1. Alice Turner Consultant respiratory physician
Smoking cessation
Alice Turner
Consultant respiratory physician

2. Background
Benefits of smoking cessation
Methods of smoking cessation
Smoking cessation and COPD

3. Smokers in the UK
24%
26%
21%
23%
25%
20%
19%
Regional
prevalence2,3
Approximately 10 million adults in Great Britain smoke cigarettes1
National prevalence
Target smoking cessation prevalence
Scotland 24%2
22% by 20104
Wales 21%2
13%–17% range5
England 21%2
10% or less by 20206
Northern Ireland 26%3
21% by 20117
1. ASH Facts at a Glance: Smoking Statistics.
2. Smoking and Drinking Among Adults. (2008).
3. Space to Breathe. Smoking facts.
4. Scottish Government (2008). Health of Scotland’s Population – Smoking.
5. Chief Medical Officer for Wales Annual Report
6. Department of Health (2010). A Smokefree Future. statistics/Publications/PublicationsPolicyAndGuidance/DH_
7. Department of Health (2008). Priorities for Action 2008–09. 3

4. Smoking is very addictive
Lifetime probability of remission from dependence1
Nicotine 83.7%
Alcohol 90.6%
Cannabis 97.2%
Cocaine 99.2%
1 Lopez-Quintero et al, Addiction (2011) 106:

5. Quitting smoking is difficult
The majority of smokers want to quit1
Most people try to quit without any assistance2
Only 3–5% of unaided quitters remain smoke-free after 6 to 12 months3
Most smokers make five to seven attempts before they finally succeed3
98% of smokers who relapse following a quit attempt are willing to try quitting again4
Boyle P et al. Eur J Public Health 2000; 10 (3 Supplement): 5–14.
Jarvis MJ. BMJ 2004; 328: 277–279.
Hughes JR et al. Addiction 2004; 99: 29–38.
Joseph A et al. Nicotine Tob Res 2004; 6: 1075–1077. 5

6. Smoking withdrawal symptoms
Nicotine withdrawal produces a range of effects, including depressed mood1,2
Effects last from a few days to a couple of weeks1,2
Duration
Symptom
Prevalence
<1 week
Night time waking
25%
<2 weeks
Poor concentration
60%
>2 weeks
Urges to smoke
70%
<4 weeks
Irritability
Restlessness
Depression
50%-60%
>10 weeks
Increased appetite
McEwan A et al (2006). Manual of Smoking Cessation. A Guide for Counsellors and Practitioners.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision. 6

7. Cardiovascular benefits
Time
Effect
24 hours
BP and heart rate improve
1 year
MI risk halves
5-15 years
IHD & CVD risk equal to never smokers
Lung Health Study  ↓mortality 45%2
Smoking bans3 ↓MI 17% - mean of all time points
Effects greatest in younger patients
26% decrease each year after implementation
1 US DOH, Report of surgeon general (1990)
2 Anthonisen et al, AJRCCM (2002) 166: 333-9
3 Meyers et al, J Am Coll Cardio (2009) 54:

8. Cancer benefits
Cancer type
OR in smokers
Duration of ↑risk
PAR (%)
N studies
Ref
Pancreatic
1.74
10 years 20 82
Iodice et al, Lang Surg Rev (2008)
Urinary tract
3.33 -
50/33 43
Zeegers et al, Cancer (2000)
Squamous lung
2.03
50% at 10 years
65/53 15
Yu et al, Lung Cancer (1996)
Upper GI
1.85
14 years 33
Tramacere et al, Epidemiology (2011)
Breast
1.03 53
Hamajima et al, Br J Cancer (2002).
PAR = population attributable risk i.e. Proportion of cancers due to smoking. Where 2 numbers given is in males then females. Breast cancer risk disappears when control for alcohol. Lung cancer risk never goes back to that of never smokers
After diagnosis of early stage lung cancer, continued smokers are much more likely to die1
OR 1.86 ( )
33% 5 year survival in smokers v 70% in quitters
1 Parsons et al, BMJ (2010) 340: b5569

9. Respiratory benefits Reduces FEV1 decline1
Reduces hospitalisations in COPD1
Reduces mortality in COPD1
Improves asthma symptoms & QOL2,3
Reduces mortality due to CAP4
1 Anthonisen et al, JAMA (1994) 272:
2 Jang et al, All Asthma Immunol Res (2010) 2: 254-9
3 Tonneson et al, Nicotine Tob Res (2005) 7:
4 Inoue et al, J Epidemiol (2007) 17:

10. Benefits in surgical patients
Trend to lower risk of complications, especially pulmonary in people who quit
Largely benefits accrue after 2/52 or more
Myers et al, Arch Intern Med (2011) 171: 983-

11. Cognitive benefits Current smoking ↑risk of 1
Alzheimers
Vascular dementia
Other dementias
Current smoking ↑risk of cognitive decline2
Global cognition score ( )
Effects twice as big when deaths/dropout excl
Effects of past smoking unclear, but appears that effects level out once quit for 10 years
Cohorts n= 7236 (Sabia)
1 Peters et al, BMC Geriatr (2008) 8: 36
2 Sabia et al , Arch Gen Psych (2012) Epub ahead of print

12. Benefits in pregnancy Reduces pre-term birth Reduces low birthweight
Average gain 52g
Lumley et al, Cochrane (2009) CD001055

