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Medicalising Smoking is Vital!

Medicalising Smoking is Vital!. Dr. Alex Bobak GP and GPSI in Smoking Cessation Wandsworth, London. Declaration of Interests.

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Medicalising Smoking is Vital!

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  1. Medicalising Smoking is Vital! Dr. Alex Bobak GP and GPSI in Smoking Cessation Wandsworth, London

  2. Declaration of Interests Dr Bobak has received sponsorship to attend scientific meetings, speaker honorariums and consultancy fees from Astra Zeneca, Boehringer Ingelheim, Glaxo Smith Kline, Novartis and Pfizer

  3. Is this lifestyle choice or addiction?

  4. Nicotine from cigarette smoking is as addictive as heroin or cocaine1 1. Royal College of Physicians, 2000.

  5. Plasma Nicotine Levels – Contrast between Cigarettes and NRT 25 20 15 10 5 0 Cigarette Spray Plasma nicotine (ng/ml) Gum/Inhalator/Tablet/Lozenge/Mini Patch 0 10 20 30 40 50 60 Time (minutes) 1. Adapted from: Tobacco Advisory Group of the Royal College of Physicians, 2000.

  6. Is nicotine addiction a disease?

  7. Definition of Disease “Disorder of structure or function, especially with adverse effects on the person.”

  8. Definition of Disease “Disorder of structureorfunction, especially with adverse effects on the person.”

  9. Non Smoker Smoker C-11Nicotine Agneta Nordberg to Karl Fagerstrom, Personal Communication.

  10. Structural Changes from Smoking Primary: • 300-400%increase in brain nicotine receptors with regular smoking2 Secondary: • Coronary heart disease (CHD) • Cerebrovascular disease (CVD) • Chronic obstructive pulmonary disease (COPD) • Lung cancer • Etc. etc. etc. 2. Perry et al. JPET 1999;289:1545–1552.

  11. Structural Changes from Type 2 Diabetes Primary: • Abnormality of pancreatic islet cells3 Secondary: • Coronary heart disease • Cerebrovascular disease • Kidney disease • Eye disease • Etc. etc. etc. 3. Deng et al., Diabetes 2004 Mar; vol. 53.

  12. Primary Functional Changes in the Brain Due to Smoking • Dysfunctional (addictive) behaviour • Neurobiochemical effects of tobacco use are well-documented4,5 • Measurable and lasting EEG changes4 4. Steinberg et al. Ann Intern Med. 2008;148:554-556; 5. Regarding the neurobiochemical effects of tobacco use on the brain, Steinberg et al. (2008) cited: Leshner AI. Addiction is a brain disease, and it matters. Science 1997;278:45-47.

  13. Smoking is the largest preventable cause of disease and premature death in the world6 More than 50% of long-term smokers die prematurely due to smoking-related diseases7 Adverse Effects of Smoking 6. WHO Report on the Global Tobacco Epidemic: The MPOWER package. Geneva, World Health Organization, 2008; 7. Doll et al. Br Med J 2004;328:1519–1527.

  14. A Treatable Disease: Long-term Cessation Rates 2-3% 4-6% 20-30% 10-15%

  15. Nicotine addiction (resulting from tobacco use and dependence) is well established as a treatable chronic disease, with a rapidly growing evidence base5,8-10 4. Steinberg et al. Ann Intern Med. 2008;148:554-556; 8. Joseph et al. Arch Intern Med. 2011;171(21):1894-1900); 9. Foulds et al. Int J Clin Pract 2010; 64(2):142-146. Epub 2009 Nov 16; 10. Fiore et al. Treating tobacco use and dependence: Clinical practice guideline. Rockville, MD: U.S. DHHS, PHS, 2008 (p. vi).

  16. A Treatable Disease: Long-term Cessation Rates 2-3% 4-6% (46% of attempts11) (49% of attempts11) 20-30% 10-15% (4% of attempts11) 11. West R, Brown J (2012) Smoking and Smoking Cessation in England 2011. London.

  17. Cardiologist advice: • “Willpower is what you need” • “All we can do is keep advising [to stop]” • “Nothing I can do”

  18. Why don’t smokers and healthcare professionals (HCPs) engage in evidence-based smoking cessation?

  19. Smokers’ Views on Smoking • Most messages they receive are about the harm caused by smoking and telling them to stop, rather than actually how to stop • Many believe smoking is a lifestyle choice • Few see it as a treatable medical condition • They often feel guilty • So they don’t seek help

  20. UK Smokers’ Misconceptions • Most smokers believe that, or are unsure whether, NRT is as harmful as cigarette smoking12 • Smokers with safety misconceptions are less likely to: • Want to quit • Intend to use NRT if they do try to quit 12. Bobak et al. Journal of Smoking Cessation 2010;5(2):115-122.

  21. HCP Training in Smoking Cessation • Most clinicians receive little or no practical training in evidence-based smoking cessation during UK undergraduate medical courses13 • The large majority of newly qualified UK doctors report feeling ill-equipped to deal with smoking and tobacco dependence in their patients13 13. Roddy et al. Tobacco Control 2004;13:74-77.

