Clinical support to aid smoking cessation

1
Clinical support to aid smoking cessation

• Robert West
• Oslo
• University College London
• March 2007

2
What is the role of the clinician in smoking
cessation?

• Clinicians should
• not get involved in discussing smoking
• raise the topic of smoking with patients
• Clinicians should
• tell smokers to stop
• advise smokers to stop
• Clinicians should
• raise the topic of smoking only with those with
  smoking-related symptoms
• raise the topic of smoking with all smokers
• Clinicians should
• not routinely offer to prescribe medication to
  help patients to stop
• routinely offer to prescribe medication to help
  patients to stop
• Clinicians should
• offer to provide behavioural support to help
  smokers to stop
• find out about and encourage smokers to use other
  behavioural support packages

3
Outline

• Understanding addiction to cigarettes
• How smokers become ex-smokers
• Injecting urgency into the process of smoking
  cessation
• What can be achieved through good clinical care
• The clinicians role

4
What is addiction?

• Addictions are activities to which individuals
  attach an unhealthy priority because of a
  disordered motivation system
• Dependence refers to the multi-faceted nature
  of that disorder
• The disorder may involve combinations of
• strong stimulus-driven impulses
• strong needs and wants
• weak motivations to exercise restraint
• reduced capacity to exercise restraint

The motivational system
5
How does addiction show itself?

• Addiction can show itself in various ways
  depending on the activity concerned
• Other activities and goals necessary for healthy
  functioning and fulfilment may be subordinated to
  the addictive behaviour
• Individuals are unable to exercise restraint when
  they try
• Individuals may experience powerful wants, needs
  or urges to engage in the activity
• The individual may experience anxiety and
  conflict about continuing engaging in the
  behaviour

6
Mechanism 1 cue-driven impulses

• When nicotine is absorbed it attaches to
  nicotinic acetylcholine receptors in the Ventral
  Tegmental Area (VTA) of the mid brain
• This stimulates firing of neurons that project
  forward to the Nucleus Accumbens (NAcc)
• This causes dopamine release in the NAcc
• This leads to impulses to smoke in the presence
  of smoking cues (e.g. being offered a
  cigarette)

Nucleus accumbens
Ventral tegmental area
7
Mechanism 2 acquired drive creating a need to
smoke

• In many smokers, after repeated ingestion of
  nicotine, the motivational system is altered to
  create a drive, somewhat similar to hunger,
  except that it is for nicotine
• The drive increases in the minutes to hours since
  the last cigarette and is influenced by triggers,
  reminders, stress and distractions
• The drive is experienced as feelings of need to
  smoke
• The drive reduces over weeks of not smoking but
  in some cases does not disappear completely

Simplified schematic of development of an
acquired drive
8
Mechanism 3 mood and physical symptoms creating
a need to smoke

• After repeated nicotine exposure, abstinence
  results in unpleasant withdrawal symptoms
  including depression
• Smokers also report that smoking helps them cope
  with stress
• Adverse mood therefore comes to generate a need
  to smoke

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Nicotine dependence
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, and direct
simulation of impulses through habit learning
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What this means in populations
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The process of stopping smoking changes in
identity
I smoke ...
... and I am happy about my smoking
I am not even thinking about giving up
I will give up some time
... but I am not happy about my smoking
I have made plans to give up
I do not smoke ...
I am trying to give up smoking
I am giving up smoking
I have given up smoking but not completely
I have given up smoking completely
12
While smoking ...
13
Motivation to stop smoking
Quit attempt
Habit/instinct
Impulse to make a quit attempt
Cues/triggers
Choice
Desire to stop smoking
Need to stop smoking
Anticipated self-respect
Fear of ill-health/death
Disgust, annoyance with smoking Felt stigma
Anticipated praise
Reminders
Positive evaluations of stopping smoking
Non-smoker identity
Beliefs about benefits of stopping smoking
Only the flow of influence towards responses are
shown
14
Resistance to stopping smoking
Not making attempt
Habit/instinct
Inhibition of making a quit attempt
Cues/triggers
Choice
Desire not to make attempt
Need not to make attempt
Anticipated enjoyment of smoking
Anticipated loss of benefits Fears of
failure Anticipated effort
Anticipated benefits of smoking
Negative evaluations of making attempt
Reminders
Beliefs about likelihood of failure
Smoker identity
Only the flow of influence towards responses are
shown
15
While not smoking
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Motivation to smoke
Smoking
Habit/instinct
Impulse to smoke
Cues/triggers
Choice
Desire to smoke
Need to smoke
Anticipated enjoyment
Nicotine hunger
Unpleasant mood and physical symptoms
Anticipated benefit
Reminders
Positive evaluation of smoking
Smoker identity
Beliefs about benefits of smoking
Only the flow of influence towards responses are
shown
17
Inhibition of smoking
Not smoking
Habit/instinct
Inhibition
Cues/triggers
Choice
Desire not to smoke
Need not to smoke
Anticipated praise
Anticipated disgust, guilt or shame Fears about
health
Anticipated self-respect
Negative evaluation of smoking
Reminders
Beliefs about benefits of not smoking
Non-smoker identity
Plan not to smoke
Only the flow of influence towards responses are
shown
18
The urgency of smoking cessation

