies e.g. bronchodilators and inhaled steroids.

Formal training courses are needed to educate smoking cessation counsellors, and courses must be repeated to take account of turn-over among staff members. It would be optimal if all pulmonary clinicians participated in the above education.

There should also be postgraduate smoking cessation courses at the annual ERS conference. Part III of III

11.4. Smoke-free health care

Smoking should be banned in hospitals, both for hospitalised and ambulatory patients and for staff.

The European Smoke-Free Hospital Network consists of 16 membership countries and this organisation has created implementation guidelines for turning a hospital smoke-free, as well as training guidelines and material for health care workers [205].

12. The costs of smoking and economics of smoking cessation

13. Research prospects

1) Examine the efficacy of NRT and bupropion SR and combinations for smoking cessation in patients with respiratory diseases, particularly COPD and asthma. Smoking cessation studies are also needed for smokers with several other respiratory disorders such as tuberculosis, alpha 1 antitrypsin deficiency, histiocytosis X, and candidates for lung transplantation.

2) Examine the efficacy of different re-treatment interventions as well as long-term treatment for smoking cessation in patients with respiratory diseases.

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3) Examine the efficacy of smokeless tobacco as a smoking cessation tool in recalcitrant smokers.

4) Examine the efficacy of lung function screening in asymptomatic and symptomatic smokers, combined with different smoking cessation approaches.

5) Explore the characteristics of tobacco dependence/nicotine addiction and barriers and motivation to quit in patients with respiratory diseases.

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6) Examine whether reduced smoking in patients not motivated to give up can increase self- confidence and motivation to quit.

7) Examine the relationship between COPD and depression and evaluate whether treatment for depression can help dependent respiratory patients to quit.

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8) Evaluate the efficacy of new drugs for smoking cessation in respiratory patients.

9) Evaluate the efficacy of smoking cessation programs in rehabilitation courses.

10) Evaluate the efficacy of web-based programmes, quit-lines and other “mass-media” methods for smoking cessation.

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2. Key points of recommendations

1. Patients with respiratory disease have a greater and more urgent need to stop smoking than the average smoker. They should be encouraged to stop but many often find it more difficult to do so (B).

2. Respiratory physicians must take a proactive and continuing role with each smoker in motivating him or her stop, and provide treatment to achieve smoking cessation, however long this might take, and deal with relapses when these occur. Smoking cessation treatment must be considered integral to the management of the patient’s respiratory condition.

Part I of IV

The role includes:• regularly assessing smoking status using methods that can objectively detect smoking, such as expired-air carbon monoxide (CO) tests. (C) • pharmacological treatment for nicotine dependence including bupropion and/or where necessary using high-dose and/or prolonged nicotine replacement therapy (NRT); it could also include giving combinations of different forms of NRT (A). Varenicline is a promising second-line agent (B). • behavioural support, which should be intensive and multi-sessional, and provided by someone who has been appropriately trained (B).

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3. To carry out this role effectively, respiratory physicians must have adequate knowledge and appropriate attitudes and skills; this requires training and continuing medical education which should be provided according to professional standards, and be accredited (C).

4. The cost of this strategy will partly be offset by a reduction in attendance for exacerbations etc., but a budget must be established to enable implementation of treatment protocols and provide medication and behavioural support (A).

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5. It is important to check lung function regularly in order to chart disease evolution and use this as a motivational tool (C).6. Smokers not motivated to stop should be offered NRT to reduce smoking as a gateway to cessation (B). 7. Smokers who are not interested in stopping or reducing should be advised that the physician will return to the question at a later visit (C).

Part IV of IV

Smokers will never be able to

“take just a pill” that will make them

in a magic way

to stop smoking !!!

Treatments for Smoking CessationTreatments for Smoking Cessation

Smoking Cessation Treatment

Smokers must want to stop smoking and must be willing to work hard to

achieve the goal of smoking abstinence.

Brief Clinical Advice

&Intensive Smoking cessation Programs

Thank you!

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