1 What can the experience of combatting tobacco addiction tell us about better ways of addressing other addictions? University College London March 2014 Robert West

Declaration of competing interest I undertake research and consultancy for companies that develop and manufacture smoking cessation medicines and licensed nicotine products I am a trustee of the charity, QUIT I am an honorary co-director of the National Centre for Smoking Cessation and Training My salary and most of my research is funded by Cancer Research UK 2

Overview 1.What is needed to change behaviour? 2.Interventions and policies to reduce tobacco use 3.Implications for combating other addictive behaviours 3

What is needed for behaviour to change To change the incidence of a behaviour there must be a change in one or more of... 4 Capability:physical and psychological abilities underlying the behaviour Opportunity:environmental factors that stimulate or inhibit behaviour Motivation:mental processes that energise and direct behaviour … relating to the target behaviour or other behaviours that compete with or support it

Knowledge Skill Strength Stamina Educate about ways of enacting the desired behaviour or avoiding the undesired one Train in cognitive, physical or social skills required for the desired behaviour or avoid the undesired one Train or enable development of mental or physical strength required for the desired behaviour or to resist the undesired one Train or enable endurance required for desired behaviour or sustained resistance to undesired one Influencing capability

Time Resources Cues/prompts Train or restructure the environment to reduce time demand or competing time demands for desired behaviour (and additionally use time restrictions to reduce undesired behaviour) Restructure the environment to increase financial or other resources, social support and cultural norms for desired behaviour (and additionally use restrictions to reduce access to undesired behaviour) Restructure the environment to provide cues and prompts for desired behaviour (and converse for undesired behaviour) Influencing opportunity Concepts Restructure the social environment or use modelling to shape people’s ways of thinking

Plans Evaluations Motives Impulses/inhibition Responses Educate or train to form clearer personal rules/action plans, and train to remember and apply the rules when needed Educate or persuade to create more positive beliefs about desired, and less positive ones about undesired, behaviour Persuade, incentivise, coerce, model or enable to feel attracted to the desired behaviour and less attracted to the undesired one Train or enable to strengthen habitual engagement in the desired behaviour or weaken the undesired one Model desired behaviour to induce automatic imitation Influencing motivation

Education What is the scope for improving understanding of –the harms of smoking? –how best to stop smoking? 8

Aids used in most recent quit attempt 9 N=4,810 adults who smoke and tried to stop or who stopped in the past year

Tobacco control: education TargetScope for improvement Understanding of harmfulness of smokingModerate Best ways of stopping smokingHigh 10 Pharmacy tip: advise on best ways of stopping

Persuasion, incentivisation and coercion What is the scope for increasing how much smokers –feel they want or need to stop smoking? –feel concerned about harms of smoking? –feel concerned about cost of smoking? 11

Relation between consumption (pounds sterling billion at 1992 prices) and real price (1992=1.0) of cigarettes in Britain during Townsend J et al. BMJ 1994;309: ©1994 by British Medical Journal Publishing Group

13 Smoking concerns and quit attempts among smokers in England Final model from forward stepwise logistic regression of attempt to stop in past 12 months on to beliefs about smoking. Odds ratios less than 1 represent negative associations. N=5647; Source: Smoking Toolkit Study

14 Desire to stop of smokers in England N=6,000+ Source: Smoking Toolkit Study

15 Concerns of smokers in England N=15,000+ Source: Smoking Toolkit Study

Tobacco control: persuasion, incentivisation and coercion TargetScope for improvement Feeling of wanting to stop smokingModerate Feeling of need to stop smokingModerate Concern about cost of smokingModerate Concern about health effects of smokingModerate Concern about effect of smoking on friends and familyModerate Concern about stigma from smokingModerate 16 Pharmacy tip: reinforce messages about immediate benefits of quitting

Training How far can we usefully improve –the planning skills needed to stop smoking? 17

