Smoking cessation in New

Zealand

Hayden McRobbie MB ChB (Otago) PhD (London)

Faculty of Health and Environmental Sciences, Auckland University of TechnologyWolfson Institute of Preventive Medicine, Queen Mary University of London

26.6 25.2 20.0 21.3 19.20

5

10

15

20

25

30

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Percent

Smoking in people aged 15–64

Source: 2009 New Zealand Tobacco Use Survey

Do smokers want to smoke?

• 4 in 5 smokers said that they would not smoke if they had their life over again• Females were significantly

more likely than males to say this

• 3 in 5 had tried to quit in the last 5 years

Source: 2009 New Zealand Tobacco Use Survey

What are we up against?

• The addictive nature of tobacco

• The tobacco industry

• Optimism and over confidence of smokers• “It won’t happen to me”• “I’ll be able to give up when the

time comes”

Tension, Triggers, Treatment

• Tension and triggers• Maximising smokefree norms• Raise the price of tobacco• Restrict the supply• Regulate tobacco• Remove temptations to smoke• Continue with fear arousing messages• Populate the smokers’ world with QUIT NOW

messages

• Provide evidence based treatment

Policy and treatment

UK Australia

Canada US

Visited a doctor or other HCP 55% 72% 68% 71%

Got advice to quit 55% 48% 57% 69%

Made 1 or more quit attempts 37% 41% 43% 39%

Got additional help 20% 6% 9% 10%

Got meds and behavioural support

19% 8% 9% 10%

Reid et al 2010 Nicotine & Tobacco Research 12 (supl 1) S20-S33

• ITC project: in first year after recruitment

• Odds of quitting for a month

UK Australia Canada US

Odds ratio 1.0 0.59 0.72 0.51

95% confidence interval

referent 0.49-0.71 0.61-0.87 0.42-0.62

Stop smoking services

• Do not have a large effect on smoking prevalence

Offer a life saving treatment for those smokers who want to use it

NZ Smoking Cessation Guidelines

• Screen for tobacco use• Brief advice to quit smoking • Offer help to quit• Behavioural support

• Face-to-face and telephone cessation support

• Setting a quit date and providing multi-session behavioural support

• Medication• Nicotine replacement therapy• Bupropion & Nortriptyline• Varenicline

Put simply…• A - ask whether a

person smokes

• B - give brief advice to quit to all people who smoke and

• C – make an offer of, and provide or refer for cessation treatment

Treatment of Tobacco Use

Treatment WorksData from Cochrane reviews; bars represent 95% CIs based on risk ratios versus placebo (for medications) or brief advice/no treatment (for BehSup)

Slide courtesy of Prof Robert West, UCL, London

Smoking Cessation in NZ

Proactive Telephone Counselling

Group Counselling

Individual Counselling

Web and text basedsupport

•Pregnancy services•DHB services

Frontline Healthcare Professionals

Pharmacotherapy

Nicotine Replacement Varenicline

Bupropion

Nortriptyline

PatchGumLozengeMicrotabInhaler

✔

✖

Subsidised

User pays✔

✔

✔

✔✔✔✖✖

NRT• Roughly doubles the

chances of quitting long-term

• Safe to use in ALL people who smoke

• Patch, gum and lozenge fully subsidised

• Combination therapy recommended

• Available on prescription or via a QuitCard

Stead, L. F., Perera, R., Bullen, C., Mant, D. & Lancaster, T. (2008) Nicotine replacement therapy for smoking cessation, Cochrane Database Syst Rev, CD000146.

Quit Card Providers

• Registered Healthcare Professionals can become quit card providers by doing a 30 minute online training module

• www.smokingcessationabc.org.nz

• Face-to-face training for other healthcare workers

Varenicline (Champix)• Partial agonist of nicotinic

acetylcholine receptors

• At least doubles chances of quitting

• Able to be used my most smokers, BUT need to fulfill special authority criteria

• Prescription only

• Nausea and vivid dreams are common side effects

Cahill, K., Stead, L. F. & Lancaster, T. (2008) Nicotine receptor partial agonists for smoking cessation, Cochrane Database Syst Rev, CD006103

Champix available on prescription

• Special authority• The patient is part of, or is about to enroll in, a

comprehensive support and counseling smoking cessation programme, which includes prescriber or nurse monitoring AND

• The patient is not pregnant AND• The patient has tried but failed to quit smoking after at

least two separate trials of nicotine replacement therapy, at least one of which included the patient receiving comprehensive advice on the optimal use of nicotine replacement therapy OR

• The patient has tried but failed to quit smoking using bupropion or nortriptyline

Nortriptyline

• Tricyclic antidepressant

• Doubles chances of quitting

• Not suitable for some smokers

• Prescription only

• Dry mouth, blurred vision are common side effects

Zyban

• Atypical antidepressant

• Roughly doubles the chances of quitting

• Number of contraindications, cautions, and drug interactions to consider

• Prescription only

• Side effects: headache, dry mouth, insomnia, seizure (rare)

Is the ABC approach working?

Smokers ‘ABC’d’ in past year

25.3 30.7 32.1 31.9 39.2 35.7 34.90

10

20

30

40

50

60

15Š19 20Š24 25Š29 30Š39 40Š49 50Š59 60Š64

Age group (years)

Percent

Source: 2009 New Zealand Tobacco Use Survey

The Tobacco Health Target

• “Eighty percent of smokers will be provided with advice and help to quit by July 2010; 90 percent by 2011; and 95 percent by July 2012.”

Health Target Results – 2009/10

Percent provided with advice and/or help to quit

New

Zeala

nd

Dis

tric

t H

ealt

h B

oard

s

What are smokers doing?

Tried to quit in the last year

44.9 40.0 41.8 40.4 36.9 33.7 21.80

10

20

30

40

50

60

15Š19 20Š24 25Š29 30Š39 40Š49 50Š59 60Š64

Age group (years)

Percent

Source: 2009 New Zealand Tobacco Use Survey

Going cold turkey?

• No – almost 40% of recent quit attempts involved advice or smoking cessation products• Quitline• NRT

Cessation Support

Source: 2009 New Zealand Tobacco Use Survey

Where are they getting their NRT?

48.3 13.1 3.7 14.2 2.20

10

20

30

40

50

60

Quitline GP Hospital doctor Pharmacy Supermarket

Subsidised source of NRT Full price over-the-counter NRT

Percent

Source: 2009 New Zealand Tobacco Use Survey

Where to from here?

• A range of support that best fits the person (and the health care system)

• Need to maximize access• Priority populations• Go to where the people are• People want choice and the service that fits

THEM

• Innovative, effective, and safe ways to manage tobacco dependence

Quality of treatment services

• Its not just about throughput, outcome is also important

• Service user feedback and input

• Monitoring and improvement (as opposed to evaluation)

Novel approaches

• ‘Drop-In’ clinics• Halls, shopping centres• Outside working hours• No appointments, multi-

session,

• Potential use of ‘lay’ community members to• Promote and ‘sign post

treatment• Provide support

Different Routes to Quitting

• UK NHS Stop Smoking Service is considering implementing different options for smokers• Abrupt quitting (status quo)• Rapid reduction to quit• Slow reduction to quit• Harm reduction

Conclusions

• Smoking cessation treatment is part of a comprehensive tobacco control strategy

• For many smokers, smoking cessation will be life-saving

• ‘ABC’ is part of ‘core practice’ for healthcare professionals

• New Zealand has a good range of options for smokers who wish to quit, but we need to improve utilisation of these