1. How to stop smoking: latest findings Robert West Cancer Research UK Health Behaviour Research Centre Department of Epidemiology and Public Health

2. Smoking in England: the latest figures Data from; www.smokinginengland.info 8.5 million smokers

3. Adding years by stopping smoking Stopping smoking 35 years old70 years old Smoker Stopping smoking adds up to 10 healthy life years Death

4. Adding years by stopping smoking 35 years old 80 years old Ex-smoker 35 years old70 years old Smoker Death

5. Stopping smoking is always urgent Every year that stopping is delayed after mid-thirties loses the smoker 3 months of life on average Doll et al (2004) BMJ

6. Major disorders caused by smoking Lung cancer Heart Disease Chronic Obstructive Lung Disease Other cancers (e.g. bladder) Peripheral vascular disease (leading to amputation) Stroke Blindness and deafness Infertility, miscarriage and perinatal death

7. Numbers stopping smoking in England 8,500,000 3,400,000 Smokers Tried to stop in 2009 Long-term ex-smokers 255,000 Data from; www.smokinginengland.info

8. Relapse to smoking Period of strong urges and adverse symptoms: depression, anxiety, poor concentration, irritability, restlessness West et al (2007) Thorax, 62, 998-1002

9. Time course of craving Unpublished data

10. Time course of mood and physical symptoms Unpublished data

11. Nicotine dependence: how it starts Puff on cigarette Nicotine absorbed through large surface area of the lungs Rapid transport to the brain’s ventral tegmental area where nicotine attaches to acetylcholine receptors West (2009) COPD, 6, 277-283 This activates neural pathway leading to dopamine release in nucleus accumbens

12. Nicotine dependence: what happens next Dopamine release in NAcc signals ‘reward’ and generates urge to smoke in presence of smoking cues Cue-driven urges to smoke Need to smoke to relieve nicotine hunger After repeated exposure the brain reward system is damaged and develops a ‘nicotine hunger’ (a need for nicotine when CNS concentrations are depleted) West (2009) COPD, 6, 277-283

13. Cigarette addiction Nicotine dependence –cue-driven urges –nicotine hunger Psychological factors –social reward –positive beliefs about smoking (e.g. it relieves stress) Usually diminish over first month or two Can persist for years West (2009) COPD, 6, 277-283

14. Stopping smoking Resolve not to smoke Urge/need to smoke Maximise resolve: ‘Not a puff rule’ Ex-smoker identity Social contract Personal satisfaction Minimise urge/need: Avoid cues Reduce physiological need Distraction/coping

15. The ‘behaviour system’ Opportunity Capability Motivation Behaviour

16. The ‘behaviour system’ Opportunity Capability Motivation Behaviour Physical and mental ability: changeable by education, training, enablement/resources Values, desires and habits: changeable by education, persuasion, inducement, punishment, environmental restructuring Physical and psychological/social availability: changeable by restrictions, education, persuasion, enablement/resources, environmental restructuring

17. Definitions Interventions –activities designed to change behaviours Policies –decisions made by authorities concerning interventions Behaviour –anything a person does in response to internal and external events System –a set of identifiable entities and a specification of how they influence other

18. The behaviour change wheel A method for –describing systems in which policies, interventions and behaviour interact –designing interventions and policies starting with an understanding of the relevant behaviour system –evaluating the likely effects and side-effects of existing or proposed policies Based on categories of interventions and policies that –are mutually exclusive –provide comprehensive coverage –are specified at the same conceptual level

19. The Behaviour Change Wheel Regulation Environmental/ social planning Mass media Legislation Fiscal Persuasion Education Coercion Environmental restructuring Inducement (incentives/rewards) Enablement/ resources Capability Opportunity Physical Psych/ social Emot/ Habit Rational d-m Psych Motivation Behavioural system Intervention system Policy system Training Michie & West, 2010 Restriction Service provision Guidelines

20. What has been known for more than 20 years ‘Behavioural support’ –focused advice, encouragement and discussion for at least 4 weeks –bolsters resolve, helps avoid and cope with urges –doubles the chances of stopping permanently Adding Nicotine Replacement Therapy or bupropion –patches, gum, lozenges etc. for up to 8 weeks –reduces physiological need –further increases the chances of stopping permanently Cochrane Library

