Medicalising Smoking Medicalising Smoking is Vital!is Vital!

Dr. Alex BobakDr. Alex Bobak

GP and GPSI in Smoking Cessation GP and GPSI in Smoking Cessation Wandsworth, LondonWandsworth, London

Declaration of InterestsDeclaration of Interests

Dr Bobak has received sponsorship to attend Dr Bobak has received sponsorship to attend scientific meetings, speaker honorariums and scientific meetings, speaker honorariums and

consultancy fees from Astra Zeneca, consultancy fees from Astra Zeneca, Boehringer Ingelheim, Glaxo Smith Kline, Boehringer Ingelheim, Glaxo Smith Kline,

Novartis and PfizerNovartis and Pfizer

Is this lifestyle choice or Is this lifestyle choice or addiction?addiction?

Nicotine from cigarette Nicotine from cigarette smoking is as addictive as smoking is as addictive as

heroin or cocaineheroin or cocaine11

1. Royal College of Physicians, 2000.1. Royal College of Physicians, 2000.

Plasma Nicotine Levels Plasma Nicotine Levels – – Contrast Contrast between Cigarettes and NRTbetween Cigarettes and NRT

Pla

sma

nic

otin

e (

ng/

ml)

25

20

15

10

5

0100 20 4030 50 60

Cigarette

Spray

Gum/Inhalator/Tablet/Lozenge/Mini

Patch

Time (minutes)

1. Adapted from: Tobacco Advisory Group of the Royal College of Physicians, 2000.

Is nicotine addiction a Is nicotine addiction a disease?disease?

Definition of DiseaseDefinition of Disease

““Disorder of structure or function, Disorder of structure or function, especially with adverse effects on especially with adverse effects on

the personthe person.”.”

Definition of DiseaseDefinition of Disease

““Disorder of Disorder of structurestructure oror functionfunction, , especially with especially with adverse effects adverse effects on on

the personthe person.”.”

Smoker Non SmokerC-11

Nicotine

Agneta Nordberg to Karl Fagerstrom, Personal Communication.

Structural Changes from SmokingStructural Changes from Smoking

Primary:Primary:●300-400%300-400% increase in brain nicotine receptors with increase in brain nicotine receptors with regular smokingregular smoking22

Secondary:Secondary:●Coronary heart disease (CHD)Coronary heart disease (CHD)●Cerebrovascular disease (CVD)Cerebrovascular disease (CVD)●Chronic obstructive pulmonary disease (COPD)Chronic obstructive pulmonary disease (COPD)●Lung cancerLung cancer●EEtc. etc. etc.tc. etc. etc.

2. Perry et al. JPET 1999;289:1545–1552.

Structural Changes from Type 2 DiabetesStructural Changes from Type 2 Diabetes

Primary:Primary:●Abnormality of pancreatic islet cellsAbnormality of pancreatic islet cells33

Secondary:Secondary:●Coronary heart diseaseCoronary heart disease●Cerebrovascular diseaseCerebrovascular disease●Kidney diseaseKidney disease●Eye diseaseEye disease●EEtc. etc. etc.tc. etc. etc.

3. Deng et al., Diabetes 2004 Mar; vol. 53.

Primary Functional Changes in Primary Functional Changes in the Brain Due to Smokingthe Brain Due to Smoking

● Dysfunctional (addictive) behaviourDysfunctional (addictive) behaviour

● Neurobiochemical effects of tobacco Neurobiochemical effects of tobacco use are well-documenteduse are well-documented4,54,5

● Measurable and lasting EEG Measurable and lasting EEG changeschanges44

4. Steinberg et al. Ann Intern Med. 2008;148:554-556; 5. Regarding the neurobiochemical effects of tobacco use on the brain, Steinberg et al. (2008) cited: Leshner AI. Addiction is a brain disease, and it matters. Science 1997;278:45-47.

