Everything you wanted to know about smoking cessation ... Robert West University College London East Kent, July 2006

Topics What really goes on in the process of stopping smoking? What this means for treatment Is there a role for telephone support? Is there a role for the internet? Physical activity to aid cessation Making the most of NRT What is the latest on Zyban? Watch out for varenicline Why isn’t smoking prevalence going down more quickly? Unproven stop-smoking gadgets and methods Roll-ups, cigars and pipes Professional development and data gathering

The process of stopping smoking

Attempts to stop smoking These are switches in ‘identity’ from ‘smoker’ to any of: ‘smoker attempting to stop’ ‘smoker trying not to smoke’ ‘would-be non-smoker’ ‘definite non-smoker’ etc. These switches come about at the moment when the want and/or need for the new identity is stronger than the want and/or need for the status quo coupled with inertia

The process leading up to quit attempts: Tension Smokers experience varying degrees of want or need (when it enters their consciousness) to ‘do something’ about their smoking because of their perceptions of its harmful effects That ‘motivational tension’ comes into and out of existence at varying levels of intensity over the course of any given day or week Those wants or needs stimulate a mental response to decrease that tension; this is usually no more than having a vague idea of quitting or reducing or simply thinking about something else

The process leading up to quit attempts: Triggers If the tension is sufficiently high and/or the mental response supporting the status quo is unavailable or not strong enough, a change will take place which involves either make an immediate quit attempt or planning a definite quit point for the future. The quit attempt will be ‘triggered’ If the quit attempt is planned for a future time point, then that plan will need to generate a want or need at the time that is sufficient to trigger the action in the face of other motives present

Identity and behaviour in smoking cessation Attempting to stop Identity Not smoking Behaviour Cigarettes Time

Success of quit attempts The new identity must generate wants and needs that are powerful enough to counter impulses wants and needs arising from the disposition to smoke whenever these arise As time passes, the impulses, wants and needs to smoke will usually decrease to some degree because of physiological ‘normalisation’ and so the degree of self-control required will diminish However, habituation will often also decrease the wants and needs not to smoke

Causes of relapse: same day Same-day relapse is most often a result of the new identity being too unstable to withstand the relatively modest wants and needs to smoke arising from pharmacological dependence and/or social situations But it can arise from powerful pharmacological impulses, want or needs or instabilities in the system or events that precipitate heightened wants, needs or impulses

Relapse: Early weeks Relapse in the early weeks is most often a result of strong wants and needs arising from pharmacological dependence with social and other motives superimposed on this But it can result from instabilities in the system, ‘moments of weakness’, low levels of motivational resources required to exercise self-control, persistence of wants or needs to smoke that deplete motivational resources, or events that precipitate acute wants, needs or impulses.

Relapse: Late Late relapse is most often a result of a failure of the new identity to achieve sufficient stability at all times to overpower the relatively modest and infrequent momentary motives to smoke – the main problem being that over an extended period the chances of even a relatively modest motivation to smoke failing to provoke sufficient self-control is quite high But for some smokers, the wants and needs to smoke do not diminish sufficiently, either because of continued positive evaluations of smoking, attachment to a smoker identity, continued pharmacologically based needs, or a failure for the learned habit to weaken

The process of relapse: early weeks Strength of impulse/inhibition Strength of impulse is higher than inhibition Smoke Time

The process of relapse: late relapse Strength of impulse/inhibition Strength and frequency of impulses decline but so does inhibition Smoke Time

What this means for treatment

The goal of treatment The goal is simple: make sure that any impulse to smoke is overpowered an inhibitory force Medication can reduce the drive to smoke and possibly acute stimulus-driven impulses arising from simple pharmacological needs and habits The goal of psychological treatment is to manage the rest of the motivational system minimise impulses, wants, needs and evaluations promoting smoking maximise wants, needs and evaluations inhibiting smoking

Minimising motivation to smoke Advise on minimising exposure to smoking triggers and maximise ‘effort to smoke’ Find out about and undermine smoker identity Find out about and undermine positive evaluations about smoking Advise on/train mental and physical activities that minimise the need to smoke Advise on/train mental and physical activities that distract attention from the need to smoke

Maximising motivation not to smoke Generate social pressure not to smoke Advise on/train methods of triggering negative feelings about smoking Foster a strong non-smoker identity Foster a strong ‘in control’ identity Advise on how to trigger that identity in tempting situations

Is there a role for telephone support?

