Smoking Cessation Its place in Tobacco Control Hayden McRobbie Reader in Public Health Interventions, Wolfson Institute of Preventive Medicine, Queen Mary

Smoking CessationIts place in Tobacco Control

Hayden McRobbieReader 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

1. Tobacco Dependence and Withdrawal– Students will be able to articulate the reasons why people smoke and find it

difficult to quit

2. Behavioural interventions for smoking cessation– Students will be able to describe evidence based behavioural treatments

3. Pharmacological interventions for smoking cessation– Students will be able to describe evidence based pharmacological treatments

4. 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

5. 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

Overview & Learning Objectives

Hayden McRobbie 2014

TOBACCO DEPENDENCE AND WITHDRAWAL

Nicotine

positive reinforcement

Binds to nACh receptors

Increase indopamine

nicotine

Mesolimbic dopamine pathway


Signs & symptoms Duration Prevalence

Irritability < 4 weeks 50%

Depression < 4 weeks 60%

Restlessness < 4 weeks 60%

Poor concentration < 2 weeks 60%

Increased appetite > 10 weeks 70%

Sleep disturbance < 1 week 25%

Urges to smoke > 2 weeks 70%

Mouth Ulcers > 4 weeks 40%

Constipation >4 weeks 17%

Tobacco withdrawal syndrome


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)


Smokers die early

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

Quitting Works


The quitting process

Adapted from: Hughes Drug and alcohol dependence 117.2 (2011): 111-117.

Individual and Environment• Comorbidity• Degree of Dependence• Genetic• Social factors

Tobacco Control Policies

Smoking Cessation Treatments

Brief Interventions (e.g. AB+offer of C)

Smoking Quit Attempt Abstinence


• 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

McRobbie et al NZMJ 20 June 2008, Vol 121 No 1276URL: http://www.nzma.org.nz/journal/121-1276/3117/

The New Zealand ABC Approach


THE IMPORTANCE OF BRIEF INTERVENTIONS

Making a quit attempt

Tensions and triggers– Tension

• Price• Health concerns

– Triggers • Sudden illness• Price rise• Advice from a health

professional


Remaining Quit

Treatment– Behavioural support– Pharmacotherapy– Supportive

environment


Healthcare Professionals Role

• Health care professionals can increase a patient’s odds of quitting with brief advice, medication, and behavioural support 1

• Tasks1.Identifying people who smoke2.Motivating a quit attempt3.Refer for treatment and support4.Supporting ongoing abstinence

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

New treatment

Just decided

Health warning

Gov ad

NRT ad

Smoking restrictions

Someone else stopping

Something said by family/friends

Health Prof advice

0 5 10 15 20 25

Per cent

Source: www.rjwest.co.uk - Smoking Toolkit StudyHayden McRobbie 2014

And it’s the offer of support that’s important

Not seen GP Seen GP but not advised

Advised but not offered

Offered help0

10

20

30

40

50

60

Perc

ent

trie

d to

qui

t

p<0.001N=11,119


Not advising may be worse than useless

Not seen GP Seen GP but not advised

Advised but not offered

Offered help

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Odd

s ra

tio fo

r hav

ing

quit

p<0.05

N=12,221

p<0.05

Results of multiple logistic regression adjusting for age, sex and social grade


You don’t need to assess readiness to quit

Ready to quit Not ready to quit 0

10

20

30

40

50

60

70

80

90

100

11

89

52

242737

% of totalAccepted treatmentAbstinent at end of treatment (17 weeks)

% o

f sm

oke

rs

Total N=2168

PISINGER et al (2005) Prev Med, 40: 278-284Hayden 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


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


Long-term outcomes

Unassisted

Telephone support

Group support

Bupropion + support

Varenicline + support

0% 5% 10% 15% 20% 25% 30%Placebo/Control Active Treatment

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

PHARMACOLOGICAL INTERVENTIONS FOR SMOKING CESSATION

Binds to nACh receptors

Increase indopamine

Nicotine +++ Nicotine +

Nicotine replacement therapy

Nicotine Delivery

Hayden McRobbie 2014Source: Royal College of Physicians

Series10%

5%

10%

15%

20%

17%10%

NRTPlacebo

NRT: Long-term (>6 month) quit rates vs. placebo

Pooled 150 studiesRR=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.


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


• 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

Reasons for NRT failure


Bupropion

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

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


Series10%

5%

10%

15%

20%

19%

11%

BupropionPlacebo

Bupropion: Long-term (>6 month) quit rates vs. placebo

Pooled 36 studiesRR=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

Series10%

5%

10%

15%

20%

25%

20%

10%

NortriptylinePlacebo

Nortriptyline: Long-term (>6 month) quit rates vs. placebo

Pooled 6 studiesRR=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

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.

Varenicline = partial agonist of the 42 nAchR


Series10%

5%

10%

15%

20%

25%

30%

28%

12%

VareniclinePlacebo

Varenicline: Long-term (>6 month) quit rates vs. placebo

Pooled 14 studiesRR=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

• Side effects– Nausea (30%) – mostly well tolerated– Strange dreams, headache, flatulence, and

insomnia– Serious mood and cardiovascular adverse events

Safety and side-effects


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


• 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

1 month 6 months0

5

10

15

20

25

30

35

40

45

Cytisine NRT

Conti

nuou

s ab

stine

nce

(%)

RR = 1.30, (95% CI 1.12-1.51)

RR=1·43 (95% CI: 1·13 -1·80)

Cytisine for smoking cessation

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

Documents

Smoking Cessation Its place in Tobacco Control Hayden McRobbie Reader in Public Health Interventions, Wolfson Institute of Preventive Medicine, Queen Mary