Combating%20Tobacco%20Smoking

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Combating Tobacco Smoking

• Ann McNeill, PhD
• Honorary Senior Lecturer
• Independent consultant in public health

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Sources

• www.treatobacco.net
• www.ash.org.uk

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A resource
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Global smoking

• There are an estimated 1.1 billion smokers
  worldwide, representing about a third of the
  adult global population
• 800m in developing countries and most of these
  are men (700m)
• In China there are about 300m smokers

5
World cigarette production
Source US Department of Agriculture
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Who smokes?
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Smoking since 1948
8
Smoking and deprivation
UK CIGARETTE SMOKING BY DEPRIVATION
80
70
60
prevalence
1973
50
40
1996
30
20
10
0
0
1
2
3
4
5
Poorest
Most affluent
DEPRIVATION SCORE
Jarvis (1997)
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UK Smoking Summary

• 28 men, 28 women smoked in 1996, decline in
  adults plateauing, possibly increasing again
• No changes in young peoples smoking
• No changes in pregnant womens smoking
• Large socioeconomic differences

11
Some impacts - Health

• Of those who smoke regularly, around one half
  will die prematurely
• Smoking caused 120,000 deaths in UK in 1995
• Smoking related diseases cost the NHS approx 1.5
  billion a year in England

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Some impacts - Health

• Cancer
• Heart Circulation
• Respiratory
• 20 fatal illnesses
• 50 non-fatal illnesses
• Widespread addiction

13
Health Impacts - Passive Smoking

• Harm to others -
• 600 cases of Lung cancer
• 12,000 cases of heart disease
• Trigger to 3.4 million asthma sufferers
• Pregnancy complications and cot death
• 17,000 hospital cases per year in under-5s
• 3 million non smokers work in smokey conditions

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Cigarettes are among the leading causes of death
in the United States
87
82
18
40
(under 65)
21
(all ages)
33
10
Source 1989 Surgeon General's Report. Data from
USA.
15
Annual Deaths from Smoking Compared with Selected
Other Causes in the United States
Sources (AIDS) HIV/AIDS Surveillance Report,
1998 (Alcohol) McGinnis MJ, Foege WH. Review
Actual Causes of Death in the United States.JAMA
19932702207-12 (Motor vehicle) National
Highway Transportation Safety Administration,
1998 (Homicide, Suicide) NCHS, vital statistics,
1997 (Drug Induced) NCHS, vital statistics,
1996 (Smoking) SAMMEC, 1995
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Why do people smoke?

• The tobacco industry
• Most smoke because they are addicted to nicotine
  (affects nearly every organ)
• Recent expert reports show that tobacco delivered
  nicotine is as addictive as heroin, cocaine etc
• Most smokers want to quit but cannot

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Key Findings

• Tobacco dependence withdrawal syndromes
  classified as substance use disorders under WHO
  ICD 10
• Nicotine dependence withdrawal classified
  similarly under APA DSM IV
• More common general term is addiction

18

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Rapid absorption of nicotine reinforces smoking
behaviour
Why it is so hard to stop smoking
Plasma nicotine (mg/mL)
Time after smoking a cigarette (mins)
1. Royal College of Physicians, 2000.
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The power of addiction
Why it is so hard to stop smoking
All smokers
70 want to stop1
23 succeed in stopping each year3
30 try each year2
1. Bridgwood et al., 2000. 2. West, 1997. 3.
Arnsten, 1996.
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Addiction

• The cigarette should be conceived not as a
  product but as a package. The product is
  nicotine.Think of the cigarette pack as a
  storage container for a days supply of
  nicotine.Think of a cigarette as a dispenser for
  a dose unit of nicotine. Think of a puff of smoke
  as the vehicle of nicotine.
• Smoke is beyond question the most optimised
  vehicle of nicotine and the cigarette the most
  optimised dispenser of smoke.
• Philip Morris 1972

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Reducing this public health burden

• Preventing young people taking up smoking
  (prevention)
• Encouraging smokers to stop (cessation)
• Harm reduction approaches

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Age at which smokers start
US data 1991, Institute of Medicine
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Unless Current Smokers Quit, Tobacco Deaths will
Rise Dramatically in the Next 50 years Estimated
cumulative tobacco deaths 1950-2050 with
different intervention strategies
Tobacco deaths (millions)
0
World Bank. Curbing the epidemic Governments and
the economics of tobacco control. World Bank
Publications, 1999. p80.
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Interventions

