Recent studies of clinical significance

Recent studies of clinical significance Robert West University College London June 2011

Topics The challenges facing UK Stop-Smoking Services • demonstrating the importance of clinical services • providing guidance how best to configure the services • ensuring quality of provision Relevant studies • Real world effectiveness of aids to cessation and impact of the services • What makes for an effective service and an effective practitioner • Criteria that need to be in place when commissioning providers

The place of smoking cessation interventions in tobacco control

The First Law of Smoking Cessation The number of ex-smokers E = N x S The number of smokers trying to quit The chances of success of each attempt

What does this mean? • Motivate as many smokers to try to quit as possible • Ensure that they have access to the best possible help if they wish to use it • Motivate them to use the most effective method available

The Second Law of Smoking Cessation • The best chance of success at stopping smoking is by using a combination of: • a) stop-smoking medication • b) professional advice and support

The role of clinical services • Stop-smoking services provide highly cost-effective life-preserving treatment for an addictive disorder for those people who want to use it • The services need to be accessible to all smokers and promoted so that smokers can see the benefits • The extent of the provision must be commensurate with demand Failure to provide those services is an abdication of responsibility and betrayal of the principles of the NHS

Promoting cessation

Pharmacological treatment

Effectiveness versus efficacy • Efficacy • Effect of an intervention compared with a comparator in an experimental study • Effectiveness • Effect of an intervention in the ‘real world’

Efficacy of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

Effectiveness of medication options West et al (2007) Thorax, 62, 998-1002 Brose et al (2011) Thorax, 66, 924-6 Smokers using NRT have better success rates than those not using it

Effectiveness of medication options Brose et al (2011) Thorax, 66, 924-6 Smokers using bupropion have better success rates than those using nothing

Effectiveness of medication options Brose et al (2011) Thorax, 66, 924-6 Bauld et al (2012) Addiction, in press Smokers using varenicline are more likely to succeed than those using no medication or NRT or bupropion

Efficacy of different forms of NRT Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

Efficacy of different ways of using NRT: efficacy Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

Efficacy of different ways of using NRT: effectiveness Brose et al (2011) Thorax, 66, 924-6 Smokers using dual form NRT have higher success rates than those using single form NRT Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

Efficacy of different ways of using NRT: effectiveness Beard et al (2012) Drug & Alcohol Dependence, in press Beard et al (2012) Tobacco Control, in press Smokers using NRT for smoking reduction are more likely to go on to quit, even after adjusting for possible confounding variables Beard et al (2012) Drug & Alcohol Dependence, in press Beard et al (2012) Tobacco Control, in press Smokers using NRT for smoking reduction are more likely to go on to quit, even after adjusting for possible confounding variables Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

Behavioural support

Behavioural support: efficacy Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment 25

Behavioural support: effectiveness West et al (2012) www.smokinginengland.info Smokers who receive behavioural support plus medication have higher success rates than those obtaining medication on prescription only

Optimum service provision • Brose et al (2011) Thorax, 66, 924-6 • Varenicline or dual form NRT • Provide specialist support • Offer group-based support • West et al (2010) Nic & Tob Res, 12, 742-7 • West et al (2011) Nic & Tob Res, 13, 1316-20 • more sessions • treatment manuals that focus on: • additional foster ex-smoker identity • CO monitoring • elicit client views • give options for support • betting game • communicating group member identity • advise on medication • advise on changing routine • advise on coping with cravings • advise on changing routine

Key commissioning requirements • Only pay for ex-smokers above a threshold (e.g. 25% 4-week quitters) – but pay for them appropriately • Pay more for more dependent smokers • Only commission providers who: • offer all evidence-based treatments • employ staff who are certified, trained, supervised and have appropriate continuing professional development • follow evidence based guidelines in delivery of behavioural support • use a rigorous standardised procedures for assessing abstinence according to the Russell Standard • use a fully independent service to audit claimed successes West (2011) Addiction, 106, 1730-2

Current practice McDermott et al (2012) BMC Hlth Serv Res, 12, 121

Current practice Should be 100% McDermott et al (2012) BMC Hlth Serv Res, 12, 121

Current practice Not generally appropriate McDermott et al (2012) BMC Hlth Serv Res, 12, 121

Key points • Clinical studies show: • effectiveness as well as efficacy of the recommended model of smoking cessation support in England • important components of treatment both in terms of medication and behavioural support • some deficiencies in the current commissioning process that may undermine effectiveness for some services

Recent studies of clinical significance