Smoking Cessation

Smoking Cessation

Smoking Cessation Treatment for Chronic Obstructive Pulmonary Disease Smokers Carlos A Jiménez-Ruiz,1 Susana Luhning,2 Daniel Buljubasich3 and Rogelio Pendino4 1. Head of Smokers Clinic, Comunity of Madrid; 2. Hospital Nacional de Clínicas, Universidad Nacional de Córdoba; 3. Hospital Español de Rosario; 4. Servicio Neumologia, Santorio Parque, Rosario

Abstract Tobacco smoking is the major etiological factor for the development of chronic obstructive pulmonary disease (COPD). Smoking cessation is the only therapeutic measure that can cure and avoid the chronic progression of this disorder. Smokers with COPD have a higher degree of nicotine dependence, lower motivation to quit, higher levels of depression and worse weight control than smokers without COPD. These characteristics convert COPD smokers into a hard-core group of smokers. All kinds of interventions must be offered to COPD smokers to help them to quit smoking. Cognitive-behavioural interventions and pharmacological treatments such as nicotine replacement therapy, bupropion and varenicline have been demonstrated to be effective and safe. Intensive cognitive-behavioural interventions plus pharmacological treatment are effective and cost-effective for these patients.

Keywords Smoking cessation, chronic obstructive pulmonary disease, varenicline, nicotine replacement therapy, bupropion, continued assistance Disclosure: Carlos A Jiménez-Ruiz, Daniel Buljubasich and Rogelio Pendino have undertaken research and consultancy for manufacturers of smoking cessation medications. Susana Luhning has undertaken consultancy for manufacturers of smoking cessation medications. Received: 21 July 2011 Accepted: 21 August 2011 Citation: European Respiratory Disease, 2011;7(2):106–10 Correspondence: Carlos A Jiménez-Ruiz, Unidad Especializada en Tabaquismo, C/ Santacruz del Marcenado, 9. Piso 2, Madrid 28009, Spain. E: [email protected]

Tobacco smoking is the major etiological factor for the development of chronic obstructive pulmonary disease (COPD) and between about 15 % and 20 % of smokers will develop COPD.1 Recent research has suggested that women may be more susceptible to the lung-damaging effects of smoking; however, the findings are inconsistent. Although a recent study found that female gender was associated with lung function reduction and more severe disease in subjects with COPD with early onset of disease or low smoking exposure, other studies have suggested an opposite gender effect.2,3 It is also known that smoking cessation is the only therapeutic measure that can cure and avoid chronic progression of COPD.1,4 Nevertheless, smoking cessation is usually a difficult task for smokers with COPD. In this article, we review the reasons that explain the difficulties for stopping smoking and provide an update about our knowledge of the characteristics of smoking cessation treatments for these patients.

Smoking Characteristics of Smokers with Chronic Obstructive Pulmonary Disease Nicotine dependence, motivation to quit, depression and weight control can be different in smokers with COPD compared with ‘healthy’ smokers.

smokers with COPD had a higher dependence on nicotine than healthy smokers: their FTND-score was 4.77 versus 3.10, respectively (p0.05).27 A more recent study compared the efficacy of bupropion with placebo and nortriptyline in smokers with COPD or at risk of suffering COPD. It was found that bupropion was more effective than placebo for achieving continuous abstinence by the six-month follow-up, 27.9 % versus 14.6 % in the COPD group of smokers, but was not in the group of patients at risk of suffering COPD.28

In a recent study, we reported the results of a study of 116 smokers, most of them suffering from COPD, who attended our Smoking Cessation Service but who did not want to quit abruptly. The subjects participated in a two-stage programme consisting of a four-month reduction phase followed by a six-month abstinence phase. The aim was to reduce the number of cigarettes smoked daily by at least 50 %

108

Another study has compared the efficacy and the cost-effective relationship between bupropion and nortriptyline in smokers at risk or with existing COPD.29 A total of 255 participants received smoking cessation counselling and were assigned bupropion, nortriptyline or placebo randomly for twelve weeks. Prolonged abstinence from week

EUROPEAN RESPIRATORY DISEASE

Smoking Cessation Treatment for Chronic Obstructive Pulmonary Disease Smokers

4 to week 52 were determined and validated by urinary cotinine. Costs were calculated using a societal perspective and uncertainty was assessed using the bootstrap method. The prolonged abstinence rate was 20.9 % with bupropion, 20.0 % with nortriptyline and 13.5 % with placebo. The differences between bupropion and placebo relative risk (RR)=1.6 (95 % confidence interval [CI] 0.8–3.0) and

the treatment that produced fewest side effects. Psychiatric disorders were uncommon and were equally distributed in all the groups.33 To our knowledge these are the only two studies that have analysed the efficacy and safety of varenicline in COPD smokers. Although the results are promising, more data are necessary.

between nortriptyline and placebo RR=1.5 (95% CI 0.8–2.9) were not significant. Societal costs were 1,368 euros with bupropion, 1,906 euros with nortriptyline and 1,212 euros with placebo. Van Schayck

Continued Assistance to Help Chronic Obstructive Pulmonary Disease Smokers Quit

et al. concluded that bupropion and nortriptyline seem to be equally effective, but bupropion appears to be more cost-effective compared

Hoogendoorn et al. have performed a systematic review of randomised controlled trials on smoking cessation interventions in patients with

with placebo and nortriptyline.29

COPD reporting 12-month biochemical validated abstinence rates. The different interventions were grouped into four categories: usual care,

Varenicline Varenicline is a drug specifically developed to aid smokers quit

minimal counselling, intensive counselling and intensive counselling plus pharmacotherapy. For each category the average 12-month

smoking. It acts as a selective partial agonist on the nicotinic receptor of the neurons in the ventral tegmental area of the brain. As a partial

continuous abstinence rate and intervention costs were estimated. The results showed that the average 12-month continuous abstinence rates

agonist it has characteristics in common with the agonists and antagonists. As an agonist it is capable of stimulating the nicotinic

were 1.4 % for usual care, 2.6 % for minimal counselling, 6.0 % for intensive counselling and 12.3 % for intensive counselling plus

receptor and thus of controlling craving and withdrawal syndrome. However, as an antagonist it can block the nicotine effect on the

pharmacotherapy. Compared with usual care, the costs per quality-adjusted life year (QALY) gained for minimal counselling,

receptor. Thus, when a smoker using varenicline to quit smoking suffers a relapse they do not get the same pleasant and rewarding sensation from smoking. Thus this drug helps to prevent a relapse from becoming a failure.30,31

intensive counselling and intensive counselling plus pharmacotherapy were 16,900 euros, 8,200 euros and 2,400 euros, respectively. Authors concluded that intensive counselling plus pharmacotherapy was cost saving and dominated the other interventions.34

Two recent studies have analysed the efficacy and safety of varenicline in the treatment of smokers with COPD.32,33 The first study was a multicentre, double-blind, multinational study that included 504 patients with mild to moderate COPD and without known psychiatric disturbances. Patients were randomised to receive varenicline (n=250) or placebo (n=254) for 12 weeks, with a 40-week non-treatment follow-up. The results showed that the continuous abstinence rate (CAR) for weeks 9 to 12 was significantly higher for patients in the varenicline group (42.3 %) than for those in the placebo group (8.8 %) (OR, 8.40 [95 % CI 4.99–14.14]; p