1 A practical approach to help patients who smoke Robert West University College London November

2 Outline 1.Trends in smoking prevalence and mortality 2.Nicotine dependence 3.The role of the GP 4.Treatment effectiveness 5.The special case of respiratory disease

3 1: Smoking prevalence Smoking prevalence is slowly declining in Great Britain; approximately 0.4% per year for the past 5 years In 2003/4 it was 26% (28% in men and 24% in women) At current rate of decline it will be 24% in 2010 and 20% in 2020

4 1: Smoking mortality Mortality attributable to smoking has declined sharply from ~130,000 in 1995 to ~90,000 in 2005; 28,000 under 70 years The decline is largely due to the steep decline in smoking prevalence that took place years ago In 2020 the death rate is estimated at ~66,000; 18,000 under 70

5 2: Clinical features of nicotine dependence Multiple serious attempts to stop which have failed Withdrawal symptoms during voluntary or enforced abstinence –Increased aggressiveness –Depressed mood –Hunger –Difficulty concentrating –Sleep disturbance Frequent and powerful urges to smoke, which may be situation specific

6 2: Primary mechanism of nicotine dependence Nicotine binds to nicotinic acetylcholine receptors in ventral tegmental area Acutely this results in dopamine release in the nucleus accumbens, but chronic stimulation by nicotine leads to reduced activity in the pathway in the absence of nicotine Thus nicotine generates an abnormal reward-driven habit, an acquired drive (‘nicotine hunger’) and adverse withdrawal symptoms

7 2: Motivation to smoke Smoking Impulse to smoke Desire to smoke Need to smoke Positive evaluations of smoking Anticipated pleasure/ satisfaction Anticipated benefit Nicotine ‘hunger’ Unpleasant mood and physical symptoms Smoker ‘identity’ Beliefs about benefits of smoking Cues/triggers Reminders Nicotine dependence involves generation of acquired drive, withdrawal symptoms, and direct simulation of impulses through habit learning Plan to smoke

8 2: Inhibition of smoking Not smoking Inhibition Desire not to smoke Need not to smoke Positive evaluations of not smoking; negative evaluations of smoking Anticipated praise Anticipated self-respect Plan not to smoke Anticipated disgust, guilt or shame Fears about health Non-smoker ‘identity’ Beliefs about benefits of not smoking Cues/triggers Reminders Nicotine dependence probably also involves impairment of impulse control mechanisms undermining response inhibition

9 3: The role of the GP Once a year: 1.All patients: Check smoking status –‘I just need to check something. In my records I have you down as a non-smoker/smoker’; is that correct?’ 2.Confirmed non-smokers: No further action 3.New non-smokers: Give praise and offer help if needed 4.Smokers: Discuss link between smoking and their current health condition or likely future health, ask what they have been doing about their smoking and offer help –‘I am concerned about your chest which is certainly being made worse by your smoking. Have you been seen by our Stop Smoking Service? No? Well they have helped a lot of very heavy smokers like you to stop and I would like you to make an appointment to see them straight away.’

10 3: Overcoming barriers According to GPs the main barriers are: –concerns over relationship with patient and –time The relationship –focus on links with patient’s current or future health, offer of help and dealing with replies Time –transfer all extended discussion and treatment to Stop Smoking Service

11 3: Links with patient conditions Back-pain –‘Did you know that smoking has been linked with back pain; it could be due to damage that the chemicals you ingest do to the cartilage’ Cough/URTI/breathing problems –‘I am concerned that smoking is making your condition worse and you may be starting to develop some airways obstruction’ Depression/anxiety disorders –‘A lot of smokers think that smoking helps with their stress but in most cases it is actually making it worse. We can help you overcome the problems that comes on the first few weeks of stopping and after that you can expect to feel better than you do right now’

12 3: Links with patient conditions Circulatory problems/heart disease/diabetes –‘I am concerned that smoking is starting to have an effect on your circulation/heart. If you stop now your body can start to repair the damage.’ Pregnancy –‘Smoking damages the baby in many different ways some of which will not appear until the child starts to grow up. For example, smoking during pregnancy can lead to behaviour problems in the child because of damage to the brain of the fetus.’

