1 How best to motivate and help smokers to stop University College London November 2010 Robert West

2 Topics Recent trends in smoking prevalence and cessation rates in England Effectiveness of clinical interventions to help smokers to stop Use of clinical interventions by English smokers What makes a good stop smoking practitioner NHS Centre for Smoking Cessation and Training

3 Smoking prevalence was declining prior to ‘smoking ban’

4 The rate of decline increased after the ‘ban’

5 But there has been little further reduction since the recession began

6 The picture is similar in higher social grades … A-C1: professional to clerical C2-E: skilled manual to long-term unemployed

7 … and lower social grades

8 Attempts to stop smoking have declined since 2007 … Data from Smoking Toolkit Study; p< for decline; N=19,503

9 … as has the percentage of smokers who report having stopped in the past 12 months Data from Smoking Toolkit Study; p< for decline; N=19,503

10 Clinical interventions are effective at improving success rates Data from Cochrane reviews; statistically significant effects with combined sample size >1000 and no significant heterogeneity Compared with placebo when added to group or individual support Compared with brief advice or written materials

11 Some treatments are better than others Data from Cochrane reviews; statistically significant effects with combined sample size >1000 and no significant heterogeneity

12 Highest success rates lie with using the NHS Stop Smoking Services Significantly better than no aid adjusting for confounding variables, p<0.001 Data from based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939www.smokinginengland.info

13 Very few smokers use the most effective methods Percentage of quit attempts using different methods; data from Smoking Toolkit Study: N=7,808

14 GPs are not helping as much as they could Percentage of smokers and recent ex-smokers for whom …; data from Smoking Toolkit Study, N=4,090

15 GP offer of support is associated with higher rates of attempt to stop

16 GP recommendations are strongly associated with method of quitting by smokers

17 Performance of the NHS Stop Smoking Services varies considerably Impact=Number of 4-week, CO-verified quitters generated above what would have been expected from medication alone (25% success rate) per 100,000 adult population: Data from Information Centre Negative impact means less than 25% CO-verified success rate

18 What makes a good stop smoking practitioner?

19 Session 1: Prequit 1.Establish rapport and gain confidence of the smoker 2.Ensure that the smoker has a clear understanding of the behavioural support plan and his/her role and obligations 3.Gain strong commitment to engagement with the plan and the goal of total abstinence 4.Assess and record smoking and quitting history 5.Discuss medication options and make plans to get appropriate medication 6.Record decisions taken and reasons 7.Measure and record CO and explain significance of the reading 8.Elicit and answer questions and address concerns 9.Make and record appointment for quit date session 10.Discuss the precise quit point and use of medication and smoking prior to that point 11.Advise on preparations for the quit date 12.Close consultation by ‘looking forward’ to seeing smoker on the quit date

20 Session 2: Quit day 1.Re-establish rapport and confidence in you and the plan 2.Confirm the smoker’s understanding of the plan and his/her obligations 3.Have the client confirm commitment to the plan and the total abstinence goal 4.Discuss with client beginning to think like an ‘ex-smoker’ 5.Review and record medication use to date and any side-effects 6.Discuss appropriate ways of addressing side effects or failure to use medication as required 7.Measure and record CO and explain how this will decline following abstinence 8.Elicit and answer questions and address concerns 9.Make and record next appointment and offer additional support 10.Discuss with client what to expect over the following week in terms of craving and withdrawal symptoms 11.Discuss specific actions that the smoker will take when faced with cravings and threats to abstinence 12.Close consultation by ‘looking forward’ to seeing client having not smoked

21 Sessions 3-5: Post-quit 1.Re-establish rapport 2.Assess and record self-reported smoking status 3.Measure and record CO and discuss the findings in a way that is motivational 4.Reward abstinence 5.Review and record positive and negative experiences, self- efficacy and cravings since the quit date 6.Review and record medication use and side-effects 7.If any smoking has occurred, discuss the circumstances and if appropriate gain renewed commitment to total abstinence 8.Discuss specific ways of dealing with negative experiences and medication side-effects 9.Record any proposed changes to medication 10.Elicit and answer questions and address concerns 11.Make and record appointment for the following week and renew offer of additional support that is available 12.Close consultation by ‘looking forward’ to seeing smoker next time

22 Session 6: Closing session 1.Re-establish rapport 2.Assess and record self-reported smoking status 3.Measure and record CO and discuss the findings in a way that is motivational 4.Reward abstinence 5.Review and record positive and negative experiences, self- efficacy and cravings since the quit date 6.Review and record medication use and side-effects 7.If any smoking has occurred, discuss the circumstances and if appropriate gain renewed commitment to total abstinence 8.Discuss specific ways of dealing with negative experiences and medication side-effects 9.Record any proposed changes to medication 10.Elicit and answer questions and address concerns 11.Close consultation by wishing the smoker well, advising of the possibility of follow-up and offering additional support as required

Record keeping 3 types of information for every client –characteristics of smoker –treatment provided –outcome Needs to be: –done in standard form and recorded on computer –collated and reviewed every 6 months to assess quality and consider improvements

24 Information needed about smokers Age Gender Occupational group Age when started smoking Cigs per day Expired air CO Time to first cigarette of the day Experience of urges to smoke Longest time without smoking previously Time since most recent quit attempt What led back to smoking Medical problems Psychological problems Current medication and other ongoing treatment

25 Information about treatment Choice of medication Degree of adherence to medication Number of sessions offered Number of sessions attended Type of support offered (individual or group) Components of support included

26 Information about outcome 4-week outcome –whether smoked at all in past 2 weeks –expired air CO Longer term outcome (s) –follow-up point –whether not smoking at all –duration of abstinence –expire-air CO

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28 NHS Centre for Smoking Cessation and Training (NCSCT) Undertake research to determine competences necessary for effective behavioural support for smoking cessation Develop and apply assessments of practitioners based on those competences Develop and deliver training to help staff achieve the required standard Provide continuing professional development based on the latest research findings

29 NHS Stop Smoking Services... need a cadre of professional stop smoking practitioners –registered –trained –assessed for competence –certified –working in well-run services –using the best evidence-based methods and medications –networked and supported –keeping accurate records –engaging with continuing professional development

30 Key points Motivating smokers to stop involves: –enthusiastically offering help to all smokers at least once a year, not asking about intention to stop first Helping smokers to stop involves: –a well-run service with a cadre of certified Stop- Smoking Practitioners offering: multi-session behavioural support NRT-plus (patch plus fast acting form) or Champix keeping accurate records and regularly evaluating how performance can be improved

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