• School health education
• Restricting sales to minors
• Advertising bans
• Price rises
• No smoking policies
• Media community-wide campaigns
• Cessation interventions
• Product modification

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Assessing interventions

• Efficacy
• Effectiveness
• Reach
• Cost-effectiveness

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Smoking Kills A White Paper on Tobacco

• To reduce smoking among children young people
• To help adults, especially the most
  disadvantaged, to give up
• To offer particular help to pregnant women who
  smoke
• (Lack of harm reduction apps)

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Targets

• To reduce smoking among children from 13 to 9
  by 2010 (2005 -11)
• To reduce adult smoking from 28 to 24 by 2010
  (2005 - 26)
• To reduce smoking among pregnant women from 23
  to 15 by 2010 (2005 - 18)

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Prevention

• Why do young people smoke?
• sociodemographic variables
• peer sibling smoking
• parental smoking support
• low academic achievement, alienation
• rebelliousness
• lack skills to resist offers, low self-esteem

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Prevention

• Why do young people smoke?
• Many young smokers are already dependent on
  nicotine
• They want to stop, have tried and failed
• They inhale and take in substantial doses of
  nicotine from their cigs
• Experimenters highly likely to become regular
  daily smokers

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Prevention

• Unanswered questions
• is there a minimum dosage of nicotine necessary
• is daily use a prerequisite to dependence
• are there gender/ethnic differences
• are there genetic factors involved

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Prevention

• School programmes
• health hazards did not affect smoking
• social learning theory based programmes delay
  onset for 4-10 years
• when programmes implemented in real life they
  have been shown to be ineffective
• comprehensive programmes dealing with range of
  health issues may be gt effective

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Prevention

• Restricting sales to minors
• laws rarely enforced - v expensive
• young people still easily buy tobacco
• evasion rife - ID card forgery, asking others to
  buy for them
• a few intensive campaigns have worked, but divert
  attention from tobacco industry to
  retailers/children drugs field shows inadequacy
  of supply issues

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Illegal sales recommendations

• Unpaid media to encourage retailers to comply
  with the law
• Work with magistrates to encourage higher fines
• Restrict retail outlets for tobacco?
• Fine the industry rather than retailers for
  illegal sales

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Advertising bans

• Total ban on advertising, sponsorship, promotion
  is necessary
• Tobacco industry circumvent partial bans
• Some evidence that advertising bans reduce young
  peoples smoking
• Govt reported showed advertising bans reduce
  cigarette consumption

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How it works - part 1
Younger adult smokers are the only source of
replacement smokers... If younger adults turn
away from smoking, the industry must decline,
just as a population which does not give birth
will eventually dwindle. (RJ Reynolds, 1984)
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How it works - part 2
A cigarette for the beginner is a symbolic act. I
am no longer my mother's child, I'm tough, I am
an adventurer, I'm not square As the force
from the psychological symbolism subsides, the
pharmacological effect takes over to sustain the
habit. (Philip Morris,1969)
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Examples of Marketing
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Examples of Marketing
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Appeal to kids
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Tobacco sponsorship
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Advertising bans

• EU Directive adopted on 22 June 1998 struck down
  by European Court of Justice
• UK enacting own ban following a private members
  bill which is currently going through the Houses
  of Parliament

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Taxation

• Price inversely related to consumption
• May have an influence on young peoples smoking
• UK has high tax policy
• Goal - balance this with real support for those
  wanting to quit - hypothecation?

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Price of 20 cigarettes in 2000
Price 4.14
Taxes 3.34
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Affordability of cigarettes
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EU tobacco taxation
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Smuggling

• Increased from 3 96/97 to 22 2000
• 80 containers, 20 white van
• Loss to revenue 3.8 bn
• 35m over three years to combat tobacco smuggling
• Extra customs officers
• Tougher penalites

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Responses - Smuggling

• Treat Smuggling as a criminal activity
• Big Tobacco benefits from smuggling
• Canadian Government is suing RJ Reynolds
• The DTI is investigating BAT

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No smoking policies

• Growing evidence of effectiveness of workplace
  bans
• Reduces passive smoking exposure
• Associated with increases in productivity

