Smoking Cessation
in the age of Chantix, Bribery,
and Health Care Reform
Jennifer Tamblyn, MD, MSPH
Assistant Professor of Medicine
University of Colorado at Denver
Presbyterian/St Luke’s Medical Center
The Colorado Health Foundation
Overview
 Epidemiology
 The
allure of tobacco
 Physicians’ role
 Treatment strategies
 Bribery
 Health Care Reform
It’s Common
45 million adults smoke in
the U.S. (2006 estimate)
 21% of the U.S. adult
population
 Rate highest among 18-44
year-olds at 25%

It’s deadly!
From 2000-2004, smoking
resulted in an annual
average of 443,000 deaths
in the United States.
 This is the equivalent of
the deaths of all the
residents living in Kansas
City, Missouri per year

Annual smoking attributable mortality, years of potential life lost, and economic costs—United
States 2000-2004. Available online at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5425a1.htm.
The breakdown:
Lung Cancer = 29%
CAD = 28%
COPD = 21%
Other Cancers = 8%
Stroke = 3.6%
It’s expensive!
$194 billion/ year in
economic losses in the
U.S. due to smoking
 GDP of Israel in 2008
 $97 billion a year in lost
productivity
 $97 billion spent each year
in heath care costs

The World Bank: World Development Indicators database. Gross Domestic Product, 2008.
The Allure…
 Nicotine!
 Binds
to the nicotinic acetylcholine receptors in the
brain, releasing dopamine and beta-endorphins
 Results in euphoria and relaxation
 Also acts as a stimulant, releasing norepinephrine
and epinephrine into the bloodstream
Wait, why would you want to quit?
 Increased
coagulation (platelet adhesion)
 Vasoconstriction, accelerated atherosclerosis
 Bronchospasm
 Insulin resistance**
 CNS irritability, sleep disturbance
 Cancer: Lung, Head and Neck, Cervical, Bladder
 Emphysema, chronic bronchitis
Hazard Ratio of Diabetes Incidence by years since quitting
Yeh H et al. Ann Intern Med 2010;152:10-17
©2010 by American College of Physicians
Physicians’ Role
 Do
we make a difference? YES!
 Brief physician counseling resulted in 56%
increase in smoking cessation compared with
patients who were not counseled at all
 Odds
of quitting: 1.56, CI 1.32-1.84
 Pharmacotherapy
and counseling together increase
patients’ odds of quitting substantially
Lancaster T. Cochrane Database Syst Rev. 2005;(2):CD001292.
How do you broach the subject?
 US
and UK guidelines suggest using the “5 A’s”:
 Ask
your patients about tobacco use
 Advise them to stop smoking
 Assess your patient’s motivation (stage of change) and
need for pharmacotherapy
 Assist with prescriptions and referrals to behavioral
support programs
 Arrange for follow- up on their progress.
Srivistava P, et al. BMJ 2006;332:1324-1326.
Stages of Change Model
 Pre-contemplation–
“Ignorance is bliss”
 Contemplation– Ambivalent about change
 Preparation– ** Planning to act **
 Action– Actively participating in behavior change
 Maintenance– Sustained behavior change
 Relapse– “Fell off the wagon”
Prochaska JO. Am Psychol 1992;47:1102-4.
Types of Treatment
 “Going
 Only
cold turkey”
5% chance of quitting at 1 year
 Nicotine
replacement
 Antidepressants
 Bupropion
(Zyban, wellbutrin)
 TCAs, SSRIs
 Partial
Nicotine receptor agonists
 Alternative medicine therapies
 Payment
Nicotine Replacement
 71%
increase in smoking cessation with NRT over
placebo after 1 year.

