Smoking Cessation

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Exposure to Environmental Tobacco Smoke “ETS”: A Serious Health Hazard : 

Exposure to Environmental Tobacco Smoke “ETS”: A Serious Health Hazard Tarek Safwat Professor of Chest Diseases Ain Shams University.

Smoking Cessation: New Concepts of Management to Prevent Hazardous Consequences

Epidemiology of Smoking : 

Epidemiology of Smoking

Slide 4: 

WHO World Health Report .Tobacco Atlas .2008. Global Cigarette Consumption

Gender-specific Smoking Prevalence Across the World : 

Gender-specific Smoking Prevalence Across the World Mackay J, Eriksen M. The Tobacco Atlas. Second Ed. American Cancer Society, 2006. 1.25 billion smokers worldwide1 US 24% 19% Australia 19% 16% Belarus 53% 7% Brazil 22% 14% Canada 22% 17% Chile 48% 37% China 67% 2% Egypt 45% 12% France 30% 21% Iceland 25% 20% Mexico 13% 5% Iran 22% 2% Kenya 21% 1% Sweden 17% 18% Philippines 41% 8% Portugal 33% 10% South Africa 23% 8% India 47% 17% Russian Federation 60% 16% Italy 33% 17% Spain 39% 25% Germany 37% 28% Men Women

Gender-specific Smoking Prevalence in Adolescents Across the World : 

Gender-specific Smoking Prevalence in Adolescents Across the World *Young men/women = 15-year-old students who smoke cigarettes. Mackay J, Eriksen M. The Tobacco Atlas. Second Ed. American Cancer Society, 2006. Iran 2% N/A Boys* Girls* Argentina 16% 28% Venezuela 5% 6% Canada 16% 14% France 26% 27% Portugal 18% 26% Spain 24% 32% Ireland 20% 21% Sweden 11% 19% Russian Federation 27% 19% Australia 24% 23% Philippines 10% 3% South Africa 15% 8% Belarus 36% 28% Egypt 6% 3% Italy 22% 25% Germany 32% 34% Kenya 8% 4% US 18% 12%

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Middle East Australia & New Zealand Africa (mainly south Africa) South America Southeast Asia & Japan South Asia China Central & eastern Europe Western Europe North America 45.5% 44.8% 38.9% 38.3% 37.4% 36.2% 35.9% 30.2% 29.3% 26.1% Population attributable risks associated with smoking by geographic region INTERHEART ; Lancet 2004;364:937-52 1 2 3 4 5 6 7 8 9 10

Many Health Professionals Smoke Despite Known Risks : 

Many Health Professionals Smoke Despite Known Risks 2005 or latest available data. Mackay J, Eriksen M. The Tobacco Atlas. World Health Organization; 2006.

Health Effects of Waterpipe Use : 

Health Effects of Waterpipe Use Source: Maziak W, Ward KD, Soweid RAA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-333. Many perceive waterpipes to be “less risky” than cigarettes CO yield of waterpipe smoke equal to or greater than cigarettes. Smoke stones from waterpipe use contains about same amount of nicotine and “tar” as 20 cigarettes; Waterpipe use likely increases risk of lung and other cancers, coronary heart disease and pulmonary disease Waterpipe use produces secondhand smoke

Slide 10: 

1.25 billion smokers Worldwide 30 million smokers added every year 84% of smokers live in developing countries Africa & Middle East (17% of World’s population) accounts for 7% of World’s total cigarette consumption 8 smokers die every minute Facts & Numbers Voute J, World Heart Foundation

Tobacco – a major health problem now and for the future : 

Tobacco – a major health problem now and for the future

Waterpipes : 

Waterpipes (hookah, arghile, hubble-bubble, narghile, or shisha)

Health Effects of Waterpipe Use : 

Health Effects of Waterpipe Use Source: Maziak W, Ward KD, Soweid RAA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-333. Many perceive waterpipes to be “less risky” than cigarettes CO yield of waterpipe smoke equal to or greater than cigarettes. Smoke stones from waterpipe use contains about same amount of nicotine and “tar” as 20 cigarettes; Waterpipe use likely increases risk of lung and other cancers, coronary heart disease and pulmonary disease Waterpipe use produces secondhand smoke

Slide 14: 

shisha in Egypt Narghile in Middle East Narjila in Farsi A Scene from the Middle East Café Society

Slide 15: 

Will A Day Come and This Scene Disappears From Our Society ?

