Smokeless Tobacco Cessation: Review of the evidence€¦ · A Cochrane review • Behavioural...
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Smokeless Tobacco Cessation: Review of the evidence Smokeless Tobacco Cessation: Review of the evidence Raymond Boyle, PhD Tobacco Summit 2007 MDQuit.org Raymond Boyle, PhD Tobacco Summit 2007 MDQuit.org
Transcript of Smokeless Tobacco Cessation: Review of the evidence€¦ · A Cochrane review • Behavioural...
Smokeless Tobacco Cessation: Review of the evidence
Smokeless Tobacco Cessation: Review of the evidence
Raymond Boyle, PhD
Tobacco Summit 2007
MDQuit.org
Raymond Boyle, PhD
Tobacco Summit 2007
MDQuit.org
Previous Reviews of ST evidencePrevious Reviews of ST evidence
•
Hatsukami and Boyle (1997)•
Evidence base is limited by small sample sizes and lack of control groups
•
Ebbert et al. (2007)•
A Cochrane review www.thecochranelibrary.com
•
Behavioural treatments may help people stop using ST
•
Hatsukami and Boyle (1997)•
Evidence base is limited by small sample sizes and lack of control groups
•
Ebbert et al. (2007)•
A Cochrane review www.thecochranelibrary.com
•
Behavioural treatments may help people stop using ST
Presentation GoalsPresentation Goals
•
To review the current status of ST use in the United States
•
To review the behavioral
and pharmacologic
evidence for ST cessation
•
To discuss the debate of ST as a method for smoking cessation
•
To review the current status of ST use in the United States
•
To review the behavioral
and pharmacologic evidence for ST cessation
•
To discuss the debate of ST as a method for smoking cessation
Smokeless Tobacco (ST) ProductsSmokeless Tobacco (ST) Products
Sales of Smokeless Tobacco in Dollars United States, 1987-1999
Sales of Smokeless Tobacco in Dollars United States, 1987-1999
$0.0$0.2$0.4$0.6$0.8$1.0$1.2$1.4$1.6$1.8
1987 1989 1991 1993 1995 1997 1999
Billio
ns o
f Dol
lars
Moist snuff
Loose Leaf ChewingTobacco
Source: FTC Report to Congress, 2001
Adverse Health Effects of ST UseAdverse Health Effects of ST Use
•
Oral and pharyngeal cancer•
Smokeless tobacco keratosis
/ leukoplakia
•
Gingival recession•
Dental caries
•
Cardiovascular diseases•
Nicotine addiction
•
Oral and pharyngeal cancer•
Smokeless tobacco keratosis
/ leukoplakia
•
Gingival recession•
Dental caries
•
Cardiovascular diseases•
Nicotine addiction
Current ST Use by Males Aged 18+ Yrs BRFSS, 1995-1999
Current ST Use by Males Aged 18+ Yrs BRFSS, 1995-1999
>10%7-10%<7%Data unavailable
Copyright ©1999 BMJ Publishing Group Ltd.
Fant, R. V et al. Tob Control 1999;8:387-392
Nicotine plasma concentrations, HR, and subjective ratings of drug strength
Pharmacotherapy for ST Use:
What is Known
Pharmacotherapy for ST Use:Pharmacotherapy for ST Use:
What is KnownWhat is Known
Goals of PharmacotherapyGoals of Pharmacotherapy
•
Increase abstinence (quit rates)
•
Control symptoms•
Craving
•
Withdrawal
•
Increase abstinence (quit rates)
•
Control symptoms•
Craving
•
Withdrawal
Medications Tried for ST UseMedications Tried for ST Use
•
Nicotine gum
•
Nicotine patch
•
Bupropion SR
•
Nicotine lozenge
•
Nicotine gum
•
Nicotine patch
•
Bupropion SR
•
Nicotine lozenge
Efficacy
Ebbert. Cochrane Database Syst Rev, 2007
Symptom Control: Craving & WithdrawalSymptom Control: Craving & Withdrawal
•
Nicotine gum (2 mg/d)•
Reduces cravingA
•
Reduces withdrawal symptomsA
•
Nicotine patch (21 mg/d)•
Reduces cravingB
•
Reduces withdrawal symptomsB
•
Nicotine gum (2 mg/d)•
Reduces cravingA
•
Reduces withdrawal symptomsA
•
Nicotine patch (21 mg/d)•
Reduces cravingB
•
Reduces withdrawal symptomsB
A Hatsukami et al. J Consult Clin Psychol. Feb 1996;64(1):153-161.B Hatsukami et al. J. Consult. Clin. Psychol. 2000;68(2):241-249.
