Smoking and smoking cessation in the real world

1
Smoking and smoking cessation in the real world

• Robert West
• University College London
• Rio De Janeiro
• August 2007

2
Statement of competing interest

• I undertake research and consultancy for
  manufacturers of smoking cessation medications
• My research programme is mostly funded by Cancer
  Research UK

3
Outline

• The importance of collecting real world data
• monitoring population smoking and smoking
  cessation rates
• collecting data in the general population to help
  understand the quitting process
• finding out about the effectiveness of treatments
  in the real world
• The Smoking Toolkit Study
• smoking rates
• rates of quit attempts, aids to quitting and
  success rates
• use of NRT for cutting down and when cannot smoke
• The ATTEMPT cohort study
• the effect of NRT in the real world
• New developments in treating nicotine dependence
• new evidence on counselling by telephone
• varenicline
• better ways of using NRT
• the internet
• Conclusions

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Monitoring smoking and cessation rates

• The goal is to reduce smoking-related harm by
  reducing smoking prevalence
• A range of population level interventions could
  play a role in this
• measures to increase the price
• introducing smoking restrictions
• restricting marketing
• mass media campaigns
• promoting use of smoking cessation aids
• introducing new smoking cessation aids
• inducing clinicians to advise smokers to stop and
  offer support
• smoking-cessation events e.g. No Smoking Day
• We need to know how effective these are in order
  to shape future policy

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Collecting data to understand quitting

• Need to understand
• what underlies variations in smoking by social
  grade
• the role of motivation and nicotine dependence in
  the quitting process
• the link between smoking reduction and smoking
  cessation

6
Real world effectiveness of cessation aids

• Data from randomised controlled trials may not
  generalise because
• less supervision of use
• less motivated smokers
• more difficult cases, e.g. with psychological
  comorbidity

7
The Smoking Toolkit Study

• A series of national household surveys of
  representative samples of up to 2000 adults aged
  16 in England with a special focus the 500 who
  have smoked within the past year
• The focus of the questions is on smoking, smoking
  reduction and smoking cessation activities
• After each baseline survey, those who have smoked
  in the past year are followed up by postal
  surveys 3 months and 6 months later
• The study will continue for 5 years
• Data presented are from 17144 adults (4685 who
  had smoked in the past year) questioned from
  November 2006 to July 2007

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Smoking rates
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Monthly smoking rates
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Cessation rates by social grade
Note red bars show significant differences
across social grades blue bar shows no
difference. Elow paid manual, ABprofessional/man
agerial
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Monthly cessation rates
Note Blue bars show significantly elevated rates
compared with others
12
Use of cessation aids in the past year
13
Monthly use of NRT
Note No significant differences between months
14
Trying to reduce smoking
Note No significant differences between months
15
Use of NRT to help reduce
Note No significant differences between months
16
Use of NRT in when cannot smoke
Note No significant differences between months
17
Triggers for most recent quit attempt
18
Medication use as a function of other features of
quit attempts

• Data from November 2006 to March 2007 involved
  1072 quit attempts with relevant data
• Planned quit attempts were more likely to involve
  use of medication but unplanned attempts also
  involved use in many cases
• Quits that were triggered by advice from a health
  professional were more likely to involve use of
  medication but almost 40 did not use it

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Two important questions

• Q What are smokers intentions regarding
  quitting in relation to the Smokefree legislation
  to be implemented on July 1?
• A From 435 smokers in March 2007 survey 27
  plan to quit before the ban comes into force, 8
  when it comes into force and 65 have no definite
  plans
• Q What is the relationship between cutting down
  with and without use of NRT and motivation to
  stop smoking?
• A From 1328 smokers in October to November 2006
  surveys of those cutting down 62 had tried to
  stop in the past year versus 33 of those not
  cutting down in those using NRT to cut down 81
  had tried to stop in the past year compared with
  55 in those who did not use NRT

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ATTEMPT cohort study

• Funded by Sanofi-Aventis executed by RTI
• Smokers from 5 countries 35 to 65 years old,
  smoking ?5 cpd, intending to quit within the next
  3 months, recruited and surveyed by internet and
  followed up every 3 months1
• Samples selected smokers making a quit attempt
  in the first 3 month period without counselling,
  group support or bupropion and with complete data
• No differences on key variables between those
  followed up and those not followed up

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Analysis of NRT data

• Phase 1 sample 354 made a quit attempt in
  March-June 2003
• 124 used NRT
• 59 used other methods (hypnotherapy, acupuncture
  etc.)1
• Phase 2 sample 856 made a quit attempt in
  March-June 2004
• 254 used NRT
• 132 used other methods (hypnotherapy etc.)
• Covariate FTND (nicotine dependence)
• Outcome measure 6 months continuous abstinence

1included to assess effect of motivation to use
some form of aid
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NRT findings

• Sample 1
• NRT vs no NRT
• Odds ratio3.0, p0.02, adjusted risk
  difference6.2
• Used other methods vs did not use other methods
• Odds ratio0.8, p0.86
• Sample 2
• NRT versus no NRT
• Odds ratio2.1, p0.04, adjusted risk
  difference3.7
• Used other methods vs did not use other methods
• Odds ratio1.6, p0.27

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Effect of telephone counselling
Cochrane review gt6 month cessation not validated
24
Effect of tailored internet support
Not biochemically verified
25
Effect of NRT
Cochrane LI Low intensity behavioural support
HI High intensity behavioural support RTS
Reduce To Stop Combination various combinations
versus single NRT types Population NRT versus
no NRT in population samples without behavioural
support (ATTEMPT cohort study, not RCT)
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Effect of nortriptyline, bupropion and varenicline
For bupropion and nortriptyline data from
Cochrane 6 months continuous abstinence and
biochemical verification varenicline 6 month
continuous abstinence data from JAMA 2006 blue
shading shows effect on 12 month continuous
abstinence rates of further 12w varenicline vs
placebo in smokers abstinence at 12w
27
The goal
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Conclusions

• The goal is to get every smoker to make at least
  one meaningful quit attempt every year and use
  the best available method each time
• In England almost half of smokers try to quit
  each year and approximately half use effective
  aids, mostly NRT bought over the counter
• NRT bought over the counter is effective in the
  real world
• Poorer smokers try just as often to stop smoking
  but find it more difficult
• Approximately 1 in 7 smokers in England use NRT
  to help them cut down or in situations when they
  cannot smoke the most popular form is the patch
• Smokers who try to cut down are also more likely
  to try to stop
• Telephone counselling and the internet can help
  smokers stop
• The biggest event in promoting cessation seems to
  be the New Year