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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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)

13. 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

14. 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

15. Questions and responses to the points raised