1 University College London December 2013 Robert West The science, economics and politics of tobacco control: How can we get best bang for our bucks?

Declaration of interest I receive research funds and undertake consultancy for companies that develop and manufacture smoking cessation medications (Pfizer and J&J) I am co-director of the UK National Centre for Smoking Cessation and Training I am a trustee of the stop-smoking charity, QUIT My salary is funded by the charity, Cancer Research UK 2

Decline in smoking prevalence: what is achievable? The Smoking Pipe model: what are the main targets? The Behaviour Change Wheel: how to change behaviour? Tobacco control interventions: –how are we doing? –how can we do better? –how can we overcome political barriers? Topics 3

Decline in smoking prevalence: what is achievable? The Smoking Pipe model: what are the main targets? The Behaviour Change Wheel: how to change behaviour? Tobacco control interventions: –how are we doing? –how can we do better? –how can we overcome political barriers? Topics 4

Cigarette smoking prevalence in England since 1970s 5 5% ONS and Smoking Toolkit Study

Cigarette smoking prevalence in England since 1998 (the year of ‘Smoking Kills’) 6 5%

Cigarette smoking prevalence in England since 1998 (the year of ‘Smoking Kills’) 7 5%

Decline in smoking prevalence: what is achievable? The Smoking Pipe model: what are the main targets? The Behaviour Change Wheel: how to change behaviour? Tobacco control interventions: –how are we doing? –how can we do better? –how can we overcome political barriers? Topics 8

‘Smoking Pipe’ model 9 Smokers turn 16 Start smoking post-16 Prior quitters relapse Attempt to stop Relapse Die Smokers Excludes migration as effects are very small

Key behaviours during Smoking prevalence at 16:13% 2.Uptake rate post 16:4% per year of age 3.Quit attempt rate during the year: 34.4% 4.Relapse rate during the year: 82.4% 5.Relapse rate from past quitters: 1% 10

‘Smoking Pipe’ model for England: year olds 83,000 Uptake149,000 Late relapse 61,000 Attempt to quit 3,067,000 2,589,000 relapse 92,000 Die Reduction of 325, % 540,000 stop From: The Smoking Pipe Model, Adult population: 43 million Smokers at start: 8.9 million Prevalence at start: 20%

Relative contribution of different influences on prevalence change 12

Relative contribution of different influences on prevalence change: a different view 13

Going for 1% Projected annual death rate from 20% prevalence:60,000 Annual lives saved from sustained reduction of 1%:3,000 14

Getting to 1% Model 1Model 2Model 3Model 4 Uptake rate-50%---10% Quit attempts--+22%+10% Quit success-+50%-+10% 15

Decline in smoking prevalence: what is achievable? The Smoking Pipe model: what are the main targets? The Behaviour Change Wheel: how to change behaviour? Tobacco control interventions: –how are we doing? –how can we do better? –how can we overcome political barriers? Topics 16

The COM-B model of behaviour 17 Michie S, M van Stralen, West R (2011) Implementation Science, 6, 42.

Behaviour change To change the incidence of a behaviour one needs to change one or more of: –capability increase or decrease physical or psychological ability to engage in the behaviour –opportunity increase or decrease access, resources and prompts –motivation increase or decrease plans, values, desires or habit relative to competing behaviours 18

Capability To change the incidence of a behaviour one needs to change one or more of: –capability increase or decrease physical or psychological ability to engage in the behaviour –opportunity increase or decrease access, resources and prompts –motivation increase or decrease plans, values, desires or habit relative to competing behaviours 19 C

Opportunity To change the incidence of a behaviour one needs to change one or more of: –capability increase or decrease physical or psychological ability to engage in the behaviour –opportunity increase or decrease access, resources and prompts –motivation increase or decrease plans, values, desires or habit relative to competing behaviours 20 O

Motivation To change the incidence of a behaviour one needs to change one or more of: –capability increase or decrease physical or psychological ability to engage in the behaviour –opportunity increase or decrease access, resources and prompts –motivation increase or decrease plans, values, desires or habit relative to competing behaviours 21 M

22 Behaviour Change Wheel Michie S, M van Stralen, West R (2011) Implementation Science, 6, 42.

23 Ways of influencing behaviour

24 Policy options for achieving this

Decline in smoking prevalence: what is achievable? The Smoking Pipe model: what are the main targets? The Behaviour Change Wheel: how to change behaviour? Tobacco control interventions: –how are we doing? –how can we do better? –how can we overcome political barriers? Topics 25

