1. Pre-cessation nicotine treatment Jean-François ETTER Dr polit. sci, privat docent Institute de Médicine Sociale et Préventive Faculté de Médecine, Université de Genève Berne, September 13, 2006

3. Competing interests statement The Institute of Social and Preventive Medicine of the University of Geneva has received: - -trial medications (nicotine) from Pfizer, - -grants from Novartis and Pfizer to develop computer-tailored smoking cessation counseling programs, led by JFE.

4. Nicotine replacement therapy for smoking cessation   Cochrane: 105 studies, n=32’000, 6-12 months   Modest success rates (7% over placebo)   In the long term, this effect is decreased by 30%   60% of studies were funded by pharma industry   Industry-funded studies are twice as likely to find p>.05 results

5. Smoking reduction prior to quitting   Easier to quit if one smokes fewer cigarettes   Successful reduction may increase the feeling that stopping is possible   Many smokers prefer gradual vs. abrupt cessation   Spontaneous reduction + NRT use in smokers   Ambivalence, special group   Smokers must be treated like other addicts: have all of them do stg, either quit or reduce   Those not motivated to stop should not be excluded from treatment

6. New: « Cut down to stop »   NRT now licensed for « cut down to stop » (Pfizer term) in several countries   «…reducing the amount you smoke until you decide to give up completely. You should aim to do this in 6 months. » (Nicorette website)   New customers: smokers who use NRT for several months before they stop smoking   UK: NARS report (ASH: M. Raw, A. McNeill, R. West)   UK: NICE report in preparation   Where does the evidence come from ?

7. Long-term NRT-aided reduction in smokers not willing to quit   Review 19 studies (Hughes, Addiction 2005;100:1074)   NRT for 2-12 months (25 th -75 th percentiles)   ActiveControlRR   CPD reduced:8-233-81.3-2.5   % reduced:25-56%13-26%   Achieved 50% reduc:8-27%2-22% 1.6-4.6

8. NARS report, NRT license for CDTS   Based on long-term NRT-aided reduction studies in smokers not motivated to stop…  ...but CDTS is licensed as a strategy to stop gradually   Recommendation CDTS for 6 months is arbitrary   CDTS not based on short-term pre-cessation NRT in smokers motivated to quit   … because 2-4 additional weeks of treatment not worth the effort of getting this approach licensed?

9. Short-term (1-2 weeks) pre-cessation NRT in smokers willing to quit: 3 studies NProduct Durat° pre-tx PlaceboFollow- up Quit rate pre-tx vs control RRP-value Herrera Chest 1995 200Gum 1 week No6 weeks 61% vs 52% 1.2NS Schuurmans Addiction 2004 234Patch 2 weeks Yes6 months 22% vs 9% in 16+ cig 2.40.01 Rose Nicotine Tob Res 2006 96Patch 2 weeks Yes6 months 20.8% vs 12.5% 2.30.3

10. 3 studies NRT for 1-2 weeks pre-cessation

11. Shiffman 2006 study   Gradual cessation with NRT   N=3200   2 or 4 mg gums or placebo for 4-8 weeks pre quit   NRT for 12 weeks post quit, up to 12 months   Results at 6 months (4 mg): OR = 6 (over placebo)   Presented at WCTOH, Washington, July 2006

13. Ongoing study in Geneva   Easier to quit if one smokes fewer cigarettes / day   4 mg: strong taste   Poor compliance   Hypothesized mechanisms of pre-cessation NRT: - reduce cigarette consumption - increase N gums during first crucial days a after cessation - break automatic association nicotine = cigarette

14. Geneva study   Aim: test if treatment with 4 mg nicotine gums is more effective if it starts 4 weeks before the quit date   2 groups compared: 1) gums 1 month before + 2 months after 2) gums 2 months after quit date   Randomized trial   No placebo

15. Geneva study   Gums sent by mail   No face-to-face counseling   Advice to use clinics, quitlines, web   15+ cig./day.   GE + VD

16. Follow-up   4 times   Quit date, end of treatment (2 mo), 1 yr, 5 yrs   Saliva cotinine after 12 months   CO at 12 months if quit and cotinine >10 ng/ml   215 participants (September 13, 2006)   Follow-up rate: - 98% at quit date - 94% at end of treatment

17. Conclusions   Long –term NRT reduction increases quit rates in smokers not trying to quit   Short-term (1-2 weeks) pre-cessation NRT increases quit rates in smokers trying to quit (RR = 1.2 – 2.4)   Paradoxically, NRT is licensed pre-cessation (CDTS) for smokers who do not want to stop, but not for those who do

18. Implications   Smokers should be reminded that quitting is best   All smokers should receive treatment + support   Smokers who prefer gradual quitting may use NRT   Possibility that it may weaken the ‘not a puff’ message ?   Population impact ?   To increase quit rates we need to: - increases taxes - ban smoking in public places - advocacy - evidence-based media campaigns

19. Get these slides on stop-tabac.ch