Section 2: The Hazards of Smoking : 

Section 2: The Hazards of Smoking

Slide 17: 

One out of two lifelong adult smokers will die from a smoking related disease. CDC. Projected smoking-related deaths among youth – United States. MMWR 1996;45(44):971-974

Smoking: Leading Preventable Cause of Disease and Death1 : 

Smoking: Leading Preventable Cause of Disease and Death1 Cancer Lung (#1) Leukemia (AML, ALL, CLL)2-4 Oral cavity/pharynx Laryngeal Esophageal Stomach Pancreatic Kidney Bladder Cervical Cardiovascular Ischemic heart disease (#2)Stroke – vascular dementia5 Peripheral vascular disease6 Abdominal aortic aneurysm Respiratory COPD (#3) Pneumonia Poor asthma control Reproductive Low-birth weight Pregnancy complications Reduced fertility SIDS Other Adverse surgical outcomes/wound healing Hip fractures Low-bone density Cataract Peptic ulcer disease in Helicobacter pylori-positive patients AML = acute myeloid leukemia; ALL = acute lymphocytic leukemia; CLL = chronic lymphocytic leukemia; COPD = chronic obstructive pulmonary disease; SIDS = sudden infant death syndrome. Surgeon General’s Report. The Health Consequences of Smoking; 2004. Sandler DP, et al. J Natl Cancer Inst. 1993;85:1994-2003. Crane MM, et al. Cancer Epidemiol Biomarkers Prev. 1996;5:639-644. Miligi L, et al. Am J Ind Med. 1999;36:60-69. Roman GC. Cerebrovasc Dis. 2005;20:91-100. Willigendael EM, et al. J Vasc Surg. 2004;40:1158-1165.

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Causes Related to Smoking WHO top ten causes of death3 1 in 10 adult deaths are smoking-related2 500,000,000 people alive today will die from smoking-related causes2 1. Surgeon General’s Report, 2004. 2. World Bank, 1999. 3. World Health Organization, 2003. Smoking Is Related To 5 of the Top 10 Leading Causes of Death Worldwide1

Slide 20: 

LUNGS

Constituants of Air Pollution by Tobacco Smoke : 

Constituants of Air Pollution by Tobacco Smoke Side stream smoke Main stream smoke Exhaled main stream smoke

Slide 23: 

Chemicals To Which People Are Exposed Through Second-hand Smoke

Second-Hand Smoke (Environmental Tobacco Smoke “ETS” – Passive Smoking) : 

Second-Hand Smoke (Environmental Tobacco Smoke “ETS” – Passive Smoking) Secondhand smoke is a mixture of the smoke given off by the burning end of a cigarette, pipe or cigar and the smoke exhaled from the lungs of smokers. It is involuntarily inhaled by nonsmokers, lingers in the air hours after cigarettes have been extinguished and can cause or exacerbate a wide range of adverse health effects, including Cardiovascular cancer, respiratory infections, and asthma. California Environmental Protection Agency. Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant. Executive Summary. June 2005.

The Effects of Second-Hand Smoke : 

The Effects of Second-Hand Smoke Short-term effects of second-hand smoke: Coughing Headache Eye irritation Sore throat Sneezing and runny nose Feeling sick Breathing problems (and possibly an asthma attack) Irregular heartbeat (a particular problem for people with heart disease) Long-term effects of second-hand smoke: Worsening of chest problems and allergies like asthma, hay fever, bronchitis and emphysema Increased risk of heart disease Increased risk of lung cancer Pregnant women exposed to second hand smoke can pass on the harmful gases and chemicals onto their babies.

Slide 26: 

The health consequences of smoking and second hand smoke evolve over a lifetime. Pregnancy Infant health Adolescence Adulthood Child Health and Smoking Fetal growth Birth weight Abortions Premature Birth Fetal Death SIDS Physical Growth Behavior and cognitive development Respiratory infections More hospitalization Small airway dysfunction Cough Wheezing Phlegm production other respiratory symptoms Chronic bronchitis Emphysema Lung cancer by 20%–30% Coronary heart disease Stroke COPD News release, June 27, 2006; US Department of Health & Human Services. Available at: http://www.hhs.gov/news/press/2006pres/20060627.html. Mackay J, et al. The Tobacco Atlas. World Health Organization, 2006. Teo KK, et al. Lancet. 2006;368:647-658. Fagerström K. Drugs. 2002;62:1-9. Blizzard L, et al. Arch Pediatr Adolesc Med. 2004;158:687-693. Leung GM, et al. Arch Pediatr Adolesc Med. 2004;158:687-693.