Adverse Effects of SmokingAdverse Effects of Smoking

● Smoking is the largest preventable Smoking is the largest preventable cause of disease and premature death cause of disease and premature death in the worldin the world66

● More than 50% of long-term smokers More than 50% of long-term smokers die prematurely due to smoking-related die prematurely due to smoking-related diseasesdiseases77

6. WHO Report on the Global Tobacco Epidemic: The MPOWER package. Geneva, World Health Organization, 2008; 7. Doll et al. Br Med J 2004;328:1519–1527.

A Treatable Disease: Long-term A Treatable Disease: Long-term Cessation RatesCessation Rates

No Pharmacotherapy Pharmacotherapy

Willpower alone

Support (trained adviser)

20-30%

2-3% 4-6%

10-15%

Nicotine addiction (resulting from Nicotine addiction (resulting from tobacco use and dependence) is well tobacco use and dependence) is well

established as a treatable chronic established as a treatable chronic disease, with a rapidly growing disease, with a rapidly growing

evidence baseevidence base5,8-105,8-10

4. Steinberg et al. Ann Intern Med. 2008;148:554-556; 8. Joseph et al. Arch Intern Med. 2011;171(21):1894-1900); 9. Foulds et al. Int J Clin Pract 2010; 64(2):142-146. Epub 2009 Nov 16; 10. Fiore et al. Treating tobacco use and dependence: Clinical practice guideline. Rockville, MD: U.S. DHHS, PHS, 2008 (p. vi).

A Treatable Disease: Long-term A Treatable Disease: Long-term Cessation RatesCessation Rates

No Pharmacotherapy Pharmacotherapy

Willpower alone

Support (trained adviser)

(4% of attempts11)

11. West R, Brown J (2012) Smoking and Smoking Cessation in England 2011. London.

20-30%

2-3%(46% of attempts11)

4-6%(49% of attempts11)

10-15%

Cardiologist advice:Cardiologist advice:

““Willpower is what you need”Willpower is what you need”

““All we can do is keep advising [to stop]”All we can do is keep advising [to stop]”

““Nothing I can do”Nothing I can do”

Why don’t smokers and Why don’t smokers and healthcare professionals healthcare professionals

(HCPs) engage in evidence-(HCPs) engage in evidence-based smoking cessation?based smoking cessation?

Smokers’ Views on SmokingSmokers’ Views on Smoking

● Most messages they receive are about the Most messages they receive are about the harm caused by smoking and telling them to harm caused by smoking and telling them to stop, rather than actually stop, rather than actually howhow to stop to stop

● Many believe smoking is a lifestyle choiceMany believe smoking is a lifestyle choice

● Few see it as a treatable medical conditionFew see it as a treatable medical condition

● They often feel guiltyThey often feel guilty

● So they don’t seek helpSo they don’t seek help

UK Smokers’ MisconceptionsUK Smokers’ Misconceptions

● Most smokers believe that, or are unsure Most smokers believe that, or are unsure whether, NRT is as harmful as cigarette whether, NRT is as harmful as cigarette smokingsmoking1212

● Smokers with safety misconceptions are Smokers with safety misconceptions are less likely to: less likely to: – Want to quitWant to quit

– Intend to use NRT if they do try to quitIntend to use NRT if they do try to quit

12. Bobak et al. Journal of Smoking Cessation 2010;5(2):115-122.

HCP Training in Smoking CessationHCP Training in Smoking Cessation

● Most clinicians receive little or no Most clinicians receive little or no practical training in evidence-based practical training in evidence-based smoking cessation during UK smoking cessation during UK undergraduate medical coursesundergraduate medical courses1313

● The large majority of newly qualified UK The large majority of newly qualified UK doctors report feeling ill-equipped to deal doctors report feeling ill-equipped to deal with smoking and tobacco dependence in with smoking and tobacco dependence in their patientstheir patients1313

13. Roddy et al. Tobacco Control 2004;13:74-77.

HCP views on smokingHCP views on smoking

● If it is not taught at medical school, it is not medicalIf it is not taught at medical school, it is not medical

