Smoking Cessation: population and patients A comprehensive approach to the smoker the high CVD risk smoker Catriona Jennings Cardiovascular Specialist Research Nurse Imperial College London European Society of Cardiology, Stockholm, Sweden August 28 th to September 1 st 2010
WHO Strategy for Tobacco Control Populations Provide a supportive environment, e.g higher taxation, price, smoking bans in public places and mass media and educational campaigns Individual smokers Initiate policies and activities to help dependent smokers who are motivated to quit smoking WHO Europe 2000
What are we doing as health professionals?
EUROASPIRE III Netherlands Finland Ireland Russia UK Latvia Germany Lithuania Czech Republic Poland France Belgium Romania Hungary Croatia Slovenia Greece Bulgaria Spain Italy Cyprus Turkey ESC - EUROASPIRE III - EHS
Prevalence of smoking in patients at interview by age and sex Coronary patients 17% (men 19%/ women 11%) Kotseva et al. 2009 Eur J Cardiov Prev R; 16: 121-37. Kotseva et al. 2010 Eur J Cardiov Prev R; High risk individuals 17% (men 23%/ women 13%) All Men Women
Persistent smoking Kotseva et al. 2009 Eur J Cardiov Prev R; 16: 121-37. Coronary patients who were smokers at the time of their diagnosis Kotseva et al. 2010 Eur J Cardiov Prev R; High risk individuals who were smokers when recruiting treatment started
Challenges for smoking cessation in this population Multiple issues to address eg. smoking, overweight, blood pressure, lipids A high proportion may not say they want to quit initially Heavily dependent on tobacco (age, years smoking) Several past quit attempts may lack confidence to succeed Weight gain additional risks Risk of relapse
Who is most likely to quit? (EUROASPIRE II Scholte et al 2005) Older patients > 60 years (OR 1.6) Patients with a higher level of education (OR 1.8) Post MI (OR 1.3) Under cardiologist (OR 1.4)
Who is less likely to quit? Challenge is very different for patients who have had an acute cardiac event compared to those who have not: E.g. Have a high total risk score
Success in smoking cessation with coronary patients
EUROACTION Cluster randomised controlled trial in 8 countries 24 centres 10,000+ subjects
Impact of a first cardiac event on smoking behaviour (EUROACTION) Smoking in month prior to event 35% Smoking at initial assessment (median 21 days post event) 10% Challenge was relapse prevention
EUROACTION: coronary patients Smoking cessation at one year in coronary patients who were smokers in the month prior to their event + 10% ( - 0.3% to + 21%) p = 0.06 Wood et al 2008 Lancet 371: 1999 2012
EUROACTION: coronary patients still smoking at one year Nearly three quarters had attempted to quit 1% reported using NRT to help with a quit attempt A half reported having reduced cigarette consumption Reducing cigarette consumption without concomitant use of NRT leads to compensatory behaviour like deeper inhaling and holding for longer
MULTIFIT : home based cardiac rehabilitation RCT Stanford Group USA Nurse led case management post myocardial infarction Risk factor modification (smoking cessation, exercise training, diet-drug lipid modification) Smokers defined as smoking in 6 months prior to AMI (43%) Counselling at time of admission to hospital and up to six months of structured regular follow up mostly by telephone or mail One year results De Busk R, Miller N et al 1994
MULTIFIT results smoking cessation Use of NRT 10% Intervention 2% Usual Care All hospitalised patients with acute myocardial infarction 894 Eligible 709 Randomised 585 293 INT 292 UC Smoking at baseline 131 (45%) 121 (41%) Quit at 6 months 90 (69%) 66 (55%) Quit at 1 year 92 (70%) 64 (53%) p=0.03
Success in individuals at high CVD risk
EUROACTION: high risk individuals General Practice Non-smoking at one year in high risk patients + 0.8% (- 13% to + 15%) p = 0.9 Wood et al 2008 Lancet 371: 1999 2012
How effective can we be in helping people at high risk of developing CVD to quit smoking? INT UC Advised to quit 95% 51% Attempted to quit Used NRT to quit 53% 31% 13% 24% Clinic 20% 2% Used reduction 58% 57% Want to stop 56% 42% Smokers at one year EUROACTION GP