  22. HCP views on smoking • If it is not taught at medical school, it is not medical • Many believe smoking is a lifestyle choice • Most information is from lay sources, e.g., the media • They believe many myths related to smoking, e.g., medication scare stories • They don’t know how to treat smokers • So they don’t provide correct advice or treatment

  23. HCP Misconceptions • Survey of GPs showed many believe one of the greatest health risks from smoking is nicotine14 • Less than one-third (31%) believe long-term NRT is preferable to smoking • 40% believe nicotine to be 1st or 2nd riskiest component (more harmful than smoke) • 44% believe nicotine in tobacco is associated with cancer, while 15% believe pharmaceutical nicotine is associated with cancer 14. Patwardhan SR, Murphy MA. 2013 (in press).

  24. The huge potential:clinical and cost effectiveness of smoking cessation as a medical intervention

  25. Smoking Cessation: Secondary Prevention of CHD Impact of Treatment on Mortality of Patients with CHD -blockers21 Stop Smoking23 Aspirin19 Statins20 ACE-I22 0 –10 –20 –30 –40 Mortality (%) 19. Weisman et al. Arch Intern Med 2002;162:2197–202; 20. LaRosa et al. JAMA 1999;282:2340–2346; 21. Freemantle et al. BMJ 1999;318:1730–1737; 22. Flather et al. Lancet 2000;355:1575–1581; 23. Critchley JA , Capewell S. JAMA 2003;290:86–97.

  26. Effect of Smoking Cessation in COPD24 Never smoked or not susceptible to smoke 100 75 50 25 0 Smoked regularly and susceptibleto its effects Stopped at 45 FEV1 (% of value at age 25) Disability Stopped at 65 Death 25 50 75 Age (years) 24. Fletcher C , Peto R. BMJ 1977;1(6077):1645-1648.

  27. NICE Guidance on NRT & Bupropion April 2002

  28. “Both bupropion and NRT are considered to be among the most cost effective of all healthcare interventions.”15 • “Estimates of cost effectiveness … are below £2000 per Life Year Gained”15 15. NICE Smoking Cessation Guidance, 2002.

  29. Cost per Life Year Gained £14,000 £12,000 £10,000 £11,80016 £8,000 Cost per Life Year Saved £6,000 £4,000 £2,000 <£2,00015 £0 Smoking cessation interventions Statins 15. NICE Smoking Cessation Guidance, 2002; 16. Raithatha N, Smith RD. BMJ 2004;328:400-402.

  30. NHS Annual Expenditure Approximate £ millions Expenditure Annually 70017 £millions 39.218 Smoking Cessation Interventions* Statins *Quarterly data multiplied by 4 to estimate annual expenditures; excludes cost of NRT and bupropion prescriptions. 17. Gibson. BMJ 2004; 328:1221; 18. NHS Statistics on NHS Stop Smoking Services in England, April to June 2004.

  31. Realising the potential (Utopia!)

  32. All Smokers Would … • Be aware that the best way to stop is with support and treatment • Know where to get it • Have access to the latest smoking cessation treatments; we know innovations can trigger renewed attempts to quit • Not be afraid to go back and try again if they do relapse to smoking

  33. All HCPs Would … • Accept nicotine addiction from smoking cigarettes as a treatable disease • Understand and deliver brief cessation advice routinely • Provide support and treatment for smokers as they would for any other chronic illness

  34. How to Get There • Training of all HCPs in effective, evidence-based smoking cessation interventions • Normalisation of nicotine addiction as a chronic relapsing, yet treatable, disease • Use of a chronic disease management approach to nicotine addiction treatment

  35. Seeing Nicotine Addiction from Smoking as a Chronic Disease Like Many Others

  36. A long way to go Bernstein et al, AJPH, 2013

  37. Improved Outcomes Shown by Managing Smoking as a Chronic Disease • Telephone-based, chronic disease management approach (1 year) was compared with usual support and treatment (8-week evidence based smoking cessation intervention)8 • More quit attempts and better short- and long-term abstinence from smoking with the chronic disease management approach 8. Joseph et al., 2011.

  38. Medical Approach Already Working • Czech clinic adopts a doctor-led medical approach to smoking25 • Recent study of optional support plus choice of varenicline or NRT • Overall one year continuous abstinence rate of 38.1% 25. Kralikova et al. Addiction 2013 May 13 [Epub ahead of print]

  39. What We Can Do While We Wait for HCP Training • Make it normal to talk about nicotine addiction from tobacco dependence as a treatable and manageable disease • Repeat as often as possible that the best way to stop smoking is with evidence-based treatment and support • Encourage education in smoking cessation as part of all HCP training

  40. Hopefully when the BBC next looks at the NHS, the cardiologist will be arranging stop smoking support and treatment in the same way as he arranges an angiogram

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