What is the most we can achieve with behavioural support for smoking cessation? Robert West University College 1

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3 Declaration of interests I undertake research and consultancy for companies that develop and manufacture smoking cessation medications I am a trustee of QUIT I am co-director of the NHS Centre for Smoking Cessation and Training My salary is funded by Cancer Research UK

Current evidence: medication 4 Stead et al 2008, Cahill et al 2012, Cochrane Varenicline: N=6,166 Single NRT: N=51,265 Dual NRT: 4,664 NRT for ‘reduce to quit’: N=3,429 95% confidence intervals from meta- analyses Hughes et al 2008, Cahill et al 2012, Cochrane Bupropion: 11,440 Nortripyline: N=975 Cytisine: N=937 95% confidence intervals from meta- analyses

Current evidence: behavioural support 5 Stead et al 2012, Cochrane Pro-active telephone vs reactive: N=24,994 Individual vs brief advice: N=7,855 Group vs self-help: N=4,375 Internet vs nothing: N=2,960 Text messaging versus control messages: N=9,110 Written materials: N=15,117 95% confidence intervals from meta- analyses Depends crucially on the specific intervention Generally found to be effective Figures are not directly comparable because of different samples and comparison conditions

Network meta-analysis 6 Cahill et al (2013) Cochrane Library

Achievable outcomes 7 VareniclineNRT Randomised controlled trials % (24+ weeks 1 )21.0% (26+ weeks 1 ) Prague smokers clinic (Data supplied 3 ) 42.6% (52 weeks 1 ) (95% CI ) 33.4% (52 weeks 1 ) (95% CI ) 1.Continuous abstinence verified by expired air carbon monoxide 2.Cahill et al Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 3 (2008); Stead et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev (2012). 3.Data used with kind permission from Eva Kralikova ( )

Urge versus resolve: the task when stopping smoking 8

Dynamic systems model of smoking lapse 9 West and Rivera – under construction

Reducing urge and increasing resolve 10 1.Reduce exposure to smoking cues 2.Reduce sensitivity to smoking cues 3.Reduce drive to smoke 4.Reduce impact of lapse 5.Reduce access to smoking 6.Reduce smoker identity 1.Increase desire not to smoke 2.Provide substitute 3.Improve mood 4.Improve morale 5.Increase non- smoker identity 6.Improve resolve responsiveness

Factors affecting outcomes Intervention Mechanism of action Outcome UsageContext Influences Moderates influence Adapted from Michie and West (2015) Under review

Options for improving interventions Add new components Improve components Combine components Remove components 12

Interventions 13 Intervention Content Delivery Mode Behaviour Change Techniques Fidelity Adjunctive treatment

Behaviour Change Techniques (BCTs) 14 Irreducible components of behaviour change interventions

What behaviour change techniques (BCTs)? Regulation Pharmacological support Reduce negative emotions Conserve mental resources Paradoxical instructions Goals and planning Goal setting Problem solving Action planning Behavioural contract Commitment 15

What behaviour change techniques (BCTs)? Feedback and monitoring Self-monitoring of outcomes Feedback on outcomes of behaviour Social support Social support (practical) Social support (emotional) Shaping knowledge Information about antecedents Re-attribution Behavioural experiments 16

What behaviour change techniques (BCTs)? Natural consequences Information about health consequences Salience of consequences Information about social and environmental consequences Monitoring of emotional consequences Anticipated regret Information about emotional consequences 17

What behaviour change techniques (BCTs)? Comparison of behaviour Social comparison Information about others’ approval Associations Reduce prompts/cues Remove access to the reward Remove aversive stimulus Satiation Covert learning Imaginary punishment Imaginary reward 18

What behaviour change techniques (BCTs)? Repetition and substitution Behaviour substation Habit reversal Graded tasks Comparison of outcomes Credible source Pros and cons Comparative imagining of future outcomes 19

What behaviour change techniques (BCTs)? Reward and threat Material incentive (behaviour) Social reward Social incentive Self-incentive Incentive (outcome) Self-reward Reward (outcome) Future punishment 20

What behaviour change techniques (BCTs)? Identity Identification of self as role model Framing/reframing Incompatible beliefs Valued self-identity Identity associated with changed behaviour Self-belief Verbal persuasion about capability Focus on past success Self-talk 21

Prague smokers clinic week continuous abstinence rate with varenicline: 42.6% (95% CI ) 1.Non-manual occupation 46.9% 2.Mild to severe depression (BDI-II): 24.5% 3.Schizophrenia: 0.6% 4.Tried to quit before: 90.3% 5.Female: 44.8% 6.Mean FTND: Mean cigs per day: 23.4

Conclusions Randomised trials tell us that we can achieve 25%-30%, long-term success with right medication choice plus behavioural support There remain multiple options for improving on this based on understanding what drives relapse The Prague Smokers Clinic has achieved 12-month CO- verified abstinence rates of >40% with varenicline and >30% with NRT, despite having highly dependent smokers Would be worth looking closely at what they do for clues as to how to improve outcomes 23