1. 1 Clinical support to aid smoking cessation Robert West Oslo University College London March 2007

2. What is the role of the clinician in smoking cessation? 1.Clinicians should: a.not get involved in discussing smoking b.raise the topic of smoking with patients 2.Clinicians should: a.tell smokers to stop b.advise smokers to stop 3.Clinicians should a.raise the topic of smoking only with those with smoking-related symptoms b.raise the topic of smoking with all smokers 4.Clinicians should: a.not routinely offer to prescribe medication to help patients to stop b.routinely offer to prescribe medication to help patients to stop 5.Clinicians should a.offer to provide behavioural support to help smokers to stop b.find out about and encourage smokers to use other behavioural support packages

3. Outline 1.Understanding addiction to cigarettes 2.How smokers become ex-smokers 3.Injecting urgency into the process of smoking cessation 4.What can be achieved through good clinical care 5.The clinician’s role

4. What is addiction? ‘Addictions’ are activities to which individuals attach an unhealthy priority because of a disordered motivation system ‘Dependence’ refers to the multi-faceted nature of that disorder The disorder may involve combinations of: –strong stimulus-driven ‘impulses’ –strong ‘needs’ and ‘wants’ –weak motivations to exercise restraint –reduced capacity to exercise restraint The ‘motivational system’

5. How does addiction show itself? Addiction can show itself in various ways depending on the activity concerned: –Other activities and goals necessary for healthy functioning and fulfilment may be subordinated to the addictive behaviour –Individuals are unable to exercise restraint when they try –Individuals may experience powerful wants, needs or urges to engage in the activity –The individual may experience anxiety and conflict about continuing engaging in the behaviour

6. Mechanism 1: cue-driven impulses When nicotine is absorbed it attaches to nicotinic acetylcholine receptors in the Ventral Tegmental Area (VTA) of the mid brain This stimulates firing of neurons that project forward to the Nucleus Accumbens (NAcc) This causes dopamine release in the NAcc This leads to impulses to smoke in the presence of smoking ‘cues’ (e.g. being offered a cigarette) Nucleus accumbens Ventral tegmental area

7. Mechanism 2: acquired ‘drive’ creating a need to smoke In many smokers, after repeated ingestion of nicotine, the motivational system is altered to create a ‘drive’, somewhat similar to hunger, except that it is for nicotine The drive increases in the minutes to hours since the last cigarette and is influenced by triggers, reminders, stress and distractions The drive is experienced as feelings of ‘need’ to smoke The drive reduces over weeks of not smoking but in some cases does not disappear completely Simplified schematic of development of an acquired drive

8. Mechanism 3: mood and physical symptoms creating a need to smoke After repeated nicotine exposure, abstinence results in unpleasant withdrawal symptoms including depression Smokers also report that smoking helps them cope with stress Adverse mood therefore comes to generate a need to smoke

9. Nicotine dependence Smoking Impulse to smoke Desire to smoke Need to smoke Positive evaluations of smoking Anticipated pleasure/ satisfaction 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, and direct simulation of impulses through habit learning Plan to smoke

10. What this means in populations

11. The process of stopping smoking: changes in identity I will give up some time I am giving up smoking I have given up smoking completely I am trying to give up smoking I smoke...... and I am happy about my smoking... but I am not happy about my smoking I have given up smoking but not completely I have made plans to give up I do not smoke... I am not even thinking about giving up

12. While smoking... 1. When the smoker is led to think about his or her smoking, he or she may feel a desire or need to stop that varies in strength and urgency arising from one or more of the following: Worry about health Dislike of financial cost of smoking Guilt or shame at smoking Disgust with smoking Hope for success at stopping Hope for improvement in health with stopping Hope for improved self-esteem with stopping Commitment to a remembered intention to make a quit attempt 2. These conflict with and are mitigated by habit driven impulses and by a desire or need to smoke arising from one or more of the following: Anticipated enjoyment of a forthcoming cigarette Need for the forthcoming cigarette Concern about loss of self-esteem if the quit attempt fails Concern about unpleasant short-term effects of stopping Wanting or needing to hold on to the perceived benefits of smoking 3. Depending on the strength of the competing desires and needs, the conflict may result in: Putting the idea of stopping out of his or her mind Forming an intention to stop at some vaguely conceived future time point Forming a definite plan to stop at some future time point Deciding to stop immediately

13. Motivation to stop smoking Quit attempt Impulse to make a quit attempt Desire to stop smoking Need to stop smoking Positive evaluations of stopping smoking Anticipated self-respect Anticipated praise Fear of ill- health/death Disgust, annoyance with smoking Felt stigma Non-smoker ‘identity’ Beliefs about benefits of stopping smoking Cues/triggers Reminders Choice Only the flow of influence towards responses are shown Habit/instinct

14. Resistance to stopping smoking Not making attempt Inhibition of making a quit attempt Desire not to make attempt Need not to make attempt Negative evaluations of making attempt Anticipated enjoyment of smoking Anticipated benefits of smoking Anticipated loss of benefits Fears of failure Anticipated effort Smoker ‘identity’ Beliefs about likelihood of failure Cues/triggers Reminders Choice Only the flow of influence towards responses are shown Habit/instinct

