Smoking cessation Alice Turner - PowerPoint Presentation

1. Smoking cessationAlice TurnerConsultant respiratory physician

2. BackgroundBenefits of smoking cessationMethods of smoking cessationSmoking cessation and COPD

3. 1. ASH Facts at a Glance: Smoking Statistics. www.ash.org.uk/files/documents/ASH_93.pdf. 2. Smoking and Drinking Among Adults. (2008). www.statistics.gov.uk/downloads/theme_compendia/GLF08/GLFSmoking&DrinkingAmongAdults2008.pdf3. Space to Breathe. Smoking facts. www.spacetobreathe.org.uk/article.asp?aid=199. 4. Scottish Government (2008). Health of Scotland’s Population – Smoking. www.scotland.gov.uk/Topics/Statistics/Browse/Health/TrendSmoking5. Chief Medical Officer for Wales Annual Report 2009. http://wales.gov.uk/topics/health/ocmo/publications/annual/report09/?lang=en. 6. Department of Health (2010). A Smokefree Future. www.dh.gov.uk/en/Publicationsand statistics/Publications/PublicationsPolicyAndGuidance/DH_111749.. 7. Department of Health (2008). Priorities for Action 2008–09. 24%26%21%23%25%21%20%20%19%19%21%20%Regional prevalence2,3Smokers in the UK National prevalenceTarget smoking cessation prevalenceScotland 24%222% by 20104Wales 21%213%–17% range5England 21%210% or less by 20206Northern Ireland 26%321% by 20117Approximately 10 million adults in Great Britain smoke cigarettes1

4. Smoking is very addictiveLifetime probability of remission from dependence1Nicotine 83.7%Alcohol 90.6%Cannabis 97.2%Cocaine 99.2%1 Lopez-Quintero et al, Addiction (2011) 106: 657-69

5. Quitting smoking is difficult The majority of smokers want to quit1Most people try to quit without any assistance2Only 3–5% of unaided quitters remain smoke-free after 6 to 12 months3Most smokers make five to seven attempts before they finally succeed398% of smokers who relapse following a quit attempt are willing to try quitting again4 Boyle P et al. Eur J Public Health 2000; 10 (3 Supplement): 5–14. Jarvis MJ. BMJ 2004; 328: 277–279. Hughes JR et al. Addiction 2004; 99: 29–38. Joseph A et al. Nicotine Tob Res 2004; 6: 1075–1077.

6. Nicotine withdrawal produces a range of effects, including depressed mood1,2Effects last from a few days to a couple of weeks1,2 McEwan A et al (2006). Manual of Smoking Cessation. A Guide for Counsellors and Practitioners. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision. Smoking withdrawal symptoms DurationSymptomPrevalence<1 weekNight time waking25%<2 weeksPoor concentration60%>2 weeksUrges to smoke70%<4 weeksIrritabilityRestlessnessDepression50%-60%>10 weeksIncreased appetite70%

7. Cardiovascular benefitsTimeEffect24 hoursBP and heart rate improve1 yearMI risk halves5-15 yearsIHD & CVD risk equal to never smokersLung Health Study  ↓mortality 45%2Smoking bans3 ↓MI 17% - mean of all time pointsEffects greatest in younger patients26% decrease each year after implementation1 US DOH, Report of surgeon general (1990)2 Anthonisen et al, AJRCCM (2002) 166: 333-93 Meyers et al, J Am Coll Cardio (2009) 54: 124-55

8. Cancer benefitsCancer typeOR in smokersDuration of ↑riskPAR (%)N studiesRefPancreatic1.7410 years2082Iodice et al, Lang Surg Rev (2008)Urinary tract3.33-50/3343Zeegers et al, Cancer (2000)Squamous lung2.0350% at 10 years65/5315Yu et al, Lung Cancer (1996)Upper GI1.8514 years-33Tramacere et al, Epidemiology (2011)Breast1.03--53Hamajima et al, Br J Cancer (2002).After diagnosis of early stage lung cancer, continued smokers are much more likely to die1OR 1.86 (1.33-2.59)33% 5 year survival in smokers v 70% in quitters1 Parsons et al, BMJ (2010) 340: b5569

9. Respiratory benefitsReduces FEV1 decline1Reduces hospitalisations in COPD1Reduces mortality in COPD1Improves asthma symptoms & QOL2,3Reduces mortality due to CAP41 Anthonisen et al, JAMA (1994) 272: 1497-5052 Jang et al, All Asthma Immunol Res (2010) 2: 254-93 Tonneson et al, Nicotine Tob Res (2005) 7: 139-484 Inoue et al, J Epidemiol (2007) 17: 194-202

10. Benefits in surgical patientsTrend to lower risk of complications, especially pulmonary in people who quitLargely benefits accrue after 2/52 or moreMyers et al, Arch Intern Med (2011) 171: 983-

11. Cognitive benefitsCurrent smoking ↑risk of 1AlzheimersVascular dementiaOther dementiasCurrent smoking ↑risk of cognitive decline2Global cognition score -0.09 (-0.15- -0.03)Effects twice as big when deaths/dropout exclEffects of past smoking unclear, but appears that effects level out once quit for 10 years1 Peters et al, BMC Geriatr (2008) 8: 362 Sabia et al , Arch Gen Psych (2012) Epub ahead of print

12. Benefits in pregnancyReduces pre-term birthReduces low birthweightAverage gain 52gLumley et al, Cochrane (2009) CD001055

