En Route to a

Smokefree New Zealand by 2025: Connecting evidence with practice

in smoking cessation Associate Professor Chris Bullen

Director, National Institute of Health Innovation, Co-Director, Tobacco Control Research Turanga

The University of Auckland,

NZ Rural General Practice Network Conference, Rotorua, 15 March 2013

Outline

• Background

• Achieving a Smokefree NZ by 2025

• Smoking cessation practice and research

– New evidence on assisting quitting

– Innovations to increase reach

• Conclusions

0

340

520

70

500

220

190

0

100

200

300

400

500

1950 2000 2025 2050

Year

Toba

cco

deat

hs (m

illio

n)

Business as usual

If proportion ofyoung adultstaking up smokinghalves by 2020If adultconsumptionhalves by 2020

Source: Peto et al, 1994.

Tobacco - a global disaster

Estimated number of deaths attributable to tobacco smoking in New Zealand, by cause of death, 35+ years, 2003–2007

Year Lung cancer

COPD CVD Other cancer

Upper aerodigestive cancer

Other medical

All causes

Number of deaths

Number of deaths

Number of deaths

Number of deaths

Number of deaths

Number of deaths

Number of

deaths

Rate per 100,000

2003 1217 1180 984 352 175 470 4377 214.9

2004 1298 1234 1062 368 168 514 4644 223.2

2005 1191 1048 907 335 162 455 4098 193.0

2006 1196 1085 909 323 162 509 4185 193.2

2007 1258 1095 962 367 191 545 4418 200.6

2003–07* 1232 1130 967 349 172 500 4350 204.8

Source: NZTUS; Estimates have been derived by the Health and Disability Intelligence Unit from Ministry of Health mortality counts. Notes: 1Tobacco-attributable mortality (TAM) for lung cancer is calculated differently to TAM for other diseases. 2All causes may not be the sum of specific causes, due to rounding. 3The 2003–07 calculation uses the Peto methodology (World Health Organization 1998). Analysis of linked New Zealand census and mortality data suggests that the Peto method may overestimate TAM when applied to ethnic groups such as Māori (Blakely et al 2006). Ethnic-specific estimates have therefore not been presented here. *This is a five-year moving average.

Can we get to “<5% by 2025”?

• Current prevalence estimate is 16.2% = 650,000 people • Challenge of achieving dramatic declines in smoking

among Maori (45%) and Pacific (33%)2 • Downward trend in prevalence is very gradual despite a

decade of ‘model’ tobacco control efforts, and flat for Maori and Pacific smoking.

• Prevalence falls when quitting>initiation • Initiation in NZ is falling - more ‘never smokers’ – but

changes in quitting are less dramatic. • At current rate of decline <5% by 2025 won’t be reached

until 2050+ 1. NZ Health Survey 2012 2. NZ Tobacco Use Survey 2009

26.6 25.2 20.0 21.3 19.20

5

10

15

20

25

30

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Percent

Data sources: 1997 = 1996/97 New Zealand Health Survey (NZHS); 2003 = 2002/03 NZHS; 2007 = 2006/07 NZHS; 2008 = 2008 New Zealand Tobacco Use Survey (NZTUS); 2009 = 2009 NZTUS Note: Age standardised to the WHO world population.

Daily smoking among NZers aged 15–64 years, 1997–2009 (age-standardised prevalence)

Cessation is the key

• Tobacco use is a “chronic relapsing disorder” – Most smokers try to quit many times before achieving permanent

abstinence – Most quit attempts are unsupported and fewer than 25% last

more than 1 week – Every year that a smoker delays quitting beyond their mid-30s,

they lose 3 months of life expectancy. • In NZ only about 26% of people who quit or tried

received support on their last attempt – Quitline (47%); friend or family (39%); Doctor (32%);

quitting programme (29%) – 27% used medication, 68% of these used patch

alone. • How can we dramatically increase

successful quitting?

Formula for Impact on prevalence

I = E x R Impact = Effectiveness x Reach

Enhancing effectiveness of current treatments

• Taking medication as prescribed! • Tailoring NRT dose to level of dependence • Cut down to quit regimen • Continuing NRT despite lapses • Prolonged treatment beyond 8 weeks • Combination of treatments • Combining NRT with exercise • Choice of treatments for people to try out • Pre-quitting nicotine patches

Combination of treatments

Rx combination Rationale Well tolerated

Efficacy over single agent

Patch + gum, lozenge, inhaler or spray

Better relief of withdrawal with fast onset + slow acting agents

Yes Yes

Bupropion + NRT Different actions in CNS

Yes Mixed evidence

Bupropion + Varenicline

Different actions in CNS

Yes Under study

Varenicline + NRT Varenicline may not saturate all CNS nicotine receptors

Yes Under study

Adapted from: Rigotti, JAMA 2012

Enhancing current treatments

Fit2Quit Trial (N=1400) • Randomised controlled trial of a home

and community-based exercise intervention on smoking cessation rates plus usual Quitline care vs. usual care alone

