Smoking and smoking cessation in
the real world
Robert West
University College London
Rio De Janeiro
August 2007
1
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
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
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
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
‘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
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
Smoking rates
Smoked in the last year
Ex-smokers
Ever-smokers
Women
Men
Total
Smokers
Non-daily
Daily cigarette smokers
Cigarette smokers
0
20
40
60
80
Percent of adult population
100
Monthly smoking rates
100
90
Percent
80
70
60
50
40
30
20
10
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07
Non-daily cigarette smoker
Current cigarette smoker
Jul-07
Daily cigarette smoker
Current tobacco smoker
Cessation rates by social grade
Success rate
E
D
C2
C1
AB
Quit in past year
Tried to quit in
past year
0
20
40
60
80
100
Percent of adult population
Note: red bars show significant differences across social grades; blue bar
shows no difference. E=low paid manual, AB=professional/managerial
Monthly cessation rates
45
40
35
Percent
30
25
20
15
10
5
0
Nov-06 Dec-06 Jan-07
Feb-07 Mar-07
Tried to quit last month
Apr-07
May-07 Jun-07
Quit last month
Jul-07
Success rate
Note: Blue bars show significantly elevated rates compared with others
Use of cessation aids in the
past year
Monthly use of NRT
5
Percent of all smokers
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07
NRT bought otc
NRT on prescription
Note: No significant differences between months
Jul-07
Trying to reduce smoking
100
90
Percent of smokers
80
70
60
50
40
30
20
10
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07
Note: No significant differences between months
Jul-07
Use of NRT to help reduce
16
Percent of smokers
14
12
10
8
6
4
2
0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07
Patch
Inhaler
Apr-07
Gum
Nasal spray
Note: No significant differences between months
May-07 Jun-07
Lozenge
Any NRT
Jul-07
Use of NRT in when cannot
smoke
Percent of smokers
20
18
16
14
12
10
8
6
4
2
0
Feb-07
Mar-07
Patch
Inhaler
Apr-07
May-07
Gum
Nasal spray
Note: No significant differences between months
Jun-07
Lozenge
Any NRT
Jul-07
Triggers for most recent quit
attempt
Just decided
Health warning
Worry for children
Pregnancy
Family pressure
Some ill/died
Knew someone
New treatment
NRT ad
Govt ad
Smoke-free
HP advice
Cost
Current health
Future health
0
20
40
60
Percent of adult population
80
100
Medication use as a function of
other features of quit attempts
60
50
Percent using meds
• 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
40
30
20
10
0
Planned
Unplanned
Knew someone
Future health
Current health problems
Cost
Health prof essional
0
20
40
60
Percent using meds
80
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
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
Analysis of NRT data
– Phase 1 sample: 354 made a quit attempt in MarchJune 2003
• 124 used NRT
• 59 used other methods (hypnotherapy, acupuncture etc.)1
– Phase 2 sample: 856 made a quit attempt in MarchJune 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
NRT findings
• Sample 1:
– NRT vs no NRT
• Odds ratio=3.0, p=0.02, adjusted risk difference=6.2%
– Used other methods vs did not use other methods
• Odds ratio=0.8, p=0.86
• Sample 2:
– NRT versus no NRT
• Odds ratio=2.1, p=0.04, adjusted risk difference=3.7%
– Used other methods vs did not use other methods
• Odds ratio=1.6, p=0.27
Effect of telephone counselling
Percent difference
14
12
10
8
6
4
2
0
Pro-active sessions
Adjunct to face-to-face
Adjunct to
pharmacotherapy
Cochrane review: >6 month cessation not validated
Interested in quitting
Effect of tailored internet support
Percent difference
14
12
10
8
6
4
2
0
Swartz 2006 (90 day) vs nothing Strecher 2005 (84 days) versus
generic
Not biochemically verified
Total
Effect of NRT
Percent difference
25
20
15
10
5
0
um
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ha
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ay
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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)
Effect of nortriptyline, bupropion
and varenicline
Percent difference
25
20
15
10
5
0
Bupropion
Notriptyline
Varenicline 12w
Varenicline 24w vs 12w
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
The goal
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