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
 Overview & Learning Objectives
1. Tobacco Dependence and Withdrawal
Students will be able to articulate the reasons why people smoke and find it
difficult to quit
2. Behavioural interventions for smoking cessation
Students will be able to describe evidence based behavioural treatments
3. Pharmacological interventions for smoking cessation
Students will be able to describe evidence based pharmacological treatments
4. 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
5. 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

TOBACCO DEPENDENCE AND
WITHDRAWAL
Nicotine
 Mesolimbic dopamine pathway

positive
Increase in
reinforcement dopamine

Binds to
nACh receptors

nicotine

Hayden McRobbie 2014

 Tobacco withdrawal syndrome

Signs & symptoms Duration Prevalence

Irritability < 4 weeks 50%
Depression < 4 weeks 60%
Restlessness < 4 weeks 60%
Poor concentration < 2 weeks 60%
Increased appetite > 10 weeks 70%
Sleep disturbance < 1 week 25%
Urges to smoke > 2 weeks 70%
Mouth Ulcers > 4 weeks 40%
Constipation >4 weeks 17%

Hayden McRobbie 2014

SMOKING CESSATION
 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

 Smokers die early
21st century hazards of smoking and benets of stopping:... http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547248/?rep...

Figure 5

All-cause mortality: Illustration of the effects of a 3-fold difference in annual death rates on mortality
from age 35 years to age 80 years
Pirie et al Lancet. 2013 Jan 12;381(9861):133-41
This hypothetical example takes age-specific death rates in non-smokers to be two-thirds of the UK 2010
Hayden McRobbie 2014
Quitting Works

Hayden McRobbie 2014

 The quitting process
Individual and Environment
Comorbidity
Degree of Dependence
Genetic
Social factors

Smoking Quit Attempt Abstinence

Tobacco Control
Policies

Brief Interventions Smoking Cessation

(e.g. AB+offer of C) Treatments

Adapted from: Hughes Drug and alcohol

dependence 117.2 (2011): 111-117. Hayden McRobbie 2014
 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

McRobbie et al NZMJ 20 June 2008, Vol 121 No 1276

URL: http://www.nzma.org.nz/journal/121-1276/3117/ Hayden McRobbie 2014
THE IMPORTANCE OF BRIEF
INTERVENTIONS
Making a quit attempt

Tensions and triggers

Tension
Price
Health concerns
Triggers
Sudden illness
Price rise
Advice from a health
professional

Hayden McRobbie 2014

Remaining Quit

Treatment
Behavioural support
Pharmacotherapy
Supportive
environment

Hayden McRobbie 2014

 Healthcare Professionals Role

Health care professionals can increase a

patients odds of quitting with brief advice,
medication, and behavioural support 1
Tasks
1.Identifying people who smoke
2.Motivating a quit attempt
3.Refer for treatment and support
4.Supporting ongoing abstinence

AVEYARD P. & WEST R (2007) Managing smoking cessation, BMJ, 335, 37-41.
Hayden McRobbie 2014
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 2013. Physician advice for smoking

cessation. Cochrane Database of Systematic Reviews.
CD: 000165
 Advice from a Health Professional is
the major external trigger
Health Prof advice
Something said by family/friends
Someone else stopping
Smoking restrictions
NRT ad
Gov ad
Health warning
Just decided
New treatment

0 5 10 15 20 25
Per cent
Source: www.rjwest.co.uk - Smoking Toolkit Study
Hayden McRobbie 2014
 And its the offer of support thats
important
p<0.001
60 N=11,119

50

40
Percent tried to quit

30

20

10

0
Not seen GP Seen GP but not Advised but not Offered help
advised offered

Source: www.rjwest.co.uk - Smoking Toolkit Study

Hayden McRobbie 2014
Not advising may be worse than useless
2
N=12,221
1.8
Odds ratio for having quit

1.6
1.4 p<0.05
1.2 p<0.05
1
0.8 Not seen GP Seen GP but not Advised but not Offered help
advised offered
0.6
0.4
0.2
0
Results of multiple logistic regression adjusting for age, sex
and social grade

Source: www.rjwest.co.uk - Smoking Toolkit Study

Hayden McRobbie 2014
You dont need to assess readiness to quit
100
90 Total N=2168
80 89
70
% of smokers

