tobacco dependence: implications for service provision andy... · contact with smokers, know about...

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

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Overview

Tobacco dependence

The place of smoking cessationThe place of smoking cessationinterventions in tobacco control

Implications for practice

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Tobacco dependence

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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


Four ofFrance's earlyhearttransplantpatientspatientspictured in the1970s aftertheiroperation.Three out offour continuedto smoke

BMJ News 2005;331:862 (15 October)6


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


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’

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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’

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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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The humanmotivationalsystem…

Stop smoking

“I want toquit”

Flow of influencethrough the system

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Pre-contemplation

Relapse


Active changeContemplation

Pre-contemplationMaintenance


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Externalenvironment

Evaluations(beliefs)

Plans(intentions)

Internalenvironment


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)


External stimulation

Internal stimulation

www.primetheory.com

Need a cigarette

Urge to smoke

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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.

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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’



Urges Resolve

www.primetheory.com

Urges Resolve

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The place of smoking cessationinterventions in tobacco control

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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


Promote cessation


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Aid quit attempts


Behavioural support

Drugs to reduce motivationto smoke


Reduce urges to smoke

Reduce ‘nicotine hunger’

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Reduce acute cue-driven craving

Block nicotine reward




Reduce need to smokecaused by depleted CNSnicotine concentrations

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Reduce ‘nicotine hunger’Reduce acute urge to smoke

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Reduce acute urge to smokedriven by smoking cues




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Reduce the pharmacologicalreward from nicotine if

smoking does occur

Behavioural support

Promote cessation


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Aid quit attempts


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


Address motivation

Minimise motivation tosmoke and maximise

motivation not to smoke

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Support the process

Behavioural support


Address motivation

Help to avoid and resisturges to smoke

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Support the process

Behavioural support


Address motivation

Help smokers to make best

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Support the process

Help smokers to make bestuse of medication and other

aids to cessation

Behavioural support


Address motivation

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Support the process

Do necessary assessments,build rapport, tailor treatment as

needed


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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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

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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

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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

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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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