• Intensive exercise helps relieve cravings but no effect on cessation

Maddison et al, 2010 (Methods) Results publication mid- 2013

SONIQ (n = 1,410) • Free selection box of five NRTs, delivered to door vs usual Quitline care. Behavioural support. • Patch and inhaler the most popular combination • No effect on six month quit rates, but effect on short term quit rates. • Highly acceptable, increased initial use of NRT, doubled time to relapse Walker et al, Addiction 2011

PQNIQ (n = 1,100)

• 2 weeks NRT patch or gum (pre-quit) vs Quitline usual care. Behavioural support. • Six months: No benefit over usual care, safe. • Meta-analysis = moderate benefit

Bullen et al, TID, 2007 Bullen et al, Addiction 2010

Enhancing current treatments

Pre-cessation nicotine patch

Bullen et al, 2010

New treatments - Cytisine

• Cytisine is an alkaloid found in NZ kowhai

• Partial agonist at the nicotinic acetylcholine receptor (like varenicline)

• Qualitative work indicates this idea is very appealing to Māori1

• Off-patent so can be made very cheaply

1.Glover et al, Nicotine & Tobacco Res 2011

Cytisine vs. placebo

West et al NEJM 2011

CASCAID Trial (n=1,310) Recruiting via Quitline.

25 days cytisine vs. usual Quitline care.

Non-inferiority trial: cytisine is at least as effective as NRT Main results publication

End-2013

Cytisine vs. usual Quitline care

E-cigarettes – my viewpoint

• Helping people to stop smoking is a priority • But - many people either do not wish to stop smoking or find it very hard to

do so even with currently available support. • For this group, nicotine substitution products should be made available that

deliver nicotine in a safe way, without the harmful components found in tobacco smoke.

• Most of the diseases associated with smoking are caused by inhaling smoke which contains toxic chemicals.

• By contrast, nicotine is very safe. • E-cigarettes deliver nicotine without the same doses of harmful toxins

found in tobacco smoke so appear to be a far safer alternative to smoking. • Nicotine is an addictive substance, e-cigarettes currently available are of

highly variable quality and reliability • E-cigarettes should be properly regulated to ensure safety and efficacy,

and only then made available as part of a harm reduction approach to tobacco control.

Adapted from: ASH UK, 2013

A growing body of evidence suggests e-cigarettes may be effective smoking cessation aids. • Plausible given evidence from randomised trials on nicotine delivery

and tobacco abstinence symptoms.1,2,3 • Several small case reports suggest effectiveness.4,5 • User surveys in different population groups and settings

supportive.6,7,8,9 • Small prospective studies of smokers not willing to quit and a pilot

trial provide further evidence of the potential for e-cigarettes in cessation.10,11

• Need for RCTs of cessation efficacy and safety 1. Bullen et al, Tobacco Control 2010, 19:98-103.

2. Vansickel et al, Cancer Epidemiology Biomarkers & Prevention 2010, 19:1945-1953.

3. Dawkins et al, Addictive Behaviors 2012, 37:970-973. 4. Caponnetto et al. Int J Clin Med 2011, 2:281-284 5. Caponnetto Pet al. J Medical Case Reports 2011, 5:1-6. 6. Etter. BMC Public Health 2010, 10:231.

E-cigarettes: efficacy in smoking cessation

7. Etter & Bullen. Addiction 2011, 106:2017-202 8. Siegel et al. Am J Prev Med 2011, 40:472-475. 9. Goniewicz et al. Drug Alcohol Rev 2012, 20:146 10. Polosa et al. BMC Public Health 2011, 11:786 11. Caponnetto et al. Int J Environ Res Public Health 2013, 10:446-461. .

