london respiratory team changing lifestyles and improving outcomes: reframing the way we think about...

London Respiratory Team

Changing lifestyles and improving outcomes: reframing the way we think about smoking

Dr Louise RestrickLondon RespiratoryTeam Lead

Improving the experience of all Londoners with COPD and minimising the impact of the disease


Does smoking still matter?

2006 by PCT

Smoking Prevalence in London


Does smoking still matter?

‘1 in 5 deaths due to smoking’Health Profile 2010 LondonBased on Ordnance Survey material. © www.healthprofiles.info

Londoners dying from smoking


What more do we know?

Health Profile 2010 LondonBased on Ordnance Survey material. © www.healthprofiles.info

Deprivation in London



COPD and smokingFletcher and Peto British Medical Journal 1977



Effect of Smoking Cessation Intervention on MortalityRandomised Clinical Trial5887 people with airway obstruction over 14.5 years

Anthonisen NR, Skeans MA , Wise RA; Manfreda J, Kanner RE and Connett JEfor the Lung Health Study Research Group* Ann Intern Med. 2005;142:233-239.



Smoking prevalence in COPD

At best one in four Londoners with COPD are still smokers….

No national data since 2006



What does smoking cost?

'Smoking is the single biggest preventable cause of early death and illness. Smoking is estimated to cost the NHS £2.7 billion a year in England.'

The NHS needs to address the gap between the £2.7 billion a year spent on treating smoking related illness and the less than £150 million spent on smoking cessation …..

5% of the NHS 'smoking' budget is currently spent on quit smoking support …


Right Care Respiratory Prescribing?

‘Ensure all patients with COPD are on the appropriate therapy for the severity of, and symptoms from, their disease.’

‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’

NICE 2010



Long-term effectiveness & cost-effectiveness of smoking cessation interventions in patients with COPD

1 year abstinence %

QALY£

Usual care 1.4

Minimal counselling 2.6 14,735

Intensive counselling 6 7,149

Intensive counselling + pharmacotherapy

12.3 2,092

Tiotropium £7,112/QUALYEur J Health Econ. 2007; 8(2): 123135

Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMHThorax 2010: 65:711-718

Pulmonary Rehabilitation £2,000-8,000/QALY



Smoking prevalence in COPDTORCH and Uplift Studies



Quit smoking support with pharmacotherapy..as treatment Right COPD Care

Support and treatment to help people with COPD to stop smoking

Improves survival Is cost-effective

…. the most cost-effective intervention in COPD?

However, there may be even more effective ways of supporting people with COPD to stop smoking…..



Cannabis smoking and respiratory healthDoes it matter?

'About 1 in 5 young adults say they have recently used drugs, mostly cannabis.’

‘Healthy Lives, Healthy People Nov 2010

12% of 11-15 year olds smoke cannabisSmoking, Drinking and Drug Use Among Young People in England in 2000 Boreham R and

Shaw A 2001

‘The 1:2.5 – 5 dose equivalence between cannabis joints and tobacco cigarettes for adverse effects on lung function is of major public health significance.’



Cannabis smoking and COPDInner North London experience

Trachea/wind-pipe

Bullae/holes

CT scan- emphysema

69 year old man 20 pack year smoker Cannabis for 50 years



Cannabis smoking and COPDInner North London experience

1 in 3 tobacco smokers in a hospital population also smoke cannabis* all groups in society – no assumptions! have to ask not volunteered….

History of tobacco and cannabis smoking Younger patients with severe COPD Patients with bullous emphysema Patients with a pneumothorax

*Whittington HospitalAudit Data 2010



Cannabis smoking and COPD

Synergistic damage from marijuana and tobacco.

Marijuana with tobacco increased risk of COPD with >50 ‘joints’.

Tan WC, Lo C, Jong A, Xing L, Fitzgerald MJ, Vollmer WM, Buist SA, Sin DDVancouver BOLD Research Group CMAJ 2009;180:814-20



How do we enable lifestyle changes that will reduce the risks of developing COPD?

Address gaps in information national data collection on prevalence of smoking

in COPD population Health data on prevalence and effects on

(respiratory) health of cannabis smoking What are the most effective ways to help people

with COPD to stop smoking? How do we most effectively help people who

smoke tobacco and cannabis stop smoking?



How do we enable lifestyle changes that will reduce the risks of developing COPD?

Change health professionals beliefs and behaviours ‘Quit smoking support & treatment is core work No place for nihilism/acceptance of smoking as the ‘norm’ Non-judgemental pro-active repeated approach to

supporting smokers quit Ask about cannabis

Better informed public Best treatment for COPD is to stop smoking Never too late to stop smoking Best way to stop smoking is support with pharmacotherapy Respiratory risks of cannabis



A ‘no-smoking practice’

Brief intervention

Moderate intervention

Intense intervention

> 5 mins

<1 min

2-5 mins

IPCRG Smoking cessation guidance for primary care 2007Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: 175-9

But I don’t have time…..

london respiratory team changing lifestyles and improving outcomes: reframing the way we think about...

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