26 Tobacco control: interventions Michie S, M van Stralen, West R (2011) Implementation Science, 6, 42.

27 Tobacco control: policies Michie S, M van Stralen, West R (2011) Implementation Science, 6, 42.

Decline in smoking prevalence: what is achievable? The Smoking Pipe model: what are the main targets? The Behaviour Change Wheel: how to change behaviour? Tobacco control interventions: –how are we doing? –how can we do better? –how can we overcome political barriers? Topics 28

Education How well informed is the population about: –the harms of smoking? –how best to avoid or stop smoking? 29

Royal College of Physicians report and smoking prevalence decline 30 RCP report Source: ONS

Support used in quit attempts 31 NRT OTC: Nicotine replacement therapy bought over the counter; Med Rx: Prescription medication; NHS: NHS Stop Smoking Service; E-cig: Electronic cigarette

Abrupt versus gradual quitting among smokers in England Quitting abruptly: 49.2% Odds of success for abrupt versus gradual: 3.2, p< N=901. Adjusting for baseline age, gender, social grade, cigarette dependence, use of quitting aids, motivation to quit, time since quit attempt, previous quit attempts. Smoking Toolkit Study

Where we are –Education has probably been the most important driver of prevalence reduction in the past 50 years Room for improvement –Key information about public understanding of health risks of smoking is missing –Awareness of the best ways of stopping is appears to be low Education: the bottom line 33

The secret to stopping smoking Keep rolling the dice Load the dice in your favour 34

Helping smokers to help themselves by bring the science of stopping to smokers 35

Ingredients for the SmokeFree Formula IngredientRatingIngredientRatingIngredientRating In-person support  Abrupt stop  Deep breathing  NRT (supported)  Identity change  Exercise  Champix  Avoiding smokers  Isometric exercise  Zyban  Avoiding alcohol  Mental exercises  Cytisine  Changing routine  Healthy snacks  Quitline  Keep busy  Go to bed early  Internet  One day at a time  Get rid of cigs  SMS support  Tell others  Smartphone app  Book  Quit together  E-cigs  Count savings  Glucose  36  Strong evidence  Moderate evidence  Some evidence

Persuasion and coercion How much do smokers: –want to stop smoking? –worry about the harms of smoking? –worry about the cost of smoking? 37

Relation between consumption (pounds sterling billion at 1992 prices) and real price (1992=1.0) of cigarettes in Britain during Townsend J et al. BMJ 1994;309: Chaloupka 2009 Price as a deterrent

39 Concerns of smokers in England N=15,000+ Source: Smoking Toolkit Study

40 Smoking concerns and quit attempts among smokers in England Final model from forward stepwise logistic regression of attempt to stop in past 12 months on to beliefs about smoking. Odds ratios less than 1 represent negative associations. N=5647; Source: Smoking Toolkit Study

41 More people think they ‘ought’ to stop than want to stop N=6,000+ Source: Smoking Toolkit Study

42 It is wanting and needing to stop that drives action, not ‘ought’ N=1953 Results of multiple logistic regression Source: Smoking Toolkit Study p<0.001 p<0.01 p<0.05

Stoptober: triggering quit attempts October quit rate significantly higher compared with previous months in 2012 versus pre-2012 by logistic regression, p=0.005 Brown et al (2013) Drug & Alcohol Dependence

Health professional advice is the main external trigger to quitting 44 Source: Smoking Toolkit Study

It is only when they offer support that smokers respond by trying to stop 45 p<0.001 N=11,119 Source: Smoking Toolkit Study

The offer is linked to behaviour, not desire to quit 46 p<0.001 N=11,119 Source: Smoking Toolkit Study

Offer of support is linked to successful quitting and not advising may be worse than useless 47 p<0.05 N=12,221 p<0.05 Results of multiple logistic regression adjusting for age, sex and social grade Source: Smoking Toolkit Study

Many GPs are still not offering support with quitting 48 N=11,119 Source: Smoking Toolkit Study

GP-triggered quit attempts and QOF 49 New QOF: The percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months

Where we are –Price rises are a key driver of prevalence reduction –Concern over health harms are a key driver of quitting –Mass media campaigns drive quit attempts –GP advice drives quality quit attempts when it involves offer of support Room for improvement –There is significant room for improvement on all of these Persuasion and coercion: the bottom line 50

Restriction How far do smokers or potential smokers experience: –restrictions in availability of cigarettes? –restrictions in locations where smoking is permitted? 51

Effect of raising the age of sale from 16 to 18 years in England 52 Fidler et al (2010) Addiction, 105, 1984

Decrease in smoking prevalence in England following smoke-free legislation 53 Base: All adults

Restriction: the bottom line Where we are –Smoke-free legislation may have given us a one-off hit –Raising age of sale probably reduced prevalence in year olds Room for improvement –There may be scope for further raising age of sale to 21 and extending smoking restrictions (as in New York) 54

