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Tobacco dependence:Implications for serviceprovision
Andy McEwen, PhD
University College London & National CentreUniversity College London & National Centrefor Smoking Cessation and Training (NCSCT)
Tuesday 29th January 2013
Cardiff
Conflict of interest statement
I undertake research and consultancyfor companies developing andmanufacturing medications to aidsmoking cessationsmoking cessation
I am on a patent for a novel nicotineinhalation device
Acknowledgement: Professor RobertWest
2
Overview
Tobacco dependence
The place of smoking cessationThe place of smoking cessationinterventions in tobacco control
Implications for practice
3
Tobacco dependence
4
Tobacco dependence [1]
“Nicotine delivered through tobaccosmoke should be regarded as anaddictive drug, and tobacco use themeans of self-administration”means of self-administration”
70% of smokers say they want tostop – under 5% manage to stop
Royal College of Physicians, 2000 ; General Household Survey, 20105
Tobacco dependence [2]
Four ofFrance's earlyhearttransplantpatientspatientspictured in the1970s aftertheiroperation.Three out offour continuedto smoke
BMJ News 2005;331:862 (15 October)6
Tobacco dependence [3]
Addictions are activities that are given anunhealthy priority because of a disorderedmotivational system
Dependence refers to the nature of that disorder.Dependence refers to the nature of that disorder.It varies from individual to individual andbehaviour to behaviour
The key concept of dependence is ‘motivational balance’
www.primetheory.com7
Tobacco dependence [4]
Dependence is not reallyabout this…Humans asrational decision makers
“Smoking is an adult pursuit“Smoking is an adult pursuitand should remain a matterfor informed and adultchoice”
(Tobacco Manufacturers’Association [UK], Smoking andchildren, 1997)
‘The drinker’
8
Tobacco dependence [5]
But has elements ofthis…Humans as emotionaldecision makersSelf-labels and perceptionsare important sources ofmotivation
And this…Personality traitsWe vary in propensity toimpulsiveness, anxiety etc
And this…Social experienceOur experiences andbehaviours derive from theway we construct our world
‘Smoke-scream’
9
Tobacco dependence [6]
And this…Humans asanimals
Operant conditioning Habits result from
positive reinforcement(experience of reward)(experience of reward)
Habits result fromnegative reinforcement(experience of ‘pain’)
Drive theory Behaviours derive from
biological imperatives
www.michaelmain.com/addict.jpg
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Tobacco dependence [7]
The humanmotivationalsystem…
Stop smoking
“I want toquit”
Flow of influencethrough the system
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Tobacco dependence [8]
Pre-contemplation
Relapse
The humanmotivationalsystem…
Active changeContemplation
Pre-contemplationMaintenance
Flow of influencethrough the system
12
Tobacco dependence [9]
Externalenvironment
Evaluations(beliefs)
Plans(intentions)
Internalenvironment
The humanmotivationalsystem…
I will try notto smoke
Smoking isbad for me
environment(stimuli,
information)
ResponsesImpulses(urges)
Motives(wants etc.)
environment(percepts, drives,emotional states,
arousal,ideas, frame of
mind)
Flow of influencethrough the system
External stimulation
Internal stimulation
www.primetheory.com
Need a cigarette
Urge to smoke
13
Tobacco dependence [10]
Cigarette dependence reveals itself aspowerful desires and urges to smoke whensmokers try to stop. These go alongsidefeelings of aggression, depressed mood,increased appetite, restlessness and difficultyincreased appetite, restlessness and difficultyconcentrating which weaken the resolve not tosmoke. The problem is usually strongest in thefirst few weeks of stopping and declines afterthat but sometimes it persists and the desireand urge to smoke can be triggered months oryears after stopping.
14
Tobacco dependence [11]
Cigarette dependence reveals itself aspowerful desires and urges to smoke whensmokers try to stop. These go alongsidefeelings of aggression, depressed mood,increased appetite, restlessness and difficultyThe key concept of dependenceincreased appetite, restlessness and difficultyconcentrating which weaken the resolve not tosmoke. The problem is usually strongest in thefirst few weeks of stopping and declines afterthat but sometimes it persists and the desireand urge to smoke can be triggered months oryears after stopping.
