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David Simpson OBE, Hon MFPHM Director, International Agency on Tobacco and Health

10 th Annual Congress TURKISH THORACIC SOCIETY Antalya, 25-29 April 2007. Tobacco control in Europe and Smoking cessation. David Simpson OBE, Hon MFPHM Director, International Agency on Tobacco and Health Visiting Professor, London School of Hygiene & Tropical Medicine

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David Simpson OBE, Hon MFPHM Director, International Agency on Tobacco and Health

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  1. 10th Annual Congress TURKISH THORACIC SOCIETY Antalya, 25-29 April 2007 Tobacco control in Europe and Smoking cessation David SimpsonOBE, Hon MFPHM Director, International Agency on Tobacco and Health Visiting Professor, London School of Hygiene & Tropical Medicine Honorary Fellow, Clinical Trial Service Unit, Oxford Editor, News Analysis, Tobacco Control journal

  2. A public health history of the tobacco epidemic 1940s +50s 1960s + 70s 1980s 1990s 2000- - new scientific evidence drives increase in research on tobacco & disease - development of government health policy; - industry scientists lose power to marketing executives • - companies expand international activities; • use ‘product modification’ policy as hostage to keep advertising - litigation, particularly in the USA; - Minnesota case releases >30 million documents; - health advocacy increases • - ‘We’ve changed!’ programmes, e.g. BAT’s ‘Social reports’; • WHO’S FCTC process: tobacco on health agenda worldwide; • tobacco companies try to ‘help’ with FCTC laws, while exploiting & expanding markets as fast as possible • World Trade Organisation continues pressure to open markets

  3. FCTC: what governments must do • comprehensive ban: advertising, promotion & sponsorship • protect public from smoke in public places, incl. workplaces • health warnings: +/< 30% of main pack area • ban deceptive pack terms - ‘light’, ‘low tar’, etc • tackle smuggling • tax increases • tobacco regulation • manufacturers to disclose ingredients • legal action encouraged • promote funding for global tobacco control • have national mechanism for tobacco control • include cessation services in health programmes • no distribution of free tobacco products • promote NGO action • ban underage tobacco sales • no opting out of any FCTC provisions!

  4. Europe: ‘Parties’ to FCTC European Community (23 of 25) • Parties (23): Austria, Belgium, Cyprus, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, United Kingdom • Not Parties (2): Czech Republic, Italy

  5. Europe: ‘Parties’ to FCTC Non-European Community countries (42 of 55) • Parties (42): Armenia, Austria, Azerbaijan, Belarus, Belgium, Bulgaria, Cyprus, Denmark, Estonia, European Community, Finland, France, FYR Macedonia, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Montenegro, Netherlands, Norway, Poland, Portugal, Romania, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden,Turkey, Ukraine, United Kingdom • Not Parties (13): Andorra, Bosnia and Herzegovina, Croatia, Czech Republic, Italy, Liechtenstein, Monaco, Republic of Moldova, Russian Federation, Switzerland, Tajikistan, Turkmenistan, Uzbekistan

  6. Europe: total tobacco control score* Joossens, L & Raw, M. The Tobacco Control Scale: a new scale to measure country activity. Tob. Control 2006;15;247-253.

  7. % of pack covered: both back and front Cunningham, R. Package warnings: overview of international developments. Canadian Cancer Society, 2007.

  8. % of pack covered: warnings on the front of pack Cunningham, R. Package warnings: overview of international developments. Canadian Cancer Society, 2007.

  9. The international tobacco industry Philip Morris – PM (holding company now known as ‘Altria’) Marlboro, Chesterfield, Philip Morris British American Tobacco – BAT (includes Rothmans) State Express 555, Lucky Strike, Benson & Hedges, Rothmans Japan Tobacco International – JTI (still state-controlled; former JT + non-US business of RJR Reynolds) Mild Seven, Salem also:Altadis (SEITA & Tabacalera , formerly monopolies in France & Spain); Imperial (UK), incl. Reemtsma (Germany) ; ITC (India - part-BAT); Gallaher (UK); Tekel (Turkey – monopoly, to be sold), Sampoerna (Indonesia), KT&G (S Korea),etc

  10. Tobacco companies’ sales &developing countries’ gross domestic product(GDP)

  11. Tobacco cessation: - helping people to stop smoking,in the clinical setting

  12. Smoking cessation • Doctors have unique ability to help smokers to stop smoking • Many smokers want to stop smoking, & others may be receptive to encouragement to stop • A brief intervention by the doctor increases chances that a smoker will successfully stop smoking • Nicotine replacement therapy (NRT) and other pharmaceuticals can increase the success rate of more dependent smokers

  13. The process of stopping smoking Deciding to try to stop Thinking about stopping Trying to stop Stopping “Contented Smokers” Relapsing Never smoking again!

  14. The brief intervention • Offer information, advice, & encouragement to get the patient to consider making a firm commitment to quit • Reinforce the decision to quit • Give the patient a cessation leaflet, if available • If appropriate, offer to prescribe NRT & give advice • Advise patient to plan a quit day in advance • At the end, reinforce patient’s decision to quit & offer further help

  15. Success rate of interventions %  5 minutes per patient 1 hour per patient 3 hours per patient

  16. Number of long-term successes from 50 hours of intervention

  17. Number of long-term successes from 50 hours of intervention  5 minutes per patient Success rate 8% 1 hour per patient Success rate 15% 3 hours per patient Success rate 25% 1 hour per patient Success rate 15% =/< 5 minutes / patient Success rate 8%

  18. Cochrane Database Syst Rev. 2007 Jan24;(1):CD000031 • 17 new trials identified since last update (2004); total = 53 (40 bupropion + 8 nortriptyline) • When used as sole pharmacotherapy, bupropion (31 trials) & nortriptyline (4 trials) both doubled odds of cessation. • Insufficient evidence that adding bupropion or nortriptyline to NRT provides additional long-term benefit • 3 trials of extended therapy with bupropion to prevent relapse after initial cessation found no evidence of significant long-term benefit • From available data, bupropion & nortriptyline appear to be equally effective & of similar efficacy to NRT • Pooling 3 trials comparing bupropion to varenicline showed a lower odds of quitting with bupropion (OR 0.60, 95% CI 0.46 to 0.78). • (There is a risk of about 1 in 1000 of seizures associated with bupropion)

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