Why and how to support your patients to stop smoking (when time and funding are against us!)

Dr Alex BobakGP and GPSI in Smoking Cessation Wandsworth, London

• The size of the problem of smoking and the clinical and economic benefits of cessation.

• The current smoking cessation landscape in the UK.

• The concept of tobacco dependence as a long term medical condition.

• Current smoking cessation strategies available to GPs.

We aim to look at:

HIV 59471 2

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1. NHS Digital. Statistics on Smoking, England: 2012. 16 August 2012. Available at: https://digital.nhs.uk/catalogue/PUB07019 (last accessed March 2018); 2. House of Commons Health Committee. Obesity: Third report of session 2003–4. 10 May 2004. Available at: https://publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23/23.pdf (last accessed March 2018); 3. Public Health England. Alcohol treatment in England 2013–14. October 2014. Available at: http://www.nta.nhs.uk/uploads/adult-alcohol-statistics-2013-14-commentary.pdf (last accessed March 2018); 4. Office for National Statistics. Suicides in the United Kingdom: 2012 registrations. 18 February 2014. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2014-02-18 (last accessed March 2018); 5. Office for National Statistics. Deaths Related to Drug Poisoning in England and Wales: 2013. 3 September 2014. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2014-09-03(last accessed March 2018); 6. GOV UK. Reported road casualties in Great Britain: main results 2013. 26 June 2014. Available at:https://www.gov.uk/government/statistics/reported-road-casualties-in-great-britain-main-results-2013 (last accessed March 2018); 7. Public Health England. HIV in the UK: 2016 report. 1 November 2013. Available at: https://www.gov.uk/government/publications/hiv-in-the-united-kingdom (last accessed March 2018).

• Up to two thirds of long-term smokers die prematurely due to smoking-related diseases1,2

• Causes 10-15 years lost for the general population and 20-25 for mental health patients3

• The leading cause of cancers, COPD and CHD.

• Worsens at least 15 of the 19 clinical conditions in QOF for which GPs are responsible (CHD, Heart Failure, Hypertension, Peripheral Arterial Disease,

Stroke and Transient Ischaemic Attack, Diabetes, Asthma, COPD, Dementia, Depression, Mental Health, Cancer, Chronic Kidney Disease, Osteoporosis, Rheumatoid Arthritis).

Smoking: the size of the problem

1. Doll R, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004;328:1519–27.

2. Banks E, Joshy G, Weber MF, et al. Tobacco smoking and all-cause mortality in a large Australian cohort study: findings from a mature epidemic with current low smoking prevalence. BMC Med. 2015;13:38. doi:10.1186/s12916-015-0281-z

3. Smoking and Mental Health. A joint report by the Royal College of Physicians and the Royal College of Psychiatrists. 2013

• Stopping smoking increases life expectancy, and before the age of 30 gives life expectancy similar to a non-smoker1

• Stopping smoking can greatly reduce the risk of smoking related cancers and the earlier you stop the better1,2

• Risk of coronary heart disease falls by 50% one year after stopping smoking3

• Cessation is the only intervention to change the course of COPD and is more effective than all known pharmacological treatments4,5

Smoking cessation: clinical benefits

1. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ.

2004;328(7455):1519. doi:10.1136/bmj.38142.554479.AE. 2. Pirie K, Peto R, Reeves GK, Green J, Beral V. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381(9861):133-141. doi:10.1016/S0140-6736(12)61720-6. 3.The Health Benefits of Smoking Cessation: A Report of the Surgeon General. US DHHS, 1990 4.Godtfredsen NS, et al. Risk of hospital admission for COPD following smoking cessation and reduction: a Danish population study. Thorax 2002;57:967–72; 5. Willemse BW, et al. The impact of smoking cessation on respiratory symptoms, lung function, airway hyperresponsiveness and inflammation. Eur Respir J 2004;23:464–476.

Tobacco dependence is a treatable medical condition

1. Organic basis: Permanent changes in neuro-anatomy of smokers’brains. 300-400% increase in nicotinic receptors in the midbrain, causes dependence as or more powerful than that due to heroin or cocaine

2. High health impact: Up to 66% mortality and decades of morbidity

3. Established effective treatments: varenicline (Champix), nicotine replacement therapy (NRT) and bupropion (Zyban)

4. International Classification of Disease 10th Revision, Clinical Modification (ICD-10-CM) code : F17 “Nicotine Dependence”

Cochrane reviews on interventions and the Kotz paper for SSS (https://www.ncbi.nlm.nih.gov/pubmed/24372901) and the Brown paper for e-cigs(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171752/)

• Helping people stop smoking is one of the single highest contributions tohealth that any clinician can make1

• NICE estimates for every £1 invested, £2.37 is saved on treating smoking-related disease and lost productivity1

• Smoking cessation treatments are among the most cost--effective of all healthcare interventions (NICE 2002) and areunderused

Smoking cessation: economic benefits

1. ASH: Facts at a glance: Tobacco Economics. March 2017. Available from: http://ash.org.uk/information-and-resources/fact-sheets/tobacco-economics/ (last accessed August 2017).

