1 Access to and use of aids to smoking cessation in the UK Robert West University College London Austin, Texas February 2007

Outline UK policy objectives The recent history of policy changes The current smoking cessation landscape The future

Policy objectives Public Service Agreement Targets: To reduce adult smoking prevalence in England from 26% in 2002 to 21% by 2010 To reduce smoking prevalence in ‘routine and manual’ occupational groups from 31% in 2002 to 26% by 2010

Recent history of policy changes Increasing access to effective methods to aid cessation is an important element of the strategy 1998: Government ‘White Paper’ sets up national network of NHS Stop Smoking Services 2000: Zyban made available on NHS prescription 2001: NRT fully available on NHS prescription and on ‘general sale’ 2002: National Institute for Clinical Excellence recommends use of NRT and Zyban 2006: Changes to NRT licence expanding range of allowable use

2006 NRT licensing changes Extended use Concurrent use of different forms of NRT Use by cardiac patients Use by pregnant smokers Use by young smokers ‘Cut Down Then Stop’

Extended use Evidence from clinical trials has not supported the effectiveness of extending use of nicotine patch beyond 8 weeks but … –a substantial minority of users of gum and other products feel vulnerable to relapse after 8-12 weeks –there is evidence for an increase in relapse rate on termination of use –there are no major safety concerns about extended use

Concurrent use Evidence from clinical trials indicates that combinations are more effective on average than single forms but … –the evidence is not completely conclusive –it is not clear whether some combinations are better than others or than specific individual forms of NRT –there are no significant safety concerns

Use by cardiac patients NRT has not been shown specifically to be effective in this patient group and the pharmacology of nicotine suggests a theoretical risk but … –there is a reasonable presumption of efficacy given data from healthy smokers –it appears to have been safe to use in cardiac patients –the imperative to stop smoking in this group is high

Use by pregnant smokers NRT has not been shown to be specifically effective in this group and nicotine has been shown to be teratogenic but … –there is a reasonable presumption of efficacy given data from healthy smokers –there is a reasonable presumption that NRT is much safer than smoking –the imperative to stop smoking in this group is high

Use by young smokers NRT has not been shown to be specifically effective in this group but … –there is a presumption that it may have some effect in young smokers that are clearly nicotine dependent –there are no major safety concerns

Cut Down Then Stop Clinical trials have shown that gum or inhalator use in smokers wanting to stop but who do not feel ready or able to make a quit attempt in the near future results in approximately 4% more of them stopping smoking within the next 12 months but … –it is not clear what the effect this will have when rolled out to the smoking population as a whole

The current landscape: smoking prevalence Source:

Prevalence estimates relating to cessation Percentages for attempters use all those who smoked in the last year as a base; percentages for quitters use all those who attempts in the time period specified as a base Source:

Use of aids to cessation in past year Source:

Use of aids to cessation in past month Source:

Use of NRT for reduction Percentages for cutting down use current smokers as a base; percentages for use of NRT products use those cutting down as a base Source:

NRT for reduction and cigarettes per day Source: * * *

Inflow and outflow of adult smokers in a given week Smokers: 12m QuittingRelapsing DyingSmokers immigrating Smokers reaching 16+ Starting to smoke 3k 120k 3k 114k 4k 1k This amounts to a reduction in prevalence of ~0.2% per year

Drivers of smoking prevalence in 2006 Smokers reaching age 16 yrs Smokers dying Smokers quitting and relapsing Ex-smokers relapsing Smokers: 12 million New adult smokers Smokers quitting Adult smokers continuing 6 million 5.2 million -150K -700K +400K +150K +200K During 2006End 2006

The future Increasing the numbers of smokers attempting to quit and reducing relapse are by far the largest targets for reducing smoking prevalence Even in the UK there appears still be scope for increasing usage of effective methods to aid cessation including psychological support and medication However a radical increase without loss of efficacy would be needed to have a detectable effect on prevalence in any one year.