• Every year of smoking
• damages lung function irreparably potentially
  leading to COPD later in life
• after the age of 35-40 years reduces life
  expectancy by 3 months
• increases the irreversible risk of lung cancer
• Stopping at 35 prevents 9 years loss of life
  expectancy
• Stopping at 60 prevents 3 years loss of life
  expectancy
• Stopping smoking is always urgent but never too
  late

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GP attitudes

• Helgasen Lund (2002)
• 2000 GPs in Norway, Sweden, Iceland Finland
• Agreed that discussing smoking is part of the job
  but
• tended to limit advice to those with
  smoking-related symptoms
• did not typically provide support
• because
• too time-consuming
• very low success rate
• lack of specialists to refer on to

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Creating the decision to stop

• Generate motivational tension by
• frequent or persistent, high levels of want and
  need to make the change now
• hope that the attempt to change will be
  successful
• Trigger impulses to make the change attempt by
• repeated calls to immediate action
• modelling the behaviour

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Opening lines

• When was the last time you tried to stop smoking?
• How long did it last?
• What did you use to help?
• What led you to back to smoking?
• Its always worth having another go and there are
  lots of options to suit individual smokers which
  have been proved to help in research. Would you
  like to discuss these?

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Supporting the decision to stop

• Reduce the frequency and intensity of impulses,
  needs and wants to revert
• Identify the sources of impulses and needs
• Develop a specific plan in each case to avoid,
  escape or minimise these
• Generate a strong commitment to a new identity
  with clear boundaries
• Foster the complete non smoker identity
  (smoking is not even an option, re-evaluation of
  place of smoking in their life)
• Deal with lapses by re-asserting the new identity
• One day at a time
• Maximise both intrinsic and extrinsic motives for
  not smoking (e.g. avoiding shame, gaining
  self-respect)

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Effect of face-to-face individual support
Using only studies with 6 months continuous
abstinence and biochemical verification
24
Effect of group support
Using only studies with 12 months continuous
abstinence and biochemical verification
25
Effect of telephone counselling
Cochrane review gt6 month cessation not validated
26
Effect of tailored internet support
Not biochemically verified
27
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)
28
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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Success rates up to 6 months ATTEMPT cohort study
100
100
90
80
70
60
Percent still abstinent
No aid
50
NRT
40
40
30
23.5
21.7
20
12.7
11.8
10.9
10
6.6
4.6
0
0
30
60
90
120
150
180
Days
Significant differences between NRT and no aid at
all points, plt.05
30
Comparative studies abstinence data
40
30
22.5
Responders ()
20
CA rate ()
15.7
9.4
10
0
Varenicline 1 mg bid(n692)
Bupropion150 mg bid(n669)
Placebo(n684)
12
16
20
24
28
32
36
40
44
48
52
Week
Gonzales DH, Rennard SI, Billing CB, et al. A
pooled analysis of varenicline an a4ß2 nicotinic
receptor partial agonist vs. bupropion for
smoking cessation. SRNT Paper sessions PA9-2,
PA9-3, 2006.
31
Cumulative effects of using effective cessation
treatment
If quit attempts are made every year
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Hypertension and nicotine dependence treatment

• Hypertension
• Routinely measure blood pressure
• Apply continuing stepped-care model until it is
  under control
• Nicotine dependence
• Routinely assess smoking status
• Apply continuing stepped care model until it is
  eliminated or under control

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Conclusions

• Nicotine dependence mostly involves acquisition
  of cue-driven impulses, need for relief from an
  acquired nicotine hunger and mood and physical
  symptoms
• The process of stopping involves tension arising
  from dissatisfaction with smoking and triggers
  prompting quit attempts and then different
  tensions and triggers promoting lapse and relapse
• Nicotine dependence is treatable with behavioural
  and pharmacological methods
• The clinicians role is to trigger quit attempts,
  motivate the use of effective treatments and
  continue the process until the smokers
  successfully quits

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What is the role of the clinician in smoking
cessation?

• Clinicians should
• not get involved in discussing smoking
• raise the topic of smoking with patients
• Clinicians should
• tell smokers to stop
• advise smokers to stop
• Clinicians should
• raise the topic of smoking only with those with
  smoking-related symptoms
• raise the topic of smoking with all smokers
• Clinicians should
• not prescribe medication to help patients to stop
• prescribe medication to help patients to stop
• Clinicians should
• offer to provide behavioural support to help
  smokers to stop
• find out about and encourage smokers to use other
  behavioural support packages

35
Reading

• West R Shiffman S (2007) Fast Facts Smoking
  Cessation (2nd Edition). Oxford, Health Press