Importance of Not Smoking During Pregnancy : 

Importance of Not Smoking During Pregnancy Rate of Infants with Low-Birth Weight* in Taiwanese Infants by Smoking Status of the Mother (N=9499) * Low birth weight defined as <2500 g † ORs of having low birth weight infants, adjusted for mothers’ age, education level, parity, and alcohol consumption level, as well as the sex of the infants ‡ Before or during first trimester. Abbreviations: CI, confidence interval; OR, odds ratio Wen CP, et al. Tob Control. 2005;14(Suppl 1):i56-i61. OR 1.1 (95% CI: 0.9–1.4) OR 1.7 (95% CI: 1.0–2.8)

Slide 28: 

Second hand Smoke

Passive Smoking & Coronary Disease : 

Passive Smoking & Coronary Disease

Passive Smoking and CV Disability : 

Passive Smoking and CV Disability Have a clear relationship to CV disability & mortality ~ 37,000 to 40,000 people die from cardiovascular disease caused by other people’s smoke every year. Of these, 35,000 non-smokers die from coronary heart Disease. American Heart Association 2007

Slide 31: 

Loss of Aortic Elasticity with Active and Passive Smoking

Progression of Arterial Intima Media Thickness with Smoke Exposure : 

Progression of Arterial Intima Media Thickness with Smoke Exposure Howard G, Wagenknecht L.E, Burke G.L et al. JAMA 1998, 279: 119-124 3-Year Change for the Carotid Artery

Slide 33: 

Impairment of Flow-Mediated Dilatation with ETS Exposure

Acute Effects of Passive Smoking on Coronary Arteries of Young Adults : 

Acute Effects of Passive Smoking on Coronary Arteries of Young Adults Otsuka R, Watanabe H, Hirata K et al JAMA 2001; 286:436-441

Slide 35: 

Increased Plasma Fibrinogen Levels with ETS Exposure

Passive Smoking and Adult Cardiovascular System : 

Passive Smoking and Adult Cardiovascular System 2 hours exposure in a smoky room heart beats (/min) SBP (mmHg) DBP (mmHg) HbCO % X 100 none exposed exposed well ventilated room exposed badly ventilated room 71 112 78 126 77 127 83 177 81 131 85 228 Aronow, N. Eng. J. Med 1978; 299:21

Slide 37: 

Lung cancer Risk increased by 26% Coronary heart disease Risk increased by 25% Discomfort 80 % for non smokers, 53% for smokers. The 2 Main Risks of Passive Smoking in Adults

Slide 38: 

Non-Smoker Protection

Non-Smoker Protection (World) : 

Non-Smoker Protection (World) European Parliament 1997 WHO 1999 children ILO 2002 ICOH 2002 European Commissioner 2002, 2004-2005 WHO Framework Convention for Tobacco Control 2005

Ban of Smoking Section : 

Ban of Smoking Section In place USA 11 States Canada (5 Provinces) New Zealand Australia In place Wales France … In place Ireland Italy Norway Malta Sweden(2006) Scotland (2006) Spain (2006) Lithuania England

Middle East Employees Vote for Smoking Ban in the Workplace : 

Middle East Employees Vote for Smoking Ban in the Workplace 98% of professionals in the Middle East prefer smoking to be banned or restricted in the workplace. PR Web, 2007-08-12

Beneficial Effects of Smoking Ban for Employees : 

Beneficial Effects of Smoking Ban for Employees Eisner M et coll., JAMA 1998, 280, 1909-1914 Number of barmen with symptoms Source:

Why Quit? Potential Health Benefits of Quitting Smoking : 

Why Quit? Potential Health Benefits of Quitting Smoking Cessation USDHHS. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, 1990. Available at: http://profiles.nlm.nih.gov/NN/B/B/C/T/. American Cancer Society. Guide to Quitting Smoking. Available at: http://www.cancer.org.

Quitting at Any Age May Increase Life ExpectancyAge Stopped Smoking: 45–54 Years Old : 

Quitting at Any Age May Increase Life ExpectancyAge Stopped Smoking: 45–54 Years Old Age (Years) Results From a Study of Male Physician Smokers in the UK Age Stopped: 45–54 Nonsmokers Cigarette Smokers Percentage Survival from Age 50 Even quitting smoking later in life can lead to longer life expectancy Doll R, et al. BMJ. 2004;328:1519-1527.

Nicotine Addictive or Just a Bad Habit?????? : 

Nicotine Addictive or Just a Bad Habit??????