Effect of telephone counselling Cochrane review, in preparation: >6 month cessation not validated

Is there a role for the internet?

Effect of tailored internet support Not biochemically verified

Physical activity to aid cessation Clear evidence that moderate activity reduces urges to smoke and withdrawal symptoms and the effect lasts for a short while after the activity has finished Some evidence that a course of relatively intensive activity improves cessation rates but studies to date have not found advice regarding moderate activity to have an effect

Making the most of NRT

Effect of NRT Cochrane: LI: Low intensity behavioural support; HI: High intensity behavioural support RTS: Reduce To Stop; Combination: various combinations versus single NRT types; Population: NRT versus no NRT in population samples without behavioural support (ATTEMPT – cohort study, not RCT)

The latest on Zyban It is still unclear whether it is more effective than NRT ZORN trial is due to report early 2007 Allergic reactions appear to be the main cause for concern Extending Zyban treatment beyond 8 weeks does not appear to improve success rates (Killen et al, 2006) One small trial in schizophrenic patients showed effectiveness during use but not afterwards (Evins, 2005) Usage in the UK is very low

Varenicline A ‘partial agonist’ at the alpha4-beta-2 nicotinic receptor: it attaches strongly to the receptor preventing nicotine from attaching to it, and it has a small effect at the receptor (enough to reduce the drive to smoke and withdrawal symptoms) It has been found to be more effective than Zyban

Effect of nortriptyline, bupropion and varenicline For bupropion and nortriptyline data from Cochrane: ≥6 months’ continuous abstinence and biochemical verification; varenicline 6 month continuous abstinence data from JAMA 2006; blue shading shows effect on 12 month continuous abstinence rates of further 12w varenicline vs placebo in smokers abstinence at 12w

Smoking prevalence The decline is very slow – perhaps 0.4% per year There is little evidence that fewer young people are taking up smoking and the quite rate is about 2.5% of smokers per year Treatments can have only a very small effect on this The best bets for making an impact are: 20p on a pack of cigarettes putting more resources into combating smuggling banning smoking in indoor public places much more hard-hitting anti-smoking mass media campaigns

Unproven gadgets and methods Anyone offering a gadget or treatment needs to be able to back up their claims using the same standard of evidence as NRT, Zyban, individual counselling, group support, telephone support or internet support have had to do. The following have not done this: Nicobloc Nicobrevin Acupuncture Acupressure Hypnotherapy Allan Carr

Roll-ups, cigars and pipes Own-roll smoking in the UK is common and increasing The main reason is cost Pipe and cigar smoking add about 2% to the true smoking prevalence

Professional development and data gathering Essential for practitioners to: keep up to date with evidence and methods be reflective about their work monitor their success rates objectively and consider ways of improving these

Smoking cessation quiz What should be recorded when assessing a smoker for treatment? What are the considerations when deciding about pharmacotherapy for clients? What are believed to be the important elements of behavioural support? What is known about the effectiveness of group versus individual treatment? What is known about the effectiveness of techniques for preventing relapse after the initial 4-week treatment programme? What would you say to a GP who wants to know why she should recommend smokers to attend the Stop Smoking Service? What advice should be given to a smoker who is experiencing sleep disturbance on Zyban? What advice should be given to a smoker who wants your help with cutting down? How would you respond to a GP who points out that the Stop Smoking Services don’t appear to have made a dent in smoking prevalence? What advice would you give to a smoker who is still feeling bad at the end of your treatment?