Medicalising Smoking
is Vital!
Dr. Alex Bobak
GP and GPSI in Smoking Cessation
Wandsworth, London
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
Is this lifestyle choice or
addiction?
Nicotine from cigarette
smoking is as addictive as
heroin or cocaine1
1. Royal College of Physicians, 2000.
Plasma Nicotine Levels – Contrast
between Cigarettes and NRT
Plasma nicotine (ng/ml)
25
Cigarette
20
15
Spray
10
Gum/Inhalator/Tablet/Lozenge/Mini
5
Patch
0
0
10
20
30
40
50
60
Time (minutes)
1. Adapted from: Tobacco Advisory Group of the Royal College of Physicians, 2000.
Is nicotine addiction a
disease?
Definition of Disease
“Disorder of structure or function,
especially with adverse effects on
the person.”
Definition of Disease
“Disorder of structure or function,
especially with adverse effects on
the person.”
Non Smoker
Smoker
C-11
Nicotine
Agneta Nordberg to Karl Fagerstrom, Personal Communication.
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.
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.
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.
Adverse Effects of Smoking
●
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
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.
A Treatable Disease: Long-term
Cessation Rates
No
Pharmacotherapy
Willpower alone
Support (trained
adviser)
2-3%
10-15%
Pharmacotherapy
4-6%
20-30%
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):142146. 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).
A Treatable Disease: Long-term
Cessation Rates
No
Pharmacotherapy
Willpower alone
2-3%
Pharmacotherapy
4-6%
(46% of attempts11) (49% of attempts11)
Support (trained
adviser)
10-15%
20-30%
(4% of attempts11)
11. West R, Brown J (2012) Smoking and Smoking Cessation in England 2011. London.
Cardiologist advice:

“Willpower is what you need”

“All we can do is keep advising [to stop]”

“Nothing I can do”
Why don’t smokers and
healthcare professionals
(HCPs) engage in evidencebased smoking cessation?
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
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.
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.
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
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).
The huge potential:
clinical and cost effectiveness
of smoking cessation as a
medical intervention
Smoking Cessation:
Secondary Prevention of CHD
Impact of Treatment on Mortality of Patients with CHD
Aspirin19
Mortality (%)
0
Statins20
22
ACE-I
21
blockers
Stop
Smoking23
–10
–20
–30
–40
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.
FEV1 (% of value at age 25)
Effect of Smoking Cessation in
COPD24
Never smoked
or not susceptible
to smoke
100
75
Smoked regularly
and susceptible
to its effects
Stopped at 45
50
Disability
25
Stopped at 65
Death
0
25
50
75
Age (years)
24. Fletcher C , Peto R. BMJ 1977;1(6077):1645-1648.
NICE Guidance
on NRT &
Bupropion
April 2002
●
“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.
Cost per Life Year Saved
Cost per Life Year Gained
£14,000
£12,000
£10,000
£11,80016
£8,000
£6,000
£4,000
£2,000
<£2,00015
£0
Statins
Smoking cessation
interventions
15. NICE Smoking Cessation Guidance, 2002; 16.
Raithatha N, Smith RD. BMJ 2004;328:400-402.
NHS Annual Expenditure
Approximate £ millions Expenditure Annually
£millions
70017
39.218
Statins
*Quarterly data multiplied by 4 to estimate
annual expenditures; excludes cost of NRT and
bupropion prescriptions.
Smoking Cessation
Interventions*
17. Gibson. BMJ 2004; 328:1221; 18. NHS Statistics on
NHS Stop Smoking Services in England, April to June 2004.
Realising the potential
(Utopia!)
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
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
How to Get There
●
Training of all HCPs in effective, evidencebased 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
Seeing Nicotine Addiction from Smoking
as a Chronic Disease Like Many Others
Smoking
CHD
DM
COPD
Asthma
Depression
Chronic
√
√
√
√
√
√
Relapsing
√
√
√
√
√
Causes other
diseases
√
√
√
Responds to
pharmacological
treatment
√
√
√
√
√
Responds to
behavioural
support
√
√
√
√
√
Exacerbated by
avoidable or
manageable
triggers
√
√
√
√
√
√
Requires longterm follow-up,
even if stable
√
√
√
√
√
√
√
A long way to go
Bernstein et al, AJPH, 2013
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.
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]
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
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