● Many believe smoking is a lifestyle choice Many believe smoking is a lifestyle choice

● Most information is from lay sources, e.g., the mediaMost information is from lay sources, e.g., the media● They believe many myths related to smoking, e.g., They believe many myths related to smoking, e.g.,

medication scare storiesmedication scare stories

● They don’t know how to treat smokersThey don’t know how to treat smokers

● So they don’t provide correct advice or treatmentSo they don’t provide correct advice or treatment

HCP MisconceptionsHCP Misconceptions● Survey of GPs showed many believe one of the greatest health Survey of GPs showed many believe one of the greatest health

risks from smoking is nicotinerisks from smoking is nicotine1414

● Less than one-third (31%) believe long-term NRT is preferable to Less than one-third (31%) believe long-term NRT is preferable to smokingsmoking

● 40% believe nicotine to be 140% believe nicotine to be 1stst or 2 or 2ndnd riskiest component (more riskiest component (more harmful than smoke)harmful than smoke)

● 44% believe nicotine in tobacco is associated with cancer, while 44% believe nicotine in tobacco is associated with cancer, while 15% believe pharmaceutical nicotine is associated with cancer15% believe pharmaceutical nicotine is associated with cancer

14. Patwardhan SR, Murphy MA. 2013 (in press).

The huge potential:The huge potential:clinical and cost effectiveness clinical and cost effectiveness

of smoking cessation as a of smoking cessation as a medical interventionmedical intervention

Smoking Cessation: Smoking Cessation: Secondary Prevention of CHDSecondary Prevention of CHD

19. Weisman et al. Arch Intern Med 2002;162:2197–202; 20. LaRosa et al. JAMA 1999;282:2340–2346; 21. Freemantle et al. BMJ 1999;318:1730–1737; 22. Flather et al. Lancet 2000;355:1575–1581; 23. Critchley JA , Capewell S. JAMA 2003;290:86–97.

Aspirin19 ACE-I22-

blockers21Statins20Stop

Smoking23

Mo

rta

lity

(%)

0

–10

–20

–30

–40

Impact of Treatment on Mortality of Patients with CHD

Effect of Smoking Cessation in Effect of Smoking Cessation in COPDCOPD2424

24. Fletcher C , Peto R. BMJ 1977;1(6077):1645-1648.

FE

V1

(% o

f va

lue

at a

ge

25) 100

75

50

25

025 50 75

Never smoked or not susceptible to smoke

Stopped at 65

Stopped at 45

Disability

Smoked regularlyand susceptible

to its effects

Death

Age (years)

NICE Guidance on NRT & Bupropion

April 2002

● ““Both bupropion and NRT are Both bupropion and NRT are considered to be among the most considered to be among the most cost effective cost effective of all of all healthcare healthcare interventions.interventions.””1515

● ““Estimates of cost effectiveness … Estimates of cost effectiveness … are below £2000 per Life Year are below £2000 per Life Year GainedGained””1515

15. NICE Smoking Cessation Guidance, 2002.

Cost per Life Year GainedCost per Life Year Gained

£11,80016

<£2,00015

£0

£2,000

£4,000

£6,000

£8,000

£10,000

£12,000

£14,000

Statins Smoking cessation interventions

15. NICE Smoking Cessation Guidance, 2002; 16. Raithatha N, Smith RD. BMJ 2004;328:400-402.

Co

st

pe

r L

ife

Ye

ar S

ave

d

NHS Annual Expenditure NHS Annual Expenditure

Statins Smoking Cessation Interventions*

Approximate £ millions Expenditure Annually

70017

39.218

17. Gibson. BMJ 2004; 328:1221; 18. NHS Statistics on NHS Stop Smoking Services in England, April to June 2004.

£mil

lio

ns

*Quarterly data multiplied by 4 to estimate annual expenditures; excludes cost of NRT and bupropion prescriptions.

Realising the potential Realising the potential (Utopia!)(Utopia!)

