1 Identifying affordable, practicable and effective clinical interventions to promote smoking cessation University College London February 2013 Robert West

Declaration of interest I receive research funds and undertake consultancy for companies that develop and manufacture smoking cessation medications I am co-director of the National Centre for Smoking Cessation and Training I am a trustee of the stop-smoking charity, QUIT My salary is covered by Cancer Research UK 2

Aim To examine the role of clinical smoking cessation interventions in tobacco control To review their effectiveness, affordability and practicability 3

Outline 1.Reminder of the health benefits of cessation 2.The role of clinical interventions 3.Brief physician advice 4.Medication options 5.Specialist behavioural support 4

Health benefits of cessation On quitting the average smoker in young middle-aged and older: –gains 6 hours of healthy life expectancy for every day of smoking prevented –prevents escalation of the risk of cancer –reduces excess risk of CHD by 50% within the first year of stopping –normalises the rate of decline in lung function –improves quality of life and mental health –reduces risk of dementia and peripheral vascular disease In pregnancy it reduces risk of spontaneous abortion, perinatal death, neonatal death and later health problems in the offspring 5

Annual smoking prevalence since % 20.0% 14.4% 31.9% 24.1% 17.9% A-C1: Professional to clerical occupation C2-E: Manual occupation 14.7% decline% 17.8% decline% 19.6% decline%

Smoking prevalence since 2007 by age 7 A-C1: Professional to clerical occupation C2-E: Manual occupation No change

8 Behaviour Change Wheel Michie S, van Stralen M, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

9 Intervention functions

10 Tobacco control interventions

11 Policy options

Policy options for tobacco control 12

13 Clinical interventions Interventions delivered by healthcare workers Brief opportunistic advice Behavioural support Medicines Clinical interventions Interventions delivered by healthcare workers Brief opportunistic advice Behavioural support Medicines

The first law of smoking cessation E = N x S For a given population: –E is the number of ex-smokers created in a given time period –N is the number of smokers who try to stop –S is the probability of success in those who try 14

The role of clinical interventions 1.To encourage as many smokers to try to stop each year as possible 2.To encourage them to use the most effective method available to them 3.To deliver that method where desired 4.To help them to use that method as effectively as possible 15

Brief physician advice Ask‘Can I check – are you still smoking at all?’ ‘Have you managed to stop smoking?’ ‘Do you ever smoke these days?’ Advise‘What you do is of course up to you but I can tell you that he best way of stopping is with a combination of support and one of the stop-smoking medicines that are now available. It’s always worth having a go however long you last because every day you don’t smoke gives you an extra 6 hours of life’ Assist‘I can refer you to an excellent stop-smoking specialist who can talk to you about the options. Is that something that would interest you?’ ‘If you think you’d just like to try one of the medicines, then I can prescribe that for you’ ‘Even if you do not feel ready to stop, we now know that using one of the nicotine replacement products to help you cut down can be an important step along the way’ 16

Brief advice: efficacy 17 Stead et al 2008, Cochrane Very brief advice: N=13,724 More extensive advice: N=1,254 95% confidence intervals from meta-analyses Aveyard et al 2012, Addiction Advice only increased quit attempts by 24% (95% CI: 16-33%) Offering behavioural support increased quit attempts by 117% (95% CI: %) Offering prescription increased quit attempts by 68% (95%CI: 48-89%)

Medication options NRTtransdermal patch, gum, inhaler, lozenge, nasal spray, mouthspray use for >8 weeks varying doses can be used in combinations (‘dual form’) not contra-indicated in CVD no increased risk of serious adverse events low addictive potential Varenicline partial agonist binding with high affinity to  4  2 nAch receptor targets craving and blocks nicotine reward increase dose over 7 days then 1mg twice daily for >11 weeks not contraindicated in CVD mixed findings on potential CVD risk no clear evidence of other serious adverse events main adverse events: nausea, disturbed dreams 18