WHAT IS ADDICTION? : 

WHAT IS ADDICTION? ”Compulsive drug use, without medical purpose, in the face of negative consequences” Alan I. Leshner, Ph.D. Former Director, National Institute on Drug Abuse National Institutes of Health

NICOTINE PHARMACODYNAMICS : 

NICOTINE PHARMACODYNAMICS Nicotine binds to receptors in the brain and other sites in the body. Other: Neuromuscular junction Sensory receptors Other organs Central nervous system Exocrine glands Adrenal medulla Peripheral nervous system Gastrointestinal system Cardiovascular system Nicotine has predominantly stimulant effects.

Mechanism of Action of Nicotine in the Central Nervous System : 

Mechanism of Action of Nicotine in the Central Nervous System Nicotine binds preferentially to nAChRs in the central nervous system; one key area is the a4ß2 nicotinic receptor in the VTA After nicotine binds to the a4ß2 nAChR in the VTA, dopamine is released in the nAcc which is believed to be linked to reward

The Cycle of Nicotine Addiction : 

The Cycle of Nicotine Addiction Nicotine binding causes an increase in release of dopamine1,2 Dopamine gives feelings of pleasure and calmness1 Competitive binding of nicotine to nicotinic acetylcholine receptors causes prolonged activation, desensitization, and upregulation2 Jarvis MJ. BMJ. 2004; 328:277-279. Picciotto MR, et al. Nicotine and Tob Res. 1999:Suppl 2:S121-S125. Dopamine Nicotine

The Cycle of Nicotine Addiction ( continued) : 

The Cycle of Nicotine Addiction ( continued) As nicotine levels decrease, receptors revert to an open state causing hyperexcitability leading to cravings1,2 The dopamine decrease between cigarettes leads to withdrawal symptoms of irritability and stress1 The smoker craves nicotine to release more dopamine to restore pleasure and calmness1 Jarvis MJ. BMJ. 2004; 328:277-279. Picciotto MR, et al. Nicotine and Tob Res. 1999:Suppl 2:S121-S125. Dopamine Nicotine

Withdrawal Syndrome: A Combination of Physical and Psychological Conditions, Making Smoking Hard to Treat : 

Withdrawal Syndrome: A Combination of Physical and Psychological Conditions, Making Smoking Hard to Treat Restlessness or impatience Increased appetite or weight gain Anxiety (may increase or decrease with quitting) Dysphoric or depressed mood Irritability, frustration, or anger Difficulty concentrating Insomnia/sleep disturbance DSM-IV-TR. APA; 2006: Available at: http://psychiatryonline.com Decreased heart rate

The (DIFFICULT) DECISION to QUIT : 

Faced with change, most people are not ready to act. Change is a process, not a single step. Typically, it takes multiple attempts. HOW CAN I LIVE WITHOUT TOBACCO? The (DIFFICULT) DECISION to QUIT

Why Some Smokers May Need More Helpto Quit : 

Why Some Smokers May Need More Helpto Quit It takes most smokers a number of quit attempts before they are finally smoke-free. Why Relapse? The nature of addiction, not the failure of the individual In the United States, of 19 million adults who tried to quit in 2005, only ~4%–7% were likely successful Although most relapse occurs early after the quit attempt, some relapse can happen months to years later DSM-IV-TR. APA; 2006: Available at: http://psychiatryonline.com

Slide 55: 

The greatest risk of relapse is during the first three months after quitting. 37% have their first lapse between 8:00pm and midnight 50% are likely to relapse in the first month 67% are likely to relapse in the first three months DSM-IV-TR. APA; 2006: Available at: http://psychiatryonline.com

“Nine out of ten ex-smokers who have a cigarette after quitting later return to smoking” (Brandon, 1990) : 

“Nine out of ten ex-smokers who have a cigarette after quitting later return to smoking” (Brandon, 1990)

Many Health Organizations Emphasise the Important Role Physicians Can Play in Helping Their Patients Quit Smoking : 

Many Health Organizations Emphasise the Important Role Physicians Can Play in Helping Their Patients Quit Smoking World Health Organization. Mayo report on addressing the worldwide tobacco epidemic through effective, evidence-based treatment. Report of an expert meeting, March 1999, Rochester (Minnesota) USA. Available at: http://www.who.int/tobacco/resources/publications/mayo/en/print.html. Accessed July 2006. American Cancer Society. Tobacco control strategy planning, companion guide #2: Engaging doctors in tobacco control. Available at: http://strategyguides.globalink.org/doctors.htm. The American Academy of Family Physicians. Tobacco use, prevention and cessation. Available at: http://www.aafp.org/online/en/home/policy/policies/t/tobacco.printerview.html. National Institute for Health and Clinical Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. Available at: www.nice.org.uk/page.aspx?o=299611. World Health Organization1 Health Professionals Against Smoking2 The American Academy of Family Physicians3 American Medical Association2 National Institute for Health and Clinical Excellence4