13 3: Patient – doctor Patient: ‘I enjoy/need my cigarettes too much to stop or I would like to stop smoking but this is not a good time’ Doctor: ‘That is entirely your choice. One thing you may want to consider is trying to cut down with the help of nicotine gum or the nicotine inhaler’ Patient: ‘I’ve tried the Stop Smoking Service and it didn’t help’ Doctor: ‘Obviously there are no guarantees of success but I would like you to give it another go, perhaps with a different specialist’ Patient: ‘I’ve tried nicotine patches/gum and it didn’t help’ Doctor: ‘Not everyone gets on with one or other type medicine, I would like you to see a specialist who can advise you on some alternatives’

14 3: Patient – doctor Patient: ‘I used … the last time and managed to go for a long time but then I went back to smoking because of (a silly slip-up/stressful event)’ Doctor: ‘It sounds as though you did quite well and just got caught out, which happens to many smokers. There is no reason why you should not try the same approach this time or else I can recommend …’ Patient: ‘I used … the last time but after a while (the weight gain, lack of enjoyment in life) became too much.’ Doctor: ‘Some smokers find it hard to manage without nicotine in some form; I would like to refer you to the specialist stop smoking service because we may need prescribe you nicotine on a longer term basis.’

15 3: What this adds up to... Doctor: ‘Are you still smoking?’ Patient: ‘Yes, I’m afraid so. I know I should stop.’ Doctor: ‘Are you ready to have another go at stopping altogether... [link with condition]...there are now lots of different options from a new pill you can take to tackle the cravings to better ways of using things like nicotine patch and gum. I’m very keen for you speak to one of our specialist stop smoking advisors who can take you through the options and decide which one best suits you. You can even stop gradually if you don’t think you can manage it all in one go.’

16 4: Effect of face-to-face individual support Using only studies with ≥6 months’ continuous abstinence and biochemical verification

17 4: Effect of group support Using only studies with ≥12 months’ continuous abstinence and biochemical verification

18 4: Effect of telephone counselling Cochrane review: >6 month cessation not validated

19 4: Effect of tailored internet support Not biochemically verified

20 4: Effect of NRT Cochrane: LI: Low intensity behavioural support; HI: High intensity behavioural support RTS: Reduce To Stop; Combination: various combinations versus single NRT types; Population: NRT versus no NRT in population samples without behavioural support (ATTEMPT – cohort study, not RCT)

21 4: Effect of nortriptyline, bupropion and varenicline For bupropion and nortriptyline data from Cochrane: ≥6 months’ continuous abstinence and biochemical verification; varenicline 6 month continuous abstinence data from JAMA 2006; blue shading shows effect on 12 month continuous abstinence rates of further 12w varenicline vs placebo in smokers abstinence at 12w

22 5: Health Survey for England 2001 Representative household sample Five measurements of FEV1 and FVC Best valid test used Data collected on demographics, smoking history, cotinine, and respiratory symptoms Used 35+ age range for this analysis Effective sample size: 8331

23 5: Prevalence of COPD 23% in 65+ age group –39% in smokers –26% in ex-smokers –15% in never-smokers –Odds ratio: 3.6

24 5: Smoking prevalence in COPD Current smokers: –35% in COPD –23% in normal Peaks at 47% in middle age in COPD group versus steady decline in normal Error bars are approximate 95% CIs

25 5: Quit ratios by COPD status Quit ratios: –defined as ex-smokers as a proportion of ever- smokers Clear negative association with COPD severity at all ages Very little quitting in middle-aged smokers with COPD Some increase in quitting in moderate and severe COPD patients after 65y

26 5: Nicotine intake and COPD COPD smokers smoke more cigarettes and ingest more nicotine than healthy smokers Effect remains once age, and sex are controlled for (p<.001 in both cases)

27 5: Dependence and COPD COPD smokers start earlier in the morning (p<.05) COPD smoker report greater difficulty going without cigarettes for a day (p<.001)

28 5: Desire to quit and COPD Little difference in desire to stop between COPD and healthy smokers Desire to stop declines with age in both groups

29 5: Summary of findings More than one third of adults with spirometry- defined COPD smoke Almost half of middle aged adults with spirometry-defined COPD smoke Smoking cessation in COPD primarily occurs late in life Smokers with COPD take in more nicotine and are more dependent than other smokers Smokers with COPD have no greater desire to stop than other smokers

30 5: Implications Middle-aged smokers with COPD need to be identified and subject to interventions aimed at: –increasing desire to stop –addressing their greater level of addiction High levels of dependence probably militate against effectiveness of spirometry feedback plus limited support

31 Conclusions Advising patients to stop smoking need not be difficult, awkward or time consuming but it is extremely important The focus should be on: –checking smoking status, –linking smoking with the current condition or future health, –offering help with stopping and then dealing with replies Middle-aged smokers are at particularly high risk of COPD and should receive regular lung function checks, followed up with aggressive and if necessary long-term management of nicotine dependence

32 The best smoking study ever conducted Anthonisen et al (2005) Annals of Internal Medicine: the ‘Lung Health Study’ Study sample: 5887 patients newly diagnosed with mild- moderate COPD Intervention: NRT and behavioural support Control: usual care Follow up: 14.5 years Findings: The intervention significantly reduced overall mortality and mortality due to respiratory disease