Environmental restructuring How far is the environment –limiting prompts and cues for smoking? –making smoking non-normative or stopping smoking normative? 55

Billboards and printed publication: 2003 Direct mail and sponsorship: 2005 Point of sale: being phased in Product placement still permitted Restrictions of promotion in UK 56

Effect of limiting tobacco promotion 57 Difficult to estimate specific effects because typically occur with other measures but evidence suggests effects of uptake of comprehensive bans

Advertising bans and prevalence in UK 58

A very small effect on uptake can have a large effect on death rates 59 If standard packaging prevented 1 in 20 young people from starting to smoke, it would end up saving 2,000 live a year

Where we are –Some evidence that can reduce prevalence but effects are likely to accrue of years and be very difficult to detect –Even very small effects can save many lives Room for improvement –Key areas left are cigarette packages and smoking in films and on TV Environmental restructuring: the bottom line 60

Enablement How far do smokers: –have convenient and attractive ways of reducing craving and withdrawal symptoms when they try to quit? 61

Medications: efficacy 62 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

Behavioural support: efficacy 63 Stead et al 2012, Cochrane 1 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 Issues with unexplained heterogeneity or conversion to practice

64 Relative success rate in England by method of stopping Significantly better than no aid adjusting for confounding variables, p<0.001 Kotz et al (2013) Addiction, In Press

English Stop-Smoking Services: Numbers of 4-week quitters generated (impact)

66 Success rates of English Stop Smoking Services

What makes for an effective stop-smoking service? 67 Brose et al, 2011 Thorax

Components behavioural support Medication options Service structure Identify best practice Online knowledge and face-to-face skills training Online assessment Website and resources (e.g. Standard Treatment Plan) Online Very Brief Advice training Translate into training, assessment and resources Evaluate knowledge and skills training Evaluate upgrading of service (e.g. Boots Trial) Evaluate specific innovations (e.g. text messaging) Evaluate innovation 68

Where we are –We have effective treatments, some more effective than others –The most effective treatments are not being delivered consistently –A new treatment is available, cytisine, that could save £20 million+ –NRT OTC is not being used effectively Room for improvement –Increase use of most effective treatment –Raise quality of weaker Stop-Smoking Services –Put onus on NRT companies to ensure their products are used effectively –License cytisine Enablement: the bottom line 69

Annual expenditure £18 billion by smokers on cigarettes and tobacco £80 million QOF payments to GPs £86 million on stop-smoking services £80 million by NHS on stop smoking medication £100 million+ by smokers on NRT bought OTC £15 million on communications £10 million on legislation Economics of tobacco control 70

Options for increasing rate of decline in smoking prevalence in England 71 Policies (over and above what is currently being done) Estimated prevalence reduction per annum Extra cost to exchequer per annum 5% real cost increase (versus no increase) %-0.25%Net gain Double effective GP opportunistic advice %-0.10%None Promoting effective use of OTC NRT %-0.03%None Improve effectiveness of NHS support %-0.03%£1m Licence cytisine0.01%-0.02%£20m gain Boosting autumn events (Stoptober) %-0.02%<£5m Standard packagingto be determinednot known Point of sale banto be determinednot known Total over and above current 0.75%

Electronic cigarettes: a game changer? 72 NRT OTC: Nicotine replacement therapy bought over the counter; Med Rx: Prescription medication; NHS: NHS Stop Smoking Service; E-cig: Electronic cigarette

Stopped smoking in past 12 months 73 Graph shows prevalence estimate and upper and lower 95% confidence intervals Base: Adults who smoked in the past year

Success rate for stopping in those who tried to stop 74 Graph shows prevalence estimate and upper and lower 95% confidence intervals Base: Smokers who tried to stop n the past year

Decrease in smoking prevalence in England in Base: All adults

There are ideologies and morals but there are also important ‘material interests’ Some material interests: –Pharmaceutical industrysell products –Smokersprotect freedom, save money –Tobacco control communityget funds, win battle –Research communityget funds, get published –Governmentstay in power, protect friends –Public sectorkeep jobs, get promoted –PR/Ad agenciessell services, win awards The realpolitik of tobacco control 76

Conclusions 1.Raise the cost, particularly at the cheaper end of the market 2.Incentivise GPs to offer support effectively 3.Use mass media and health professionals to educate about best ways of stopping and introduce urgency 4.Bring all Stop Smoking Services up to a high standard and improve access 5.Force big pharma to find ways of making their products effective when bought from shops 6.License cytisine 7.Do not get in the way of e-cigarettes unless and until there is a problem 8.Introduce standard packaging 77 We can exceed 1% pa reduction in cigarette smoking prevalence without spending more by better implementation of evidence- based approaches

It’s not that hard! Put another way … 78