Abrupt versus gradual quitting among smokers in England Quitting abruptly: 49.2% Odds of success for abrupt versus gradual: 3.2, p<0.001 N=901. Adjusting for baseline age, gender, social grade, cigarette dependence, use of quitting aids, motivation to quit, time since quit attempt, previous quit attempts. Smoking Toolkit Study 18

Tobacco control: training TargetScope for improvement Planning skills for stopping smokingModerate 19 Pharmacy tip: advise smokers to stop abruptly

Restriction What further scope is there for –restrictions in availability of smoking? –restrictions in locations where smoking is permitted? 20

Effect of raising the age of sale from 16 to 18 years in England 21 Fidler et al (2010) Addiction, 105, 1984

22 Smoking prevalence before ‘smoke-free’

23 Smoking prevalence immediately after ‘smoke-free’

24 Smoking prevalence to Jan

Decrease in smoking prevalence in England following smokefree legislation 25 Base: All adults

Tobacco control: restriction TargetScope for improvement Restrictions on getting cigarettesHigh Restrictions on where smoking is permittedModerate 26 Pharmacy tip: advise on use of nicotine products when cannot smoke

Environmental restructuring How much further can we go in –limiting availability of smoking? –limiting prompts and cues for smoking? –making smoking non-normative? –providing triggers for stopping smoking? 27

Effect of advertising ban in UK on awareness of tobacco marketing 28 Harris et al (2006) Tobacco Control suppl 3 26

Smoking prevalence and quit attempts following introduction of graphic health warnings in Canada Azagba S, and Sharaf M F Nicotine Tob Res 2013;15: © The Author Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please

Tobacco control: environmental restructuring TargetScope for improvement Limited availability of cigarettesHigh Limited prompts to smokeHigh-Moderate Exposure to triggers to stop smokingHigh-Moderate 30 Pharmacy tip: use point of sale materials to trigger quitting

Enablement How much further can we help to –limit drives and impulses to smoke? –help smokers with self-regulation? 31

Medications: efficacy 32 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

Behavioural support: efficacy 33 Stead et al 2012, Cochrane 1 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

Tobacco control: enablement TargetScope for improvement Effectiveness of stop smoking medicinesModerate Effectiveness of alternative nicotine productsHigh-moderate Effectiveness of stop smoking advice/supportModerate Access to stop smoking medicinesHigh-moderate Access to stop alternative nicotine productsHigh-moderate Access to behavioural supportHigh-moderate 34 Pharmacy tip: offer specialist support and expert advice for quitting

Helping smokers to help themselves by bring the science of stopping to smokers 35

Cigarette smoking prevalence 36 Graph shows prevalence estimate and upper and lower 95% confidence intervals Base: All adults

Decrease in smoking prevalence 37 Base: All adults

Stopped smoking in past 12 months 38 Graph shows prevalence estimate and upper and lower 95% confidence intervals Base: Adults who smoked in the past year

Tried to stop smoking in past year 39 Graph shows prevalence estimate and upper and lower 95% confidence intervals Base: Adults who smoked in the past year

Success rate for stopping in those who tried 40 Graph shows prevalence estimate and upper and lower 95% confidence intervals Base: Smokers who tried to stop n the past year

Aids used in most recent quit attempt 41 N=4,810 adults who smoke and tried to stop or who stopped in the past year

What about other addictive behaviours? Should policies follow tobacco control? –Run mass media campaigns –Promote brief advice from health professionals –Impose moderately high duty and control illicit supply –Partially stigmatise use –Permit widespread sale –Impose legal age of sale –Restrict marketing –Restrict locations where can be used –Require warning labels on packets –Provide treatments to aid cessation 42

Is this a success story? 43

Is this a success story? Lim et al 2012 Lancet

Conclusions Tobacco control is probably not a great example of how to combat a lethal addictive behaviour Most of the potential levers of change to combat tobacco use is being applied in most of society at best to a moderate degree Pharmacy can do more to reach more smokers with expert professional advice on: –best ways of stopping –how to use medicines effectively –where feasible, providing specialist support 45

46 Commercial interests and political indifference

47 Tobacco control policies