Is it worth trying to motivate smokers to quit if they are not planning to quit immediately? Inter99 Denmark Randomised population based intervention study (3 groups: intensive A, less intensive B, background C) Prevention of CVD and diabetes with nonpharmacological intervention addressing smoking, diet and physical activity Individual cardiovascular risk assessment with PRECARD and lifestyle consultation 2408 smokers in all (2168 in Group A offered group based smoking cessation)
Inter99 smoking cessation results for Group A Agreed to attend smoking cessation group n Quit Rate * % No serious plans to quit prior to lifestyle consultation % 575 35 84 Agreeing to quit in a group increased the likelihood of abstinence at 1 year OR 4.6 Majority would not have accessed traditional programmes eg UK NHS stop smoking *Continuously abstinent at end of group cessation programme Pisinger et al 2005 Prev Med 40 278 284
Predictors of success and failure Inter99 Higher socio-economic status Educational level in the unemployed made no difference Older age at onset of daily smoking Higher wish to quit at baseline Being male Having a job High nicotine dependence and smoking spouse predicted failure Pisinger et al 2005 Prev Med 40 285-292
Proposed model of smoking cessation for high CVD risk smokers Use motivational techniques to explore ambivalence and recruit apparently unmotivated smokers to attempt to quit How you ask Don t nag Raise sense of urgency Offer help Inform about effective treatments Get commitment
Motivational techniques How do you feel about your smoking? Reflecting back So what you are saying is that you can never see yourself giving up smoking? I can see that you have had no success with using nicotine patches, do you know about any other treatments? OR Can you tell me more about how you used the patches?
Proposed model of smoking cessation for high CVD risk smokers Assess dependence Fagerstrom Test for Nicotine Dependence Inform about effective treatments and withdrawal oriented therapy
Proposed model of smoking cessation for high CVD risk smokers Integrated lifestyle management Smoking cessation Tailored dietary advice following a detailed assessment Tailored physical activity and exercise advice following a detailed assessment Weight maintenance and minimisation of weight gain in overweight and obese quitters
Proposed model of smoking cessation for high CVD risk smokers Management of CVD risk factors Monitor blood pressure and observe for rise in longer term Monitor lipids expect rise in HDL-C Check for dysglycaemia in longer term
Proposed model of smoking cessation for high CVD risk smokers Relapse prevention Withdrawal oriented approach Structured and regular follow up Involve the partner and other family members (especially if they smoke)
Smokers at high total risk Not just smokers a number of risk factors and adverse lifestyles to address Need a total risk management approach
Family focussed nurse-led multidisciplinary case management approach for high CVD risk smokers in community Comprehensive initial assessment of lifestyle and risk factors aimed at smokers in all stages of motivation to quit by a nurse, dietitian and physical activity specialist Goal setting One to one Follow up with progress in achieving goals Multidisciplinary team meets with dedicated physician Weekly Group activities Group health promotion workshops Supervised exercise programme
www.myaction.org.uk Integrated nurse led multidisciplinary family focussed vascular prevention programme developed for the UK NHS 10 programmes in the UK and Ireland
EUROACTION + Intensive Smoking Cessation with Varenicline RCT in 4 countries UK Italy Netherlands Spain
Summary of key points In Europe smoking cessation support for vascular and high risk patients is inadequate We face numerous challenges in helping patients to quit Population at risk but without vascular disease present a particularly big challenge It is worth using motivational techniques and counselling patients to quit even if they do not present with a request for help Smokers with a high total CVD risk require a total management approach addressing both lifestyle and risk factors