Smoking Cessation Its place in Tobacco Control Hayden

Smoking Cessation Its place in Tobacco Control Hayden Mc. Robbie Reader in Public Health Interventions, Wolfson Institute of Preventive Medicine, Queen Mary University of London Adjunct Professor, Faculty of Health and Environmental Sciences, Auckland University of Technology

Overview & Learning Objectives 1. Tobacco Dependence and Withdrawal – Students will be able to articulate the reasons why people smoke and find it difficult to quit 2. Behavioural interventions for smoking cessation – Students will be able to describe evidence based behavioural treatments 3. Pharmacological interventions for smoking cessation – Students will be able to describe evidence based pharmacological treatments 4. The ABC approach for smoking cessation – Students will be able to articulate the ABC approach to smoking cessation and deliver the key messages of this approach 5. The place of smoking cessation treatment in tobacco control and the 2025 goal – Students will be able to articulate the role smoking cessation can play in achieving the 2025 smokefree goal Hayden Mc. Robbie 2014

TOBACCO DEPENDENCE AND WITHDRAWAL

Nicotine

Mesolimbic dopamine pathway positive reinforcement Increase in dopamine Binds to n. ACh receptors nicotine Hayden Mc. Robbie 2014

Tobacco withdrawal syndrome Signs & symptoms Duration Prevalence Irritability < 4 weeks 50% Depression < 4 weeks 60% Restlessness < 4 weeks 60% Poor concentration < 2 weeks 60% Increased appetite > 10 weeks 70% Sleep disturbance < 1 week 25% Urges to smoke > 2 weeks 70% Mouth Ulcers > 4 weeks 40% Constipation >4 weeks 17% Hayden Mc. Robbie 2014

SMOKING CESSATION

Why help people to quit? • Obvious health gains – save lives • Reduce inequalities in health • To give people back control (smoking is a behaviour over which people have lost control) Hayden Mc. Robbie 2014

Smokers die early Pirie et al Lancet. 2013 Jan 12; 381(9861): 133 -41 Hayden Mc. Robbie 2014

Quitting Works Hayden Mc. Robbie 2014

The quitting process • • Smoking Individual and Environment Comorbidity Degree of Dependence Genetic Social factors Quit Attempt Abstinence Tobacco Control Policies Brief Interventions (e. g. AB+offer of C) Adapted from: Hughes Drug and alcohol dependence 117. 2 (2011): 111 -117. Smoking Cessation Treatments Hayden Mc. Robbie 2014

The New Zealand ABC Approach • A - ask whether a person smokes • B - give brief advice to quit to all people who smoke and • C – make and offer of and refer to cessation treatment Mc. Robbie et al NZMJ 20 June 2008, Vol 121 No 1276 URL: http: //www. nzma. org. nz/journal/121 -1276/3117/ Hayden Mc. Robbie 2014

THE IMPORTANCE OF BRIEF INTERVENTIONS

Making a quit attempt Tensions and triggers – Tension • Price • Health concerns – Triggers • Sudden illness • Price rise • Advice from a health professional Hayden Mc. Robbie 2014

Remaining Quit Treatment – Behavioural support – Pharmacotherapy – Supportive environment Hayden Mc. Robbie 2014

Healthcare Professionals Role • Health care professionals can increase a patient’s odds of quitting with brief advice, medication, and behavioural support 1 • Tasks 1. Identifying people who smoke 2. Motivating a quit attempt 3. Refer for treatment and support 4. Supporting ongoing abstinence AVEYARD P. & WEST R (2007) Managing smoking cessation, BMJ, 335, 37 -41. Hayden Mc. Robbie 2014

Importance of brief advice • Brief advice from a healthcare professional prompts people to quit • Increases long-term abstinence rates by up to 3 percentage points • Number needed to treat = 33 Stead et al 2013. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews. CD: 000165

Advice from a Health Professional is the major external trigger Health Prof advice Something said by family/friends Someone else stopping Smoking restrictions NRT ad Gov ad Health warning Just decided New treatment 0 Source: www. rjwest. co. uk - Smoking Toolkit Study 5 10 15 Per cent 20 25 Hayden Mc. Robbie 2014

And it’s the offer of support that’s important 60 p<0. 001 N=11, 119 50 Percent tried to quit 40 30 20 10 0 Not seen GP Seen GP but not advised Source: www. rjwest. co. uk - Smoking Toolkit Study Advised but not offered Offered help Hayden Mc. Robbie 2014

Not advising may be worse than useless Odds ratio for having quit 2 1. 8 N=12, 221 1. 6 p<0. 05 1. 4 p<0. 05 1. 2 1 0. 8 0. 6 Not seen GP Seen GP but not advised Advised but not offered Offered help 0. 4 0. 2 0 Results of multiple logistic regression adjusting for age, sex and social grade Source: www. rjwest. co. uk - Smoking Toolkit Study Hayden Mc. Robbie 2014

You don’t need to assess readiness to quit 100 90 89 80 % of smokers Total N=2168 70 % of total 60 50 52 40 30 0 37 27 20 10 Accepted treatment 24 11 Ready to quit Abstinent at end of treatment (17 weeks) Not ready to quit PISINGER et al (2005) Prev Med, 40: 278 -284 Hayden Mc. Robbie 2014