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The key concept of dependenceis ‘motivational balance’
Tobacco dependence [12]
The humanmotivationalsystem…
Urges Resolve
www.primetheory.com
Urges Resolve
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The place of smoking cessationinterventions in tobacco control
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The place of smoking cessationinterventions in tobacco control
Reduce total harm from tobacco use
Reduce prevalence
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Reduce harm from use
Reduce uptake
Promote cessation
Promoting cessation
Promote cessation
Promote quit attempts
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Aid quit attempts
Pharmacological treatment
Behavioural support
Pharmacological treatment
Promote cessation
Promote quit attempts
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Aid quit attempts
Pharmacological treatment
Behavioural support
Drugs to reduce motivationto smoke
Pharmacological treatment
Reduce urges to smoke
Reduce ‘nicotine hunger’
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Reduce acute cue-driven craving
Block nicotine reward
Pharmacological treatment
Reduce urges to smoke
Reduce ‘nicotine hunger’
Reduce need to smokecaused by depleted CNSnicotine concentrations
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Reduce acute cue-driven craving
Block nicotine reward
Pharmacological treatment
Reduce urges to smoke
Reduce ‘nicotine hunger’Reduce acute urge to smoke
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Reduce acute cue-driven craving
Block nicotine reward
Reduce acute urge to smokedriven by smoking cues
Pharmacological treatment
Reduce urges to smoke
Reduce ‘nicotine hunger’
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Reduce acute cue-driven craving
Block nicotine reward
Reduce the pharmacologicalreward from nicotine if
smoking does occur
Behavioural support
Promote cessation
Promote quit attempts
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Aid quit attempts
Pharmacological treatment
Behavioural support
Advice and support aimedat boosting motivation,
helping with self-regulation, and promoting
effective use ofsupporting activities
Behavioural support
Behaviour Change Techniques ...
Address motivation
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Enhance self-regulation
Promote adjunctive activities
Support the process
Behavioural support
Behaviour Change Techniques ...
Address motivation
Minimise motivation tosmoke and maximise
motivation not to smoke
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Enhance self-regulation
Promote adjunctive activities
Support the process
Behavioural support
Behaviour Change Techniques ...
Address motivation
Help to avoid and resisturges to smoke
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Enhance self-regulation
Promote adjunctive activities
Support the process
Behavioural support
Behaviour Change Techniques ...
Address motivation
Help smokers to make best
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Enhance self-regulation
Promote adjunctive activities
Support the process
Help smokers to make bestuse of medication and other
aids to cessation
Behavioural support
Behaviour Change Techniques ...
Address motivation
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Enhance self-regulation
Promote adjunctive activities
Support the process
Do necessary assessments,build rapport, tailor treatment as
needed
The place of smoking cessationinterventions in tobacco control
Prevention is important…..
…..but so is the provision of treatment forthose that want to stop
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Implications for treatment
Awareness and referral Ensure that smokers, and health professionals in
contact with smokers, know about your serviceand know how to referand 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 ofbehavioural support
Feedback to referrer
Keep in touch with your clients
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Implications for treatment
Optimal service configurationAssociation between intervention characteristics and 4-weekCO verified success rates adjusting for key smokingcharacteristics
• 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 practitionersAssociation between intervention characteristics and 4-weekCO verified success rates adjusting for key smokingcharacteristics
Differences between practitioners accountedfor 7.6% of the variance in success rates, alarger differences than is typically foundbetween active and placebo NRT
34
Implications for treatment
Why specialist practitioners achievebetter success ratesSurvey data were used to identify factors mediating thedifferences in success ratesdifferences in success rates
• Greater use of abrupt rather than gradual cessationapproach
• 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-remittingdisorder of motivation
Specialist behavioural support plus varenicline or dualform NRT provide the optimal treatment to helpsmokers to stop
Specific behaviour change techniques in behaviouralsupport are linked to better success rates
A national training and assessment programme forstop-smoking practitioners appears to have improvedthe impact of stop-smoking support in England
Standardised monitoring and recording of data fromstop-smoking clinics will allow continued improvement
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enquiries@ncsct.co.uk
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