13. Is there anything bad about stopping?Weight gain5kg in first year8% in women, 6% in menWise et al, AJRCCM (1998) 157: 866-72

14. Is it ever too late? FEV1 declineQuitters decline slower  effect most marked in ♀1Quit before 30 & FEV1 decline is same as if never smoked. Quit after 40 rate no diff from continuous smokers?21 Anthonisen et al, JAMA (1994) 272: 1497-5052 Konhansal et al, AJRCCM (2009) 180: 3-10

15. Is it ever too late? Cancer risk and lung function interactEberley et al, Int J Epidemiol (2003) 32: 592-9

16. Long-term quit rates are highest with a combination of pharmacotherapy and behavioural support1Cochrane grade A evidence2Simple advice from a physician can have a small but significant effect on smoking cessation. Advice and/or counselling given by nurses also significantly increase the likelihood of quittingHughes JR et al. CA Cancer J Clin 2000; 50: 143–151. 2. DOH Guidance 20010/11. www.dh.gov.uk/prod _consum_dh/groups/dh.digitalassets/@dh/@en/@ps/@sta/@perf/documents /digitalasset/dh_109889.pdf.Most effective interventions combine pharmacotherapy with behavioural support Behavioural therapy Brief adviceNo treatment Medication30%20%10%No medication15%10%5%

17. Support availableIndividualGroupWeb-basedMeta-analysis suggests effective1Intensity of supportMay not make a difference2Group better than one to one31 Myung et al, Arch Intern Med (2009) 169: 929-372 Stead et al, Cochrane (2008) CD000146 3 Bauld et al, J Public Health (2010) 32: 71-82

18. PharmacotherapyNicotine replacement therapy (NRT)Bupropion (and other antidepressants)Varenicline (and other partial agonists)

19. NRTNRT typeOR of quitting95% CINumber of trialsAll1.581.50-1.66108Patch1.661.53-1.8141Spray2.021.49-3.734Gum1.431.33-1.5353Inhaler1.901.36-2.676Lozenges/tablets2.001.63-2.454Stead et al, Cochrane review (2008) CD000146

20. How to prescribe NRTWork out the dose they need from the amount smoked<10/dayMedium strength patch (10mg)2mg gum prn or 10mg cartridges for inhalator>10/dayHigh strength patch (15mg)May need to use 4mg gum prn or 15mg inhalator

21. Bupropion & antidepressantsDrugOR of quitting95% CIN trialsBupropion1.691.53-1.8536Nortriptyline2.031.48-2.796SSRI0.92*0.68-1.246MAOI1.49*0.92-2.414Venlafaxine1.220.64-2.321Adding bupropion or nortriptyline to NRT do not provide additional benefitHughes et al, Cochrane (2011) CD000031* OR for paroxetine (n=4 trials) and selegiline (n=3)

22. Prescribing bupropionStart 1-2/52 pre cessation150mg od for 6 days then bd for up to 7/52Dose reductions with age, liver and renal disease

23. Prescribing vareniclineStart 1-2/52 pre cessation150mcg od for 3/7, then bd for 4/71mg bd for 11/52 thereafterCourse can be repeated if neededDose reduction if eGFR <30

24. Partial nicotine agonistsWorks better than placebo, most trials are varenclineNNT= 10Cahill et al, Cochrane review (2011) CD006103

25. How do they work?

26. Who can have varenicline?Case reports of pre-existing psychiatric disease worsening, but remains a cautionTrial data did not show thisNot in age <18 or pregnancyReduce dose in severe renal impairment

27. Psychiatric SEsNS diff between groups for all except sleep, which was worse with placeboTonstad et al, Drug Saf (2010) 33: 289-300

28. What are the options in depressed patients?NRTBupropion or nortriptylineOngoing studies of varenicline suggest likely to be safe, but most are retrospective

29. Varenicline v placebo, 12 weeks, smokers with mild to moderate COPD; n=5041.Tashkin DP et al. Chest 2011; 139: 591–599.Varenicline v placebo in COPD

30. Varenicline v placebo in IHD

31. Varenicline v NRTPrimary endpoint: Continuous abstinence rate last 4 weeks of treatmentSecondary endpoint: Continuous abstinence 52 weeks

32. Varenicline v bupropion9/52 and 1 year quit ratesN= 10251 and n= 10272Pooled data OR 1.85 and 1.593Gonzales D et al. JAMA 2006; 296: 47–55. Jorenby DE et al. JAMA 2006; 296: 56–63. Nides M et al. Am J Health Behav 2008; 32: 664–675

33. Overall effect sizesMeta-analysis of all RCTs that followed up for at least 6/12Total numbers studied = 10300NNT v placeboAll types of NRT23 (95% CI 20–27)Bupropion18 (95% CI 14–23)Varenicline10 (95% CI 7–14)Cahill K et al. Cochrane Database of Systematic Reviews 2008, CD006103.

34. Cost effectivenessCost per QALY NHS will consider is £20000Above is equivalent to £3018-6415Wu & Sin, Int J COPD (2011) 6: 259-67

35. Greater cost effectiveness in COPDQuit rates1.4% for usual care2.6% for minimal6.0% for intensive12.3% counselling + pharmacotherapyIf 50% patients quit, effects at 25 yearsCost per QALY = £1982-13960Hoogendoorn M et al. Thorax 2010;65:711-718

36. SummarySmoking cessation is beneficialCOPD patients benefit mostMost forms of NRT work the sameVarenicline may work better but costs more

37. Questions?