1. 1 Should behavioural support for smoking cessation address wider psychological problems? University College London October 2013 Robert West

2. Statement of Potential Conflicts of Interest Should behavioural support for smoking cessation address wider psychological problems?) Relating to this presentation, the following relationships could be perceived as potential conflict of interests: Research and consultancy for companies that develop and manufacture smoking cessation medications

3. Outline 1.Do psychological problems inhibit smoking cessation? 2.Can psychological problems be effectively addressed in smoking cessation support? 3.Is there direct evidence that addressing psychological problems improves treatment outcomes? 3

4. Outline 1.Do psychological problems inhibit smoking cessation? 2.Can psychological problems be effectively addressed in smoking cessation support? 3.Is there direct evidence that addressing psychological problems improves treatment outcomes? 4

5. Addiction to cigarettes 5 Cue-driven urges Nicotine hunger Nicotine withdrawal symptoms Concern about cost Worry about health Dislike of other aspects of smoking and Addiction to cigarettes involves the moment-to-moment conflict between

6. 6 Addiction to cigarettes I really want to stop smoking: it’s costing me money and it will probably kill me Just smoke

7. What is needed for behaviour change: The COM-B model 7 Michie et al (2011) Implementation Science Physical and psychological capability: knowledge, skill, strength, stamina

8. The COM-B model of behaviour change 8 Michie et al (2011) Implementation Science Reflective and automatic motivation: plans, evaluations, desires and impulses

9. The COM-B model of behaviour change 9 Michie, van Stralen & West (2011) Implementation Science Physical and social opportunity: time, resources, triggers, concepts

10. What is required for smoking cessation? Motivation to stop Desire to quit and hope for success versus concern about lost benefits of smoking and fear of failure Ability to stop Ability to maintain self-control in the face of immediate urges, need and desire to smoke Opportunity to stop Protection from smoking triggers Exposure to stopping triggers 10

11. 11 Goals of treatment Urges to smoke Resolve (motivation and ability to resist urges) Time Abstinent Smoking The treatment may have chronic or short-term effects on either or both curves

12. How might psychological problems inhibit cessation? Reducing Motivation to quit Hope for success in quitting Ability to exercise self-control Quitting triggers Increasing Concern about lost benefits of smoking Immediate, urges, needs and desire to smoke Smoking triggers 12

13. Anxiety and depression appear not to reduce motivation to quit Data from Smoking Toolkit Study N=1,330 smokers in general population in England Household survey Measures: –number of quit attempts in the past year –motivation to quit on 7-point scale (MTSS) –Anxiety/depression (EQ5D) –Age, gender, social grade Results: –smokers with poor mental health are as motivated to quit and try to quit at least as often as those with good mental health –adjusted beta: 0.03, p=.31 for motivation; 0.06, p=0.05 for quit attempts 13

14. People with anxiety and depression are more likely to be offered quitting support Data from Smoking Toolkit Study N=1,301 smokers in general population in England Household survey Measures: –GP advice to quit –GP offer of support to quit –Anxiety/depression (EQ5D) –Age, gender, social grade Results: –smokers with poor mental health are more likely to receive offer of support –adjusted beta: 1.44, p<0.001 –but this is only because they see the GP more often 14

15. Depressed mood predicts failure of quit attempts with low intensity support Data from StopAdvisor RCT N=4,613 smokers signed up to a trial of an internet intervention Measures: –Rating of depression (1 to 5 scale) –Age, gender, socio-economic group, Heaviness of Smoking Index –Sustained smoking abstinence for 6 months, biochemically verified by saliva cotinine (Russell Standard) Results: –adjusted odds ratio=0.88, p=0.009 15

16. Outline 1.Do psychological problems inhibit smoking cessation? 2.Can psychological problems be effectively addressed in smoking cessation support? 3.Is there direct evidence that addressing psychological problems improves treatment outcomes? 16

17. Depressed mood does not predict failure of quit attempts with high intensity support Data from glucose RCT N=819 smokers signed up to a trial of glucose added to group support Measures: –Rating of depression (1 to 5 scale) –Age, gender, socio-economic group, Heaviness of Smoking Index –Sustained smoking abstinence for 6 months, biochemically verified by saliva cotinine (Russell Standard) Results: –adjusted odds ratio=1.03, p=0.81 17

18. Depressed mood and quit success with low and high intensity support 18

19. Depression does not predict failure of quit attempts with high intensity support: Czech Data from Prague smokers clinic N=855 smokers attending intensive behavioural support programme and receiving NRT or varenicline Measures: –Currently suffering from depression –Age, gender, educational level, FTCD –Sustained smoking abstinence for 12 months, biochemically verified by expired air CO Results: –adjusted odds ratio=0.76, p=0.42 19

20. Depression does not predict failure of quit attempts with high intensity support: Polish Data from Tabex RCT N=740 smokers attending intensive behavioural support programme and receiving NRT or varenicline Measures: –Beck Depression Inventory –Age, gender, occupational group, HIS, cytisine vs placebo –Sustained smoking abstinence for 12 months, biochemically verified by expired air CO Results: –adjusted odds ratio=0.96, p=0.16 20

21. Outline 1.Do psychological problems inhibit smoking cessation? 2.Can psychological problems be effectively addressed in smoking cessation support? 3.Is there direct evidence that addressing psychological problems improves treatment outcomes? 21

22. Mood management in smoking cessation Gierisch et al (2011) JGIM, 27, 351 Systematic review of RCTs of mood management added to smoking cessation support 5 trials with current depression or history of depression Interventions included CBT and Behavioural Activation treatment Results suggestive of benefit 22

23. Mood management in smoking cessation 23

24. Mood management in smoking cessation: current depression van de Meer et al (2013) Cochrane Database, CD006102 Systematic review of RCTs of mood management added to smoking cessation support 11 trials with current depression Interventions included CBT and behavioural activation treatment Results showed benefit 24

25. Current depression 25

26. Mood management in smoking cessation: past depression van de Meer et al (2013) Cochrane Database, CD006102 Systematic review of RCTs of mood management added to smoking cessation support 13 trials with past depression Interventions included CBT and behavioural activation treatment Results showed benefit 26

27. Past depression 27

28. Conclusions 1.Psychological problems may, in theory undermine cessation by reducing motivation or ability to quit or quitting triggers 2.Evidence suggests that in fact they operate primarily by reducing ability to quit, not motivation or quitting triggers 3.Intensive behavioural support may mitigate this, even when it is not directly targeted at these problems 4.There is some evidence that adding mood management may enhance quit rates, even in smokers not currently depressed 28