1. New Paradigms for Smoking Cessation and Tobacco Harm Reduction
Edward Anselm, MD
Medical Director,
Health Republic Insurance of New Jersey
Assistant Professor of Medicine,
Ichan School of Medicine at Mount Sinai

3. Fifty years of progress in tobacco control
50% percent reduction in the prevalence of smoking
520,000 excess deaths per year
Evidence-based interventions
Taxes
Smoke-free workplaces
Media- abased campaigns
Smoking Cessation
Funding of state programs
De-normalization of smoking
Life span of a smoker is ten years shorter
Economic Cost $170 Billion
Adult prevalence 16.7%
Taxes range from 35 cents to $4.35
States with lower taxes have more tobacco related death and disease
Decline in smoking has slowed

4. Current Smoking Cessation Interventions
Five “A”s
Ask about smoking
Advise tobacco users to quit
Assess readiness to quit
Assist with a plan for quitting
Arrange follow-up
Every patient quitting cigarettes should be offered a medication
Two “A”s + R
Ask about smoking
Advise tobacco users to quit
Refer to cessation services
Five “R”s
Relevance
Risks
Rewards
Roadblocks
Repetition

5. Smoking Cessation Interventions by Physicians: How well are they working?
Advising Smokers and Tobacco Users to Quit.
a rolling average represents the percentage of adults 18 years of age and older who are current smokers or tobacco users and who received cessation advice during the measurement year.
Discussing Cessation Medication.
a rolling average represents the percentage of adults 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year.
Discussing Cessation Strategies.
a rolling average represents the percentage of adults 18 years of age and older who are current smokers or tobacco users and who discussed or were provided cessation methods or strategies during the measurement year.
NCQA CAHPS Questions

6. Over 75% of smokers recall having been advised to quit smoking in 2012
Discussing Cessation Strategies
Commercial Medicaid
HMO PPO HMO
Discussing Cessation Medications
Commercial Medicaid
HMO PPO HMO
NCQA 2013 State of Health Care Quality Report

7. Effectiveness of Medications
handout
Effectiveness of Medications
Odds ratio
Abstinence
Placebo
1.0
13.8
Varenicline
3.1
33.2
Nicotine nasal spray
2.3
26.7
Nicotine patch
26.6
Nicotine gum
2.2
26.1
Nicotine inhaler
2.1
24.8
Bupropion SR
2.0
24.2
Nicotine lozenge 2 mg
4 mg
2.8
24.2/14.2* /10.2

8. Demographic trends in smoking: Overall prevalence declines, smoking becomes more concentrated in groups at risk
Mental Health Overall prevalence of smoking 21.4% Prevalence of Any Mental Illness 19.9% Prevalence of smoking among people w any mental illness 36.1% LGBT Studies consistently show LGBT smoking prevalence is 35‐200% higher than the general population. Socioeconomic Status Americans with a high school education or less have a smoking rate of 55% Medicaid Percentage of Adults on Medicaid Who smoke cigarettes 37% Rural Percentage of adults smokers in rural areas is 5-6% greater than peers in urban areas

9. Advances in Treatment I
Natural History of smoking cessation
The successful Quitter makes up to 20 efforts
Each quit attempt is longer than the previous
Process over several years
Reasons for relapse
Nicotine withdrawal symptoms
Minor life stress
Major life stress
Self-medication
It is important to note that the majority of people who quit smoking do so on their own. There is little research on this population.

10. Advances in Treatment II
Correct use of medication
Longer duration of treatment
Increased use of behavioral interventions
Combination Therapy
Nicotine plus bupropion
Combination of Nicotine products
Treatment of Craving
Clonidine
Naltrexone
Topiramate
Use of FDA approved medications for harm reduction
Use telephonic counseling
Referral to psychiatry

11. Advances in Treatment III
Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance.  Paul Aveyard,et al
Results Thirteen studies were included. Compared to no intervention, advice to quit on medical grounds increased the frequency of quit attempts [risk ratio (RR) 1.24, 95% confidence interval (CI): 1.16–1.33], but not as much as behavioural support for cessation (RR 2.17, 95% CI 1.52–3.11) or offering NRT (RR 1.68, 95% CI: 1.48–1.89). In a direct comparison, offering assistance generated more quit attempts than giving advice to quit on medical grounds (RR 1.69, 95% CI: 1.24–2.31 for behavioural support and 1.39, 95% CI: 1.25–1.54 for offering medication). There was evidence that medical advice increased the success of quit attempts and inconclusive evidence that offering assistance increased their success.
Nicotine Therapy Sampling to Induce Quit Attempts Among Smokers Unmotivated to Quit: A Randomized Clinical Trial Matthew J. Carpenter, et al
Results: Compared with PQA intervention, nicotine therapy sampling was associated with a significantly higher incidence of any quit attempt (49% vs 40%; relative risk [RR], 1.2; 95% CI, ) and any 24-hour quit attempt (43% vs 34%; 1.3; ). Nicotine therapy sampling was marginally more likely to promote floating abstinence (19% vs 15%; RR, 1.3; 95% CI, ); 6-month
point prevalence abstinence rates were no different between groups (16% vs 14%; 1.2; )
Effect of varenicline on smoking cessation through smoking reduction: a randomized clinical trial
 The varenicline group (n = 760) had significantly higher continuous abstinence rates during weeks 15 through 24 vs the placebo group (n = 750) (32.1% for the varenicline group vs 6.9% for the placebo group; risk difference (RD), 25.2% [95% CI, 21.4%-29.0%]; relative risk (RR), 4.6 [95% CI, ]). The varenicline group had significantly higher continuous abstinence rates vs the placebo group during weeks 21 through 24 (37.8% for the varenicline group vs 12.5% for the placebo group; RD, 25.2% [95% CI, 21.1%-29.4%]; RR, 3.0 [95% CI, ]) and weeks 21 through 52 (27.0% for the varenicline group vs 9.9% for the placebo group; RD, 17.1% [95% CI, 13.3%-20.9%]; RR, 2.7 [95% CI, ]).

