Transcript Document

Smoking Cessation
Its place in Tobacco Control
Hayden McRobbie
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 McRobbie 2014
TOBACCO DEPENDENCE AND
WITHDRAWAL
Nicotine
Mesolimbic dopamine pathway
positive
reinforcement
Increase in
dopamine
Binds to
nACh receptors
nicotine
Hayden McRobbie 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%
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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 McRobbie 2014
Smokers die early
21st century hazards of smoking and benefits of stopping:...
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547248/?rep...
Figure 5
All-cause mortality: Illustration of the effects of a 3-fold difference in annual death rates on mortality
from age 35 years to age 80 years
Pirie et al Lancet. 2013 Jan 12;381(9861):133-41
This hypothetical example takes age-specific death rates in non-smokers to be two-thirds of the UK 2010
Hayden McRobbie 2014
Quitting Works
Hayden McRobbie 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 McRobbie 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
McRobbie et al NZMJ 20 June 2008, Vol 121 No 1276
URL: http://www.nzma.org.nz/journal/121-1276/3117/
Hayden McRobbie 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
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Remaining Quit
Treatment
– Behavioural support
– Pharmacotherapy
– Supportive
environment
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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 McRobbie 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
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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 McRobbie 2014
Not advising may be worse than useless
Odds ratio for having quit
2
N=12,221
1.8
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
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You don’t need to assess readiness to quit
100
90
89
80
% of smokers
Total N=2168
70
% of total
60
50
Accepted treatment
52
40
37
30
27
20
10
0
Abstinent at end of
treatment (17 weeks)
24
11
Ready to quit
Not ready to quit
PISINGER et al (2005) Prev Med, 40: 278-284
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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
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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 McRobbie 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 McRobbie 2014
PHARMACOLOGICAL INTERVENTIONS
FOR SMOKING CESSATION
Nicotine replacement therapy
Increase in
dopamine
Binds to
nACh receptors
Nicotine +++
Nicotine +
Nicotine Delivery
Source: Royal College of Physicians
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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.: CD000146. DOI:
10.1002/14651858.CD000146.pub4.
Hayden McRobbie 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
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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 McRobbie 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 McRobbie 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.: CD000031. DOI: 10.1002/14651858.CD000031.pub3.
Hayden McRobbie 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.: CD000031. DOI: 10.1002/14651858.CD000031.pub3.
Hayden McRobbie 2014
Varenicline
Varenicline = partial
agonist of the 42
nAchR
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 McRobbie 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.: CD006103. DOI: 10.1002/14651858.CD006103.pub6.
Hayden McRobbie 2014
Safety and side-effects
• Side effects
– Nausea (30%) – mostly well tolerated
– Strange dreams, headache, flatulence, and
insomnia
– Serious mood and cardiovascular adverse events
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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 McRobbie 2014
Cytisine for smoking cessation
•
1310 smokers
randomised to 25day course of
cytisine or NRT
Self-reported
adverse events
were more common
in cytisine users
(Incidence rate
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 McRobbie 2014