US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update Tobacco Dependence Support – The “5 A’s” : 

US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update Tobacco Dependence Support – The “5 A’s”

US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update Tobacco Dependence Support – The “5 A’s” : 

US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update Tobacco Dependence Support – The “5 A’s” Ask about tobacco use at every visit Advise to quit in a clear, strong, and personalised manner Assess willingness to make a quit attempt Assist in quit attempt with counselling, pharmacotherapy, and social support Arrange follow-up through personal and telephone contact and continue supporting, encouraging, and treating the patient Referral to a specialist can also be valuable to Assist and Arrange smoking cessation treatment Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. US Department of Health and Human Services. Public Health Service; May 2008. Available at: www.surgeongeneral.gov/tobacco/default.htm.

US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update First-line Pharmacotherapies for Tobacco Dependence1 : 

US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update First-line Pharmacotherapies for Tobacco Dependence1 Nicotine replacement therapy (NRT) Patch Gum Inhaler Nasal spray Sublingual tablets/lozenges Bupropion SR Champix (Varenicline) Fiore MC, et al. Clinical Practice Guideline. Treating Tobacco Use and Dependence: 2008 Update. USDHHS. PHS. Rockville, MD. 2008.

Nicotine Gum : 

Dosing Chew at least 9 pieces/day during first 6 weeks Chewing technique critical to correct use Use for 12 weeks Avoid alcohol and caffeinated beverages Side effects Local: irritation of tongue, mouth and throat, ulceration of oral mucosa, jaw-muscle ache Systemic: indigestion, nausea, dizziness Nicotine Gum Nicorette® prescribing information, 2006

Nicotine Patch : 

Nicotine Patch Dosing 1 patch/day worn for 16 or 24 hours Available doses range from 7-21 mg/patch Side effects Local: skin irritation, rash More marked reactions with 24-hour patch Systemic: insomnia, sleep disturbances, dyspepsia To limit sleep disturbances, e.g., vivid dreams, remove 24-hour patch before bedtime Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. Page 74. Nicoderm CQ®, Habitrol® labeling information, 2006. Krogstad AL, Pegenius G, Elam M. Skin Res Tech. 1996; 2: 161.

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21

Bupropion for Tobacco Dependence : 

Bupropion for Tobacco Dependence Mechanism of Action is still uncertain Reuptake inhibitor of dopamine in the nucleus accumbens and noradrenaline in the locus ceruleus May also act as weak antagonist of a4ß2 nicotinic receptors Dosing 300 mg (150 mg BID) Begin therapy while still smoking Side effects Dry mouth and insomnia Risk of seizure: approximately 1 in 1,000 Contraindicated for patients with seizure disorder or predisposing factors that increase seizure risk (head injury, active substance abuse, eating disorder) . Zyban™ prescribing information, 2006

Combination Therapy : 

Combination Therapy Combination bupropion and nicotine patch slightly more effective than bupropion or nicotine patch alone in at least one study Combination of nicotine patch with short acting NRT such as gum has been shown to increase effectiveness Combining NRT with varenicline should not increase efficacy as nicotine antagonist effect of varenicline would severely limit nicotine binding to a4ß2 receptor. Jorenby DE, et al. N Engl J Med. 1999;340(9):685-691. Kornitzer M, et al. Eur Respri J. 1993;6(17 Suppl):630s. PuskaP, et al. Tob Control. 1995;4:231-235. Blondal T, et al. BMJ. 1999;318:285-288.