12. Advances in Treatment IV
Smoking cessation has been called the ‘gold standard’ of healthcare cost effectiveness, producing additional years of life at costs that are well below those estimated for a wide range of healthcare interventions.” Ken Warner, Dean of the School of Public Health at the University of Michigan
Hospital Based Smoking Cessation
Mullen et al reported on the impact of inpatient smoking cessation services over usual care in 14 Canadian hospitals. Follow up at 30 days, one year and two years showed absolute reduction in risk for all-cause readmissions at 6.1%, 11.7%, and 11.6% at a p<0.001). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 6.0% and year 2, 7.3%; p<0.001).  
The return on investment of a Medicaid tobacco cessation program in Massachusetts
West and Ku measured the cost-effectiveness of a statewide smoking cessation initiative in at 13 months by reduction of hospital admissions. Every $1 in investment resulted in a $3.12 saving. As other tobacco-related expenses were not measured and additional benefits might accrue over time, the real savings should be substantially higher.
Changes in healthcare expenditure appear quickly after changes in smoking behavior.
A 10% relative drop in smoking in every state is predicted to be followed by an expected $63 billion reduction (in 2012 US dollars) in healthcare expenditure the next year. State and national policies that reduce smoking should be part of short term healthcare cost containment.

13. New paradigms in Tobacco Treatment
Ask about E-cigarettes
Screen for, and treat mental illness
Harm reduction discussion
Support cessation or harm reduction efforts if already in progress, even if using e-cigarettes
Structured quit attempt
Change in the choice architecture for smokers

14. Comparison of Combusted Smoke and Vaping

15. Fig. 2. Overall weighted scores for each of the products
Fig. 2. Overall weighted scores for each of the products. Cigarettes, with an overall harm score of 99.6, are judged to be most harmful, and followed by small cigars at 67. The heights of the colored portions indicate the part scores on each of the criteria. Product‐related mortality, the upper dark red sections, are substantial contributors to those two products, and they also contribute moderately to cigars, pipes, water pipes, and smokeless unrefined. The numbers in the legend show the normalized weights on the criteria. Higher weights mean larger differences that matter between most and least harmful products on each criterion. Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, Fagerstrom K, Letlape K, Milton A, Polosa R, Ramsey J, SweanorD. Estimating the harms of nicotine‐containing products using the MCDA approach. European Addiction Research April; 20:218‐225 link:

16. Most of the toxic compounds in cigarettes are not present
Most of the toxic compounds in cigarettes are not present. When found, their concentrations are lower than in combusted cigarettes.

17. Tobacco Harm Reduction-E-cigarette
Public Health England Evidence review
Royal College of Medicine
Cochrane and other recent reviews
Outcomes
Increased successful quit attempts
Replacement of combusted smoking
Dual use with reduction of cigarettes smoked
Return to smoking
Grade of evidence

18. Evidence map for e-cigarettes with reduction or cessation as outcomes
Science based medicine: Mechanism of action-nicotine from e-cigarettes replaces the need for nicotine from combusted cigarettes. The experience of vaping provides an experience that nicotine gum, nicotine patch, or prescription medications cannot reproduce
Types of studies supporting use of e-cigarettes
Anecdotes and testimonials
Surveys
Clinical Trials
Evidence-based medicine:
No evidence of reduced burden of illness- Lead time to onset of disease is lengthy
No proof of safety of e-cigarettes- Great variation in product types and liquids

19. Levels of evidence for use of e-cigarettes in smoking cessation and tobacco harm reduction (citations tie to paper on my website, last updated May 2016)
STUDY RESULT
Strong Negative
Somewhat Negative
Neutral
Somewhat Positive
Strong Positive
Citations
Type of evidence
Personal Anecdotes ②→
23,24
Physician Experience ③→
43-45
Retrospective Survey ⑤→
17,25-30
Meta-Analysis of Surveys ←① 34
Longitudinal Studies
31,2,5
Clinical Trial ④→
36-39
Randomized Clinical Trial ①→ 40
Higher Dose Nicotine More Effective
11, 27, 41
Clinical outcomes
48, 49

20. you-may-be-using-the-wrong-type-of-e-cigarette-to-quit-smoking

22. Framing the issues in harm reduction with e-cigarettes

23. Balancing the benefit to smokers and the potential harm to adolescents
Any smoker who switches to E-cigarettes will have reduced harm
Any smoker who becomes a dual user will have reduced harm
Teenagers who adopt e-cigarettes instead of regular smokes will have reduced harm
Youth adoption of E-cigarettes
Young people grew up hearing of the harm of cigarettes, so use of ecigs may seem a healthier choice
Cost may be a factor in youth adoption
Difficulties in demonstrating that e-cigs are a gateway to cigarette use

24. A Checklist for tobacco control performance
Alignment with State Tobacco Control Initiatives
Tobacco 21
Increased taxes
Align with inpatient smoking cessation
Optimal use of state Quitlines
Toll free numbers
Fax to Quit
Measurement of physician performance on counseling and use of medication enhanced by incentives
Member engagement through HRA, DM and CM, enhanced by incentives
More training for physicians, allied health professionals and cetified tobacco treatment specialists (CTTS)
Resource allocation relative to the magnitude of the problem