Large meta analysis of 70 trials including 28,343 patients (OR
1.71, CI 1.55-1.88, p = 0.0001).6
 Options:
inhaler, nasal spray, gum, patch, lozenges
 Side effects: local irritation, HA, insomnia, GI sx
 Contraindicated in patients with recent MI,
unstable angina, arrhythmias
Wu P, et al. BMC Public Health 2006;6:300.
Dosing the nicotine patch
Depends on how much you
smoke!
 > 10 cigarettes/day

Start with 21 mg/day x 6-8 wks
 14 mg/day for 2-4 weeks
 7 mg/day for 2-4 more weeks


< 10 cigarettes/day
Start with 14 mg/day x 6 wks
 7 mg/day for 2-4 more weeks

Bupropion (Zyban, Wellbutrin)
 Norepinephrine
and dopamine reuptake inhibitor
 Nicotinic receptor agonist
 Bupropion has twice the quit rate at 1 year
compared with placebo
 Meta analysis of 31 trials, 5228 patients
 Odds of quitting: 1.94, CI 1.72-2.19. P = 0.001
Hughes JR, et al. Cochrane Database Syst Rev 2007;(1)CD000031.
Bupropion (Zyban, Wellbutrin)
 PROS:
Weight loss, improves mood
 Side effects: insomnia, HA, tremulousness
 Contraindicated in patients with seizure disorders,
eating disorders, bipolar or schizophrenia.
 Dose: Start at 150 mg daily x 1 wk, then BID
 Most effective if started 2-3 weeks before the
intended quit date
Other antidepressants
 SSRI’s
studied --paroxetine and fluoxetine
 No better than placebo
 Odds quitting: 1.08 (CI 0.88-1.21)
 Unless patient is a depressed recovering alcoholicthen can increase chance of quitting
Hughes JR, et al. Cochrane Database Syst Rev 2007;(1)CD000031.
Other antidepressants
 Nortriptyline
2.34 times as effective as placebo
Meta analysis of 4 trials CI 1.61-3.41, p = 0.001
 Side
effects: dry mouth, sedation, MS changes
 Contraindicated in patients with recent MI,
unstable angina, arrhythmias, seizure disorders,
bipolar, eating disorders, suicidal ideation
 Dose 25 mg qhs, can increase to 75 mg qhs
Hughes JR, et al. Cochrane Database Syst Rev 2007;(1)CD000031.
Varenicline (Chantix)
 Partial
nicotinic receptor agonist
 Varenicline has three times quit rate compared
with placebo (Pfizer-sponsored studies)
Meta analysis of 4 studies, 2428 patients
 Odds of quitting: 2.96, CI 2.12-4.12 p = 0.0001

 Gained
FDA approval May 2006
 Side effects: GI sx, HA, insomnia, nightmares
Wu P, Wilson K, Dimoulas P, Mills E. Effectiveness of smoking cessation therapies: a systematic
review and meta-analysis. BMC Public Health 2006;6:300.
Varenicline (Chantix)
 2007–
death of Carter Albrecht (Dallas musician)
brought media attention to the unwanted
psychiatric side effects: suicidal ideation,
aggressive, unusual behavior
 Black box warning issued May 2008 for increased
suicide risk
 Contraindicated in patients with depression, mood
disorders, suicidal ideation
Comparing therapies
 NO
difference between bupropion and NRT
 Meta
analysis of 2 trials, 548 patients,
 Odds quitting: 1.14, CI 0.20-6.42, p = 0.88
 Varenicline
50% more effective than Bupropion
 Meta
analysis of 3 trials, 2128 patients
 Odds quitting: 1.58, CI 1.16-2.21, p = 0.004
Wu P, Wilson K, Dimoulas P, Mills E. Effectiveness of smoking cessation therapies: a
systematic review and meta-analysis. BMC Public Health 2006;6:300.
Combination Therapy
 Nicotine
patch plus bupropion 50% more effective
than either alone (equivalent to Varenicline).
 Triple therapy (Nicotine patch PLUS prn nicotine
PLUS buproprion 2x more effective than nicotine
patch alone (better than Verenicline)**
 No trials of Varenicline plus NRT
Okuyemi, NS. Am Fam Phys 2006;7:6-12.
Steinberg, MB, et al. Ann Intern Med 2010;150(7):447-454.
Which way
do I go from
here?
Summary
Cold Turkey: 5% per year
 Cold turkey plus physician counseling: 8% per year
 NRT (patch plus extra): ~ 15% per year
 Bupropion: 15% per year
 NRT plus Bupropion: 23-35% per year
 Varenicline: 23% per year
 Nortriptyline: 20% per year

