London Respiratory Team Changing lifestyles and improving outcomes: reframing the way we think about smoking Dr Louise Restrick London RespiratoryTeam Lead

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Does smoking still matter? 2006 by PCT Smoking Prevalence in London

London Respiratory Team Does smoking still matter? ‘1 in 5 deaths due to smoking ’ Health Profile 2010 London Based on Ordnance Survey material. © Londoners dying from smoking

London Respiratory Team What more do we know? Health Profile 2010 London Based on Ordnance Survey material. © Deprivation in London

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team COPD and smoking Fletcher and Peto British Medical Journal 1977

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Effect of Smoking Cessation Intervention on Mortality Randomised Clinical Trial 5887 people with airway obstruction over 14.5 years Anthonisen NR, Skeans MA, Wise RA; Manfreda J, Kanner RE and Connett JE for the Lung Health Study Research Group* Ann Intern Med. 2005;142:

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Smoking prevalence in COPD At best one in four Londoners with COPD are still smokers…. No national data since 2006

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team What does smoking cost? 'Smoking is the single biggest preventable cause of early death and illness. Smoking is estimated to cost the NHS £2.7 billion a year in England.' The NHS needs to address the gap between the £2.7 billion a year spent on treating smoking related illness and the less than £150 million spent on smoking cessation ….. 5% of the NHS 'smoking' budget is currently spent on quit smoking support …

London Respiratory Team Right Care Respiratory Prescribing? ‘Ensure all patients with COPD are on the appropriate therapy for the severity of, and symptoms from, their disease.’ ‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’ NICE 2010

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Long-term effectiveness & cost-effectiveness of smoking cessation interventions in patients with COPD 1 year abstinence % QALY £ Usual care1.4 Minimal counselling2.614,735 Intensive counselling67,149 Intensive counselling + pharmacotherapy 12.32,092 Tiotropium £7,112/QUALY Eur J Health Econ. 2007; 8(2): Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65: Pulmonary Rehabilitation £2,000-8,000/QALY

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Smoking prevalence in COPD TORCH and Uplift Studies

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Quit smoking support with pharmacotherapy..as treatment Right COPD Care Support and treatment to help people with COPD to stop smoking Improves survival Is cost-effective …. the most cost-effective intervention in COPD? However, there may be even more effective ways of supporting people with COPD to stop smoking…..

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Cannabis smoking and respiratory health Does it matter? 'About 1 in 5 young adults say they have recently used drugs, mostly cannabis.’ ‘Healthy Lives, Healthy People Nov % of year olds smoke cannabis Smoking, Drinking and Drug Use Among Young People in England in 2000 Boreham R and Shaw A 2001 ‘The 1:2.5 – 5 dose equivalence between cannabis joints and tobacco cigarettes for adverse effects on lung function is of major public health significance.’

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Cannabis smoking and COPD Inner North London experience Trachea/wind-pipe Bullae/holes CT scan- emphysema 69 year old man 20 pack year smoker Cannabis for 50 years

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Cannabis smoking and COPD Inner North London experience 1 in 3 tobacco smokers in a hospital population also smoke cannabis* all groups in society – no assumptions! have to ask not volunteered…. History of tobacco and cannabis smoking Younger patients with severe COPD Patients with bullous emphysema Patients with a pneumothorax *Whittington Hospital Audit Data 2010

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Cannabis smoking and COPD Synergistic damage from marijuana and tobacco. Marijuana with tobacco increased risk of COPD with >50 ‘joints’. Tan WC, Lo C, Jong A, Xing L, Fitzgerald MJ, Vollmer WM, Buist SA, Sin DD Vancouver BOLD Research Group CMAJ 2009;180:814-20

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team How do we enable lifestyle changes that will reduce the risks of developing COPD? Address gaps in information  national data collection on prevalence of smoking in COPD population  Health data on prevalence and effects on (respiratory) health of cannabis smoking  What are the most effective ways to help people with COPD to stop smoking?  How do we most effectively help people who smoke tobacco and cannabis stop smoking?

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team How do we enable lifestyle changes that will reduce the risks of developing COPD? Change health professionals beliefs and behaviours ‘Quit smoking support & treatment is core work No place for nihilism/acceptance of smoking as the ‘norm’ Non-judgemental pro-active repeated approach to supporting smokers quit Ask about cannabis Better informed public Best treatment for COPD is to stop smoking Never too late to stop smoking Best way to stop smoking is support with pharmacotherapy Respiratory risks of cannabis

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team A ‘no-smoking practice’ Brief intervention Moderate intervention Intense intervention > 5 mins <1 min 2-5 mins IPCRG Smoking cessation guidance for primary care 2007Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: But I don’t have time…..