1. Smoking cessation in New Zealand
Hayden McRobbie MB ChB (Otago) PhD (London)
Faculty of Health and Environmental Sciences, Auckland University of Technology
Wolfson Institute of Preventive Medicine, Queen Mary University of London

2. Smoking in people aged 15–64
Source: 2009 New Zealand Tobacco Use Survey

3. Do smokers want to smoke?
4 in 5 smokers said that they would not smoke if they had their life over again
Females were significantly more likely than males to say this
3 in 5 had tried to quit in the last 5 years
Source: 2009 New Zealand Tobacco Use Survey

4. What are we up against? The addictive nature of tobacco
The tobacco industry
Optimism and over confidence of smokers
“It won’t happen to me”
“I’ll be able to give up when the time comes”

5. Tension, Triggers, Treatment
Tension and triggers
Maximising smokefree norms
Raise the price of tobacco
Restrict the supply
Regulate tobacco
Remove temptations to smoke
Continue with fear arousing messages
Populate the smokers’ world with QUIT NOW messages
Provide evidence based treatment

6. Policy and treatment ITC project: in first year after recruitmentUK
Australia
Canada US
Visited a doctor or other HCP
55%
72%
68%
71%
Got advice to quit
48%
57%
69%
Made 1 or more quit attempts
37%
41%
43%
39%
Got additional help
20% 6% 9%
10%
Got meds and behavioural support
19% 8%
Odds of quitting for a month UK
Australia
Canada US
Odds ratio
1.0
0.59
0.72
0.51
95% confidence interval
referent
Reid et al 2010 Nicotine & Tobacco Research 12 (supl 1) S20-S33

7. Stop smoking services
Do not have a large effect on smoking prevalence
Offer a life saving treatment for those smokers who want to use it

8. NZ Smoking Cessation Guidelines
Screen for tobacco use
Brief advice to quit smoking
Offer help to quit
Behavioural support
Face-to-face and telephone cessation support
Setting a quit date and providing multi-session behavioural support
Medication
Nicotine replacement therapy
Bupropion & Nortriptyline
Varenicline

9. Put simply… A - ask whether a person smokes
B - give brief advice to quit to all people who smoke and
C – make an offer of, and provide or refer for cessation treatment

10. Treatment of Tobacco Use

11. Treatment Works
Data from Cochrane reviews; bars represent 95% CIs based on risk ratios versus placebo (for medications) or brief advice/no treatment (for BehSup)
Silagy C et al (2004). Cochrane Database Syst Rev: CD000146
Hughes J et al (2004). Cochrane Database Syst Rev: CD000031
Cahill K et al (2007). Cochrane Database Syst Rev: CD006103
Author’s note
“The figures used are based on risk ratios from Cochrane where these are provided or inverted from odds ratios where Cochrane provides those. Remember that for all the figures for BehSup plus Tx the figures are synthetic, being based on the risk ratio for BehSup times the risk ratio fir the med. That is the only way to get a figure compared with no treatment.”
Slide courtesy of Prof Robert West, UCL, London

12. Smoking Cessation in NZ
Individual Counselling
Frontline Healthcare
Professionals
Pregnancy services
DHB services
Options
Proactive Telephone
Counselling
Group Counselling
Web and text based
support

13. Pharmacotherapy ✔ ✔ ✖ ✔ ✔ ✔ ✔ ✖ ✔ ✖ Bupropion Subsidised User pays
Options
Nicotine Replacement
Varenicline ✔ ✔
Patch
Gum
Lozenge
Microtab
Inhaler ✔ ✔
Nortriptyline ✖ ✔ ✖

14. NRT Roughly doubles the chances of quitting long-term
Safe to use in ALL people who smoke
Patch, gum and lozenge fully subsidised
Combination therapy recommended
Available on prescription or via a QuitCard
NNT = number needed to treat
Stead, L. F., Perera, R., Bullen, C., Mant, D. & Lancaster, T. (2008) Nicotine replacement therapy for smoking cessation, Cochrane Database Syst Rev, CD

