Effects on smoking cessation of a national strategy to maximise NRT usage: the UK experience

1. Effects on smoking cessation of a national strategy to maximise NRTusage: the UK experience Robert West University College London WCTOH July 2006 Washington

2. Outline • Smoking trends in the UK • The UK national strategy on smoking prevalence • What has happened to NRT usage? • Is NRT effective outside of clinical trials? • Calculating the potential population impact of NRT

3. Cigarette smoking trends in the UK see www.rjwest.co.uk for details Initial decline Stall Projection Slow decline Peak

4. UK national strategy • 1998: ‘Smoking Kills’ policy proposals • Increase the financial cost of smoking • Extend smoking restrictions • Ban advertising • Enhance health warnings • Extend mass media campaigns • Increase access to treatment to aid smoking cessation

5. Trends in Medication Use: 1999-2002 From West, et al. 2005.

6. Reported use of NRT in UK in past 12 months 49% reported 1 quit attempts 17% reported NRT OTC 4% reported NRT Rx 2% reported NRT OTC and RX Note: These figure are likely underestimates because of high rates of forgetting of quit attempts Unpublished percentages of ALL SMOKERS from household survey of 589 adults who had smoked in the past year in May 2006

7. Real world effectiveness of NRT • Called into question from cross sectional retrospective survey data requiring recall over 12 months1 but: • inadequate control for dependence • bias because of forgetting of failed quit attempt • Needs prospective data starting BEFORE the quit attempt 1 Pierce et al, JAMA, 2002

8. 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 1West et al, Addiction, In press

9. 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

10. 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

11. Population impact in UK • 12 million smokers • 2.8 million users of NRT in 2006 • Estimated 6 month effect size: 5% • Estimated long-term effect size: 2.5% • Estimated additional ex-smokers: 70,000 • Effect on prevalence: 0.14% • Estimated premature deaths averted: 35,000 • Estimated life years gained: 280,000 • Cost: £280 million • Cost per life year gained (undiscounted): £1000

12. Conclusions • UK government initiatives have probably been largely responsible for the large rise in NRT usage • Evidence of effectiveness of NRT from RCTs is borne out by evidence from two samples in a large prospective study of smokers in the real world • The effect of NRT is small and so the impact on smoking prevalence will not be detectable in any one year • However, in absolute terms the public health impact is large