Stop smoking: advice worth giving

1. Stop smoking: advice worth giving Robert West University College London Essex November 2006

2. Outline • Nicotine dependence and smokers’ motivation to stop smoking • Latest information on what works in helping smokers stop • Practical guidance on advising smokers to stop

3. Human motivation “Humans are more or less instinctive, habit-driven, emotional decision-makers with a propensity to plan ahead, powerfully influenced by our social world, with a sense of identity which can act as a source of self-control” www.primetheory.com

4. Motivation to smoke 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, strong desires from anticipated pleasure or satisfaction and direct simulation of impulses through associative learning

5. Motivation not to smoke 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; negative evaluations of smoking Reminders Beliefs about benefits of not smoking Non-smoker ‘identity’ Plan not to smoke Nicotine dependence probably also involves impairment of impulse control mechanisms undermining response inhibition

6. What smokers say about stopping • At any one time, when asked, most smokers report that they: • want to stop, citing health concerns as the main reason • intend to stop some time in the future • regret having ever started smoking • have tried to stop in the past • have tried nicotine replacement to help them stop • are trying to ‘cut down’ • but a minority: • are ready to try to stop right now • are willing to see a stop smoking advisor or attend a stop smoking group

7. Going beyond what smokers say • Many smokers: • will respond positively to an offer of help with stopping who would not have done if they had been first asked whether they were interested in stopping • will suddenly stop without making any prior plans to do so • who say they plan to stop at a particular time or within a particular time window do not try to stop • who try to stop, will later fail to report that they tried to stop if that quit attempt does not last very long • misjudge what it is they find difficult about not smoking – focusing on the activity when in fact they are responding to a basic pharmacologically-driven need

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, in preparation: >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. 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

15. Costs and benefits • Costs • 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 £100 for medication or behavioural support only to £400 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

16. Brief advice from the GP Should ... • induce a feeling of desire or need to change now and a sense that change is possible • translate that into action before the impulse goes away • trigger supporting activities that can sustain the plan

17. The role of the GP Once a year: • All patients: Check smoking status • ‘I just need to check something. In my records I have you down as a non-smoker/smoker’; is that correct?’ • Confirmed non-smokers: No further action • New non-smokers: Give praise and offer help if needed • Smokers: Discuss link between smoking and their current health condition or likely future health, ask what they have been doing about their smoking and offer help • ‘I am concerned about your chest which is certainly being made worse by your smoking. Have you been seen by our Stop Smoking Service? No? Well they have helped a lot of very heavy smokers like you to stop and I would like you to make an appointment to see them straight away.’

18. Links with patient conditions • Back-pain • ‘Did you know that smoking has been linked with back pain; it could be due to damage that the chemicals you ingest do to the cartilage’ • Cough/URTI/breathing problems • ‘I am concerned that smoking is making your condition worse and you may be starting to develop some airways obstruction’ • Depression/anxiety disorders • ‘A lot of smokers think that smoking helps with their stress but in most cases it is actually making it worse. We can help you overcome the problems that comes on the first few weeks of stopping and after that you can expect to feel better than you do right now’

19. Links with patient conditions • Circulatory problems/heart disease/diabetes • ‘I am concerned that smoking is starting to have an effect on your circulation/heart. If you stop now your body can start to repair the damage.’ • Pregnancy • ‘Smoking damages the baby in many different ways some of which will not appear until the child starts to grow up. For example, smoking during pregnancy can lead to behaviour problems in the child because of damage to the brain of the fetus.’

20. Patient – doctor • Patient: ‘I enjoy/need my cigarettes too much to stop or I would like to stop smoking but this is not a good time’ • Doctor: ‘That is entirely your choice. One thing you may want to consider is trying to cut down with the help of nicotine gum or the nicotine inhaler’ • Patient: ‘I’ve tried the Stop Smoking Service and it didn’t help’ • Doctor: ‘Obviously there are no guarantees of success but I would like you to give it another go, perhaps with a different specialist’ • Patient: ‘I’ve tried nicotine patches/gum and it didn’t help’ • Doctor: ‘Not everyone gets on with one or other type medicine, I would like you to see a specialist who can advise you on some alternatives’

21. Patient – doctor • Patient: ‘I used … the last time and managed to go for a long time but then I went back to smoking because of (a silly slip-up/stressful event)’ • Doctor: ‘It sounds as though you did quite well and just got caught out, which happens to many smokers. There is no reason why you should not try the same approach this time or else I can recommend …’ • Patient: ‘I used … the last time but after a while (the weight gain, lack of enjoyment in life) became too much.’ • Doctor: ‘Some smokers find it hard to manage without nicotine in some form; I would like to refer you to the specialist stop smoking service because we may need prescribe you nicotine on a longer term basis.’

22. Conclusions • The GP’s role is to help patients with health problems • In the case of smoking, this simply means ensuring that all patients who could benefit from potentially life-saving treatment to help them stop are offered it and encouraged to use it

23. What this adds up to ... Doctor: ‘Are you still smoking?’ Patient: ‘Yes, I’m afraid so. I know I should stop.’ Doctor: ‘Are you ready to have another go at stopping altogether ... [link with condition] ...there are now lots of different options from a new pill you can take to tackle the cravings to better ways of using things like nicotine patch and gum. I’m very keen for you speak to one of our specialist stop smoking advisors who can take you through the options and decide which one best suits you. You can even stop gradually if you don’t think you can manage it all in one go.’