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CURENT THINKING IN TOBACCO CONTROL AND SMOKING
CESSATION JENNIFER PERCIVAL RCN TOBACCO
POLICYADVISOR
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TOBACCO IS A SERIOUS PROBLEM In the year 2000 1
in every 6 deaths worldwide was caused by
smoking By the year 2030 1 in every 3 deaths
worldwide will be due to smoking 70 of these
deaths will be in developing countries. Source
WHO
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THE SILENT EPIDEMIC
WORLD HEALTH ORGANIZATIONs Epidemiologist Sir
Richard Peto stated Tobacco use is
increasing. Over 100 million deaths from tobacco
will occur during the next 20 years. and if
nothing changes there will be 1 billion deaths
this century.

• Research has shown
• Half of all regular smokers die prematurely
• ¼ in middle age (35-69)
• ¼ in old age
• Stopping before 35 avoids most of the risks of
  premature death.
• Stopping smoking works!!

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Global statistics

•        There are more than 1 billion smokers in
  the world today
• - 20 of the world's population.
• Tobacco kills more people than any other single
  agent.
•        Five countries China, India, Indonesia,
  Russia and Bangladesh account for half of all
  the worlds smokers
•        Smoking kills at least a third of current
  smokers, many
• more will develop serious illness because of
  tobacco. 
• Those killed by tobacco lose on average 10-15
  years of life
• Globally, nearly 5 million people are
  killed by tobacco each year,
• with current trends that number will double to
  10 million
• In this 21st century, unless urgent action is
  taken,
• more than one billion people will be killed by
  tobacco.

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The WHO Framework Conventionon Tobacco
ControlMain Measures

• Ban on tobacco advertising
• Increase Taxation
• Take effective measures on passive smoking
• Put Labelling and warnings on tobacco
• Provide Education campaigns
• Cessation guidelines and services
• Take Action on illicit trade
• Control sales to minors

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What is smoking?

• Chronic relapsing dependence syndrome
• Smoking is use of the addictive drug nicotine
• Delivered to the brain by tobacco smoke via lungs
  and blood
• Reinforced by sensory, behavioural and social
  conditioning
• Entrenched by powerful withdrawal syndrome
• Great harm caused by toxins in the smoke
• Promoted commercially, exempt from consumer
  protection legislation

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Current state of play in the UK

• About 22 of adults (10 million people) smoke
• Smoking kills about 104,000 people every year
• Prevalence is declining slowly 0.4 a year
• Highest proportion of smokers are in the lower
  socio-economic groups
• The main inequalities in life expectancy can be
  attributed to tobacco use
• Smoking remains the biggest public health problem
  in the UK

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Smoking and inequality in the UK
Smoking prevalence by class sex 1998.
60
Women
Men
50
40
Percent prevalence
30
20
10
0
I
II
III
III
IV
V
All
SOCIAL CLASS
General Household Survey 1998
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Smoking and inequality in the UK
Successful smoking cessation by social class in
the UK, 1998
60
50
40
successful
30
20
10
0
Professional
II
III NM
III M
IV
Unskilled
General Household Survey 1998
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Social Deprivation is associated with

• Greater levels of smoking
• Higher rates of smoking-related disease
• Similar desire to quit as other groups
• Less chance of success in quitting
• Smoking is major contributor to inequalities in
  health

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The case for smoking cessation services

• Excellent holistic health intervention
• Treat up to 50 diseases before they can arise
• Low unaided success rate (1-3) among smokers
• Small increases in success rate accumulate over
  time
• Extremely cost effective
• 800 per life year saved
• Compares to up to 30,000 per life year for new
  health technologies approved by NICE
• Saves burdens on NHS over time
• Can reduce prescribing costs for patients at risk
  of heart disease Helps protect children from
  passive smoking exposure

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Recommendations for Clinical Practice
Ask about smoking at every opportunity and
update records Advise all smokers to stop in a
personalised and appropriate
manner Assess motivation to stop Assist the
smoker to stop Arrange follow up if possible
Recommend smokers to use NRT/Zyban and provide
accurate information and on treatment options
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Key points for a brief intervention

• Explain the value of stopping and the risks to
  health of continuing
• Personalize this by taking account of
• Existing conditions or family history
• Early signs of disease
• Impact on others including children
• Financial consequences

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NICE Guidelines

• All healthcare personnel and clinicians should
  repeatedly and consistently deliver smoking
  cessation interventions to their patients.
• Patients should be encouraged to use nicotine
  replacement therapy, bupropion or varenicline for
  smoking cessation
• To be most effective, interventions should
  include either individual, group or telephone
  counselling/contact.

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NICE Guidelines

• Intensive interventions are more effective than
  brief interventions and should be used where
  resources permit.
• Every smoker should be offered at least a minimal
  or brief intervention.
• Smoking cessation interventions should
• - help smokers recognize and cope with likely
  problems
• - provide problem solving/ skills training
• - encourage people to seek support from family /
  friends.
• Smokers reluctant to be referred should be
  provided with information on NHS Smokers Helpline
  0800 169 0169

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Effectiveness of various smoking cessation
interventions for those making an attempt to stop
Chance of being a non-smoker 12 months after
giving up
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Do you follow good advice?
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GOOD ADVICE
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Giving Advice to Stop Smoking?

• Most smokers know its bad for them.
• It actually says so on the packs they buy!.
• Most smokers can give you good reasons why they
  do not want to stop right now.
• When you encourage a quit attempt it can polarise
  them into a defensive position

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REASONS FOR SMOKING
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REASONS FOR SMOKING
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STEPS TO QUITTING

• Deciding
• Preparing
• Quitting
• Staying stopped
• Coping with setbacks

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Current Behaviour
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What works?

