Clinical support to aid smoking cessation

1. Clinical support to aid smoking cessation Robert West Oslo University College London March 2007

2. What is the role of the clinician in smoking cessation? • Clinicians should: • not get involved in discussing smoking • raise the topic of smoking with patients • Clinicians should: • tell smokers to stop • advise smokers to stop • Clinicians should • raise the topic of smoking only with those with smoking-related symptoms • raise the topic of smoking with all smokers • Clinicians should: • not routinely offer to prescribe medication to help patients to stop • routinely offer to prescribe medication to help patients to stop • Clinicians should • offer to provide behavioural support to help smokers to stop • find out about and encourage smokers to use other behavioural support packages

3. Outline • Understanding addiction to cigarettes • How smokers become ex-smokers • Injecting urgency into the process of smoking cessation • What can be achieved through good clinical care • The clinician’s role

4. What is addiction? • ‘Addictions’ are activities to which individuals attach an unhealthy priority because of a disordered motivation system • ‘Dependence’ refers to the multi-faceted nature of that disorder • The disorder may involve combinations of: • strong stimulus-driven ‘impulses’ • strong ‘needs’ and ‘wants’ • weak motivations to exercise restraint • reduced capacity to exercise restraint The ‘motivational system’

5. How does addiction show itself? • Addiction can show itself in various ways depending on the activity concerned: • Other activities and goals necessary for healthy functioning and fulfilment may be subordinated to the addictive behaviour • Individuals are unable to exercise restraint when they try • Individuals may experience powerful wants, needs or urges to engage in the activity • The individual may experience anxiety and conflict about continuing engaging in the behaviour

6. Mechanism 1: cue-driven impulses • When nicotine is absorbed it attaches to nicotinic acetylcholine receptors in the Ventral Tegmental Area (VTA) of the mid brain • This stimulates firing of neurons that project forward to the Nucleus Accumbens (NAcc) • This causes dopamine release in the NAcc • This leads to impulses to smoke in the presence of smoking ‘cues’ (e.g. being offered a cigarette) Nucleus accumbens Ventral tegmental area

7. Mechanism 2: acquired ‘drive’ creating a need to smoke • In many smokers, after repeated ingestion of nicotine, the motivational system is altered to create a ‘drive’, somewhat similar to hunger, except that it is for nicotine • The drive increases in the minutes to hours since the last cigarette and is influenced by triggers, reminders, stress and distractions • The drive is experienced as feelings of ‘need’ to smoke • The drive reduces over weeks of not smoking but in some cases does not disappear completely Simplified schematic of development of an acquired drive

8. Mechanism 3: mood and physical symptoms creating a need to smoke • After repeated nicotine exposure, abstinence results in unpleasant withdrawal symptoms including depression • Smokers also report that smoking helps them cope with stress • Adverse mood therefore comes to generate a need to smoke

9. Nicotine dependence Smoking Impulse to smoke Cues/triggers Anticipated pleasure/ satisfaction Desire to smoke Need to smoke Nicotine ‘hunger’ Unpleasant mood and physical symptoms Anticipated benefit Reminders Positive evaluations of smoking Smoker ‘identity’ Beliefs about benefits of smoking Plan to smoke Nicotine dependence involves generation of acquired drive, withdrawal symptoms, and direct simulation of impulses through habit learning

10. What this means in populations

11. The process of stopping smoking: changes in identity I smoke ... ... and I am happy about my smoking I am not even thinking about giving up I will give up some time ... but I am not happy about my smoking I have made plans to give up I do not smoke ... I am trying to give up smoking I am giving up smoking I have given up smoking but not completely I have given up smoking completely

12. While smoking ...

13. Motivation to stop smoking Quit attempt Habit/instinct Impulse to make a quit attempt Cues/triggers Choice Anticipated self-respect Desire to stop smoking Need to stop smoking Fear of ill-health/death Disgust, annoyance with smoking Felt stigma Anticipated praise Reminders Positive evaluations of stopping smoking Non-smoker ‘identity’ Beliefs about benefits of stopping smoking Only the flow of influence towards responses are shown

14. Resistance to stopping smoking Not making attempt Habit/instinct Inhibition of making a quit attempt Cues/triggers Choice Anticipated enjoyment of smoking Desire not to make attempt Need not to make attempt Anticipated loss of benefits Fears of failure Anticipated effort Anticipated benefits of smoking Negative evaluations of making attempt Reminders Beliefs about likelihood of failure Smoker ‘identity’ Only the flow of influence towards responses are shown

15. While not smoking

16. Motivation to smoke Smoking Habit/instinct Impulse to smoke Cues/triggers Choice 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 Only the flow of influence towards responses are shown

