Providing smoking cessation treatment: opportunities and challenges

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Presentation transcript:

Providing smoking cessation treatment: opportunities and challenges Robert West Durham May 2007

Statement of competing interests I undertake research and consultancy for companies the manufacture smoking cessation medications including Pfizer, GSK and Novartis

Outline The national smoking cessation picture Goals of smoking cessation treatment Treatments available and their effectiveness Encouraging smokers to continue to try to stop using effective treatments until they succeed The importance of accurate performance data Response from attendees

The national picture (England) Approximately 45% try to stop each year, many of them several times Approximately 5% of attempts involve the NHS stop smoking services Approximately 35% of quit attempts involve NRT bought over the counter Approximately 2.5% (250,000) of smokers (10 million) stop permanently each year The behavioural support element of the NHS Stop Smoking services probably contributes about 0.13% to this figure (13,000 smokers) at a cost of £3800 per permanent ex-smoker or less than £1000 per life year gained (undiscounted) See www.smokinginengland.info

Conflicting motivations during a quit attempt 1. On each occasion when the would-be ex-smoker is led to think about smoking, he or she experiences an urge to smoke arising from one or more of the following: A habit-driven impulse A need to smoke derived from ‘nicotine hunger’ A need to smoke derived from anticipated relief from negative mood A need to smoke derived from anticipated physical symptoms, e.g. mouth ulcers A desire to smoke derived from anticipated enjoyment or satisfaction A desire to smoke derived from anticipated benefits of smoking, e.g. weight loss 2. This competes with a desire or need for the smoker to stop himself or herself smoking which arises from one or more of: Commitment to the decision not to smoke Commitment to the identity of a non-smoker Worry about health Anticipated guilt or shame at having a cigarette Hope for improvement in health with stopping Anticipated disappointment at having wasted the effort expended thus far Anticipated effort required to acquire a cigarette 3. If the strength of the urge to smoke is greater than the inhibition arising from the desire or need not to smoke, and the opportunity to smoke is present, the would-be ex-smoker will: Smoke a cigarette but consider that the quit attempt is continuing Abandon the quit attempt but try to keep smoking within certain limits Abandon the quit attempt completely

Motivation to smoke Habit/instinct Choice Smoking Impulse to smoke Cues/triggers Anticipated enjoyment Desire to smoke Need to smoke Nicotine ‘hunger’ Unpleasant mood and physical symptoms Anticipated benefit Reminders Positive evaluation of smoking Smoker ‘identity’ Beliefs about benefits of smoking

Inhibition of smoking Habit/instinct Choice Not smoking Inhibition Cues/triggers Choice Anticipated praise Desire not to smoke Need not to smoke Anticipated disgust, guilt or shame Fears about health Anticipated self-respect Negative evaluation of smoking Reminders Non-smoker ‘identity’ Beliefs about benefits of not smoking Plan not to smoke

The goals of smoking cessation treatment To engage as many smokers as possible who could benefit from the treatment Maximise the number of smokers who know about the treatment available Make the treatment options as attractive as possible to smokers without compromising effectiveness Maximise the frequency of triggers that prompt smokers to engage with the treatment service To maximise the chances of permanent cessation with every treatment episode Maximise the numbers of smokers that engage with the most effective treatment options Ensure that the treatment options are implemented optimally

Treatments available and their effectiveness Clients strongly motivated to stop smoking NRT, Zyban or Champix plus: Multi-session group-based behavioural support provided by smoking cessation professionals or Multi-session individual behavioural support provided face-to-face or by telephone by smoking cessation professionals Brief or single session behavioural support provided by health professionals with limited training for whom smoking cessation is a small part of their role and weakly motivated clients Champix is more effective than Zyban and probably more effective than NRT when used as normally directed but the course is longer. It is more expensive but the cost-per life year gained is similar

Continuing engagement with treatment Smokers who use NRT for one quit attempt are very likely to use it again for subsequent quit attempts Re-engagement with NHS services appears to be less common but does occur Smokers who attempt to stop within 3 months of a failed quit attempt are less likely to be successful, other things being equal One study in Leeds (by Maria Spelacy) has found those who are prompted to re-engage with treatment after a gap of 12 months or more have broadly similar success rates (to be presented at the UKNSCC)

The importance of accurate performance data Any operation, whether it be a business or a public service, needs timely access to accurate data on its performance so that it can adjust to changing circumstances and maintain or improve its operations A minimum requirement is regular information on: Awareness of the service in the target population Attractiveness to the target population Numbers of enquiries Numbers of clients Satisfaction rates Success rates Re-engagement rates For each of the elements of the service provided: Management units Individual advisors Types of provision

What are success rates? Start with every smoker who sets a quit date and attends at least one session (N) Four or more weeks after the target quit date find out using a method that minimises bias how many have smoked at all, even a puff, in the past 2 weeks and have an expired air CO at the time of testing of less than 10ppm (S) “Have you smoked at all, even a puff on a cigarette, in the past 2 weeks?” No, Just a few puffs, One or more cigarettes Count the number of clients who you know have moved away or cannot attend the 4-week session for a good reason (D) The success rate is S/(N-D)

Factors that promote service development Collecting and sharing timely and accurate performance data at all the levels necessary Acting in a timely manner on evidence that performance is slipping Willingness to be objective about favoured treatment approaches that might not be optimal High morale

What about ‘smoking reduction’ A majority of smokers are trying to cut down at any one time About 25% of these are using NRT to do so We do not know whether this is successful and in itself reduces health risk but there is evidence that a structured programme of major reduction assisted by NRT leads some smokers to stop It is not known whether it would be cost-effective for SSSs to include this option for smokers who are not ready to stop but in certain very difficult target groups it is worth considering further

Questions and responses to the points raised