1. 1 Behaviour change in theory and in real life Robert West University College London Stockholm, April 2008

2. Statement of competing interest I undertake research and consultancy for companies that develop and manufacture smoking cessation medications I have a share of a patent for a novel nicotine delivery device I undertake training in behavioural support for smoking cessation

3. Outline What do we currently advise people trying to quit? What do people do? Is the advice well-founded? What can we learn from all this? What does this mean for improving the help we offer?

4. Advice to smokers 1.Quit abruptly, not gradually –gradual quitting saps the motivation and extends the period of craving and withdrawal 2.Plan your quit in advance –planning enables preparatory mental and practical steps to be taken to deal with issues that are likely to arise 3.Use medication –medication reduces urges to smoke and withdrawal symptoms making the transition easier 4.Use behavioural support –behavioural support bolsters motivation to remain abstinent and provides ways of avoiding or dealing with urges to smoke

5. The ‘Smoking Toolkit Study’ A series of monthly household surveys of adults in England, using representative samples Each month generates approximately 500 smokers or recent ex-smokers These data from 3350 smokers who tried to quit in past year Questions about quitting behaviours including –characteristics of quit attempts (e.g. gradual versus abrupt) –aids used (e.g. medication, behavioural support) –whether quit attempt has been successful so far Further details –www.smokinginengland.info

6. Abrupt quitting versus gradual reduction 61% of quit attempts are made abruptly –Smokers aged 25 to 54 are more likely to quit abruptly than older or younger smokers

7. Planned versus unplanned quits 42% of quit attempts are planned –Smokers from higher social grades and those between 35 and 54 years old are more likely to make planned quit attempts

8. Use of medication 47% of quit attempts involve use of medication –34% used NRT bought over the counter –10% used NRT on prescription –3% used Zyban –1% used Champix –Women and older smokers are more likely to use medication

9. Use of behavioural support 7% of quit attempts involve use of behavioural support from NHS Stop Smoking Service –More use of support from higher social grades –Use of behavioural support increased up to the age of 65 then decreased

10. Is the advice well-founded? Randomised controlled trials show efficacy of: –all licensed medications –behavioural support Observational data suggest effectiveness of these aids to cessation –longitudinal population studies on NRT (West et al, 2006) –data from smokers clinics of behavioural support, NRT, Zyban and Champix (data from NHS stop smoking services)

11. Is it better to quit abruptly? Abrupt quitting is twice as likely to result in abstinence at the time of the survey than cutting down first (p<.001 by chi-squared test) –This difference remains after adjusting for measures of age, gender, social grade, nicotine dependence and use of aids to cessation

12. Is it better to plan the quit? Planned quitting is less likely to result in abstinence at the time of the survey than stopping without planning (p<.001 by chi-squared test) –This difference remains after adjusting for measures of age, gender, social grade, nicotine dependence and use of aids to cessation

13. What can we learn from all this? Many smokers are not following advice about the best methods of stopping smoking –Most are not using medication –Very few use behavioural support –Most are not planning their quit attempts –Many are stopping gradually Not all the advice is well-founded –Unplanned quits seem to do at least as well as planned ones, perhaps better

14. What does this mean? We need to find ways of encouraging more people to use the most effective methods of quitting We need to reconsider our advice on the issue of planning

15. Encouraging people to use effective methods Why do people not do what they should? –They don’t know about it –They don’t know why they should do it –They don’t accept why they should do it –They find the prospect of doing it unattractive –They don’t know how to do it –They don’t remember to do it –They don’t give it a high enough priority

16. Possible reasons for using ineffective strategies Not having been told that they are ineffective –e.g. no information on abrupt versus gradual cessation Not having been told why they are ineffective –e.g. no explanation as to why gradual cessation is less effective Not accepting that they are ineffective –e.g. failure to be persuaded that gradual cessation is less effective Finding the effective strategies unattractive –e.g. concern about abrupt loss of perceived benefits of smoking, and craving and withdrawal symptoms

17. Possible reasons for not using effective forms of assistance Lack of awareness of the options for assistance Belief that assistance is not necessary Belief that forms of assistance are not effective Belief that using assistance is a sign of weakness Negative feelings about forms of assistance Lack of awareness of how to access forms of assistance Unwillingness to pay, or devote the time or make the effort Feeling that stopping can be done later Feeling that stopping is not very important

18. Conclusions Current advice on abrupt cessation is probably well founded but many smokers do not follow it Current advice on planning is probably misplaced but most smokers do not follow it Less than half of quit attempts use medication and only 7% use free behavioural support There are many possible reasons why smokers might not adopt optimal cessation methods Research is needed to determine which of these is most important and how to encourage smokers to switch to effective methods