1. Hot topics in smoking cessation Robert West University College London @ robertjwest 1

2. 2 Declaration of interests I undertake research and consultancy for companies that develop and manufacture smoking cessation medications I am a trustee of QUIT I am co-director of the NHS Centre for Smoking Cessation and Training My salary is funded by Cancer Research UK

3. 3 8.1 million smokers aged 16+ in England in 2014

4. Deaths in England from smoking 2013 4 Total: 79,700

5. Cigarette smoking prevalence in England by social grade Data from smoking toolkit study: www.smokinginengland.info Base: Adults 5

6. Cigarette smoking prevalence in England by gender Data from smoking toolkit study: www.smokinginengland.info Base: Adults 6

7. 7 What works in smoking cessation and how well?

8. Current evidence: medication 8 Stead et al 2008, Cahill et al 2012, Cochrane Varenicline: N=6,166 Single NRT: N=51,265 Dual NRT: 4,664 NRT for ‘reduce to quit’: N=3,429 95% confidence intervals from meta- analyses Hughes et al 2008, Cahill et al 2012, Cochrane Bupropion: 11,440 Nortripyline: N=975 Cytisine: N=937 95% confidence intervals from meta- analyses

9. Current evidence: behavioural support 9 Stead et al 2012, Cochrane Pro-active telephone vs reactive: N=24,994 Individual vs brief advice: N=7,855 Group vs self-help: N=4,375 Internet vs nothing: N=2,960 Text messaging versus control messages: N=9,110 Written materials: N=15,117 95% confidence intervals from meta- analyses Depends crucially on the specific intervention Generally found to be effective Figures are not directly comparable because of different samples and comparison conditions

10. Network meta-analysis of medications 10 Cahill et al (2013) Cochrane Library

11. 11 What is happening with e- cigarettes?

12. 12 McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD010216. DOI: 10.1002/14651858.CD010216.pub2. Efficacy of e-cigarettes in placebo- controlled randomised trials

13. Vertical lines represent 95% confidence intervals; Odds ratio of 1 means no association Data from smoking toolkit study: www.smokinginengland.info Base: Smokers who tried to quit in past 12 months 13 ‘Real-world’ effectiveness of e- cigarettes

14. Nicotine use by never smokers and long-term ex-smokers 14 N=26373 never and long-term ex-smokers from Nov 2013

15. Prevalence of electronic cigarette use: smokers and recent ex-smokers 15 N=17604 adults who smoke or who stopped in the past year; increase p<0.001

16. Use of nicotine products while smoking 16 N=16445 smokers, increase p<0.001 e-cigs and all nicotine; decrease p<0.001 for NRT

17. Use of nicotine products in recent ex- smokers 17 N=1159 adults who stopped in the past year; increase p<0.001 for e-cigs and all nicotine; decrease p<0.001 for NRT

18. Aids used in most recent quit attempt 18 N=10411 adults who smoke and tried to stop or who stopped in the past year; method is coded as any (not exclusive) use

19. Starting E-cigarette use after quitting 19 N=755 adults who stopped in the past year and did not report using an e-cigarette to help during the quit attempt

20. Take-up of smoking 20 N=13698 people aged 16-24

21. 21 Decline in NHS stop-smoking services

22. Fall in numbers using Stop Smoking Services since move to Local Authority control 22

23. 23 Varenicline safety

24. 24 FDA Black Box warning

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27. 27 Comparative observational studies and RCTs studies find no excess risk on neuropsychiatric side effects of varenicline

28. Key points Smoking prevalence is declining steadily but smoking is still killing almost 80,000 people a year in England There are numerous effective treatments to help smokers to stop: varenicline or dual form NRT, plus specialist behavioural support is the treatment package of choice E-cigarettes are increasingly popular and are effective in helping people stop; use among never smokers remains negligible and they are not currently acting as a gateway to smoking Use of NHS stop-smoking services has declined by 40% from its peak Controlled trials and large comparative observational studies find no excess risk of neuropsychiatric side-effect from varenicline 28