Stop smoking: advice worth giving

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Stop smoking advice worth giving

• Robert West
• University College London
• Essex
• November 2006

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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

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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
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Motivation to smoke
Smoking
Impulse to smoke
Cues/triggers
Desire to smoke
Need to smoke
Anticipated pleasure/ satisfaction
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
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Motivation not to smoke
Not smoking
Inhibition
Cues/triggers
Desire not to smoke
Need not to smoke
Anticipated praise
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
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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

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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-d
  riven need

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Effect of face-to-face individual support
Using only studies with 6 months continuous
abstinence and biochemical verification
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Effect of group support
Using only studies with 12 months continuous
abstinence and biochemical verification
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Effect of telephone counselling
Cochrane review, in preparation gt6 month
cessation not validated
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Effect of tailored internet support
Not biochemically verified
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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)
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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
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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

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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

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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

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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.

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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

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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.

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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 Ive tried the Stop Smoking Service and
  it didnt 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 Ive tried nicotine patches/gum and it
  didnt 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

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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.

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Conclusions

• The GPs 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

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What this adds up to ...
Doctor Are you still smoking? Patient Yes,
Im 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. Im
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 dont think
you can manage it all in one go.