All Smokers Would …All Smokers Would …

● Be aware that the best way to stop is with Be aware that the best way to stop is with support and treatmentsupport and treatment

● Know where to get itKnow where to get it

● Have access to the latest smoking cessation Have access to the latest smoking cessation treatments; we know innovations can trigger treatments; we know innovations can trigger renewed attempts to quitrenewed attempts to quit

● Not be afraid to go back and try again if they do Not be afraid to go back and try again if they do relapse to smokingrelapse to smoking

All HCPs Would …All HCPs Would …

● Accept nicotine addiction from smoking Accept nicotine addiction from smoking cigarettes as a treatable diseasecigarettes as a treatable disease

● Understand and deliver brief cessation Understand and deliver brief cessation advice routinelyadvice routinely

● Provide support and treatment for smokers Provide support and treatment for smokers as they would for any other chronic illness as they would for any other chronic illness

How to Get ThereHow to Get There

● Training of all HCPs in effective, evidence-Training of all HCPs in effective, evidence-based smoking cessation interventionsbased smoking cessation interventions

● Normalisation of nicotine addiction as a Normalisation of nicotine addiction as a chronic relapsing, yet treatable, diseasechronic relapsing, yet treatable, disease

● Use of a chronic disease management Use of a chronic disease management approach to nicotine addiction treatmentapproach to nicotine addiction treatment

Seeing Nicotine Addiction from Smoking Seeing Nicotine Addiction from Smoking as a Chronic Disease Like Many Othersas a Chronic Disease Like Many Others

Smoking CHD DM COPD Asthma Depression

Chronic √√ √√ √√ √√ √√ √√

Relapsing √√ √√ √√ √√ √√

Causes other diseases

√√ √√ √√

Responds to pharmacological treatment

√√ √√ √√ √√ √√ √√

Responds to behavioural support

√√ √√ √√ √√ √√

Exacerbated by avoidable or manageable triggers

√√ √√ √√ √√ √√ √√

Requires long-term follow-up, even if stable

√√ √√ √√ √√ √√ √√

A long way to goA long way to go

Bernstein et al, AJPH, 2013

Improved Outcomes Shown by Managing Improved Outcomes Shown by Managing Smoking as a Chronic DiseaseSmoking as a Chronic Disease

● Telephone-based, chronic disease Telephone-based, chronic disease management approach (1 year) was management approach (1 year) was compared with usual support and treatment compared with usual support and treatment (8-week evidence based smoking cessation (8-week evidence based smoking cessation intervention)intervention)88

● More quit attempts and better short- and More quit attempts and better short- and long-term abstinence from smoking with the long-term abstinence from smoking with the chronic disease management approachchronic disease management approach

8. Joseph et al., 2011.

Medical Approach Already WorkingMedical Approach Already Working

● Czech clinic adopts a doctor-led medical Czech clinic adopts a doctor-led medical approach to smokingapproach to smoking2525

● Recent study of optional support plus Recent study of optional support plus choice of varenicline or NRTchoice of varenicline or NRT

● Overall one year continuous abstinence Overall one year continuous abstinence rate of 38.1%rate of 38.1%

25. Kralikova et al. Addiction 2013 May 13 [Epub ahead of print]

What We Can Do While We Wait What We Can Do While We Wait for HCP Trainingfor HCP Training

● Make it normal to talk about nicotine Make it normal to talk about nicotine addiction from tobacco dependence as a addiction from tobacco dependence as a treatable and manageable diseasetreatable and manageable disease

Repeat as often as possible that the best Repeat as often as possible that the best way to stop smoking is with evidence-based way to stop smoking is with evidence-based treatment and supporttreatment and support

Encourage education in smoking cessation Encourage education in smoking cessation as part of all HCP trainingas part of all HCP training

Hopefully when the BBC next Hopefully when the BBC next looks at the NHS, the looks at the NHS, the

cardiologist will be arranging cardiologist will be arranging stop smoking support and stop smoking support and

treatment in the same way as treatment in the same way as he arranges an angiogramhe arranges an angiogram