Medications Tried for ST UseMedications Tried for ST Use
•
Nicotine gum
•
Nicotine patch
•
Bupropion SR
•
Nicotine lozenge
•
Nicotine gum
•
Nicotine patch
•
Bupropion SR
•
Nicotine lozenge
EfficacyEfficacy
Ebbert. Cochrane Database Syst Rev, 2007
0
1
2
3
4
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Desire to Use TobaccoDesire to Use TobaccoDesire to Use Tobacco
CP1245595-3
Mea
n sc
ore
(des
ire)
Mea
n sc
ore
(des
ire)
Day following TQDDay following TQD
BupropionPlaceboBupropionPlacebo
************
*P≤0.05 comparing groups*P≤0.05 comparing groups Dale et al. Drug Alcohol Depend. 2007
-4
-2
0
2
4
6
8
Weight Change During Medication PhaseWeight Change During Medication PhaseWeight Change During Medication Phase
CP1245595-4
Mea
n w
eigh
t cha
nge
(kg)
Mea
n w
eigh
t cha
nge
(kg)
WeekWeek
BupropionPlaceboBupropionPlacebo
**
*P≤0.05 bupropion compared to placebo*P≤0.05 bupropion compared to placebo
Start of
med
TQD 2 3 4 5 6 7 8 9 10 11 End of
med
** ** **** **
Dale et al. Drug Alcohol Depend. 2007
7-Day Point Prevalence Abstinence77--Day Point Prevalence AbstinenceDay Point Prevalence Abstinence
CP1245595-1
Abs
tinen
t (%
)A
bstin
ent (
%)
WeekWeek
70
60
50
40
30
20
10
0Start
of med
TQD 2 3 4 5 6 7 8 9 10 11 End of
med
24 52
BupropionPlaceboBupropionPlacebo
Dale et al. Drug Alcohol Depend. 2007
Bupropion SR Study ConclusionsBupropion SR Study Conclusions
•
Bupropion SR is effective for:•
Decreasing craving
•
Attenuating weight gain
•
Bupropion SR is not effective for:•
Increasing long-term ST abstinence rates
•
Decreasing withdrawal symptoms
•
Bupropion SR is effective for:•
Decreasing craving
•
Attenuating weight gain
•
Bupropion SR is not effective for:•
Increasing long-term ST abstinence rates
•
Decreasing withdrawal symptoms
Nicotine Lozenges for ST UsersNicotine Lozenges for ST Users
Nicotine Lozenge StudyNicotine Lozenge Study
Goal lozenges/day Max lozenges/day
Weeks 1-6 20 20
Weeks 7-9 8 20
Weeks 10-12 4 20
Ebbert JO, et al.. Nicotine Tob Res. Feb 2007
Nicotine Lozenge StudyNicotine Lozenge Study
•
ST users:•≥18 years of age•Daily use for the 6 months
•
4 mg nicotine lozenge
•
30 subjects
•
ST users:•≥18 years of age•Daily use for the 6 months
•
4 mg nicotine lozenge
•
30 subjects
Ebbert JO, et al.. Nicotine Tob Res. Feb 2007
Nicotine Lozenge Study ConclusionsNicotine Lozenge Study Conclusions
•
Nicotine lozenge may be
effective for addressing: •
Craving
•
Withdrawal
•
Conclusions must be interpreted with caution•
About 47% quit
•
Placebo-controlled study is ongoing
•
Nicotine lozenge may be
effective for addressing: • Craving• Withdrawal
•
Conclusions must be interpreted with caution• About 47% quit• Placebo-controlled study is ongoing
Ebbert JO, et al.. Nicotine Tob Res. Feb 2007
ST Behavioral interventions randomized by organization
ST Behavioral interventions randomized by organization
ST behavioral interventions randomized by individual
ST behavioral interventions randomized by individual
Ebbert. Cochrane Database Syst Rev, 2007
ST Behavioral Interventions: Evidence Summary
ST Behavioral Interventions: Evidence Summary
•
The Cochrane review identified 8 RCTs
•
Positive, strong effects are seen for •
Telephone counseling
•
Dental team advice•
Self-help materials (web, video, manual)
•
Interventions with athletic teams
•
The Cochrane review identified 8 RCTs
•
Positive, strong effects are seen for •
Telephone counseling
•
Dental team advice•
Self-help materials (web, video, manual)
•
Interventions with athletic teams
Recommended Treatment ApproachRecommended Treatment ApproachRecommended Treatment Approach
1. Behavioral treatment•
Oral examination
• Oral replacement products
• Reducing/blending
• Telephone based CBT
2. Consider tailored nicotine therapy•
Patch/gum/lozenge for self-titration
1. Behavioral treatment1. Behavioral treatment••
Oral examinationOral examination
•• Oral replacement products Oral replacement products
•• Reducing/blendingReducing/blending
•• Telephone based CBTTelephone based CBT
2. Consider tailored nicotine therapy2. Consider tailored nicotine therapy••
Patch/gum/lozenge for selfPatch/gum/lozenge for self--titrationtitration
The ST harm reduction debateThe ST harm reduction debate
Brad Rodu, DDS1992
Snus vs. Snuff
TSNAs
A product is harm reducing if it lowers total tobacco-related mortality and morbidity even though continued use may involve exposure to tobacco toxins (Stratton et al. 2001)
Cigarette companies enter the marketCigarette companies enter the market
Mayo Clinic College of Medicine. All Rights Reserved.
ContactContact
Raymond Boyle
Telephone: 612 789 4146
Raymond Boyle
Telephone: 612 789 4146
