1. Robert West University College London WCTOH Washington 2006
Behavioural and pharmacological approaches to treating smokers: the state of the art
Robert West
University College London
WCTOH Washington 2006

2. Outline The need for treatment The goals of treatment
The effectiveness of treatment
The future of treatment

3. The need for treatment
Repeated nicotine from cigarettes interacts with other smoking stimuli to generate:
impulses to smoke generated by smoking cues
a ‘drive’ to smoke somewhat resembling hunger
unpleasant physical and psychological symptoms associated with not smoking
feelings of attraction to smoking
positive evaluations of smoking
These act at all levels of the motivational system and overwhelm, undermine and subvert self-conscious decisions to become a non-smoker

4. Motivation to smoke Smoking Cues Impulse to smoke Anticipated
enjoyment
Nicotine ‘hunger’
Desire to smoke
Need to smoke
Adverse mood
and physical
symptoms
Expected benefit
Positive evaluation
of smoking
Smoker ‘identity’
Functional beliefs
Derived from PRIME Theory of motivation:

5. The role of treatment
After some days or weeks of abstinence most of these motivational forces tend to diminish in frequency and intensity, but ...
the rate of decay is variable
upsurges are common
sometimes they persist indefinitely
The goal of treatment:
to keep the moment-to-moment motivation to smoke lower than the motivation to to at all times until the motivational system ‘recovers’

6. Schematic of the moment-to-moment flux of motivation to smoke
Action threshold
(restraint, competing
motives)
Lapses
Impulse to smoke
Day 1
Day 2
Day 5
Day 10
Day 20

7. Potential treatment targets
Minimising frequency and intensity of motivation to smoke:
Minimise the strength of the drive to smoke
Minimise frequency and intensity of cue-driven impulses to smoke
Minimise adverse mood and physical symptoms
Undermine smoker identity
Undermine functional beliefs about smoking
Foster adaptive mental or physical responses to smoking triggers
Raising the action threshold
Maximise social pressure not to smoke
Maximise negative feelings about smoking (disgust, worry etc.)
Foster an ‘in-control’, ‘non-smoker’ identity
Foster functional beliefs about not smoking
Preserve mental energy needed for self-control
Foster alternative behaviours

8. Assessing treatment outcome
Ultimate goal is usually ‘permanent remission’ (Peter Selby)
Self-report of continuous abstinence for 6 months, biochemically verified, usually allows reliable estimation of this (Russell Standard1)
permanent remission rate~50% RS6M
‘Point-prevalence’ estimation and estimation for shorter time periods are less reliable
The key effect-size measure is difference in the proportion of smokers abstinent in treatment versus control conditions
1West et al, Addiction 2005

9. Effect of face-to-face individual support
Using only studies with ≥6 months’ continuous abstinence
and biochemical verification

10. Effect of group support
Using only studies with ≥12 months’ continuous abstinence
and biochemical verification

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

12. Effect of tailored internet support
Not biochemically verified

13. 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)

14. 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

15. Treatment options
Enrol in a structured, multi-session face-to-face or telephone-based behavioural support programme and (unless contra-indicated):
take varenicline for 12 weeks or longer if required, or
take nicotine patch for 2 weeks prior to quit date then and patch plus an acute form prn for 8 weeks or longer as required, or
take bupropion for 1-2 weeks prior to quit date and then for up to 8 weeks
Use Rx medications under clinical supervision with additional help packages supplied
Use NRT OTC with help packages supplied

16. Costs and benefits Costs Benefits
Treatments to aid cessation carry very low risk
Behavioural treatments require some investment of time and effort on part of smokers
Side effects of medications vary but are generally mild
Cost per treatment episode could range from $200 for medication or behavioural support only to $800 for extended combined treatment
Benefits
Approximately 2 to 10 percentage point improvement in chances of ‘permanent remission’ (50% of effect on 6m abstinence)
Most successful quitters arising from the treatment gain an average of 3 to 6 healthy life years depending on their age and current state of health

17. The future of treatment
More effective use of existing treatments
combinations
pre-treatment
longer term use if required
wider access
Better treatments
novel medications
cheaper medications
more comprehensive behavioural treatments
A realistic goal
25% of quit attempts that would have failed, lasting for at least 6 months