15. While not smoking 1. On each occasion when the would-be ex- smoker is led to think about smoking, he or she experiences an urge to smoke arising from one or more of the following: A habit-driven impulse A need to smoke derived from ‘nicotine hunger’ A need to smoke derived from anticipated relief from negative mood A need to smoke derived from anticipated physical symptoms, e.g. mouth ulcers A desire to smoke derived from anticipated enjoyment or satisfaction A desire to smoke derived from anticipated benefits of smoking, e.g. weight loss 2. This competes with a desire or need for the smoker to stop himself or herself smoking which arises from one or more of: Commitment to the decision not to smoke Commitment to the identity of a non-smoker Worry about health Anticipated guilt or shame at having a cigarette Hope for improvement in health with stopping Anticipated disappointment at having wasted the effort expended thus far Anticipated effort required to acquire a cigarette 3. If the strength of the urge to smoke is greater than the inhibition arising from the desire or need not to smoke, and the opportunity to smoke is present, the would-be ex-smoker will: Smoke a cigarette but consider that the quit attempt is continuing Abandon the quit attempt but try to keep smoking within certain limits Abandon the quit attempt completely

16. Motivation to smoke Smoking Impulse to smoke Desire to smoke Need to smoke Positive evaluation of smoking Anticipated enjoyment Anticipated benefit Nicotine ‘hunger’ Unpleasant mood and physical symptoms Smoker ‘identity’ Beliefs about benefits of smoking Cues/triggers Reminders Habit/instinct Choice Only the flow of influence towards responses are shown

17. Inhibition of smoking Not smoking Inhibition Desire not to smoke Need not to smoke Negative evaluation of smoking Anticipated praise Anticipated self-respect Plan not to smoke Anticipated disgust, guilt or shame Fears about health Non-smoker ‘identity’ Beliefs about benefits of not smoking Cues/triggers Reminders Choice Only the flow of influence towards responses are shown Habit/instinct

18. The urgency of smoking cessation Every year of smoking: –damages lung function irreparably potentially leading to COPD later in life –after the age of 35-40 years reduces life expectancy by 3 months –increases the irreversible risk of lung cancer Stopping at 35 prevents 9 years’ loss of life expectancy Stopping at 60 prevents 3 years’ loss of life expectancy Stopping smoking is always urgent but never too late

19. GP attitudes Helgasen & Lund (2002) –2000+ GPs in Norway, Sweden, Iceland & Finland –Agreed that discussing smoking is part of the job but … tended to limit advice to those with smoking-related symptoms did not typically provide support –because … too time-consuming very low success rate lack of specialists to refer on to

20. Creating the decision to stop Generate motivational tension by: –frequent or persistent, high levels of want and need to make the change now –hope that the attempt to change will be successful Trigger impulses to make the change attempt by: –repeated calls to immediate action –modelling the behaviour

21. Opening lines When was the last time you tried to stop smoking? How long did it last? What did you use to help? What led you to back to smoking? It’s always worth having another go and there are lots of options to suit individual smokers which have been proved to help in research. Would you like to discuss these?

22. Supporting the decision to stop Reduce the frequency and intensity of impulses, needs and wants to revert –Identify the sources of impulses and needs –Develop a specific plan in each case to avoid, escape or minimise these Generate a strong commitment to a new identity with clear boundaries –Foster the ‘complete non smoker’ identity (smoking is not even an option, re-evaluation of place of smoking in their life) –Deal with lapses by re-asserting the new identity –‘One day at a time’ –Maximise both intrinsic and extrinsic motives for not smoking (e.g. avoiding shame, gaining self-respect)

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

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

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

26. Effect of tailored internet support Not biochemically verified

27. 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)

28. 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

29. Success rates up to 6 months: ATTEMPT cohort study Significant differences between NRT and no aid at all points, p<.05 100 23.5 12.7 6.6 4.6 40 21.7 11.8 10.9 0 10 20 30 40 50 60 70 80 90 100 0306090120150180 Days Percent still abstinent No aid NRT

30. Comparative studies: abstinence data Gonzales DH, Rennard SI, Billing CB, et al. A pooled analysis of varenicline: an α4β2 nicotinic receptor partial agonist vs. bupropion for smoking cessation. SRNT Paper sessions PA9-2, PA9-3, 2006. 0 5 10 15 20 25 30 35 40 45 50 Responders (%) Week 1216202428323640444852 0 10 20 30 40 Odds Ratio (95% CI) V vs P2.82(2.06, 3.86; P <0.0001) V vs B1.56(1.19, 2.06; P <0.0013) B vs P1.80(1.29, 2.51; P <0.0004) Varenicline 1 mg bid (n=692) 22.5% Bupropion 150 mg bid (n=669) 15.7% Placebo (n=684) 9.4% CA rate (%) Varenicline Bupropion Placebo

31. Cumulative effects of using effective cessation treatment If quit attempts are made every year

32. Hypertension and nicotine dependence treatment Hypertension –Routinely measure blood pressure –Apply continuing stepped-care model until it is under control Nicotine dependence –Routinely assess smoking status –Apply continuing stepped care model until it is eliminated or under control

33. Conclusions Nicotine dependence mostly involves acquisition of cue- driven impulses, need for relief from an acquired ‘nicotine hunger’ and mood and physical symptoms The process of stopping involves tension arising from dissatisfaction with smoking and triggers prompting quit attempts and then different tensions and triggers promoting lapse and relapse Nicotine dependence is treatable with behavioural and pharmacological methods The clinicians role is to trigger quit attempts, motivate the use of effective treatments and continue the process until the smokers successfully quits

34. What is the role of the clinician in smoking cessation? 1.Clinicians should: a.not get involved in discussing smoking b.raise the topic of smoking with patients 2.Clinicians should: a.tell smokers to stop b.advise smokers to stop 3.Clinicians should a.raise the topic of smoking only with those with smoking-related symptoms b.raise the topic of smoking with all smokers 4.Clinicians should: a.not prescribe medication to help patients to stop b.prescribe medication to help patients to stop 5.Clinicians should a.offer to provide behavioural support to help smokers to stop b.find out about and encourage smokers to use other behavioural support packages

35. Reading West R & Shiffman S (2007) Fast Facts: Smoking Cessation (2 nd Edition). Oxford, Health Press