Perspectives on treatment for tobacco addiction Robert West University College London Rio de Janeiro November 2006

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

Anticipated enjoyment Unpleasant mood and physical symptoms Motivation to smoke Smoking Impulse to smoke Desire to smoke Need to smoke Positive evaluations of smoking Anticipated enjoyment Anticipated benefit Nicotine ‘hunger’ Unpleasant mood and physical symptoms Smoker ‘identity’ Beliefs about benefits of smoking Cues/triggers Reminders Nicotine dependence involves generation of acquired drive, withdrawal symptoms, strong desires from anticipated enjoyment and direct simulation of impulses through habit learning

Inhibition of smoking Not smoking Inhibition Cues/triggers Anticipated praise Desire not to smoke Need not to smoke 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

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

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

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 rate~50% 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

Effect of face-to-face individual support Using only studies with ≥6 months’ continuous abstinence and biochemical verification

Effect of group support Using only studies with ≥12 months’ continuous abstinence and biochemical verification

Effect of telephone counselling Cochrane review: >6 month cessation not validated

Effect of tailored internet support Not biochemically verified

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)

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

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

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

Principles underpinning policy: Health promotion concepts Education Increasing knowledge and understanding about the behaviour and its effects Persuasion Actively attempting to shape attitudes and behaviour through argument, imagery etc. Inducements Making the desired behaviour more attractive Coercion Making the undesired behaviour less attractive Upskilling Providing training or instruction on how to achieve the desired behaviour Regulating access Restricting opportunities to engage in the undesired behaviour Empowerment Making it easier to engage in the desired behaviour West, R British Medical Bulletin, In Press

Policy options Price increases Smoke-free legislation 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

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