Smoking cessation

1. Smoking cessation

2. How do we stop people from smoking? Population measures

3. The 5 basic ways to help smokers quitSchroeder AS. JAMA 2005;294:482-7 Increase the price of cigarettes Prohibit smoking in public places Create and disseminate effective counter marketing messages about smoking (media, pack displays) Ban tobacco advertising and promotion Provide cessation aids Counselling / Behavioural therapy Pharmacotherapy NRT Bupropion Varenicline Nortriptyline, Clonidine

4. How do you stop people smoking? Changing behaviour

5. Changing behaviour"Giving up smoking is easy: I've done it a hundred times�Mark Twain Most smokers want to stop 90% of the practice populations will visit the surgery during a three-year period (and more will see other health professionals) This provides a good opportunity to change behaviour� Theories of behaviour change: - Health Belief Model (Becker, 1974) - Theory of Reasoned Action (Ajzen & Fishbein 1980) - Stages of Change (Prochaska & DiClemente 1984) - Catastrophe pathway (West & Sohal, 2006)

7. Summary: Changing behaviour Most smokers want to quit, but changing behaviour is difficult People need to recognise that their health is threatened, and that the benefits of giving up outweigh the benefits they obtain from smoking (Health Belief Model) Intention to change behaviour is influenced by personal attitudes and by the behaviour and attitudes of people around them (Theory of Reasoned Action and Planned Behaviour) Smokers go through a series of distinct phases in their attitudes towards smoking cessation (�Stages of Change� model) Many people get to the stage of wanting to quit without formal planning of their quit date � responding to immediate needs (e.g. by providing NRT and/or behavioural support) may be appropriate (Catastrophe Model)

8. Public Health Intervention Guidance 1NICE March 2006. Brief Interventions and referral for smoking cessation in primary care and other settings  Everyone who smokes should be advised to quit Advice to stop smoking should be sensitive to the individual�s preferences, needs and circumstances Those who want to stop should be offered a referral to an intensive support service The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year

9. �Hard to reach� and �high smoking prevalence� groups NICE Public Health Guidance 10. Smoking Cessation Services February 2008 Managers and providers of NHS Stop Smoking Services should ensure services are responsive to the needs of people who smoke from minority ethnic and disadvantaged communities Consider developing links with local community groups Wherever possible provide people with advice, counselling and support in their first language

10. Smoking cessation servicesNICE Public Health Guidance 10. Smoking Cessation Services February 2008 Interventions proven to be effective for smoking cessation: Brief interventions Individual behavioural counselling Group behaviour therapy Pharmacotherapies Self-help materials Telephone counselling and quitlines Mass media campaigns

11. Smoking cessation: PharmacotherapyNICE Public Health Guidance 10. Smoking Cessation Services February 2008 Nicotine replacement therapy (NRT), bupropion and varenicline can be used to help people quit smoking All pharmacotherapy options can be offered to smokers with cardiovascular or respiratory disease, according to clinical judgement Neither varenicline or bupropion should be offered to people under 18 years nor to pregnant or breastfeeding women Normally treatment should only be prescribed as part of an abstinent-contingent treatment (ACT), in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date)

12. Smoking cessation: PharmacotherapyNICE Public Health Guidance 10. Smoking Cessation Services February 2008 Initial prescription should be sufficient to last only until 2 weeks after the target stop date (normally 2 weeks of NRT, and 3-4 weeks of varenicline or bupropion therapy) Second prescriptions only given if demonstrated that quit attempt is continuing on re-assessment If a smoker�s attempt to quit is unsuccessful with treatment using either NRT, varenicline or bupropion, the NHS should normally fund no further attempts within 6 months, unless special circumstances hampered the initial attempt � �

13. Smoking cessation: PharmacotherapyNICE Public Health Guidance 10. Smoking Cessation Services February 2008 Do not offer NRT, varenicline or bupropion in any combination There is insufficient evidence to conclude that one form of NRT is more effective than another Combinations of NRT patches and other fast release formulations such as gum can be considered for people with high level of dependence, or have found single forms inadequate People receiving pharmacotherapy should also be offered advice encouragement and support, including referral to NHS Stop Smoking Service

14. What about combinations of NRT?NRT: MHRA Q&A document December 2005  And agreement from NICE �� NICE Public Health Guidance 10. Smoking Cessation Services February 2008

15. �Nicotine Assisted Reduction to Stop� (NARS)NICE Public Health Guidance 10. Smoking Cessation Services February 2008 Smokers who want to stop smoking but not immediately can consider NRT to help them to cut down with a view to stopping at a later date NICE state this strategy should only be used if part of a properly designed and conducted research study for people who have failed repeatedly to quit smoking abruptly Suggested reduction programme from CKS Smoking Cessation 2006:

16. CSM advice for bupropionCSM 2002 CSM advice (bupropion). The CSM has issued a reminder that bupropion is contra-indicated in patients with a history of seizures or of eating disorders, a CNS tumour, or who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal. Bupropion should not be prescribed to patients with other risk factors for seizures unless the potential benefit of smoking cessation clearly outweighs the risk. Factors that increase the risk of seizures include concomitant administration of drugs that can lower the seizure threshold (e.g. antidepressants, antimalarials [such as mefloquine and chloroquine], antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids, theophylline, tramadol), alcohol abuse, history of head trauma, diabetes, and use of stimulants and anorectics.

17. Europe-wide review recommends updates to product information for varenicline?MHRA December 2007 Doctors are already aware of the risk of using Champix in patients who have an underlying mental illness. They also need to be aware of the possibility that patients who are trying to stop smoking can develop symptoms of depression, and they should advise their patients accordingly Patients who are taking Champix and develop suicidal thoughts should stop their treatment and contact their doctor immediately

18. KEY POINTS Smoking cessation

19. Pharmacotherapy � Key points Pharmacotherapy e.g. NRT/ bupropion/ varenicline, can be prescribed, if appropriate, by trained professionals but are most effective when used with other forms of support Abrupt smoking cessation is desirable, however a NARS strategy with NRT can be considered for those who are unwilling or unable to stop completely, if part of a research study Safety and efficacy data for bupropion and varenicline are limited NRT is a less harmful alternative to smoking and, where non-drug approaches alone are not sufficient, can now be considered for adolescents, women who are pregnant or breastfeeding

20. Smoking cessation � Key points Advising and effectively assisting a person to stop smoking is the single most important thing that can be done for their health All health professionals should take the opportunity to advise smokers to stop smoking, and consider referral to the NHS Stop Smoking Service