Perspectives on treatment for tobacco addiction

1
Perspectives on treatment for tobacco addiction

• Robert West
• University College London
• Rio de Janeiro
• November 2006

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Outline

• Motivation to smoke and not to smoke
• The treatment strategy
• Treatment tactics
• Treatment effectiveness
• The future of treatment
• Treatment in the context of tobacco control

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Motivation to smoke
Nicotine dependence involves generation of
acquired drive, withdrawal symptoms, strong
desires from anticipated enjoyment and direct
simulation of impulses through habit learning
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Inhibition of smoking
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
Reminders
Non-smoker identity
Beliefs about benefits of not smoking
Plan not to smoke
Nicotine dependence also involves impairment of
impulse control mechanisms undermining response
inhibition
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The treatment strategy

• Best outcome to cure the smoker so that he or
  she never feels a strong desire or need to smoke
  again
• Second best outcome to generate remission so
  that the smoker at least temporarily does not
  feel a strong desire or need to smoke
• Third best suppression of smoking completely or
  partially by reducing the desire or need to smoke
  or bolstering motivation not to smoke

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Treatment tactics

• Suppress smoking completely using any means,
  thereby allowing the brain to recover its normal
  functioning
• Changing the way the brain operates so that
• it no longer generates needs, desires and
  impulses to smoke or these are less frequent or
  less powerful
• it habitually generates strong resistance to
  smoking impulses

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Assessing treatment outcome

• Ultimate goal is usually permanent remission
  (Peter Selby)
• Self-report of continuous abstinence for 6
  months, biochemically verified, usually allows
  reliable estimation of this (Russell Standard1)
• permanent remission rate50 RS6M
• Point-prevalence estimation and estimation for
  shorter time periods are less reliable
• The key effect-size measure is difference in the
  proportion of smokers abstinent in treatment
  versus control conditions

1West et al, Addiction 2005
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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 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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The future of treatment

• More effective use of existing treatments
• combinations
• pre-treatment
• longer term use if required
• wider access
• Better treatments
• novel medications
• cheaper medications
• more comprehensive behavioural treatments
• A realistic goal
• 25 of quit attempts that would have failed,
  lasting for at least 6 months

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Principles underlying policy options Economic
concepts

• Financial incentives
• Concept Increase the financial cost relative to
  ability to pay
• Barriers Social and political resistance, lower
  affordability of other goods, possible
  substitution for other incentives, get-arounds
• Moral and social incentives
• Concept Increase the feeling of moral and
  normative pressure
• Barriers Difficult to achieve, risk of backlash,
  stigmatisation of those that do not change
• Personal incentives
• Concept Change balance of perceived personal
  happiness/ease and discomfort/effort in favour of
  not smoking
• Barriers Practical and financial constraints may
  limit reach and effectiveness

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Principles underpinning policy Health promotion
concepts
West, R British Medical Bulletin, In Press
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Policy options

• Price increases
• increase taxes
• reduce options for cheap smoking
• Smoke-free legislation
• Increasing access to help with stopping
• Mass media campaigns and media advocacy
• Warning labels on tobacco packaging
• Further work on restricting tobacco promotion
• Decreasing youth access to tobacco
• School-based programmes

See Framework Convention on Tobacco Control Levy
et al (2004) Journal of Public Health Management
and Practice, 10, 338-353 West, R British
Medical Bulletin, In Press
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Conclusions

• Treatments to aid cessation have a small but
  important and reliable effect
• The aim to work by suppressing the motivation to
  smoke or bolstering motivation not to smoke
  either temporarily or permanently
• More work is needed to improve behavioural
  treatments using a more comprehensive model of
  smoking behaviour
• Treatments to aid cessation must be just one part
  of a wider tobacco control strategy