.

Local Authority smoking cessation budgets <year on year

1. Cancer Research UK. Cutting Down: The Reality of Budget Cuts to Local Tobacco Control. November 2016. Available at: https://www.cancerresearchuk.org/sites/default/files/local_authority_survey_2016_report_cruk_finalfinal.pdf (last accessed March 2018).

59%

39%

17%

35%

56%

65%

6%

5%

19%

2016/17

2015/16

2014/15

Decreased Stayed the Same Increased

Changes to local authority smoking cessation budgets

816,444in 2011–12

Smokers attending NHS stop smoking services from 2001–2012

1. Figure based on data from: NHS Digital. Statistics on NHS Stop Smoking Services: England. April-March, 2001-09/ 2009-10/2010-11/2011-12/2012-13/2013-14/2014-15/2015-16/2016-17. Available at: https://digital.nhs.uk/search?q=Statistics+on+NHS+Stop+Smoking+Services%3A+England&s=s(last accessed September 2018).

816,444in 2011–12

307,507in 2016–17

Smokers attending NHS stop smoking services from 2001–2017

Smoking cessation transferred from NHS to Local Authorities

1. Figure based on data from: NHS Digital. Statistics on NHS Stop Smoking Services: England. April-March, 2001-09/ 2009-10/2010-11/2011-12/2012-13/2013-14/2014-15/2015-16/2016-17. Available at: https://digital.nhs.uk/search?q=Statistics+on+NHS+Stop+Smoking+Services%3A+England&s=s(last accessed September 2018).

• Brief advice

• Behavioural support

• Pharmacotherapy– Nicotine replacement therapy (prescribed but not OTC)– Bupropion (Zyban) – Varenicline (Champix)

• E-cigarettes

Proven smoking cessation interventions

Giving advice to smokers

“Advice to quit smoking from a GP, can be one of the most

important triggers for a quit attempt”

Russell MA, Wilson C, Taylor C, et al. (1979) Effect of general practitioners' advice

against smoking. BMJ 2:231–235, .

What is the most common advice GPs give to smokers?

Advice to stop smoking

Potential limitations with ‘advice to stop’

• Negative message

• Nagging

• Nothing new

• Encourages conflict and denial

• Frustrating for both doctor and smoker

• Takes longer

• Puts you off doing it again

Ideas for potentially better advice?

Advice on HOW to stop smoking

Keys to stopping successfully

1. Hughes JR et al. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004; 99(1): 29-38.

1Wanting to stop

smoking.

2Good-quality

support

3Evidence-based

treatmentsBut for 95–97% of smokers wanting to stop is not enough1

Efficacy of Behavioural Support and Pharmacotherapy

BS = Behavioural Support

Var = Varenicline

NRT = Nicotine ReplacementTherapy

Bup = Bupropion

tment

Professor Robert West, figure developed by combining individual relative risk estimates given in Cochrane reviews; bars represent 95% CIs based on risk ratios versus placebo (for medications) or brief advice/no treatment (for BS); figures for BS + NRT/Bup/Nor/Var involve multiplying effect of BS and effect of medication

A simple form of advice

how to stop designed to be used

opportunistically in less than

30 seconds in almost

any consultation with a

smoker

Concept of Very Brief Advice (VBA) for smokers

VBA deliberately does not…

• Advise smokers to stop

• Ask how much or what they smoke

• Even ask if they want to stop

• Brief! (<30 seconds or it won’t be used)

• Records smoking status (future VBA as 70%+ relapse)

• Opportunistic (suitable for almost any consultation)

• Positive (or you put them off trying)

• Not confrontational (not telling them to stop)

• Informative (saying how to stop)

• Engaging (new information)

• Satisfies QOF

• NOT a smoking cessation consult (that’s for next time)

Benefits of VBA

1. Establish and record smoking status (QOF):“Do you smoke?/Are you still smoking?”

2. Advise how to stop: “The best way to stop is with support and treatment”

3. Offer support and treatment (QOF):“When you are ready just make an appointment to see … who can really help you stop!”

Very Brief Advice (VBA) for smokers

1 in 2 people will be diagnosed with one or more cancers in their lifetime

10 year survival has improved to reach 50%, but…

Cancer survival in the UK still lags behind comparable health economies

This is a free module click on the link to the join the course:http://elearning.rcgp.org.uk/smoking

RCGP Essentials of Smoking Cessation e-Learning Module - Launched September 2018

Health Professional Smoking Cessation Resources: cruk.org/smokingcessation

Many thank you for you participation today.

Your support is really important to address the biggest cause of cancer.

Time for questions?