1 Encouraging and helping smokers to stop: the science and the practice University College London Feburary 2011 Robert West

2 Topics Smoking cessation and smoking prevalence in England Best practice in smoking cessation support Current practice in smoking cessation support How to protect and enhance NHS smoking cessation support

3 Fewer than 25% of smokers in England stop before smoking shortens their life Moving average of 5 years. Green Line: A-C1; Blue Line: C2-E, Red Line: All Watershed of death

4 Attempts to stop smoking have declined since 2007 … Data from Smoking Toolkit Study; p< for decline; N=19,503

5 … as has the percentage of smokers who report having stopped in the past 12 months Data from Smoking Toolkit Study; p< for decline; N=19,503

6 Decline in smoking prevalence has stalled since the recession started

7 Smoking prevalence : social grade A-C1 A-C1: professional to clerical C2-E: skilled manual to long-term unemployed

8 Smoking prevalence : social grade C2-E

9 Clinical interventions are effective at improving success rates Data from Cochrane reviews; statistically significant effects with combined sample size >1000 and no significant heterogeneity Compared with placebo when added to group or individual support Compared with brief advice or written materials

10 Some treatments are better than others Data from Cochrane reviews; statistically significant effects with combined sample size >1000 and no significant heterogeneity

11 Highest success rates lie with using the NHS Stop Smoking Services Significantly better than no aid adjusting for confounding variables, p<0.001 Data from based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939www.smokinginengland.info

12 Very few smokers use the most effective methods Percentage of quit attempts using different methods; data from Smoking Toolkit Study: N=7,808

13 GPs are not helping as much as they could Percentage of smokers and recent ex-smokers for whom …; data from Smoking Toolkit Study, N=4,090

14 GP offer of support is associated with higher rates of attempt to stop

15 Performance of the NHS Stop Smoking Services varies considerably Impact=Number of 4-week, CO-verified quitters generated above what would have been expected from medication alone (25% success rate) per 100,000 adult population: Data from Information Centre Negative impact means less than 25% CO-verified success rate

16 Principles underlying treatment Resolve not to smoke Urge/need to smoke Maximise resolve: ‘Not a puff rule’ Ex-smoker identity Social contract Personal satisfaction Minimise urge/need: Avoid cues Reduce physiological need Distraction/coping To keep the motivation not to smoke above the motivation to smoke at all times

17 Planning behavioural support Pre-quit session Quit date session Post-quit sessions Closing session 45 mins, engagement, assessment, preparation 30 mins, review, motivation, confidence, action planning 30 mins, review, motivation, problem solving 30 mins, review, motivation, problem solving, closure

18 What is behavioural support? Advice, discussion and materials aimed at helping smokers to stop Four components (MASS): 1.Addressing motivation Maximising motivation to remain abstinent and minimising motivation to smoke 2.Promoting optimal use of adjunctive activities Helping smokers to make best use of medication or other quitting aids 3.Maximising capacity for self-regulation Helping smokers avoid, minimise or resist urges to smoke 4.Activities that support the above Establishing rapport, undertaking assessment, engaging the smoker, tailoring the support plan to the smoker’s needs

19 Addressing motivation Provide information on consequences of smoking and smoking cessation Boost motivation and self efficacy Provide feedback on current behaviour and progress Provide rewards contingent on successfully stopping smoking Provide normative information about others' behaviour and experiences Prompt commitment from the client there and then Provide rewards contingent on effort or progress Strengthen ex-smoker identity Conduct motivational interviewing Identify reasons for wanting and not wanting to stop smoking Explain the importance of abrupt cessation Measure carbon monoxide (CO) Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

20 Maximising self-regulatory capacity Facilitate barrier identification and problem solving Facilitate relapse prevention and coping Facilitate action planning/develop treatment plan Facilitate goal setting Prompt review of goals Prompt self-recording Advise on changing routine Advise on environmental restructuring Set graded tasks Advise on conserving mental resources Advise on avoidance of social cues for smoking Facilitate restructuring of social life Advise on methods of weight control Teach relaxation techniques Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red Facilitate barrier identification and problem solving Facilitate relapse prevention and coping Facilitate action planning/develop treatment plan Facilitate goal setting Prompt review of goals Prompt self-recording Advise on changing routine Advise on environmental restructuring Set graded tasks Advise on conserving mental resources Advise on avoidance of social cues for smoking Facilitate restructuring of social life Advise on methods of weight control Teach relaxation techniques

21 Promote use of adjunctive activities Advise on stop-smoking medication Advise on/facilitate use of social support Adopt appropriate local procedures to enable clients to obtain free medication Ask about experiences of stop smoking medication that the smoker is using Give options for additional and later support Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

22 Supportive activities: general and assessment Tailor interactions appropriately Emphasise choice Assess current and past smoking behaviour Assess current readiness and ability to quit Assess past history of quit attempts Assess withdrawal symptoms Assess nicotine dependence Assess number of contacts who smoke Assess attitudes to smoking Assess level of social support Explain how tobacco dependence develops Assess physiological and mental functioning Blue: present in 2+ BSPs tested by RCTs

23 Supportive activities: communication Build general rapport Elicit and answer questions Explain the purpose of CO monitoring Explain expectations regarding treatment programme Offer/direct towards appropriate written materials Provide information on withdrawal symptoms Use reflective listening Elicit client views Summarise information / confirm client decisions Provide reassurance Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs

24 Broad treatment characteristics associated with greater success Brose et al (submitted) Data from 126,000 smokers attending 24 Stop- Smoking Services Association between treatment characteristics and 4-week CO-verified success rates adjusting for smoker characteristics Results –Use of varenicline or dual NRT > single NRT –Group > individual –Specialist clinic > primary care

25 Protecting and enhancing smoking cessation support 1.Focus on ‘impact’ rather than sheer number of 4-week quitters 2.Independent audit of claimed 4-week-quitters 3.Clear commissioning guidelines specifying the kind of provision required

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