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 Tobacco Dependence and Withdrawal Students will be able to articulate the reasons why people smoke and find it difficult to quit Behavioural interventions for smoking cessation Students will be able to describe evidence based behavioural treatments Pharmacological interventions for smoking cessation Students will be able to describe evidence based pharmacological treatments 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 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 Binds to nACh receptors Increase in dopamine nicotine positive reinforcement Hayden McRobbie 2014

Tobacco withdrawal syndrome Signs & symptoms Duration Prevalence Irritability < 4 weeks 50% Depression 60% Restlessness Poor concentration < 2 weeks Increased appetite > 10 weeks 70% Sleep disturbance < 1 week 25% Urges to smoke > 2 weeks Mouth Ulcers > 4 weeks 40% Constipation >4 weeks 17% Hayden McRobbie 2014

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 Pirie et al Lancet. 2013 Jan 12;381(9861):133-41 Hayden McRobbie 2014

Quitting Works Hayden McRobbie 2014

Individual and Environment The quitting process Individual and Environment Comorbidity Degree of Dependence Genetic Social factors Smoking Quit Attempt Abstinence Tobacco Control Policies Brief Interventions (e.g. AB+offer of C) Smoking Cessation Treatments Adapted from: Hughes Drug and alcohol dependence 117.2 (2011): 111-117. 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 New Zealand’s comprehensive approach, which includes this range of options for cessation treatment is set out in the ABC programme. The ABCs highlight the important but different roles played by health care workers and cessation service providers to provide good help for smokers to quit. The ABCs are about addressing smoking with every patient, and ensuring that they get joined up with cessation treatment that works for them. ABC is about Asking every patient if they smoke, providing brief advice to quit, and providing smoking cessation medications and or referring on to more intensive cessation support services. And then, of course, the role of cessation services in the ABC is to provide the C in a high quality, evidence based way. 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 Triggers Price Health concerns Triggers Sudden illness Price rise Advice from a health professional Hayden McRobbie 2014

Remaining Quit Treatment Behavioural support Pharmacotherapy Supportive environment Hayden McRobbie 2014

Healthcare Professionals Role Health care professionals can increase a patient’s odds of quitting with brief advice, medication, and behavioural support 1 Tasks Identifying people who smoke Motivating a quit attempt Refer for treatment and support Supporting ongoing abstinence This slide provides some basic reasons why education and training of HCPs is necessary. For example: Dangers of smoking Effectiveness of HCP intervention on increasing quit odds Common barriers to TDT 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 Source: www.rjwest.co.uk - Smoking Toolkit Study Hayden McRobbie 2014

And it’s the offer of support that’s important Source: www.rjwest.co.uk - Smoking Toolkit Study Hayden McRobbie 2014

Not advising may be worse than useless p<0.05 p<0.05 Results of multiple logistic regression adjusting for age, sex and social grade Source: www.rjwest.co.uk - Smoking Toolkit Study Hayden McRobbie 2014

You don’t need to assess readiness to quit Total N=2168 In this study that catagorised people by readiness to quit (using stages of change model). Then they offered everyone treatment, regardless of whether they said they were ready or not. Key point is that you don’t need to assess if someone is ready, just offer them treatment. Yes, those who are ready are more likely to accept the offer (52% vs. 24%), but given the majority of people in this study said that they weren’t ready making an offer to everyone is important. PISINGER et al (2005) Prev Med, 40: 278-284 Hayden McRobbie 2014

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 Hayden McRobbie 2014

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 Source: New Zealand Guidelines for Helping People Stop Smoking Hayden McRobbie 2014

Pharmacological Interventions for Smoking Cessation

Nicotine replacement therapy Binds to nACh receptors Increase in dopamine Nicotine +++ Nicotine +

Nicotine Delivery Source: Royal College of Physicians Hayden McRobbie 2014

NRT: Long-term (>6 month) quit rates vs. placebo Pooled 150 studies RR=1.60 (95% CI: 1.53 - 1.68) 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 Facilitator: Hayden Hayden McRobbie 2014

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 Pooled 36 studies RR=1.69 (95% CI:1.53-1.85) 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 Pooled 6 studies RR=2.03 (95% CI 1.48 - 2.78) 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 Pooled 14 studies RR=2.27 (95% CI 2.02 - 2.55) 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 Nausea (30%) – mostly well tolerated Strange dreams, headache, flatulence, and insomnia Serious mood and cardiovascular adverse events Facilitator: Hayden Hayden McRobbie 2014

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 25-day 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 RR = 1.30, (95% CI 1.12-1.51) RR=1·43 (95% CI: 1·13 -1·80) Walker et al 2014. IS CYTISINE AT LEAST AS EFFECTIVE AS NICOTINE REPLACEMENT THERAPY FOR SMOKING CESSATION? FINDINGS FROM A NON-INFERIORITY TRIAL Hayden McRobbie 2014