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
Hayden McRobbie 2014
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
Hayden McRobbie 2014
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)
Hayden McRobbie 2014
Smokers die early
Pirie et al Lancet. 2013 Jan 12;381(9861):133-41 Hayden McRobbie 2014
Quitting Works
Hayden McRobbie 2014
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
Hayden McRobbie 2014
• 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
Hayden McRobbie 2014
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
Hayden McRobbie 2014
Remaining Quit
Treatment– Behavioural support– Pharmacotherapy– Supportive
environment
Hayden McRobbie 2014
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
Source: www.rjwest.co.uk - Smoking Toolkit StudyHayden McRobbie 2014
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
Source: www.rjwest.co.uk - Smoking Toolkit StudyHayden McRobbie 2014
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
Hayden McRobbie 2014
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
Hayden McRobbie 2014
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.
Hayden McRobbie 2014
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
Hayden McRobbie 2014
• 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
Hayden McRobbie 2014
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
Hayden McRobbie 2014
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
Hayden McRobbie 2014
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
Hayden McRobbie 2014
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
Hayden McRobbie 2014
• 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
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