1. 1 Recent studies of clinical significance University College London June 2011 Robert West

2. 2 Topics The challenges facing UK Stop-Smoking Services 1.demonstrating the importance of clinical services 2.providing guidance how best to configure the services 3.ensuring quality of provision Relevant studies 1.Real world effectiveness of aids to cessation and impact of the services 2.What makes for an effective service and an effective practitioner 3.Criteria that need to be in place when commissioning providers

3. 3 The place of smoking cessation interventions in tobacco control Reduce total harm from tobacco use Reduce prevalence Reduce uptake Promote cessation Reduce harm from use

4. 4 The First Law of Smoking Cessation E = N x S The number of ex-smokers The number of smokers trying to quit The chances of success of each attempt

5. 5 What does this mean? 1.Motivate as many smokers to try to quit as possible 2.Ensure that they have access to the best possible help if they wish to use it 3.Motivate them to use the most effective method available

6. 6 The Second Law of Smoking Cessation The best chance of success at stopping smoking is by using a combination of: –a) stop-smoking medication –b) professional advice and support

7. 7 The role of clinical services Stop-smoking services provide highly cost- effective life-preserving treatment for an addictive disorder for those people who want to use it The services need to be accessible to all smokers and promoted so that smokers can see the benefits The extent of the provision must be commensurate with demand Failure to provide those services is an abdication of responsibility and betrayal of the principles of the NHS

8. 8 Promoting cessation Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support

9. 9 Pharmacological treatment Reduce urges to smoke Reduce ‘nicotine hunger’ Reduce acute cue-driven craving Block nicotine reward

10. 10 Effectiveness versus efficacy Efficacy –Effect of an intervention compared with a comparator in an experimental study Effectiveness –Effect of an intervention in the ‘real world’

11. 11 Efficacy of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

12. 12 Efficacy of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

13. 13 Efficacy of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

14. 14 Efficacy of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

15. 15 Efficacy of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

16. 16 Efficacy of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

17. 17 Effectiveness of medication options West et al (2007) Thorax, 62, 998-1002 Brose et al (2011) Thorax, 66, 924-6 Smokers using NRT have better success rates than those not using it

18. 18 Effectiveness of medication options Brose et al (2011) Thorax, 66, 924-6 Smokers using bupropion have better success rates than those using nothing

19. 19 Effectiveness of medication options Brose et al (2011) Thorax, 66, 924-6 Bauld et al (2012) Addiction, in press Smokers using varenicline are more likely to succeed than those using no medication or NRT or bupropion

20. 20 Efficacy of different forms of NRT Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

21. 21 Efficacy of different ways of using NRT: efficacy Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

22. 22 Efficacy of different ways of using NRT: effectiveness Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support Brose et al (2011) Thorax, 66, 924-6 Smokers using dual form NRT have higher success rates than those using single form NRT

23. 23 Efficacy of different ways of using NRT: effectiveness Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support Beard et al (2012) Drug & Alcohol Dependence, in press Beard et al (2012) Tobacco Control, in press Smokers using NRT for smoking reduction are more likely to go on to quit, even after adjusting for possible confounding variables Beard et al (2012) Drug & Alcohol Dependence, in press Beard et al (2012) Tobacco Control, in press Smokers using NRT for smoking reduction are more likely to go on to quit, even after adjusting for possible confounding variables

24. 24 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process

25. 25 Behavioural support: efficacy Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

26. 26 Behavioural support: efficacy Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

27. 27 Behavioural support: efficacy Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

28. 28 Behavioural support: efficacy Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

29. 29 Behavioural support: efficacy Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

30. 30 Behavioural support: effectiveness West et al (2012) www.smokinginengland.info Smokers who receive behavioural support plus medication have higher success rates than those obtaining medication on prescription only

31. 31 Optimum service provision Brose et al (2011) Thorax, 66, 924-6 –Varenicline or dual form NRT –Provide specialist support –Offer group-based support West et al (2010) Nic & Tob Res, 12, 742-7 West et al (2011) Nic & Tob Res, 13, 1316-20 –more sessions –treatment manuals that focus on: advise on medication advise on changing routine advise on coping with cravings advise on changing routine additional foster ex-smoker identity CO monitoring elicit client views give options for support betting game communicating group member identity

32. 32 Key commissioning requirements 1.Only pay for ex-smokers above a threshold (e.g. 25% 4-week quitters) – but pay for them appropriately 2.Pay more for more dependent smokers 3.Only commission providers who: a.offer all evidence-based treatments b.employ staff who are certified, trained, supervised and have appropriate continuing professional development c.follow evidence based guidelines in delivery of behavioural support d.use a rigorous standardised procedures for assessing abstinence according to the Russell Standard e.use a fully independent service to audit claimed successes West (2011) Addiction, 106, 1730-2

33. 33 Current practice McDermott et al (2012) BMC Hlth Serv Res, 12, 121

34. 34 Current practice McDermott et al (2012) BMC Hlth Serv Res, 12, 121 Should be 100%

35. 35 Current practice McDermott et al (2012) BMC Hlth Serv Res, 12, 121 Not generally appropriate

36. 36 Key points Clinical studies show: –effectiveness as well as efficacy of the recommended model of smoking cessation support in England –important components of treatment both in terms of medication and behavioural support –some deficiencies in the current commissioning process that may undermine effectiveness for some services