15. Quit Card Providers
Registered Healthcare Professionals can become quit card providers by doing a 30 minute online training module
Face-to-face training for other healthcare workers

16. Varenicline (Champix)
Partial agonist of nicotinic acetylcholine receptors
At least doubles chances of quitting
Able to be used my most smokers, BUT need to fulfill special authority criteria
Prescription only
Nausea and vivid dreams are common side effects
Cahill, K., Stead, L. F. & Lancaster, T. (2008) Nicotine receptor partial agonists for smoking cessation, Cochrane Database Syst Rev, CD006103

17. Champix available on prescription
Special authority
The patient is part of, or is about to enroll in, a comprehensive support and counseling smoking cessation programme, which includes prescriber or nurse monitoring AND
The patient is not pregnant AND
The patient has tried but failed to quit smoking after at least two separate trials of nicotine replacement therapy, at least one of which included the patient receiving comprehensive advice on the optimal use of nicotine replacement therapy OR
The patient has tried but failed to quit smoking using bupropion or nortriptyline

18. Nortriptyline Tricyclic antidepressant Doubles chances of quitting
Not suitable for some smokers
Prescription only
Dry mouth, blurred vision are common side effects

19. Zyban Atypical antidepressant Roughly doubles the chances of quitting
Number of contraindications, cautions, and drug interactions to consider
Prescription only
Side effects: headache, dry mouth, insomnia, seizure (rare)

20. Is the ABC approach working?

21. Smokers ‘ABC’d’ in past year
Received the ABC approach from a health care worker in the past 12 months, among 15–64-year-old current smokers, by age group, 2009 (unadjusted prevalence)
Source: 2009 New Zealand Tobacco Use Survey

22. The Tobacco Health Target
“Eighty percent of smokers will be provided with advice and help to quit by July 2010; 90 percent by 2011; and 95 percent by July 2012.”
New Zealand’s Health Targets set defined goals to motivate and assist smokers to quit and to achieve a reduction in smoking prevalence

23. Health Target Results – 2009/10
New Zealand District Health Boards
Percent provided with advice and/or help to quit

24. What are smokers doing?

25. Tried to quit in the last year
Quit smoking for at least 24 hours in the past 12 months, among current and casual smokers aged 15–64 years, by age group, 2009 (unadjusted prevalence
Source: 2009 New Zealand Tobacco Use Survey

26. Going cold turkey?
No – almost 40% of recent quit attempts involved advice or smoking cessation products
Quitline
NRT

27. Cessation Support
Services and products used in most recent quit attempt, among recent quit attempters aged 15–64 years
Source: 2009 New Zealand Tobacco Use Survey

28. Where are they getting their NRT?
Source: 2009 New Zealand Tobacco Use Survey

29. Where to from here?
A range of support that best fits the person (and the health care system)
Need to maximize access
Priority populations
Go to where the people are
People want choice and the service that fits THEM
Innovative, effective, and safe ways to manage tobacco dependence

30. Quality of treatment services
Its not just about throughput, outcome is also important
Service user feedback and input
Monitoring and improvement (as opposed to evaluation)

31. Novel approaches ‘Drop-In’ clinics
Halls, shopping centres
Outside working hours
No appointments, multi-session,
Potential use of ‘lay’ community members to
Promote and ‘sign post treatment
Provide support

32. Different Routes to Quitting
UK NHS Stop Smoking Service is considering implementing different options for smokers
Abrupt quitting (status quo)
Rapid reduction to quit
Slow reduction to quit
Harm reduction

33. Conclusions
Smoking cessation treatment is part of a comprehensive tobacco control strategy
For many smokers, smoking cessation will be life- saving
‘ABC’ is part of ‘core practice’ for healthcare professionals
New Zealand has a good range of options for smokers who wish to quit, but we need to improve utilisation of these