Perspectives on treatment for tobacco addiction

1. Perspectives on treatment for tobacco addiction Robert West University College London Rio de Janeiro November 2006

2. Outline • Motivation to smoke and not to smoke • The treatment strategy • Treatment tactics • Treatment effectiveness • The future of treatment • Treatment in the context of tobacco control

3. 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 evaluations of smoking Smoker ‘identity’ Beliefs about benefits of smoking Motivation to smoke Nicotine dependence involves generation of acquired drive, withdrawal symptoms, strong desires from anticipated enjoyment and direct simulation of impulses through habit learning

4. Inhibition of smoking Not smoking Inhibition Cues/triggers Anticipated praise Desire not to smoke Need not to smoke Anticipated disgust, guilt or shame Fears about health Anticipated self-respect Positive evaluations of not smoking Reminders Non-smoker ‘identity’ Beliefs about benefits of not smoking Plan not to smoke Nicotine dependence also involves impairment of impulse control mechanisms undermining response inhibition

5. The treatment strategy • Best outcome: to cure the smoker so that he or she never feels a strong desire or need to smoke again • Second best outcome: to generate remission so that the smoker at least temporarily does not feel a strong desire or need to smoke • Third best: suppression of smoking completely or partially by reducing the desire or need to smoke or bolstering motivation not to smoke

6. Treatment tactics • Suppress smoking completely using any means, thereby allowing the brain to recover its normal functioning • Changing the way the brain operates so that: • it no longer generates needs, desires and impulses to smoke or these are less frequent or less powerful • it habitually generates strong resistance to smoking impulses

7. 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

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

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

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

11. Effect of tailored internet support Not biochemically verified

12. 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)

13. 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

14. 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

15. Principles underlying policy options: Economic concepts • Financial incentives • Concept: Increase the financial cost relative to ability to pay • Barriers: Social and political resistance, lower affordability of other goods, possible substitution for other incentives, get-arounds • Moral and social incentives • Concept: Increase the feeling of moral and normative pressure • Barriers: Difficult to achieve, risk of backlash, stigmatisation of those that do not change • Personal incentives • Concept: Change balance of perceived personal happiness/ease and discomfort/effort in favour of not smoking • Barriers: Practical and financial constraints may limit reach and effectiveness

16. Principles underpinning policy: Health promotion concepts West, R British Medical Bulletin, In Press

17. Policy options • Price increases • increase taxes • reduce options for cheap smoking • Smoke-free legislation • Increasing access to help with stopping • Mass media campaigns and media advocacy • Warning labels on tobacco packaging • Further work on restricting tobacco promotion • Decreasing youth access to tobacco • School-based programmes See Framework Convention on Tobacco Control; Levy et al (2004) Journal of Public Health Management and Practice, 10, 338-353; West, R British Medical Bulletin, In Press

18. Conclusions • Treatments to aid cessation have a small but important and reliable effect • The aim to work by suppressing the motivation to smoke or bolstering motivation not to smoke either temporarily or permanently • More work is needed to improve behavioural treatments using a more comprehensive model of smoking behaviour • Treatments to aid cessation must be just one part of a wider tobacco control strategy