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

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

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!

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

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

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.

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.

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.

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

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

Tobacco cessation:

- helping people to stop smoking,in the clinical setting

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

Deciding to try to stop

Trying to stop

Stopping

Relapsing

Thinking about stopping

“Contented Smokers”

Never smoking again!

The process of stopping smoking

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

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

%

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%

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%

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)