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

4. 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

5. 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

8. Smoking rates

9. Monthly smoking rates

10. Cessation rates by social grade Note: red bars show significant differences across social grades; blue bar shows no difference. E=low paid manual, AB=professional/managerial

11. 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

19. 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

20. 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

21. 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

22. 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

23. Effect of telephone counselling Cochrane review: >6 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)

26. 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

28. 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