1. 1 Smoking Cessation Specialists: creating a profession University College London May 2012 Robert West

2. 2 Declaration of interests I undertake research and consultancy for companies that develop and manufacture smoking cessation medications I am a trustee of QUIT I am co-director of the National Centre for Smoking Cessation and Training

3. 3 Where treating cigarette addiction fits in Reduce total harm from tobacco use Reduce use 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? Encourage as many smokers to try to quit as possible Do your best to ensure that they have access to the best possible help if they wish to use it Encourage 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 Behaviour Change Wheel

8. 8 Education Persuasion Incentivisation Coercion Taining Restriction Environmental restructuring Modelling Enablement

9. 9 Behaviour Change Wheel Education Persuasion Incentivisation Coercion Taining Restriction Environmental restructuring Modelling Enablement Legislation Communication/marketing Service provision Guidelines Environmental/social planning Fiscal measures Regulation Service provision

10. 10 ‘Public health negligence’ Failing to applying a minimum standard of competence in analysing public health data Similar to ‘clinical negligence’ but capable of doing far more damage

11. 11 The First Fallacy of Smoking Cessation Foolish student: Most ex-smokers quit without help; therefore that is the best method of quitting Teacher: That is patent nonsense; most failed quitters also did so without help! What counts is whether a quit attempt has a higher or lower chance of succeeding with or without help

12. 12 The Second Fallacy of Smoking Cessation Foolish student: Very few smokers want help with stopping so we should not waste resources on such help Teacher: That means denying what we know to be cost-effective life-saving treatment to people who would use it and benefit from it The resources we put into it should obviously be commensurate with demand

13. 13 Third Fallacy of Smoking Cessation Foolish student: Most smokers manage to stop eventually so they don’t need help Teacher: Every day a smoker carries on after his or her mid-thirties loses an average of 6 hours of life Only a quarter of ever-smokers stop before they start to lose life expectancy We must strive to help smokers to stop as early as possible

14. 14 Addiction treatment is needed because unaided success rates are usually very low Estimated relapse curve from unpublished data

15. 15 The battle over time between resolve and urge to smoke Urge to smoke Time When the urge is stronger than resolve and cigarettes are available, a lapse will occur Resolve Strength of urge

16. 16 The role of treatment is to keep these lines as far apart as possible Urge to smoke Time Resolve Strength of urge

17. 17 Aiding cessation Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support

18. 18 Behavioural support Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support Drugs to reduce motivation to smoke

19. 19 Pharmacological treatment Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support Advice and support aimed at boosting motivation, helping with self-regulation, and promoting effective use of supporting activities

20. 20 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process

21. 21 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process Minimise motivation to smoke and maximise motivation not to smoke

22. 22 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process Help to avoid and resist urges to smoke

23. 23 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process Help smokers to make best use of medication and other aids to cessation

24. 24 Behavioural support Do necessary assessments, build rapport, tailor treatment as needed

25. 25 Effectiveness 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

26. 26 Effectiveness 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

27. 27 Effectiveness 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

28. 28 Effectiveness 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

29. 29 Effectiveness 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

30. 30 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

31. 31 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

32. 32 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

33. 33 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

34. 34 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

35. 35 The Fourth Fallacy of Smoking Cessation Foolish student: The results of clinical trials do not translate into the ‘real world’ Patient teacher: It only looks like that if you mis- understand what the ‘real world’ data are telling you. You have to take account of the fact that in the real world it is more dependent smokers who seek help so they start with a lower chance of success

36. 36 Smokers’ clinics give the best results in the ‘real world’ Significantly better than no aid adjusting for confounding variables, p<0.001 Data from www.smokinginengland.info; 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=10,728www.smokinginengland.info

37. 37 Behavioural support for smoking cessation Involves a wide set of competences to deliver the necessary ‘behaviour change techniques’ Differences between individual practitioners can be greater than the difference between active and placebo medication Therefore it is vital that specialists are selected, trained and supported to give the highest possible quality of support

38. 38 AASCP A huge step forward What it means: –smokers can be confident in the competence of the person who is advising them –specialists get recognition for their skills and knowledge –there is a sound basis for advancing the field and improving quality Another way in which Australia is leading the world in tobacco control