1. Smoking Cessation Its place in Tobacco Control
Hayden McRobbie
Reader in Public Health Interventions, Wolfson Institute of Preventive Medicine, Queen Mary University of London
Adjunct Professor, Faculty of Health and Environmental Sciences, Auckland University of Technology

2. Overview & Learning Objectives
Tobacco Dependence and Withdrawal
Students will be able to articulate the reasons why people smoke and find it difficult to quit
Behavioural interventions for smoking cessation
Students will be able to describe evidence based behavioural treatments
Pharmacological interventions for smoking cessation
Students will be able to describe evidence based pharmacological treatments
The ABC approach for smoking cessation
Students will be able to articulate the ABC approach to smoking cessation and deliver the key messages of this approach
The place of smoking cessation treatment in tobacco control and the 2025 goal
Students will be able to articulate the role smoking cessation can play in achieving the 2025 smokefree goal
Hayden McRobbie 2014

3. Tobacco Dependence and Withdrawal

5. Nicotine

6. Mesolimbic dopamine pathway
Binds to
nACh receptors
Increase in
dopamine
nicotine
positive reinforcement
Hayden McRobbie 2014

7. Tobacco withdrawal syndrome
Signs & symptoms
Duration
Prevalence
Irritability
< 4 weeks
50%
Depression
60%
Restlessness
Poor concentration
< 2 weeks
Increased appetite
> 10 weeks
70%
Sleep disturbance
< 1 week
25%
Urges to smoke
> 2 weeks
Mouth Ulcers
> 4 weeks
40%
Constipation
>4 weeks
17%
Hayden McRobbie 2014

8. Smoking Cessation

9. Why help people to quit? Obvious health gains – save lives
Reduce inequalities in health
To give people back control (smoking is a behaviour over which people have lost control)
Hayden McRobbie 2014

10. Smokers die early Pirie et al Lancet. 2013 Jan 12;381(9861):133-41
Hayden McRobbie 2014

11. Quitting Works
Hayden McRobbie 2014

12. Individual and Environment
The quitting process
Individual and Environment
Comorbidity
Degree of Dependence
Genetic
Social factors
Smoking
Quit Attempt
Abstinence
Tobacco Control Policies
Brief Interventions (e.g. AB+offer of C)
Smoking Cessation Treatments
Adapted from: Hughes Drug and alcohol dependence (2011):
Hayden McRobbie 2014

13. The New Zealand ABC Approach
A - ask whether a person smokes
B - give brief advice to quit to all people who smoke and
C – make and offer of and refer to cessation treatment
New Zealand’s comprehensive approach, which includes this range of options for cessation treatment is set out in the ABC programme.
The ABCs highlight the important but different roles played by health care workers and cessation service providers to provide good help for smokers to quit.
The ABCs are about addressing smoking with every patient, and ensuring that they get joined up with cessation treatment that works for them.
ABC is about Asking every patient if they smoke, providing brief advice to quit, and providing smoking cessation medications and or referring on to more intensive cessation support services.
And then, of course, the role of cessation services in the ABC is to provide the C in a high quality, evidence based way.
McRobbie et al NZMJ 20 June 2008, Vol 121 No 1276
URL:
Hayden McRobbie 2014

14. The importance of brief interventions

15. Making a quit attempt Tensions and triggers Tension Triggers Price
Health concerns
Triggers
Sudden illness
Price rise
Advice from a health professional
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16. Remaining Quit Treatment Behavioural support Pharmacotherapy
Supportive environment
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17. Healthcare Professionals Role
Health care professionals can increase a patient’s odds of quitting with brief advice, medication, and behavioural support 1
Tasks
Identifying people who smoke
Motivating a quit attempt
Refer for treatment and support
Supporting ongoing abstinence
This slide provides some basic reasons why education and training of HCPs is necessary. For example:
Dangers of smoking
Effectiveness of HCP intervention on increasing quit odds
Common barriers to TDT
AVEYARD P. & WEST R (2007) Managing smoking cessation, BMJ, 335,
Hayden McRobbie 2014

18. Importance of brief advice
Brief advice from a healthcare professional prompts people to quit
Increases long-term abstinence rates by up to 3 percentage points
Number needed to treat = 33
Stead et al Physician advice for smoking cessation. Cochrane Database of Systematic Reviews. CD:

19. Advice from a Health Professional is the major external trigger
Source: - Smoking Toolkit Study
Hayden McRobbie 2014

20. And it’s the offer of support that’s important
Source: - Smoking Toolkit Study
Hayden McRobbie 2014

21. Not advising may be worse than useless
p<0.05
p<0.05
Results of multiple logistic regression adjusting for age, sex and social grade
Source: - Smoking Toolkit Study
Hayden McRobbie 2014