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UK approach

• Voluntary action preferred over legislation
• Public places charter developed with the
  hospitality industry, problem pubs
• Approved Code of Practice (legal guidance for
  workplaces) stalled
• Opposition DTI DCMS

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Public places charter
The signatories to this Charter recognise that
non-smoking is the general norm and that there
should be increasing provision of facilities for
non- smokers and the availability of clean air.
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Workplaces with Smoking Policies (1995)
80 target
Source NOP (1996) Smoking in public places 2nd
survey report
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Approved Code of Practice

• ACoP is quasi-legal like Highway Code
• Gives meaning to Health Safety at Work Act
• Employers must take all reasonable and
  practicable steps to reduce or eliminate passive
  smoking exposure
• Presumption in favour of banning smoking

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Mass media community campaigns

• Effective in reducing adult smoking
• Model combination of both
• Little effect with teenage smoking behaviour
• Expensive
• Unpaid publicity media advocacy gt cost-effective

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Mass media community campaigns

• 50m over 3 years for public education
• Priority groups - young people, adults who want
  to quit, pregnant women
• National media activity
• Local involvement

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Health Benefits of Smoking Cessation

• Major immediate health benefits for men and
  women of all ages whether or not they have
  smoking-related diseases
• Former smokers live longer than continuing
  smokers
• Decreases risk of lung other cancers, heart
  attack, stroke, COPD can affect reproductive
  outcomes

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Cessation interventions

• Not routine - in spite of supporting evidence
• Advice on smoking given to
• only 29 of smokers by GP (HEA, 1995)
• only 39 of pregnant smokers (HEA, 1996)

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Smoking cessation guidelines

• Based on evidence from
• AHCPR Guidelines
• Cochrane Centre Reviews
• Evidence based evidence
• Peer-reviewed and professionally endorsed

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Smoking cessation guidelines

• Raw M, McNeill A, West R. Smoking Cessation
  Guidelines for Health Professionals. Thorax,
  1998 53 (Suppl 5, Part 1) S1-S19
• West R, McNeill A, Raw M. Smoking cessation
  guidelines for health professionals an update.
  Thorax, 2000 55 987-999.

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Brief opportunistic advice
Brief advice from a primary care physician during
a routine consultation is effective in increasing
the number of smokers stopping for at least 6
months
West R, McNeill A and Raw M. Thorax 2000 55
987-999. Silagy C. Physician advice for smoking
cessation. Cochrane Database Syst Rev 2002 1.
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Brief opportunistic advice

• May trigger quit attempt in 40 of cases
• Reduced effect with repeated exposure
• Minimal effect on heavy smokers in absence of
  NRT/bupropion or beh suppt
• GPs prefer to give to patients with
  smoking-related diseases but no greater in effect
  in this group

West R, McNeill A and Raw M. Thorax 2000 55
987-999.
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Face-to-face behaviouralsupport

• Behavioural support with multiple sessions of
  individual or group counselling aids smoking
  cessation,
• Dose-response relationship between the amount of
  therapist-client contact and successful cessation

West R, McNeill A and Raw M. Thorax 2000 55
987-999. USDHHS. Treating Tobacco use and
dependence. A clinical practice guideline.
Rockville, MD AHQR 2000. Lancaster T, Stead LF.
Individual behavioural counselling for smoking
cessation. Cochrane Database Syst Rev 2002 1.
Stead LF, Lancaster T. Group therapy for smoking
cessation. Cochrane Database Syst Rev 2002 1.
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Face-to-face behaviouralsupport
West R, McNeill A and Raw M. Thorax 2000 55
987-999. USDHHS. Treating Tobacco use and
dependence. A clinical practice guideline.
Rockville, MD AHQR 2000.
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Effect of smokers clinic
Expected effect combining effect of medication
with effect of behavioural support
West R, McNeill A and Raw M. Thorax 2000 55
987-999.
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Face-to-face behaviouralsupport

• Nurses can be effective where trained and
  employed for the purpose1
• Specialist counselling for pregnant smokers is
  effective but brief midwife delivered advice
  probably is not2
• There has been limited research on support for
  adolescent smokers, and no clear evidence2

