Tobacco dependence: Implications for service provision Andy McEwen, PhD University College London & National Centre for Smoking Cessation and Training (NCSCT) Tuesday 29th January 2013 Cardiff
Conflict of interest statement I undertake research and consultancy for companies developing and manufacturing medications to aid smoking cessation I am on a patent for a novel nicotine inhalation device Acknowledgement: Professor Robert West 2
Overview Tobacco dependence The place of smoking cessation interventions in tobacco control Implications for practice 3
Tobacco dependence 4
Tobacco dependence [1] Nicotine delivered through tobacco smoke should be regarded as an addictive drug, and tobacco use the means of self-administration 70% of smokers say they want to stop under 5% manage to stop Royal College of Physicians, 2000 ; General Household Survey, 2010 5
Tobacco dependence [2] Four of France's early heart transplant patients pictured in the 1970s after their operation. Three out of four continued to smoke BMJ News 2005;331:862 (15 October) 6
Tobacco dependence [3] Addictions are activities that are given an unhealthy priority because of a disordered motivational system Dependence refers to the nature of that disorder. It varies from individual to individual and behaviour to behaviour The key concept of dependence is motivational balance www.primetheory.com 7
Tobacco dependence [4] Dependence is not really about this Humans as rational decision makers Smoking is an adult pursuit and should remain a matter for informed and adult choice (Tobacco Manufacturers Association [UK], Smoking and children, 1997) The drinker 8
Tobacco dependence [5] But has elements of this Humans as emotional decision makers Self-labels and perceptions are important sources of motivation And this Personality traits We vary in propensity to impulsiveness, anxiety etc And this Social experience Our experiences and behaviours derive from the way we construct our world Smoke-scream 9
Tobacco dependence [6] And this Humans as animals Operant conditioning Habits result from positive reinforcement (experience of reward) Habits result from negative reinforcement (experience of pain ) Drive theory Behaviours derive from biological imperatives www.michaelmain.com/addict.jpg 10
Tobacco dependence [7] The human motivational system I want to quit Flow of influence through the system Stop smoking 11
Tobacco dependence [8] The human motivational system Relapse Maintenance Pre-contemplation Active change Contemplation Flow of influence through the system 12
Tobacco dependence [9] The human motivational system External environment (stimuli, information) Internal stimulation External stimulation Flow of influence through the system Responses Plans (intentions) Internal environment (percepts, drives, emotional states, arousal, ideas, frame of mind) I will try not to smoke Impulses (urges) Evaluations (beliefs) Motives (wants etc.) Smoking is bad for me Need a cigarette Urge to smoke www.primetheory.com 13
Tobacco dependence [10] Cigarette dependence reveals itself as powerful desires and urges to smoke when smokers try to stop. These go alongside feelings of aggression, depressed mood, increased appetite, restlessness and difficulty concentrating which weaken the resolve not to smoke. The problem is usually strongest in the first few weeks of stopping and declines after that but sometimes it persists and the desire and urge to smoke can be triggered months or years after stopping. 14
Tobacco dependence [11] Cigarette dependence reveals itself as powerful desires and urges to smoke when smokers try to stop. These go alongside feelings of aggression, depressed mood, increased appetite, restlessness and difficulty concentrating which weaken the resolve not to The key concept of dependence is motivational balance smoke. The problem is usually strongest in the first few weeks of stopping and declines after that but sometimes it persists and the desire and urge to smoke can be triggered months or years after stopping. 15
Tobacco dependence [12] The human motivational system Urges Resolve www.primetheory.com 16
The place of smoking cessation interventions in tobacco control 17
The place of smoking cessation interventions in tobacco control Reduce total harm from tobacco use Reduce prevalence Reduce uptake Promote cessation Reduce harm from use 18
Promoting cessation Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support 19
Pharmacological treatment Promote cessation Promote quit attempts Aid quit attempts Drugs to reduce motivation to smoke Pharmacological treatment Behavioural support 20
Pharmacological treatment Reduce urges to smoke Reduce nicotine hunger Reduce acute cue-driven craving Block nicotine reward 21
Pharmacological treatment Reduce urges to smoke Reduce need to smoke caused by depleted CNS nicotine concentrations Reduce nicotine hunger Reduce acute cue-driven craving Block nicotine reward 22
Pharmacological treatment Reduce urges to smoke Reduce acute urge to smoke driven by smoking cues Reduce nicotine hunger Reduce acute cue-driven craving Block nicotine reward 23
Pharmacological treatment Reduce urges to smoke Reduce nicotine hunger Reduce the pharmacological reward from nicotine if smoking does occur Reduce acute cue-driven craving Block nicotine reward 24
Behavioural support Promote cessation Promote quit attempts Aid quit attempts Advice and support aimed at boosting motivation, helping with selfregulation, and promoting effective use of supporting activities Pharmacological treatment Behavioural support 25
Behavioural support Behaviour Change Techniques... Address motivation Enhance self-regulation Promote adjunctive activities Support the process 26
Behavioural support Minimise motivation to Behaviour Change Techniques smoke and maximise motivation not to smoke... Address motivation Enhance self-regulation Promote adjunctive activities Support the process 27
Behavioural support Behaviour Change Techniques... Help to avoid and resist urges to smoke Address motivation Enhance self-regulation Promote adjunctive activities Support the process 28
Behavioural support Behaviour Change Techniques... Address motivation Help smokers to make best use of medication and other aids to cessation Enhance self-regulation Promote adjunctive activities Support the process 29
Behavioural support Behaviour Change Techniques... Address motivation Enhance self-regulation Do necessary assessments, build rapport, tailor treatment as needed Promote adjunctive activities Support the process 30
The place of smoking cessation interventions in tobacco control Prevention is important....but so is the provision of treatment for those that want to stop 31
Implications for treatment Awareness and referral Ensure that smokers, and health professionals in contact with smokers, know about your service and know how to refer Have multiple referral routes (including opt-out) Respond quickly and positively to referrals Offer quick and flexible access to a choice of behavioural support Feedback to referrer Keep in touch with your clients 32
Implications for treatment Optimal service configuration Association between intervention characteristics and 4-week CO verified success rates adjusting for key smoking characteristics Specialist treatment rather than primary care Group rather than one-to-one Use of varenicline or combination NRT rather than single NRT 33
Implications for treatment Differences between practitioners Association between intervention characteristics and 4-week CO verified success rates adjusting for key smoking characteristics Differences between practitioners accounted for 7.6% of the variance in success rates, a larger differences than is typically found between active and placebo NRT 34
Implications for treatment Why specialist practitioners achieve better success rates Survey data were used to identify factors mediating the differences in success rates Greater use of abrupt rather than gradual cessation approach Stronger emphasis on medication use Number of days training received Number of sessions observed when starting out Better supervision 35
Conclusions Tobacco dependence is a chronic relapsing-remitting disorder of motivation Specialist behavioural support plus varenicline or dual form NRT provide the optimal treatment to help smokers to stop Specific behaviour change techniques in behavioural support are linked to better success rates A national training and assessment programme for stop-smoking practitioners appears to have improved the impact of stop-smoking support in England Standardised monitoring and recording of data from stop-smoking clinics will allow continued improvement 36
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