(varenicline) A Selective ?4?2 Nicotinic Acetylcholine Receptor Partial Agonist : 

(varenicline) A Selective ?4?2 Nicotinic Acetylcholine Receptor Partial Agonist

Champix? (varenicline): A Highly Selective ?4?2 Receptor Partial Agonist : 

Binding of nicotine at the ?4?2 nicotinic receptor in the Ventral Tegmental Area (VTA) is believed to cause large amounts of dopamine to be released at the Nucleus Accumbens (nAcc) Champix? (varenicline): A Highly Selective ?4?2 Receptor Partial Agonist Nicotine 1. Coe JW et al. Presented at the 11th Annual Meeting and 7th European Conference of the Society for Research on Nicotine and Tobacco. 2005. Prague, Czech Republic. 2. Picciotto MR et al. Nicotine Tob Res. 1999; Suppl 2:S121-125. Varenicline Binding of nicotine at the ?4?2 nicotinic receptor in the Ventral Tegmental Area (VTA) is believed to cause release of dopamine at the Nucleus Accumbens (nAcc) Varenicline is an ?4?2 nicotinic receptor partial agonist, a compound with dual agonist and antagonist activities. This is believed to result in both a lesser amount of dopamine release from the VTA at the nAcc as well as the prevention of nicotine binding at the ?4?2 receptors

Champix as a Partial Agonist : 

Champix as a Partial Agonist In the absence of nicotine Champix has agonistic effects causing amelioration of nicotine withdrawal symptoms. It provides a low-to-moderate level of dopamine stimulation to reduce craving & withdrawal symptoms.

Champix as an Antagonist : 

Champix as an Antagonist In the presence of nicotine, Champix is blocking nicotine-induced reward by having antagonistic blocking effects at ?4?2 receptors. The antagonist effect blocks the reinforcing effects of nicotine & potentially reduces the risk that a lapse to smoking would turn into a full blown relapse.

Champix? (varenicline) Efficacy Measurements: CO-Confirmed 4-Wk Continuous Abstinence Rates Wks 9–12 : 

Champix? (varenicline) Efficacy Measurements: CO-Confirmed 4-Wk Continuous Abstinence Rates Wks 9–12 Gonzales et al. Jorenby et al. Varenicline Bupropion SR Placebo 1. Gonzalez D et al. JAMA. 2006;296:47-55. 2. Jorenby DE et al. JAMA. 2006;296:56-63. The 9-12 week Continuous Abstinence Rate is defined as the percentage of subjects who abstained from smoking (not even a puff) from Week 9 through 12 of the study as confirmed by both subject self-report and by end-expiratory carbon monoxide (CO) measurement P < 0.001 P < 0.001 P < 0.001 P < 0.001 P < 0.001 Continuous Abstinence Rate (%) P = 0.001

Champix versus Transdermal Nicotine Patch forsmoking cessation: 4-Wk Continuous Abstinence Rates : 

Champix versus Transdermal Nicotine Patch forsmoking cessation: 4-Wk Continuous Abstinence Rates P < 0.01 The primary outcome was the biochemically confirmed (exhaled carbon monoxide(10 ppm) self-reported continuous abstinence rate (CAR) for the last 4 weeks of the treatment period in participants who had taken at least one dose of treatment. H-J Aubin, A Bobak, J R Britton, C Oncken, C B Billing, Jr, J Gong, K E Williams originally published online 8 Feb 2008; Thorax

Recommendations : 

Recommendations In its Final Appraisal Determination, NICE concluded that: “Varenicline was superior to NRT [nicotine replacement therapy] and bupropion in achieving continuous abstinence” and that its use in smoking cessation was “likely to be a cost-effective use of National Health Service resources.” (*) NICE: National Institute of Health and Clinical Excellence. Source: Pfizer internal source – May 30, 2007 (*)

Champix Efficacy Profile : 

Champix Efficacy Profile Varenicline is efficacious in smoking cessation By the end of 12 weeks of therapy, smokers taking varenicline were significantly more likely to quit than smokers taking bupropion or placebo Varenicline significantly reduced the reinforcing effects of smoking, craving, and symptoms of nicotine withdrawal 1. Jorenby DE, et al. JAMA. 2006;296:56-63. 2. Champix Summary of Product Characteristics. Pfizer Ltd. Sandwich, UK. 2006. 3. Gonzales D, et al. JAMA. 2006;296:47-55.

Side-Effect Profile : 

Side-Effect Profile

Post-Marketing Data : 

Post-Marketing Data EMEA: European Medicines Agency

Champix? (varenicline) packs : 

Champix? (varenicline) packs Starter Pack First Two Weeks Continuation Packs 28 Days

Champix Dose : 

Champix Dose

Very Wide Experience around the World since the Launch : 

Very Wide Experience around the World since the Launch Source: Verispan Chantix Cumulative New Patients Over 6 Million smokers have received a starter pack of CHAMPIX since launch in the US (2006) Over 7.9 Million smokers received Champix since the launch worldwide

Slide 80: 

OR

Slide 81: 

QUIT EARLY AND RUN FOR YOUR LIFE

Slide 82: 

Thank you