1. Rice VH, Stead LF. Cochrane Database Syst Rev
2002 1. 2. West R, McNeill A and Raw M. Thorax
2000 55 987-999.
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Self-help interventions
Generic self-help interventions provided without
personal support have a small effect on quit
rates. Their impact is smaller and less certain
than face-to-face interventions
Lancaster T, Stead LF. Self-help interventions
for smoking cessation. Cochrane Database Syst Rev
2002 1. West R, McNeill A and Raw M. Thorax
2000 55 987-999.
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Tailored vs. generic behavioural support material
There is some evidence that self-help materials
tailored for the needs of individual smokers are
more effective than standard materials
Abstinent at 4 months
Strecher VJ. Patient Educ Couns 1999 36
107-117. Strecher VJ, et al. Journal of Family
Practice 1994 39(3) 262270.
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Other support
Telephone calls from a counsellor may be more
effective than self-help materials alone
West R, McNeill A and Raw M. Thorax 2000 55
987-999. USDHHS. Treating Tobacco use and
dependence. A clinical practice guideline.
Rockville, MD AHQR 2000.
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Nicotine replacement therapy

• Nicotine replacement therapy (NRT) can be used
  instead of tobacco to aid quitting
• NRT delivers nicotine without toxins from tobacco
• NRT helps combat symptoms of withdrawal
• Nicotine dose from NRT is lower administered
  more gradually than with smoking and this reduces
  the addictive potential

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Nicotine Replacement Therapy

• Effectiveness of NRT does not depend on the
  amount of face-to-face behavioural support
• All forms NRT appear to be similarly effective
• Choice may be based on susceptibility to side
  effects, patient preference and availability
• There is evidence that heavy smokers are more
  successful on 4mg than 2mg nicotine gum

West R, McNeill A and Raw M. Thorax 2000 55
987-999. Silagy C, et al. Cochrane Database Syst
Rev 2002 1. USDHHS. Treating Tobacco use and
dependence. A clinical practice guideline.
Rockville, MD AHQR 2000.
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Nicotine Replacement Therapy

• There has been little research on combinations of
  different types of NRT
• There is limited evidence that adding another
  form of NRT to the nicotine patch increases
  success rates

West R, McNeill A and Raw M. Thorax 2000 55
987-999. Silagy C, et al. Nicotine replacement
therapy for smoking cessation. Cochrane Database
Syst Rev 2002 1. USDHHS. Treating Tobacco use
and dependence. A clinical practice guideline.
Rockville, MD AHQR 2000.
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Plasma nicotine concentrations for smoking and NRT
14
12
10
8
Increase in nicotine concentration ( ng/ml )
Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal
spray Patch
6
4
2
0
5 10 15 20 25 30
Minutes
Source Balfour DJ Fagerström KO. Pharmacol
Ther 1996 7251-81.
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NRT with limitedbehavioural support
West R, McNeill A and Raw M. Thorax 2000 55
987-999. Silagy C, et al. Nicotine replacement
therapy for smoking cessation. Cochrane Database
Syst Rev 2002 1.
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NRT with intensive support
West R, McNeill A and Raw M. Thorax 2000 55
987-999. Silagy C, et al. Nicotine replacement
therapy for smoking cessation. Cochrane Database
Syst Rev 2002 1.
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The effectiveness of smoking cessation in primary
care
Importance of primary care
Intensive service with NRT
20
15
Brief advice with NRT
Cessation rates ()
10
Brief advice
No action
5
0
Conservative figures absolute cessation rates,
CO validated not one puff throughout one year
Reproduced and adapted with kind permission of
Gay Sutherland and John Stapleton of the Maudsley
Hospital Smoking Cessation Clinic and the
Institute of Psychiatry.
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Pharmacotherapy
Bupropion HCl SR acts on the neurotransmitters
involved innicotine addiction
Modifies dopaminereleasein reward pathway
(mesolimbic system)
Alters noradrenergic activityin
withdrawalpathway(locus coeruleus)
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Bupropion

• Bupropion is an effective aid to smoking
  cessation

West R, McNeill A and Raw M. Thorax 2000 55
987-999. Hughes JR, et al. Antidepressants for
smoking cessation. Cochrane Database Syst Rev
2000 4.
79
Bupropion

• Limited evidence from a single trial that
  bupropion is more effective than nicotine patch
  alone, and that a combination of bupropion and
  the patch is more effective than nicotine patch
  alone.