13. Is there anything bad about stopping?
Weight gain
5kg in first year
8% in women, 6% in men
Wise et al, AJRCCM (1998) 157:

14. Is it ever too late? FEV1 decline
Quitters decline slower  effect most marked in ♀1
Quit before 30 & FEV1 decline is same as if never smoked. Quit after 40 rate no diff from continuous smokers?2
1 Anthonisen et al, JAMA (1994) 272:
2 Konhansal et al, AJRCCM (2009) 180: 3-10

15. Is it ever too late? Cancer risk and lung function interact
Eberley et al, Int J Epidemiol (2003) 32: 592-9

16. Most effective interventions combine pharmacotherapy with behavioural support
Long-term quit rates are highest with a combination of pharmacotherapy and behavioural support1
Cochrane grade A evidence2
Simple advice from a physician can have a small but significant effect on smoking cessation. Advice and/or counselling given by nurses also significantly increase the likelihood of quitting
Behavioural therapy
Brief advice
No treatment
Medication
30%
20%
10%
No medication
15% 5%
Hughes JR et al. CA Cancer J Clin 2000; 50: 143–151.
2. DOH Guidance 20010/11.
/digitalasset/dh_ pdf. 16

17. Support available Individual Group Web-based Intensity of support
Meta-analysis suggests effective1
Intensity of support
May not make a difference2
Group better than one to one3
1 Myung et al, Arch Intern Med (2009) 169:
2 Stead et al, Cochrane (2008) CD000146
3 Bauld et al, J Public Health (2010) 32: 71-82

18. Pharmacotherapy Nicotine replacement therapy (NRT)
Bupropion (and other antidepressants)
Varenicline (and other partial agonists)

19. NRT NRT type OR of quitting 95% CI Number of trials All 1.58 1.50-1.66
108
Patch
1.66 41
Spray
2.02 4
Gum
1.43 53
Inhaler
1.90 6
Lozenges/tablets
2.00
Stead et al, Cochrane review (2008) CD000146

20. How to prescribe NRT
Work out the dose they need from the amount smoked
<10/day
Medium strength patch (10mg)
2mg gum prn or 10mg cartridges for inhalator
>10/day
High strength patch (15mg)
May need to use 4mg gum prn or 15mg inhalator

21. Bupropion & antidepressants
Drug
OR of quitting
95% CI
N trials
Bupropion
1.69 36
Nortriptyline
2.03 6
SSRI
0.92*
MAOI
1.49* 4
Venlafaxine
1.22 1
Adding bupropion or nortriptyline to NRT do not provide additional benefit
* OR for paroxetine (n=4 trials) and selegiline (n=3)
Hughes et al, Cochrane (2011) CD000031

22. Prescribing bupropion
Start 1-2/52 pre cessation
150mg od for 6 days then bd for up to 7/52
Dose reductions with age, liver and renal disease

23. Prescribing varenicline
Start 1-2/52 pre cessation
150mcg od for 3/7, then bd for 4/7
1mg bd for 11/52 thereafter
Course can be repeated if needed
Dose reduction if eGFR <30

24. Partial nicotine agonists
Works better than placebo, most trials are varencline
NNT= 10
Cahill et al, Cochrane review (2011) CD006103

25. How do they work?

26. Who can have varenicline?
Case reports of pre-existing psychiatric disease worsening, but remains a caution
Trial data did not show this
Not in age <18 or pregnancy
Reduce dose in severe renal impairment

27. Psychiatric SEs
NS diff between groups for all except sleep, which was worse with placebo
Tonstad et al, Drug Saf (2010) 33:

28. What are the options in depressed patients?
NRT
Bupropion or nortriptyline
Ongoing studies of varenicline suggest likely to be safe, but most are retrospective

29. Varenicline v placebo in COPD
Varenicline v placebo, 12 weeks, smokers with mild to moderate COPD; n=504
1.Tashkin DP et al. Chest 2011; 139: 591–599.

30. Varenicline v placebo in IHD

31. Varenicline v NRT
Primary endpoint: Continuous abstinence rate last 4 weeks of treatment
Secondary endpoint: Continuous abstinence 52 weeks

32. Varenicline v bupropion
9/52 and 1 year quit rates
N= and n= 10272
Pooled data OR 1.85 and 1.593
Gonzales D et al. JAMA 2006; 296: 47–55.
Jorenby DE et al. JAMA 2006; 296: 56–63.
Nides M et al. Am J Health Behav 2008; 32: 664–675

33. Overall effect sizes NNT v placebo All types of NRT 23 (95% CI 20–27)
Bupropion
18 (95% CI 14–23)
Varenicline
10 (95% CI 7–14)
Meta-analysis of all RCTs that followed up for at least 6/12
Total numbers studied = 10300
Cahill K et al. Cochrane Database of Systematic Reviews 2008, CD

34. Cost effectiveness Cost per QALY NHS will consider is £20000
Above is equivalent to £
Wu & Sin, Int J COPD (2011) 6:

35. Greater cost effectiveness in COPD
Quit rates
1.4% for usual care
2.6% for minimal
6.0% for intensive
12.3% counselling + pharmacotherapy
If 50% patients quit, effects at 25 years
Cost per QALY = £
Hoogendoorn M et al. Thorax 2010;65:

36. Summary Smoking cessation is beneficial
COPD patients benefit most
Most forms of NRT work the same
Varenicline may work better but costs more

37. Questions?