% of total
60
50 Accepted treatment
40
52
Abstinent at end of
30 37 treatment (17 weeks)
20 27 24
10
0
11
Ready to quit Not ready to quit

PISINGER et al (2005) Prev Med, 40: 278-284

Hayden McRobbie 2014
SMOKING CESSATION TOOLS
 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

 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

 Long-term outcomes
Varenicline + support
Nortriptyline + support
Bupropion + support
NRT + support
Group support
Individual support
Telephone support
Text support
Unassisted

0% 5% 10% 15% 20% 25% 30%

Placebo/Control Active Treatment

Source: New Zealand Guidelines for Helping People Stop Smoking

Hayden McRobbie 2014
PHARMACOLOGICAL INTERVENTIONS
FOR SMOKING CESSATION
Nicotine replacement therapy

Increase in
dopamine

Binds to
nACh receptors

Nicotine +++ Nicotine +

 Nicotine Delivery

Source: Royal College of Physicians

Hayden McRobbie 2014
 NRT: Long-term (>6 month) quit rates
vs. placebo
20%
Pooled 150 studies
RR=1.60 (95% CI: 1.53 - 1.68)
15%

NRT
10%
17% Placebo
10%
5%

0%

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.: CD000146. DOI:
10.1002/14651858.CD000146.pub4.
Hayden McRobbie 2014
 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

Hayden McRobbie 2014

 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

 Bupropion

Atypical antidepressant which

acts on dopamine and
noradrenaline pathways and
possibly as a nicotinic
antagonist, designed to reduce
motivation to smoke by What to say to your patients?

reducing cravings and Works by alleviating

craving and other
withdrawal symptoms withdrawal symptoms

reducing the rewarding effect Its not a magic cure, but it

of smoking will make quitting easier

Hayden McRobbie 2014

 Bupropion: Long-term (>6 month) quit
rates vs. placebo
20%
Pooled 36 studies
RR=1.69 (95% CI:1.53-1.85)
15%

Bupropion
10% 19%
Placebo
11%
5%

0%

Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic
Reviews 2007, Issue 1. Art. No.: CD000031. DOI: 10.1002/14651858.CD000031.pub3. Hayden McRobbie 2014
 Nortriptyline: Long-term (>6 month)
quit rates vs. placebo
25%
Pooled 6 studies
RR=2.03 (95% CI 1.48 - 2.78)
20%

15%
Nortriptyline
10% 20% Placebo

5% 10%
0%

Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews
2007, Issue 1. Art. No.: CD000031. DOI: 10.1002/14651858.CD000031.pub3. Hayden McRobbie 2014
Varenicline
Varenicline = partial
agonist of the 42
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 its no magic
cure and effort is still
required.

Hayden McRobbie 2014

 Varenicline: Long-term (>6 month) quit
rates vs. placebo
30%
Pooled 14 studies
25% RR=2.27 (95% CI 2.02 - 2.55)

20%
Varenicline
15% 28%
Placebo
10%

5% 12%
0%

Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database
of Systematic Reviews 2012, Issue 4. Art. No.: CD006103. DOI: 10.1002/14651858.CD006103.pub6. Hayden McRobbie 2014
 Safety and side-effects
Side effects
Nausea (30%) mostly well tolerated
Strange dreams, headache, flatulence, and
insomnia
Serious mood and cardiovascular adverse events

Hayden McRobbie 2014

 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 1960s.
Reduces tobacco withdrawal symptoms, making
quitting easier
25 day treatment course
Very cheap

Hayden McRobbie 2014

 Cytisine for smoking cessation

1310 smokers 45
RR = 1.30, (95% CI 1.12-1.51)
randomised to 25- 40

Continuous abstinence (%)

day course of
35
cytisine or NRT
30
Self-reported
adverse events 25 RR=143 (95% CI: 113 -180)
were more common 20
in cytisine users 15
(Incidence rate
10
ratio=1.67, 95% CI
1.38-2.01, p<0.001), 5
but were generally 0
non-serious and 1 month 6 months
self-limiting Cytisine NRT

Walker et al 2014. IS CYTISINE AT LEAST AS EFFECTIVE

AS NICOTINE REPLACEMENT THERAPY FOR SMOKING
CESSATION? FINDINGS FROM A NON-INFERIORITY TRIAL
Hayden McRobbie 2014