Transcript backtomedicalschool.co.uk

Treating Smokers
Heather Thomson
Leeds NHS Stop Smoking Service
Why Bother?
• Smoking is the biggest single cause of premature
death & preventable illness in UK.
• Deaths caused by smoking (114,000) are five times
higher than the combined deaths from road traffic
accidents, accidents, poisoning & overdose, alcoholic
liver disease, murder & manslaughter, suicides & HIV
infection
• Single most effective step to lengthen and improve
patients’ lives
• Quitting smoking has immediate and long-term
benefits and is well worth the difficulty, both for
patient and clinician
British male physicians who quit smoking1
Aged 55-64
Aged 35-44
•
•
Quitting at any age increases life
expectancy1
1. Doll R et al. BMJ 2004; 328:1519–1527.
Quitting at a younger age is most
beneficial1
The Benefits Of Quitting Smoking
• At 24 hours levels of COHb start to fall
• At 48 hours nerve endings start
regenerating, and the ability to smell and
taste is enhanced
• At 2 weeks to 3 months circulation
improves, walking becomes easier, and
lung function improves
The Benefits
Of Quitting Smoking (2)
• At 1 year excess risk of coronary heart
disease decreases to half that of a smoker
• At 5 years stroke risk reduces to that of
people who have never smoked
• At 10 years the risk of lung cancer drops
to one-half that of continuing smokers
The Benefits
Of Quitting Smoking (3)
• At 15 years the risk of coronary heart disease is
now similar to that of people who have never
smoked and the risk of death returns to nearly
the level of people who have never smoked
• Children in households will be less likely to
become smokers once their parents quit. All
family members will be exposed to less secondhand smoke
•
The majority of smokers want to quit1
Two thirds (70%) say they want to quit and each year
30% will make a quit attempt but only 2-3% will
succeed.
• Most people try to quit without any
assistance2
Nationally only 18% use LSSS, the rest go ‘cold turkey’
or OTC
1. Boyle P et al. Eur J Public Health 2000; 10(3 Supplement):5-14. 2. Jarvis MJ. BMJ 2004; 328:277-279. 3. Hughes JR et al. Addiction 2004; 99:29-38. 4. Joseph A et al.
Nicotine Tob Res 2004; 6:1075-1077.
Longer term
•
Only 3-5% of unaided quitters remain smoke-free
after 12 months 1
•
Most smokers make five to seven attempts before
they finally succeed 1
•
98% of smokers who relapse following a quit attempt
are willing to try quitting again 2
• Only about 5% are able to smoke low levels of tobacco
and have periods of non-smoking without any problems 3
1. Hughes JR et al. Addiction 2004; 99:29-38. 2. Joseph A et al. Nicotine Tob Res 2004; 3:1075-1077. 5.(RCP
2000:118)
If it’s so beneficial and
patients want to quit, why
don’t clinicians help more
patients quit?
Barriers to helping patients quit
1. Too busy
2. Lack of expertise
3. Most smokers can’t/won’t quit
4. Impact on clinician / patient relationship
1. Too busy?
• Smoking cessation is basic treatment
• Interventions can take as little as 30
seconds
• No other health result could be achieved
with such a small investment of time
NICE Guidance
Brief Interventions and referral for smoking
cessation in PC and other settings (March 2006)
Recommendation 3
• GPs should take the opportunity to advise all patients
who smoke to quit when they attend a consultation.
Those who want to stop should be offered a referral to
an intensive support service (for example, NHS Stop
Smoking Services). If they are unwilling or unable to
accept this referral they should be offered
pharmacotherapy, in line with NICE technology appraisal
guidance no. 39, and additional support. The smoking
status of those who are not ready to stop should be
recorded and reviewed with the individual once a year
where possible.
NNTs
Smoking Interventions:
To save one life
• Brief advice (<5 mins)
• NRT & support
• Bupropion & support
• Varenicline & support
80
40
30
16
• c/w
• screening for cervical cancer to prevent one death over 10 years is
1,140
• Statin (as primary prevention) Prevent one death (from MI, stroke or
other cause) over 5 years is 1071
• Antihypertensive therapy in mild hypertension to prevent one stroke,
MI or death over 1 year is 701
2. Lack of knowledge?
• Virtually no knowledge is needed to refer patients to a
NHS Stop Smoking Service
• The only knowledge that a HC provider needs is:
 that people are four times more likely to quit if they
have behavioural support from an experienced advisor
and pharmacological therapy
 how to refer patients for support
• Basic facts are straightforward– Behavioural therapy
plus treatment can greatly help patients quit
3. Patients unlikely to quit?
• Many smokers have numerous quit
attempts before being successful in
stopping smoking
• Smoking cessation treatment can be
viewed as a process over time
• With help from a clinician, the number of
patients who quit smoking doubles
4. Afraid of scaring off patients?
• Numerous studies show that patients, even
those who plan to continue smoking, prefer that
health professionals advise them to quit
• Most smokers want to quit and want support to
do so, especially from those they highly respect
and trust
• Almost everyone is aware of the health risks of
smoking. It is expected that a health
professional will mention it
NHS Stop Smoking Services
What you can expect
Accessing services
• Health care professionals referring to Leeds
NHS Stop Smoking Service using referral pad /
phone referral / letter / email / fax
• Self referral using 0800 169 4219
• text to quit - text ‘quit’ to 07811 ‘kick it’ (07811
542548 )
Referrals taken by
Dedicated NHS Stop Smoking Team
Includes:• Operational Lead
• Administration team
• Specialist advisors
• Lead specialist advisors
What’s on offer
• Sessions held at various times of the day,
including evenings
• 50 or more clinics
Group support / rolling
programmes
One to one support
Home visits
Telephone support
Assessing Smokers
• Determine nicotine dependence
• Explore past quit attempts
• Assess readiness to quit
• Does the client really want to quit?