NNT = 4-5
Cost per day
 Cigarettes:
$5/pack
 Nicotine Replacement therapy**:
 Gum:
$9-10
 Nasal Spray: $16
 Patch: $3-4 **
 Bupropion:
$2.33
 Varenicline: $6.67
 Nortriptyline: $0.13
**Financial assistance
available through CO
quit line
Alternative Therapies
Acupuncture
 Meta
analysis of 22 trials demonstrated no benefit
compared with “sham acupuncture” or placebo
 No mention of what “sham acupuncture” entails
 Odds quitting: 1.08, CI 0.77-1.52
White AR, et al. Cochrane Database Syst Rev 2006;(1)CD000009.
Hypnotherapy
Meta analysis of 9 trials
demonstrated no benefit
compared with
psychological counseling.
 Not able to perform
statistical analysis– studies
variable

Abbot NC. Cochrane Database Syst Rev
1998;(2)CD001008.
What about bribery?
 Study
of 878 corporate employees
 Randomized to information on smoking cessation
or financial incentives for smoking cessation
 Patients given $100 for completing a course, $250
if tobacco-free at 6 months, and $400 at 12 months
 3 times greater quit rate in those being paid at 9-12
months after enrollment (14.9% vs 5.0% p < 0.001)
Volpp KG, et al. NEJM. 2009;360(7):700-709.
Health Care Reform
 Expands
coverage to 32 million Americans
 Provisions to close Medicare Part D donut hole
 “Patch” to maintain Medicare reimbursement to
Physicians adjusted for inflation/cost of living
 Will it include reimbursement for smoking
cessation or other behavioral change counseling?
 No–
would have to reverse entire payment system to
value prevention over procedures
Take home points
 You
can make a difference!
 Five A’s
 Focus your attention on those in the planning stage
 If you can’t pay your patients– prescribe!
 NRT
plus bupropion
 Varenicline – maybe?
 Nortriptyline
Thank you!
Questions?
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Annual smoking attributable mortality, years of potential life lost, and economic costs—United
States 2000-2004. Available online at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5425a1.htm.
Accessed November 2009.
The World Bank: World Development Indicators database. Gross Domestic Product, 2008.
Lancaster T, Stead LF. Individual behavioral counselling for smoking cessation. Cochrane
Database Syst Rev. 2005;(2):CD001292.
Srivistava P, Currie GP, Britton J. Smoking Cessation. BMJ 2006;332:1324-1326.
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol
1992;47:1102-4.
Wu P, Wilson K, Dimoulas P, Mills E. Effectiveness of smoking cessation therapies: a systematic
review and meta-analysis. BMC Public Health 2006;6:300.
Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst
Rev 2007;(1)CD000031.
Abbot NC, Stead LF, White AR, Barnes J. Hypnotherapy for smoking cessation. Cochrane
Database Syst Rev 1998;(2)CD001008.
White AR, Rampes H, Campbell JL. Acupuncture and related interventions for smoking cessation.
Cochrane Database Syst Rev 2006;(1)CD000009.
Okuyemi KS, Nollen NL. Interventions to facilitate smoking cessation. Am Fam Phys 2006;7:6-12.
References
1.
2.
3.
4.
5.
6.
Jorenby D E, Hays J T, Rigotti N A, Azoulay S, Watsky E J, Williams K E, Billing C B, Gong J,
Reeves K R (2006). "Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor
partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized
controlled trial". JAMA 296 (1): 56–63
Steinberg, MB, et al. Triple-Combination Pharmacotherapy for Mediclaly Ill Smokers. Ann Intern
Med 2010;150(7):447-454.
Volpp KG et al. A Randomized Control Trial of Financial Incentives for Smoking Cessation.
NEJM. 2009;360(7):700-709.
Yeh, HC, et al. Smoking, Smoking Cessation, and Risk for Type 2 Diabetes Mellitus. Ann Intern
Med 2010;152(1):10-17.
Ranney, L, et al. Systematic Review: Smoking Cessation Intervention Strategies for Adults and
Adults in Special Populations. Annals Intern Med 2006;145:11:845-856.
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