21. What is new? Nicotine Replacement Therapy Success rates are higher if: –Use patch plus a faster acting form (e.g. gum) –Start the patch 2-weeks before the quit date Using nicotine gum or inhaler to cut-down can lead to quitting later on Stead et al (2008) Cochrane Library; Moore et al (2009) BMJ + +

22. What’s new: varenicline (Champix) Taken as a tablet for 12 weeks starting before the quit date Targets nicotine receptors in the reward pathway Partially mimics the actions of nicotine to reduce urges/need to smoke and blocks the effects of nicotine More effective than bupropion and NRT Common side effect is nausea If taken for 24 weeks can get even higher success rates Cahill et al (2008) Cochrane Library

23. Scare stories Newspaper reports of heart attacks, suicides and other major adverse events Reviews of the evidence to date have not shown higher rates than would be expected Medicines and Healthcare Regulatory Authority (MHRA) continue to review the evidence Gunnell et al (2009) BMJ 2009;339:b3805; MHRA website

24. What’s new: behavioural support Using telephone helplines can improve the chances of stopping smoking Internet sites may help but not clear what makes an effective site Provide structure, practical advice, exercises, moral support

25. Reducing craving Experimental studies have found the following to be effective: –walking –isometric exercise –‘body scan’ (mindfulness) –glucose tablets –imagery

26. Walking 5-10 minutes of brisk walking effect lasts for 10-20 minutes afterwards also improves mood the effect is probably not just distraction

27. Isometric exercise tensing and relaxing muscles (e.g. arms, buttocks, thighs) can be done while sitting still 5-10 minutes

28. Body scan part of ‘mindfulness’ training focus attention on different parts of the body while relaxing, concentrating on breathing accepting the feelings, not fighting them about 10 minutes

29. Glucose tablets 3g of glucose (Dextrosol, Lucozade etc.) chew up to 4 at a time smokers may confuse hunger for food with nicotine hunger effect lasts at least 15 minutes

30. Imagery Virtual reality programme in which smokers crushed cigarettes in one study led to higher short- term abstinence rates

31. Effective ‘behaviour change techniques’ (BCTs) NHS Stop Smoking Services use a wide variety of BCTs We have looked at associations between these and their short-term success rates BCTs associated with higher success rates include: –Measure expired-air carbon monoxide concentration –Strengthen ex-smoker identity –Advise on changing routine –Provide rewards contingent on successfully stopping smoking –Facilitate relapse prevention and coping –Advise on use of stop smoking medication This is an ongoing area of research by the NHS Centre for Smoking Cessation and Training based at UCL West et al (In press) Nicotine and Tobacco Research

32. Expired-air carbon monoxide (CO) CO is a poisonous gas absorbed from cigarette smoke Stays in the blood for many hours High readings when smoking can bolster resolve to stop and low readings when abstinent can be rewarding

33. Ex-smoker identity Help smoker to think and feel like an ex-smoker, not a smoker who is struggling against cravings –smoking is ‘not an option’ –can still be a ‘rebel’

34. Advice on changing routine Routines supply a regular sources of smoking cues Changing routines can reduce exposure to those cues –E.g. different route to work, different place for coffee, different seat to watch TV

35. Rewarding abstinence Lavish praise and heap respect on clients who have not smoked At the end of each session create sense of anticipated praise when they come back next time still not smoking

36. Relapse prevention and coping Equip smoker with active things they can do to avoid lapses when the urges strike –mental exercise –physical tasks Important not to just ‘wait it out’

38. Routes to quitting in English smokers www.smokinginengland.info

39. Relative success rate by ‘route to quit’ Significantly better than no aid, p<0.001 www.smokinginengland.info

40. Conclusions Smoking is still a major problem in Britain despite ‘smoke- free’ legislation Almost half of smokers try to stop but success rates are low The best option by far is the NHS Stop Smoking Service which gives practical support and advice plus medication The best medication options are varenicline or NRT patch plus fast-acting NRT form Most smokers still try to go it alone and many will die prematurely as a result The NHS Stop Smoking Services are being revamped and we at UCL are collecting evidence to ensure that they deliver the best possible help (NCSCT)