Selecting a therapy
• Does the patient have any known medical
contra-indications? (n.b. it is the
responsibility of the prescriber to conduct
a medical assessment)
• What is the patient’s preference?
• If the patient has used pharmacological
therapy previously, was it effective?
1st 2nd 3rd line?
• Services should, to a large extent be
patient/client led
• Is a patient / client who believes in a
particular treatment, likely to be successful
using other treatments?
• Creating barriers in services … many
clients who relapse will not access again
Obtaining Treatment
• NRT – voucher scheme (running in Leeds
since October 2006 now being taken up by
other services in the region)
• Varenicline and Bupropion –
Recommendation letter sent to GP (new
format currently being developed)
Follow up
• Continued support, if needed, either face
to face or via telephone
• Regular telephone follow up if required
• 52 week follow up
• Opportunity to access service again if not
successful
Smoking Referral Procedure for Primary Care
Does your patient want to STOP SMOKING?
Do you have a Registered Advisor in your practice?
If NO, refer to
Leeds NHS Stop Smoking Service
0800 169 4219
If YES, conduct 2 question assessment
Does your patient smoke within 15 minutes of waking?
Has your patient had a quit attempt in the last year
If YES to both,
refer to
Leeds NHS Stop Smoking Service
0800 169 4219
If NO to either,
refer to Practice
Registered Advisor
Performance 04/1999 – 03/2007
(Success rates @ 4 weeks)
Specialist service
Registered Advisors
• Success rate – 63%
• Success rate - 53%
• % of quitters from
most deprived areas
44% - (rising over
time from 29% to
50%)
• Success rate – 64%
• % of quitters from
most deprived areas
29% - (falling over
time from 40% to
25%)
• Success rate – 49%
Champix™
(Varenicline Tartrate)
• Nicotine binds to 42 nicotinic
acetylcholine receptor stimulating
dopamine release1-3
•
•
This results in the satisfaction
associated with smoking1-3
Nucleus
Accumbens
(nAcc)
Ventral
Tegmental
Area
(VTA)
A drop in nicotine levels leads to
craving and withdrawal1,4
α4β2
Nicotinic
Receptor
NIC
β2 β2
α4
α4
β2
NIC
Nicotine
Dopamine
1. Jarvis MJ. BMJ 2004; 328:277-279. 2. Dani JA, Harris RA. Nature Neuroscience 2005; 8:1465-1470. 3. Coe JW. J Med Chem 2005; 48: 3474-3477. 4. West R, Shiffman S. Smoking
cessation. Fast Facts. Indispensable guides to clinical practice. Health Press, Oxford, 2004.
Varenicline at the 42 receptor
Partial agonist
Antagonist
• Binds with high affinity to the 42
• Prevents stimulation of the receptor
receptor, only partially stimulating
dopamine release1
• Provides relief from craving and
withdrawal symptoms1-3
by nicotine
• This reduces the pleasurable effects
of smoking and potentially the risk of
full relapse after a temporary lapse1-4
1. Coe JW. J Med Chem 2005; 48:3474-3477. 2. Gonzales D et al. JAMA 2006; 296:47-55. 3. Jorenby DE et al. JAMA 2006; 296:56-63. 4. Foulds J. Int J Clin Pract 2006; 60:571-576.
How effective is Champix?
• only been tested alongside a structured smoking
cessation support programme
• 2 clinical trials - vs placebo and bupropion (NRT
study currently being peer reviewed)
• The primary end point of the trials considered
the percentage of smokers who demonstrated
(using CO readings) continuous abstinence for a
period of 4 weeks from weeks 9 to 12 of
treatment.
How effective is Champix?
Results
Varenicline
tartrate
Bupropion
Placebo
Study 1 (n=1022)
4 weeks
Continuous
abstinence abstinence @
(from weeks
52 weeks
9-12)
(weeks 9-52)
44.0%
21.9%
Study 2 (n=1023)
4 weeks
Continuous
abstinence abstinence @
(from weeks
52 weeks
9-12)
(weeks 9-52)
43.9%
23.0%
29.5%
16.1%
29.8%
14.6%
17.7%
8.4%
17.6%
10.3%
And in the ‘real world‘
(data from Jan-June 07 – Leeds Specialist
Service)
Quit
Date Set
Varenicline
NRT
Bupropion
TOTAL
Q
R
L
%Q
%R
%L
551
423
80
48
77%
15%
9%
1019
682
233
104
67%
23%
10%
97
70
20
7
72%
21%
7%
1667
1175
333
159
70%
20%
10%
Registered smoking advisors (Leeds)
1/1- 31/3/07
Quit Date
Set
Varenicline
NRT
Bupropion
TOTAL
Q
R
L
%Q
%R
%L
524
356
81
87
68%
15%
17%
1670
953
318
475
57%
19%
28%
104
61
15
28
59%
14%
27%
2298
1370
414
590
60%
18%
26%
Combined service (Leeds)
01/01/07 – 30/06/07
% service
users,
who set a
quit day
using
treatment
Quit
Date
Set
Q
R
L
%Q
%R
%L
Varenicl
ine
27%
1075
779
161
135
72%
15%
13%
NRT
68%
2689
1635
551
579
61%
20%
22%
5%
201
131
35
35
65%
17%
17%
100%
3965
2545
747
749
64%
19%
19%
Bupropi
on
TOTAL
Safety / Side Effects
• US, approximately 2 million people have
now been prescribed it
• Mild – moderate nausea as expected
• Recommend take with water and food
• Sleep disturbance as expected – Could
reduce 2nd dose or withdraw to determine
cause (could be nicotine withdrawal)
Any questions?