• Ask what they have been told before about
  stopping and their interest in receiving new
  information
• Find out what they think their personal risks of
  continuing are
• Provide information/advice neutrally

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Stopping Smoking - Not ready!

• Respect this decision
• Ask What would need to be different for you to
  consider stopping?
• Explain your concerns and health observations
• Leave the door open for future discussions

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Unsure about change?

• Help them explore the advantages and
  disadvantages of continuing smoking
• Ask more about any current concerns and if they
  dont stop now in the future
• Explore any ambivalence
• Ask questions to plant a seed of change

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Making plans to quit?

• Congratulate this decision and offer your support
  or referral to specialist
• Recommend they use a treatment product and get
  NHS support
• Help them choose a quit date
• Check their expectations
• Ask What could get in your way and What can you
  do about it?

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RELAPSEWhy do smokers return to tobacco?

• Stopping under pressure from someone else
• Lack of personal motivation
• Attaching insufficient importance to stopping
• Withdrawal symptoms
• Poor timing
• A question of self-image
• I thought just one wouldnt hurt

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What happens when you try to stop? Withdrawal
effects duration and frequency

• Light-headedness
• Sleep disturbance
• Poor concentration
• Craving
• Irritability/aggression
• Depression
• Restlessness
• Increased appetite

• 2 wks 70
• 10 wks 70

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NHS TREATMENT THERAPIESEndorsed by NICE

• NRT ALL FORMULATIONS ALLOWED
• Combination of two types
• ZYBAN
• CHAMPIX
• ALL THESE PRODUCTS ARE WIDELY USED ACROSS THE
  NHS STOP SMOKING SERVICES

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NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE

• NICE recommended treatment be made available on
  prescription for smokers who are prepared to quit
  and ready to set a stop date.
• The initial prescription should be given for 2
  weeks with further prescriptions if the quit
  attempt is successful
• NICE concluded there was insufficient evidence to
  show whether one form of NRT is more effective
  than another.
• All products significantly increase a quitters
  chance of success.
• Treatment is extremely cost effective and all
  clients should be encouraged to use a product.
• Providing advice and motivational support is
  essential.

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Changes to the licensing of NRT

• Key messages1. All forms of NRT can be used by
  patients with cardiovascular disease.2. All
  forms of NRT can be used by smokers aged 12 to 17
  years.3. NRT can be used by pregnant and
  lactating women4. More than one form of NRT can
  now be used concurrently.5. NRT can now be
  prescribed for up to 9 months if patients show
  evidence of a continued need for NRT beyond the
  initial 8 to 12 week treatment phase.6. NRT can
  now be used while still smoking, with a view to
  reducing the amount smoked as a prelude to
  quitting.

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Nicotine delivery
Royal College of Physicians, Nicotine Addiction
in Britain, 2000
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Nicotine delivery
Royal College of Physicians, Nicotine Addiction
in Britain, 2000
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Bupropion (Zyban)
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CHAMPIX a new class of therapy in smoking
cessation

• CHAMPIX (varenicline) is the first drug
  specifically developed for smoking cessation1
• Launched December 2006
• Oral prescription-only medicine
• Unique dual mode of action - targets the nicotine
  receptors which is key in the addiction pathway1,2

1. Coe JW. J Med Chem 2005 483474-3477. 2. Dani
JA, Harris RA. Nature Neuroscience 2005
81465-1470.
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Nicotine withdrawal symptoms and smoking
cessation - What to look out for and patients to
treat with caution

• Smoking cessation, with or without treatment, is
  associated with nicotine withdrawal symptoms e.g.
  depression and the exacerbation of underlying
• psychiatric illness
• Care should be taken with patients with a history
  of psychiatric illness and patients should be
  advised accordingly

1. CHAMPIX Summary of Product Characteristics.
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The UK is a world leader in smoking cessation
and there has never been a better time to raise
the issue and offer support to quit.
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Picture warnings Oct 1st 2008
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THE BIG QUESTION WILL TOBACCO USE VANISH IN
OUR LIFE TIME?
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Tobacco Smoking in Britain

• A report issued this week by
• the Royal College of Physicians
• says that if the Government was prepared to take
  far more radical measures to combat smoking,
• we could practically eradicate
• smoking in Britain by 2025.

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All conventional approaches to preventing smoking
have now been implemented

• Increasing the cost of cigarettes
• Advertising bans
• Smokefree public places and workplaces
• Mass media health promotion campaigns
• Cessation programmes
• Banning sales to minors
• Unfortunately these will only reduce smoking
  prevalence by 0.5 to 1.0 per year
• At this rate it will take 11 to 22 years for the
  smoking rates in England to drop from
• 10 million to 5 million people.

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RCP -Tobacco Smoking in Britain suggests

• Smokers are addicted to nicotine which is not
  particularly harmful
• It is the other chemicals and particles in
  tobacco smoke that are responsible for the great
  majority of the lung cancer and other diseases
  caused by smoking
• Quitting smoking and all nicotine use is the
  healthiest option for any smoker.
• If thats not possible, switching them to a
  source of nicotine that does not involve inhaling
  smoke is the next best option.
• Using smoke-free nicotine products greatly
  reduces the risk to smokers themselves, would
  prevent others exposure, to second hand smoke and
  role models.

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Harm Reduction in Nicotine Addiction Helping
people who cant quit This book by leading
experts this RCP report makes the case for harm
reduction strategies to protect smokers. It
shows that smokers smoke, predominantly for
nicotine, - nicotine itself is not especially
hazardous, and if nicotine could be provided in a
form that is acceptable and effective as a
cigarette substitute, millions of lives could be
saved