Primary Care Smoking Cessation Dr John McMenamin GP and Clinical Director WRPHO Primary Care Advisor MOH Tobacco Team Target Champion Primary Care Tobacco
Target or Tickbox? The Tobacco health target: 90% smokers attending practices given brief advice each year What s our role?
Tobacco use is the leading cause of preventable death in New Zealand, accounting for around 4300 to 4600 deaths per year. 1 Half of the people who smoke today and continue smoking will eventually be killed by tobacco. 2 Half of them will die in middle age. 3 Smoking causes one in four of all cancer deaths in New Zealand. 8 1 Peto, R., Lopez, A., et al. (2000). Mortality from Smoking in Developed Countries 1950 2000: Indirect estimates from national vital statistics. New York: Oxford University Press. 2 World Health Organization. Why is tobacco a public health priority? Tobacco Free Initiative. http://www.who.int/tobacco/health_priority/en/print.html. 8 Laugesen, M. (2000). Tobacco Statistics 2000. Wellington: Cancer Society of New Zealand. 471-4
Smokers die early The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK Lancet. 2013 January 12; 381(9861): 133 141.
Quitting Works The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK Lancet. 2013 January 12; 381(9861): 133 141.
Tobacco plays a significant role in health inequalities within New Zealand. Higher smoking prevalence seen among lowincome groups, Māori and Pacific peoples. 11. 11 Hill, S., Blakely, T., Howden-Chapman, P. (2003). Smoking Inequalities: Policies and patterns of tobacco use in New Zealand. 1981 to 1996. Wellington: Ministry of Health.
90% of enrolled patients who smoke and are seen in General Practice, will be provided with advice and help to quit. Why the target was developed... Brief advice about doubles quit rates Cochrane database 2004/2008
% Patients making a quit attempt % patients making a quit attempt in 6 months following a GP visit 40 35 30 25 20 15 10 5 0 20 No intervention Baseline 25 Brief advice to quit on medical grounds 35 Making an offer of treatment AVEYARD, P., R. BEGH, et al. (2011). "Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance." Addiction.
Acceptance of smoking cessation treatment by readiness to quit 100 90 % of smokers 80 70 60 50 40 30 52 89 37 Total N=2168 % of total Accepted treatment Abstinent at end of treatment (17 weeks) 20 10 27 24 0 11 Ready to quit Not ready to quit PISINGER et al (2005) Prev Med, 40: 278-284
In a direct comparison, offering assistance generated more quit attempts than giving advice to quit on medical grounds more effective to offer cessation support to all smokers than by advising smokers to quit and offering assistance only to those who express an interest in doing so
stage-based interventions neither more nor less effective than the standard one.. These findings confirm the known effectiveness of these interventions, whether staged or unstaged.
NRT about doubles quit rates No overall difference in effectiveness of different forms of NRT Heavier smokers may need higher doses of NRT. People who use NRT during a quit attempt are likely to further increase their chance of success by using a combination of the nicotine patch and a faster acting form. Starting to use NRT shortly before the planned quit date may increase the chance of success.
NRT: Long-term (>6 month) quit rates vs. placebo Pooled 36 studies RR=1.60 (95% CI: 1.53-1.68) 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.
bupropion and nortriptyline aid longterm smoking cessation but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not. Evidence suggests that the mode of action of bupropion and nortriptyline is independent of their antidepressant effect and that they are of similar efficacy to nicotine replacement. Adverse events with both medications appear to be rarely serious or lead to stopping medication.
Bupropion: Long-term (>6 month) quit rates vs. placebo Pooled 36 studies RR=1.69 (95% CI:1.53-1.85) 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.
Nortriptyline: Long-term (>6 month) quit rates vs. placebo Pooled 6 studies RR=2.03 (95% CI 1.48-2.78) 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.
(14 trials, 6166 people), varenicline at standard dose increased the chances of quitting more than two-fold compared with placebo. Concerns re depressed mood, agitation, or suicidal thinking and behaviour in some smokers. Concerns that it may slightly increase heart and circulatory problems in people already at increased risk of these illnesses. Surveillance studies and further analyses of the trial data have not found strong support for either of these associations so far, but we cannot rule out the possibility of such links. Cochrane report 2012
Varenicline: Long-term (>6 month) quit rates vs. placebo Pooled 14 studies RR=2.27 (95% CI 2.02-2.55) 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.
Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Cessation success not directly related to time spent per session More frequent sessions improve quit success Some people need intensive support
Quitting without support 100 % abstinent 80 60 40 20 With support (behavioural + pharmacological) 0 0 7 14 21 28 35 42 49 56 63 70 77 84 91 Days since quitting
neither reducing or abrupt quitting produced superior quit rates smokers should be given a choice of quitting methods, either reducing smoking before quitting or abrupt quitting Comparing reducing smoking to quit with abrupt quitting. Lindson-Hawley N, Aveyard P, Hughes JR Published Online: November 14,
Proactive Telephone Counselling RR=1.37, 95%CI: 1.26-1.50 Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD002850. DOI: 10.1002/14651858.CD0028 50.pub2
Mobile Phone (SMS Text) Support RR=1.71, 95%CI: 1.47-1.99 Whittaker R,McRobbie H, Bullen C, Borland R, Rodgers A,Gu Y.Mobile phone-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD006611. DOI: 10.1002/14651858.CD006611.pub3
Health Targets 90% of enrolled patients who smoke and are seen in General Practice, will be provided with advice and help to quit. By July 2012 32% By Oct 2012 37% By Jan 2013 43% By April 2013 51% Message : targets focus attention and resources on good clinical practice and desired health outcomes
63% Impact of contacting patients on offering support ABC 40%
Effect of increased offering support on quit rates 24%
Most outreach activities yield: 10-20% of those contacted have already stopped 10-40% want to stop now 20% want to stop some time The rest are not ready just now
Recording smoking cessation support -> identifies the support for that person -> allows an audit of who else needs contact Making recording easy
Cessation pathway available
Reduction in Tobacco sales in NZ last 4 years: 2009 1.01% 300 million fewer cigarettes sold each year 2010 4.39% 2011 8.83% 2012 2.48% http://www.ash.org.nz/wp-content/uploads/2013/06/summary-of-tobacco-returns-2012.pdf
Our role: Better help for smokers to stop Asking Brief advice and Cessation support For 650,000 smokers -> 20 per year per GP until 2025 1948: The Department of Health produced the first posters in New Zealand linking cancer with smoking