17. Inhibition of smoking Not smoking Habit/instinct 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 Beliefs about benefits of not smoking Non-smoker ‘identity’ Plan not to smoke Only the flow of influence towards responses are shown

18. The urgency of smoking cessation • Every year of smoking: • damages lung function irreparably potentially leading to COPD later in life • after the age of 35-40 years reduces life expectancy by 3 months • increases the irreversible risk of lung cancer • Stopping at 35 prevents 9 years’ loss of life expectancy • Stopping at 60 prevents 3 years’ loss of life expectancy • Stopping smoking is always urgent but never too late

19. GP attitudes • Helgasen & Lund (2002) • 2000+ GPs in Norway, Sweden, Iceland & Finland • Agreed that discussing smoking is part of the job but … • tended to limit advice to those with smoking-related symptoms • did not typically provide support • because … • too time-consuming • very low success rate • lack of specialists to refer on to

20. Creating the decision to stop • Generate motivational tension by: • frequent or persistent, high levels of want and need to make the change now • hope that the attempt to change will be successful • Trigger impulses to make the change attempt by: • repeated calls to immediate action • modelling the behaviour

21. Opening lines • When was the last time you tried to stop smoking? • How long did it last? • What did you use to help? • What led you to back to smoking? • It’s always worth having another go and there are lots of options to suit individual smokers which have been proved to help in research. Would you like to discuss these?

22. Supporting the decision to stop • Reduce the frequency and intensity of impulses, needs and wants to revert • Identify the sources of impulses and needs • Develop a specific plan in each case to avoid, escape or minimise these • Generate a strong commitment to a new identity with clear boundaries • Foster the ‘complete non smoker’ identity (smoking is not even an option, re-evaluation of place of smoking in their life) • Deal with lapses by re-asserting the new identity • ‘One day at a time’ • Maximise both intrinsic and extrinsic motives for not smoking (e.g. avoiding shame, gaining self-respect)

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

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

25. Effect of telephone counselling Cochrane review: >6 month cessation not validated

26. Effect of tailored internet support Not biochemically verified

27. 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)

28. 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

29. Success rates up to 6 months: ATTEMPT cohort study 100 100 90 80 70 60 Percent still abstinent No aid 50 NRT 40 40 30 23.5 21.7 20 12.7 11.8 10.9 10 6.6 4.6 0 0 30 60 90 120 150 180 Days Significant differences between NRT and no aid at all points, p<.05

30. Odds Ratio (95% CI) V vs P 2.82 (2.06, 3.86; P<0.0001) V vs B 1.56 (1.19, 2.06; P<0.0013) B vs P 1.80 (1.29, 2.51; P<0.0004) 50 VareniclineBupropionPlacebo 45 40 35 30 25 20 15 10 5 0 Comparative studies: abstinence data 40 30 22.5% Responders(%) CA rate (%) 20 15.7% 9.4% 10 0 Varenicline 1 mg bid(n=692) Bupropion150 mg bid(n=669) Placebo(n=684) 12 16 20 24 28 32 36 40 44 48 52 Week Gonzales DH, Rennard SI, Billing CB, et al. A pooled analysis of varenicline: an α4β2 nicotinic receptor partial agonist vs. bupropion for smoking cessation. SRNT Paper sessions PA9-2, PA9-3, 2006.

31. Cumulative effects of using effective cessation treatment If quit attempts are made every year

32. Hypertension and nicotine dependence treatment • Hypertension • Routinely measure blood pressure • Apply continuing stepped-care model until it is under control • Nicotine dependence • Routinely assess smoking status • Apply continuing stepped care model until it is eliminated or under control

33. Conclusions • Nicotine dependence mostly involves acquisition of cue-driven impulses, need for relief from an acquired ‘nicotine hunger’ and mood and physical symptoms • The process of stopping involves tension arising from dissatisfaction with smoking and triggers prompting quit attempts and then different tensions and triggers promoting lapse and relapse • Nicotine dependence is treatable with behavioural and pharmacological methods • The clinicians role is to trigger quit attempts, motivate the use of effective treatments and continue the process until the smokers successfully quits

34. What is the role of the clinician in smoking cessation? • Clinicians should: • not get involved in discussing smoking • raise the topic of smoking with patients • Clinicians should: • tell smokers to stop • advise smokers to stop • Clinicians should • raise the topic of smoking only with those with smoking-related symptoms • raise the topic of smoking with all smokers • Clinicians should: • not prescribe medication to help patients to stop • prescribe medication to help patients to stop • Clinicians should • offer to provide behavioural support to help smokers to stop • find out about and encourage smokers to use other behavioural support packages

35. Reading • West R & Shiffman S (2007) Fast Facts: Smoking Cessation (2nd Edition). Oxford, Health Press