22. You don’t need to assess readiness to quit
Total N=2168
In this study that catagorised people by readiness to quit (using stages of change model). Then they offered everyone treatment, regardless of whether they said they were ready or not.
Key point is that you don’t need to assess if someone is ready, just offer them treatment. Yes, those who are ready are more likely to accept the offer (52% vs. 24%), but given the majority of people in this study said that they weren’t ready making an offer to everyone is important.
PISINGER et al (2005) Prev Med, 40:
Hayden McRobbie 2014

23. Smoking cessation tools

24. What do people need help with?
The first major obstacle to quitting is withdrawal discomfort
Worse in smokers with high pre-abstinence nicotine intake
Urges to smoke and depression predict relapse
Hayden McRobbie 2014

25. Getting over the initial withdrawal discomfort
Behavioural support is of proven efficacy
Can be delivered in different formats
Face-to-face (individual or group)
Telephone
Internet
NRT, bupropion (Zyban), nortriptyline and varenicline (Champix) are of proven efficacy
Hayden McRobbie 2014

26. Long-term outcomes
Source: New Zealand Guidelines for Helping People Stop Smoking
Hayden McRobbie 2014

27. Pharmacological Interventions for Smoking Cessation

28. Nicotine replacement therapy
Binds to
nACh receptors
Increase in
dopamine
Nicotine +++
Nicotine +

29. Nicotine Delivery Source: Royal College of Physicians
Hayden McRobbie 2014

30. NRT: Long-term (>6 month) quit rates vs. placebo
Pooled 150 studies
RR=1.60 (95% CI: )
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD DOI: / CD pub4.
Hayden McRobbie 2014

31. NRT - safety and side-effects
There are no ‘real’ contraindications to NRT
Some individual product differences e.g. gum not good for people with dentures
No drug interactions
The most common side effects are localised e.g.
Taste of oral products
Hiccups with the mouth spray
Skin irritation with patch
Facilitator: Hayden
Hayden McRobbie 2014

32. Reasons for NRT failure
Unrealistic expectations
Incorrect use
Not used for long enough
Nicotine is often seen as the dangerous element in cigarette smoke
Safety concerns can be a barrier to use
Hayden McRobbie 2014

33. Bupropion
Atypical antidepressant which acts on dopamine and noradrenaline pathways and possibly as a nicotinic antagonist, designed to reduce motivation to smoke by
reducing cravings and withdrawal symptoms
reducing the rewarding effect of smoking
What to say to your patients?
Works by alleviating craving and other withdrawal symptoms
It’s not a magic cure, but it will make quitting easier
Hayden McRobbie 2014

34. Bupropion: Long-term (>6 month) quit rates vs. placebo
Pooled 36 studies
RR=1.69 (95% CI: )
Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD DOI: / CD pub3.
Hayden McRobbie 2014

35. Nortriptyline: Long-term (>6 month) quit rates vs. placebo
Pooled 6 studies
RR=2.03 (95% CI )
Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD DOI: / CD pub3.
Hayden McRobbie 2014

36. Varenicline Varenicline = partial agonist of the 42 nAchR
What to say to patients
Varenicline works by reducing craving for cigarettes making quitting smoking a little easier and increases the chances of stopping for good.
However it’s no magic cure and effort is still required.
Hayden McRobbie 2014

37. Varenicline: Long-term (>6 month) quit rates vs. placebo
Pooled 14 studies
RR=2.27 (95% CI )
Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD DOI: / CD pub6.
Hayden McRobbie 2014

38. Safety and side-effects
Nausea (30%) – mostly well tolerated
Strange dreams, headache, flatulence, and insomnia
Serious mood and cardiovascular adverse events
Facilitator: Hayden
Hayden McRobbie 2014

39. Cytisine Alkaloid from a plant Cytisus laburnum (also found in Kowhai)
Nicotine analogue, acting as a partial nicotinic acetylcholine receptor agonist (like Champix)
Cytisine has been used in Eastern European countries to help people stop smoking since the 1960’s.
Reduces tobacco withdrawal symptoms, making quitting easier
25 day treatment course
Very cheap
Hayden McRobbie 2014

40. Cytisine for smoking cessation
1310 smokers randomised to 25-day course of cytisine or NRT
Self-reported adverse events were more common in cytisine users (Incidence rate ratio=1.67, 95% CI , p<0.001), but were generally non-serious and self-limiting
RR = 1.30, (95% CI )
RR=1·43 (95% CI: 1·13 -1·80)
Walker et al IS CYTISINE AT LEAST AS EFFECTIVE AS NICOTINE REPLACEMENT THERAPY FOR SMOKING CESSATION? FINDINGS FROM A NON-INFERIORITY TRIAL
Hayden McRobbie 2014