Smoking Cessation Post EAGLES

M. S. McMurtry, MD PhD FSVM May 30 2019

DisclosuresI served as an event adjudicator for the THEMIS trial (AstraZeneca).

Mokdad et al. JAMA. 2018;319(14):1444-1472.

Smoking still accounts for the most life lost…

It’s never too late to quit smoking...

Jha et al. N Engl J Med 2013;368:341-50.

“Adults who had quit smoking at 25 to 34, 35 to 44, or 45 to 54 years of age gained about 10, 9, and 6 years of life, respectively…”

Arnett et al. Circulation. March 27 2019 Epub ahead of print.

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

”All adults should be assessed at every

healthcare visit for tobacco use, and those

who use tobacco should be assisted and strongly

advised to quit.”

The 5 A’s Approach

Siu et al for the USPSTF. Ann Intern Med. 2015;163:622-634

• Ask about tobacco use: • “Do you ever smoke cigarettes or use other forms of

tobacco? • Advise quitting: • “You should quit smoking to improve your health.”

• Assess readiness to quit: • “Are you ready to quit?”

• Assist smokers ready to quit* • Set a quit date • address barriers • behavioural interventions and pharmacotherapy

• Arrange follow-up

Behavioral Interventions

• Brief Intervention • Individual Counseling • Group Counseling • Telephone Counseling: 1-800-QUIT-NOW • Text Messaging: SmokefreeTXT • Web Resources • Heart.org, The Great American Smokeout, Stop

Smoking, Smokefree • Phone Apps

Siu et al for the USPSTF. Ann Intern Med. 2015;163:622-634

• Content: • Education about withdrawal symptoms • Education about triggers • Problem solving and coping skills • Stress management and relaxation • Support

• Duration: • Ideally at least weekly through the quitting process • monthly for at least three months of maintenance

Features of Behavioral Interventions

Siu et al for the USPSTF. Ann Intern Med. 2015;163:622-634

Not ready to quit? The 5 R’s Approach• Relevance

• exploration of why quitting is personally relevant • Risks • highlight risks to the patient and loved ones

• Rewards • identify rewards from smoking cessation

• Roadblocks • identify barriers to smoking cessation and address them

• Repetition • prime the patient for the next interview

Fiore MC, Jaen C, Baker T, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services.

2008.

Pharmacotherapy: The EAGLES trial• Evaluated the neurospsychatic safety and efficacy of varenicline,

bupropion, and nicotine patch in smokers with and without psychiatric disorders

• Randomized, double-blind, triple dummy with placebo control and active control (nicotine patch 21 mg/day)

• Active arms were Varenicline 1 mg bid or buproprion 150 mg bid for 12 weeks with 12 weeks of further follow-up

• 8144 participants (4166 psychiatric cohort, 4028 non-psychiatric cohort) • Primary endpoint: composite measure of moderate and severe

neuropsychiatric adverse events • Efficacy endpoint: abstinence between weeks 9-12 (biochemically

confirmed) Anthenelli et al. Lancet 2016; 387: 2507–20

Anthenelli et al. Lancet 2016; 387: 2507–20

Anthenelli et al. Lancet 2016; 387: 2507–20

Anthenelli et al. Lancet 2016; 387: 2507–20

Anthenelli et al. Lancet 2016; 387: 2507–20

Anthenelli et al. Lancet 2016; 387: 2507–20

Anthenelli et al. Lancet 2016; 387: 2507–20

“varenicline and bupropion can be used safely by psychiatrically stable smokers”

“Although varenicline appears to be the most effective single pharmacotherapy available, all of the first-line medications—varenicline, bupropion, and nicotine patch—are efficacious compared with

placebo”

What about electronic cigarettes?

• No RCT data to support efficacy as a quit tool

• In a systematic review and meta-analysis, odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes (OR 0·72, 95% CI 0·57-0·91) Kalkoran et al. Lancet Respir Med. 2016 Feb;4(2):116-28.

Smoking Cessation Post EAGLES”All adults should be assessed at every healthcare visit for

tobacco use, and those who use tobacco should be assisted and strongly advised to quit.”

Address smoking with the 5 A’s: Ask, Advise, Assess Readyness, Assist, Arrange.

Offer behavioral intervention.

Offer pharmacotherapeutic intervention: varenicline, bupropion, nicotine replacement.