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Contraindications to bupropion HCl SR
Pharmacotherapy

• Hypersensitivity to bupropion / excipients
• Current/previous seizure or eating disorder
• Known CNS tumour
• Abrupt withdrawal from alcohol or benzodiazepines
• Severe hepatic cirrhosis
• Concomitant use with MAOIs
• History of bipolar disorder

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Acupuncture and Hypnotherapy

• Acupuncture and hypnotherapy have not been shown
  to aid smoking cessation over and above any
  placebo effect

White AR, et al. Acupuncture for smoking
cessation. Cochrane Database Syst Rev 2002 1.
Abbot NC, et al. Hypnotherapy for smoking
cessation. Cochrane Database Syst Rev 2002 1.
USDHHS. Treating Tobacco use and dependence. A
clinical practice guideline. Rockville, MD AHQR
2000.
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Cost-effectiveness of smoking cessation

• Effect on other expenditures arising from the
  consequences of smoking
• 87 with heart attack risk over 3 (the risk
  threshold used in Sheffield tables) are smokers
• Stopping smoking would reduce the risk to below
  the threshold for statins prescribing for most
  patients

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Cost effectiveness comparisons

• Smoking cessation lt 1,000
• Statins 6,000-13,000
• Benchmark 30,000?

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NICE

• Acknowledged the cost-effectiveness of smoking
  cessation
• NRT and bupropion should be recommended for
  smokers who have expressed a desire to quit
  smoking

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Assuming we meet our targets

• Reduce smoking rates among manual groups from 32
  (1998) to 26 (2010)
• This would still leave millions of smokers
• Highly likely that prevalence would not decrease
  uniformly and that smoking prevalence would
  remain very high in most deprived groups

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Assuming we meet our targets

• High prevalence among specific groups such as
  psychiatric populations, prison populations
• Health effects of active smoking, passive smoking
  effects, role models..
• Still not offering a less harmful alternative for
  those that cannot or will not stop

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What would a harm reduction policy look like?

• Cigarette dirty syringe
• Focus on less harmful ways of using nicotine
• make cigarettes less harmful
• broaden access to NRT products
• encouraging other forms of tobacco use which may
  be less harmful
• encouraging other less harmful forms of nicotine
  delivery

89
Controversies?

• Could it increase overall (population) harm?
• If it dissuaded some smokers from quitting
• If it attracted non-smokers?
• If it encouraged ex-smokers to relapse
• But can we deny individuals the right to use a
  less harmful product?

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Harm reduction approaches

• Low priority
• Main changes last century were introduction of
  filters low tar cigarettes
• Danger - some have argued that consumption would
  be lower today if these products had not been
  introduced

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Harm reduction approaches

• Smokers compensate to maintain their nicotine
  levels
• Tobacco industry exploited low tar by marketing
  as light, mild etc

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Harm reduction approaches

• Could cigarettes be made less harmful?
• Knowledge largely rests with tobacco industry
• Cigarette is highly technical engineered product
• But if effective, product modification would be
  beneficial to those who cannot stop ( improve
  inequalities) could have beneficial
  internationally

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Harm reduction approaches

• Happening anyway - tobacco industry introducing
  new nicotine delivery devices
• Smokeless tobacco - less harmful, but banned
  throughout EU except Sweden

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Harm reduction approaches

• Least harmful, most beneficial products most
  stringently regulated
• Most toxic, lethal products (cigarettes) are
  hardly regulated at all
• Regulation is upside down

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NRT Regulation Critiques

• McNeill A, Foulds J, Bates C (2001) Regulation of
  nicotine replacement therapies (NRT) a critique
  of current practice. Addiction, 96 1757-68.
• McNeill A, Hendrie A (2001) Regulation of
  nicotine therapies an expert consensus. WHO
  European Partnership Project, WHO Europe.

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NRT Regulation Critiques

• Pregnancy advice
• Age restrictions
• Smokers with cardiovascular disease
• Use of NRT to reduce and control cigarette
  consumption
• Use of NRT to support temporary abstinence
• Reducing smoke intake from tobacco by allowing
  concomitant NRT use and smoking

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NRT Regulation Critiques

• Use for long-term maintenance
• NRT combinations
• Wider availability of NRT products
• Possibility of tobacco competitive nicotine
  delivery devices for recreational use

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NRT Regulation Critiques

• Framework in which NRT is regulated
• does not properly weigh the risks and benefits
  of NRT use in situations in which its use is
  qualified, restricted or contraindicated
• considers the risk of the medication but not the
  risks of failure to stop smoking

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