Smoking cessation: the value of working together Dr Donita Baird and Dr Sarah L White
Brief Interventions Aim is to start the conversation Generate a quit attempt (momentary desire to quit now) Maximise efficacy of quit attempt Many models 5As, 3 step models, very brief advice 3 to 20 minutes
Behavioural Interventions Aim is cessation: Generate a quit attempt (set a quit date) Maximise efficacy of quit attempt (aim for not a puff rule; use medicines appropriately) Preventing relapse: minimise desire to smoke, maximise resolve not to smoke Interventions enhance motivation, develop skills to resist the urge to smoke and develop capacity to implement plans to not smoke. Multiple sessions
The value of working together Brief Intervention Pharmacotherapy Behavioural Interventions (such as Quitline) 7 out of 100 Quit for at least 6 months 11 in 100 10-12 16 in 100 in 100 Lancaster & Stead et al., 2016. Cochrane Review
Complementary processes Characteristic Physician Tobacco Cessation Specialist Style of working Knowledge/skills Prescriptive (helpful for a brief intervention) Personalised advice of health risks of smoking Pharmacotherapy Collaborative / patient-centred Psychological therapies plus supporting use of nicotine replacement therapies products Conceptualisation General conceptualisation Detailed formulation Customise treatment Pharmacotherapy Strong behavioural treatment foundation can integrate strategies suitable for co-morbidities Adapted from Hitson & Baker (2017) in press
What often happens Brief interventions are not routinely offered to all smokers Referrals to cessation specialists like Quitline are low: Lack of knowledge about Quitline counselling service May not know that referral (compared to recommending a person call) increases uptake (13x) 1 and improves outcomes 2 Confusion over roles of generalist and tobacco cessation specialist Some practitioners prefer to do the behavioral support themselves 1 Vidrine et al. (2013) 2 Sherman et al. (2017):
UK Context Invested heavily in stop-smoking support Brief Intervention + providing behavioural support and cessation medication via free stop smoking services 1 Competencies required to deliver effective stop smoking interventions from national guidance and randomised control trials 2 Services differ in use of generalist or tobacco cessation specialists 1. Bauld et al. IJERPH 13(12). 2016. 2. Michie et al. Anns behav Med 2011; 41; 59-70
Does it matter? Smokers receiving stop-smoking support from specialist clinics: are more likely to succeed than those receiving treatment in primary care (OR PC:SC 0.80, 95% CI 0.66 to 0.99)1 more likely to quit long term (OR 2.3, 95% CI 1.2-4.6) 2 higher rate of longer-term smoking abstinence (OR 1.48, CI=1.09 to 2.00%)3 1. Brose et al., Thorax 2011; 66;924-926). 2. Bauld et al. Int. J. Environ Res. Public Health. 2016. 13(12) 3. Song et al. 2016
Other lessons from the UK Stop smoking services that primarily used most intensive behavioural intervention (closed groups) had highest quit rates (32%) but the lowest reach (6299 clients, April 2012 to March 2013) Scottish services, which are 75% pharmacy led, had the lowest quit rates (6%) but a high reach of 116, 198 quit attempts. Improving abstinence is likely to require a greater emphasis on providing specialist smoking cessations support Bauld et al. 2016 See Bauld et al. 2016
Examples from other countries USA Public Health Service guideline for treating tobacco use and dependence Tobacco Treatment Specialist training available to those with counselling credential Specialist recognised as more likely to achieve higher quit rates 1. New Zealand National accreditation and core competencies framework in stop smoking treatment and practice. The Stop Smoking Practitioner training program 1. Histman, Baker & King. Chest.2017 In press
Would it be useful to have National Guidelines for Treatment of Tobacco Dependence? Vision Develop a shared vision e.g. Every person who smokes is offered best practice smoking cessation support Objectives Develop clear objectives e.g. Brief interventions are embedded in usual care; equitable access to quit specialists Actions Define principles, domains, roles and actions for health professionals and services e.g. Core competencies of quit specialists, minimum standard for stop smoking services
Would National Guidelines make a difference? English stop smoking services which showed greatest improvements in success rates had the greater uptake of a national evidence-based training program 1 Inclusion of behaviour change techniques in service treatment manuals associated with quit rates of service 2 Specialists achieved higher quit rates and this was associated with more extensive training, ongoing supervision and greater adherence to evidence-based practice 3. 1.Brose et al. Preventative Medicine. 2014 69.1-4 2. West et al. Nicotine Tob Res. 2010: 12: 742-7 3. McDermott et al. Nicotine Tob Res. 2013: 1597)1239-47
Summary We need to work together so brief interventions are embedded in clinical practice and patients are offered pharmacotherapy and referral to a quit specialist. National guidelines could be valuable in ensuring best practice smoking cessation support Further education options are needed for tobacco cessation specialists