SMOKING CESSATION TOOLS

What do people need help with? • The first major obstacle to quitting is withdrawal discomfort • Worse in smokers with high pre-abstinence nicotine intake • Urges to smoke and depression predict relapse Hayden Mc. Robbie 2014

Getting over the initial withdrawal discomfort • Behavioural support is of proven efficacy – Can be delivered in different formats • Face-to-face (individual or group) • Telephone • Internet • NRT, bupropion (Zyban), nortriptyline and varenicline (Champix) are of proven efficacy Hayden Mc. Robbie 2014

Long-term outcomes Varenicline + support Nortriptyline + support Bupropion + support NRT + support Group support Individual support Telephone support Text support Unassisted 0% 5% 10% 15% 20% 25% 30% Placebo/Control Source: New Zealand Guidelines for Helping People Stop Smoking Active Treatment Hayden Mc. Robbie 2014

PHARMACOLOGICAL INTERVENTIONS FOR SMOKING CESSATION

Nicotine replacement therapy Increase in dopamine Binds to n. ACh receptors Nicotine +++ Nicotine +

Nicotine Delivery Source: Royal College of Physicians Hayden Mc. Robbie 2014

NRT: Long-term (>6 month) quit rates vs. placebo 20% Pooled 150 studies RR=1. 60 (95% CI: 1. 53 - 1. 68) 15% 10% 5% 17% 10% NRT Placebo 0% Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No. : CD 000146. DOI: 10. 1002/14651858. CD 000146. pub 4. Hayden Mc. Robbie 2014

NRT - safety and side-effects • There are no ‘real’ contraindications to NRT – Some individual product differences e. g. gum not good for people with dentures • No drug interactions • The most common side effects are localised e. g. – Taste of oral products – Hiccups with the mouth spray – Skin irritation with patch Hayden Mc. Robbie 2014

Reasons for NRT failure • • Unrealistic expectations Incorrect use Not used for long enough Nicotine is often seen as the dangerous element in cigarette smoke • Safety concerns can be a barrier to use Hayden Mc. Robbie 2014

Bupropion Atypical antidepressant which acts on dopamine and noradrenaline pathways and possibly as a nicotinic antagonist, designed to reduce motivation to smoke by reducing cravings and withdrawal symptoms reducing the rewarding effect of smoking What to say to your patients? • Works by alleviating craving and other withdrawal symptoms • It’s not a magic cure, but it will make quitting easier Hayden Mc. Robbie 2014

Bupropion: Long-term (>6 month) quit rates vs. placebo 20% Pooled 36 studies RR=1. 69 (95% CI: 1. 53 -1. 85) 15% 10% 5% 19% 11% Bupropion Placebo 0% Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No. : CD 000031. DOI: 10. 1002/14651858. CD 000031. pub 3. Hayden Mc. Robbie 2014

Nortriptyline: Long-term (>6 month) quit rates vs. placebo 25% Pooled 6 studies RR=2. 03 (95% CI 1. 48 - 2. 78) 20% 15% 10% 5% Nortriptyline Placebo 20% 10% 0% Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No. : CD 000031. DOI: 10. 1002/14651858. CD 000031. pub 3. Hayden Mc. Robbie 2014

Varenicline = partial agonist of the 4 2 n. Ach. R What to say to patients • Varenicline works by reducing craving for cigarettes making quitting smoking a little easier and increases the chances of stopping for good. • However it’s no magic cure and effort is still required. Hayden Mc. Robbie 2014

Varenicline: Long-term (>6 month) quit rates vs. placebo 30% Pooled 14 studies RR=2. 27 (95% CI 2. 02 - 2. 55) 25% 20% 15% Varenicline Placebo 28% 10% 5% 12% 0% Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No. : CD 006103. DOI: 10. 1002/14651858. CD 006103. pub 6. Hayden Mc. Robbie 2014

Safety and side-effects • Side effects – Nausea (30%) – mostly well tolerated – Strange dreams, headache, flatulence, and insomnia – Serious mood and cardiovascular adverse events Hayden Mc. Robbie 2014

Cytisine • Alkaloid from a plant Cytisus laburnum (also found in Kowhai) • Nicotine analogue, acting as a partial nicotinic acetylcholine receptor agonist (like Champix) • Cytisine has been used in Eastern European countries to help people stop smoking since the 1960’s. • Reduces tobacco withdrawal symptoms, making quitting easier • 25 day treatment course • Very cheap Hayden Mc. Robbie 2014

Cytisine for smoking cessation • 1310 smokers randomised to 25 day course of cytisine or NRT Self-reported adverse events were more common in cytisine users (Incidence ratio=1. 67, 95% CI 1. 38 -2. 01, p<0. 001), but were generally non-serious and self -limiting Walker et al 2014. IS CYTISINE AT LEAST AS EFFECTIVE AS NICOTINE REPLACEMENT THERAPY FOR SMOKING CESSATION? FINDINGS FROM A NON-INFERIORITY TRIAL 45 Continuous abstinence (%) • 40 RR = 1. 30, (95% CI 1. 12 -1. 51) 35 30 25 RR=1· 43 (95% CI: 1· 13 -1· 80) 20 15 10 5 0 1 month Cytisine 6 months NRT Hayden Mc. Robbie 2014