N=657 Three arms: NRT patch, 16 mg or 0 mg e-cigarettes (4:4:1)

Builds on WIRED trial on withdrawal and cravings

Main results publication Sept 2013

The ASCEND Trial

Bullen et al. Addiction 2009 Etter, Bullen et al Tobacco Control 2011 Bullen et al, BMC Public Health 2013

RELIQ Trial (n=1,410) • Nicotine-free cigarettes (nicotine ≤ 0.05 mg

yield, 0.5 mg content, 4mg tar) plus usual Quitline care vs. usual Quitline care alone

• Six-month follow-up

Main results: Mid-2013

Reduced nicotine cigarettes

Walker et al. Nicotine & Tob Res 2009

NICOTINE REDUCTION STUDY Dr Natalie Walker1, Dr Murray Laugesen2, Dr Penny Truman3, Trish

Fraser4, Associate Professor Chris Bullen1, Dr Marewa Glover5

• 3 arm RCT that explores smoking behaviour of

those with access to de-nicotinised cigarettes – In addition to their usual cigarettes – Instead of their usual cigarettes – With NRT

• Will help to inform the potential contribution of removal of nicotine from tobacco as a strategy

• Completed by April 2013 1. NIHI 4. Global Public Health 2. End Smoking NZ 5. CTCR 3. Institute of Environmental Science and Research (ESR)

Reach – demand and supply

• Background ‘push’: – Tobacco tax increases, advertising bans,

smokefree environments legislation etc – Mass media messages about tobacco harms – Social marketing, social networks and social

media, mobile messaging • Encourage smokers to demand ABC:

– Changing perceptions and correcting misinformation about nicotine

– Informing of availability and affordability of support - promotion of Quitline & other quit services

Doubled self-reported short term quit rates in all groups

STOMP Trial

Rodgers et al. Tobacco Control 2005 Bramley et al. NZMJ 2005

Bosworth et al, J Sm Cessation 200 Free et al, Tobacco Control 2009 N=5800 Presentation at SRNT Feb 2011

Cochrane review of mHealth cessation

Whittaker R, McRobbie H, Bullen C, et al. Mobile phone-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2012

WERO GROUP STOP SMOKING COMPETITION Dr Marewa Glover1, Dr Chris Paton2, Nathan Cowie1, Dr Anette Kira1

• Maori and Pacific group stop smoking contest to trigger mass quitting: 36% quit at 3 months

• www.wero.me + iPad App + iPad Game • WeroChallenge

1. Centre for Tobacco Control Research (CTCR), University of Auckland 2. National Institute for Health Innovation (NIHI), University of Auckland

SMOKEFREE ROHE Dr Janine Paynter1, Associate Professor Chris Bullen2, Dr

Marewa Glover1

• To test the feasibility of establishing smokefree communities and trial tobacco supply reduction initiatives

• Auckland City location; collaboration between Tūranga, Auckland City, Cancer Society, ARPHS, CMDHB and Waitemata DHB

• Opportunity to reach a large population group and so re-set social norms around smoking

1. CTCR 2. NIHI

Systems

• Capturing all ABC activity in primary care is a challenge!

• Supportive systems – Co-ordinated team approach – EHR effective for increasing documentation, referral etc1

• Chronic care model more effective for cessation vs. episodic care model.2

• Population management – regular unprompted offers of support to quit.3

1. Linder et al. JAMA Int Med 2009; 2.Joseph et al Arch Int Med 2011; 3. Rigotti et al, Am J Prev Med 2011

Quasi-experimental study of personalised GP letter plus Study Quitcards for NRT posted to all smoking patients on GP records.

Compared smokers registered with GPs in one DHB with intervention to those in another DHB

Collected Study Quitcard redemptionns and Quitline calls for 2 months before and 2 months after

• 5% more Quitline caller registrations (but not significant)

• 9% more Quit Card redemptions in intervention area (significant) Watson, Bullen et al. J Primary Health Care 2010

The MINUTE study

COST OF SMOKING STUDY: QUIT PRICE POINT Prof Randolph Grace1, Dr Murray Laugesen2, Dr Bronwyn Kivell3

• Face to face questionnaire in 4 cities, n=343

• How many cigarettes would you smoke if they were X price (range from free to $5 per stick)?

• $40 per pack of 20 cigs would cause 75% of smokers to quit and thus achieve 5% goal almost overnight (by 2016 1 pkt will cost $20)

• 67% would use e-cigarettes if affordable and available to help them quit.

1. University of Canterbury 2. Health New Zealand 3. Victoria University

Conclusions

• A combination of innovative effective cessation and reach strategies is needed if we are to meet the 2025 Smokefree NZ target

• Equity challenge - ‘No-one left behind’ • Some strategies can be tried now especially those

involving minor variations with NRT • Emerging treatments on the way but present

challenges to providers, funders and regulators • Widening reach is vital to success – need systems

and population management in primary care

Acknowledgements

• Colleagues at NIHI & CTCR • Turanga Tobacco Control Research

Programme • Health Research Council • NZ Ministry of Health • National Heart Foundation

Assoc. Professor Chris Bullen Director National Institute for Health Innovation, School of Population Health The University of Auckland Auckland, New Zealand c.bullen@nihi.auckland.ac.nz www.nihi.auckland.ac.nz www.turanga.org.nz