Medication options Bupropionuse for 8 weeks starting 1 week before quit date no addictive potential main adverse event: sleep disturbance rare adverse events: seizures, allergic reaction Cytisine partial agonist binding with high affinity to  4  2 nAch receptor no addictive potential targets craving and blocks nicotine reward 4-week course starting 1 week before quit date main adverse event: nausea 19

Medications: efficacy 20 Stead et al 2008, Cahill et al 2012, Cochrane Varenicline: N=6,166 Single NRT: N=51,265 Dual NRT: 4,664 NRT for ‘reduce to quit’: N=3,429 95% confidence intervals from meta-analyses Hughes et al 2008, Cahill et al 2012, Cochrane Bupropion: 11,440 Nortripyline: N=975 Cytisine: N=937 95% confidence intervals from meta-analyses

Specialist behavioural support TelephoneMultiple sessions Significant heterogeneity Individual6+ sessions starting on or before the quit date Use specific ‘behaviour change techniques’ to boost resolve, reduce motivation to smoke, avoid and cope with smoking urges, make optimum use of stop-smoking medication Key elements include: measuring expired-air CO concentrations, getting commitment to a definite quit date, emphasising the ‘not a puff’ rule, advising on ways of avoiding smoking triggers Group6+ sessions starting before the quit date As above but with additional focus on using group processes to maintain motivation not to smoke Self-helpWebsites, text messaging, written materials Significant heterogeneity No proven programmes currently generally available 21

Behavioural support: efficacy 22 Stead et al 2012, Cochrane 1 Pro-active telephone vs reactive: N=24,994 Individual vs brief advice: N=7,855 Group vs self-help: N=4,375 Internet vs nothing: N=2,960 Text messaging versus control messages: N=9,110 Written materials: N=15,117 95% confidence intervals from meta-analyses 1 Updates about to be published See caveats on previous slide Available as evaluated through the NHS

23 Relative success rate in England by ‘route to quit’ Significantly better than no aid adjusting for confounding variables, p<0.001 Data from based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939www.smokinginengland.info

Affordability Ability within a given budget to apply the intervention to those to whom it should be applied In wealthy nations: –Brief advice: $15 per smoker –Behavioural support: $150 per course –Medication: $150 per course 24

Practicability Ability to deliver the intervention to a required standard to those to whom it should be applied Issues: –getting the right intervention protocols –practitioner competence and motivation –infrastructure support 25

Effectiveness, affordability, practicability InterventionEffectivenessAffordabilityPracticability Brief phys advice Single form NRT++?++ Dual form NRT Varenicline Bupropion++ Nortriptyline++ + Cytisine Face-to-face+++++ Telephone++?+++ Text-messaging++?++++ Internet++?

Clinical options for increasing rate of decline in smoking prevalence in England 27 PolicyEstimated prevalence reduction per annum Promoting effective use of OTC NRT0.02%-0.03% Double use of NHS support0.03%-0.05% Improve effectiveness of NHS support0.02%-0.03% Double effective GP opportunistic advice0.05%-0.10% Double use of nicotine for harm reduction0.04%-0.08% ? Total over and above -0.5%0.16%-0.29% Number of ex-smokers generated68, ,250

Conclusions Clinical smoking cessation interventions play a key role on tobacco control Even in smokers who have tried many times to stop or who have shown no interest, regular offer of support with quitting is a simple, easy and highly cost-effect life-saving intervention Optimal treatment is specialist support plus varenicline or dual form NRT (patch plus faster acting form) In patients who do not want specialist support a prescription for varenicline or dual form NRT is worthwhile In patients who are not interested in stopping, recommendation to use NRT to help them cut down is worthwhile Cytisine could be a very low cost option in the future Text messaging and internet-based interventions could be effective low-cost behavioural support options 28

Future priorities Research –identifying components of effective digital, SMS and telephone support –how to implement best practice in face to face support –how to improve effectiveness of NRT bought over the counter –how to encourage more smokers to use the most effective methods Translation –make cytisine available –improve delivery of brief advice 29

% nowEffect% possibleImpact Using prescription medication Using nothing Using NRT OTC ineffectively Using NRT OTC effectively Using behavioural support 30

Thank you 31