David Simpson OBE, Hon MFPHM Director, International Agency on Tobacco and Health
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David Simpson OBE, 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
Tobacco control in Europeand
Smoking cessation
10th Annual Congress
TURKISH THORACIC SOCIETY
Antalya, 25-29 April 2007
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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
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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!
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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
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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
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Europe: total tobacco control score*
0 20 40 60 80 100
SpainLithuania
SwitzerlandSlovenia
GermanyCzech Rep.
GreecePortugal
DenmarkEstonia
BulgariaHungarySlovakiaBelgium
PolandCyprus
NetherlandsFrance
ItalyFinlandSweden
MaltaIcelandNorway
UKIreland
PricePublic places banPublic info $Ad banHealth warningCessation
Joossens, L & Raw, M. The Tobacco Control Scale: a new scale to measure country activity. Tob. Control 2006;15;247-253.
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0 20 40 60 80
Norway
EC countries
Canada
India
Finland
Belgium
Australia
% of pack covered: both back and front
Cunningham, R. Package warnings: overview of international developments. Canadian Cancer Society, 2007.
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38 40 42 44 46 48 50 52
EC countries
Finland
Belgium
India
Canada
Singapore
% of pack covered: warnings on the front of pack
Cunningham, R. Package warnings: overview of international developments. Canadian Cancer Society, 2007.
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The international tobacco industry
Philip Morris – PM (holding company now known as ‘Altria’)
British American Tobacco – BAT (includes Rothmans)
Japan Tobacco International – JTI (still state-controlled; former JT + non-US business of RJR Reynolds)
Marlboro, Chesterfield,Philip Morris
State Express 555, Lucky Strike, Benson & Hedges, Rothmans
Mild Seven, Salem
also: Altadis (SEITA & Tabacalera , formerly monopolies in France & Spain);
Imperial (UK), incl. Reemtsma (Germany) ; ITC (India - part-BAT); Gallaher (UK); Tekel (Turkey – monopoly, to be sold), Sampoerna (Indonesia), KT&G (S Korea), etc
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Tobacco companies’ sales &developing countries’ gross domestic product (GDP)
BAT
JT
Imperial
Algeria
Morocco
Tunisia
Kenya
Senegal
Mauretania
Philip Morris
0 10 20 30 40 50 60 70 80 90 100 110
US$ Billions
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Tobacco cessation:
- helping people to stop smoking,in the clinical setting
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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
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Deciding to try to stop
Trying to stop
Stopping
Relapsing
Thinking about stopping
“Contented Smokers”
Never smoking again!
The process of stopping smoking
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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
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Success rate of interventions
8%
15%
25%
0
5
10
15
20
25
30
35
40
Brief intervention Advice & follow-up Intensive therapy 5 minutes per patient 1 hour per patient 3 hours per patient
%
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Number of long-term successes from 50 hours of intervention
Number of patientstreated in 50 hours
Success rate
Brief intervention 600 8%
Advice & follow-up 50 15%
Intensive therapy 17 25%
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Number of long-term successes from 50 hours of intervention
48
48
Intensive therapy Advice & follow-up Brief intervention
5 minutes per patientSuccess rate 8%
1 hour per patient Success rate 15%
=/< 5 minutes / patient
Success rate 8%
3 hours per patient
Success rate 25%
1 hour per patient
Success rate 15%
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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)