1. Perspectives on treatment for tobacco addiction
Robert West
University College London
Rio de Janeiro
November 2006

2. Outline Motivation to smoke and not to smoke The treatment strategy
Treatment tactics
Treatment effectiveness
The future of treatment
Treatment in the context of tobacco control

3. Anticipated enjoyment Unpleasant mood and physical symptoms
Motivation to smoke
Smoking
Impulse to smoke
Desire to smoke
Need to smoke
Positive evaluations of smoking
Anticipated enjoyment
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, strong desires from anticipated enjoyment and direct simulation of impulses through habit learning

4. Inhibition of smoking
Not smoking
Inhibition
Cues/triggers
Anticipated praise
Desire not to smoke
Need not to smoke
Anticipated disgust, guilt or shame
Fears about health
Anticipated self-respect
Positive evaluations of not smoking
Reminders
Non-smoker ‘identity’
Beliefs about benefits of not smoking
Plan not to smoke
Nicotine dependence also involves impairment of impulse control mechanisms undermining response inhibition

5. The treatment strategy
Best outcome: to cure the smoker so that he or she never feels a strong desire or need to smoke again
Second best outcome: to generate remission so that the smoker at least temporarily does not feel a strong desire or need to smoke
Third best: suppression of smoking completely or partially by reducing the desire or need to smoke or bolstering motivation not to smoke

6. Treatment tactics
Suppress smoking completely using any means, thereby allowing the brain to recover its normal functioning
Changing the way the brain operates so that:
it no longer generates needs, desires and impulses to smoke or these are less frequent or less powerful
it habitually generates strong resistance to smoking impulses

7. Assessing treatment outcome
Ultimate goal is usually ‘permanent remission’ (Peter Selby)
Self-report of continuous abstinence for 6 months, biochemically verified, usually allows reliable estimation of this (Russell Standard1)
permanent remission rate~50% RS6M
‘Point-prevalence’ estimation and estimation for shorter time periods are less reliable
The key effect-size measure is difference in the proportion of smokers abstinent in treatment versus control conditions
1West et al, Addiction 2005

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

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

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

11. Effect of tailored internet support
Not biochemically verified

12. 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)

13. 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

14. The future of treatment
More effective use of existing treatments
combinations
pre-treatment
longer term use if required
wider access
Better treatments
novel medications
cheaper medications
more comprehensive behavioural treatments
A realistic goal
25% of quit attempts that would have failed, lasting for at least 6 months

15. Principles underlying policy options: Economic concepts
Financial incentives
Concept: Increase the financial cost relative to ability to pay
Barriers: Social and political resistance, lower affordability of other goods, possible substitution for other incentives, get-arounds
Moral and social incentives
Concept: Increase the feeling of moral and normative pressure
Barriers: Difficult to achieve, risk of backlash, stigmatisation of those that do not change
Personal incentives
Concept: Change balance of perceived personal happiness/ease and discomfort/effort in favour of not smoking
Barriers: Practical and financial constraints may limit reach and effectiveness

16. Principles underpinning policy: Health promotion concepts
Education
Increasing knowledge and understanding about the behaviour and its effects
Persuasion
Actively attempting to shape attitudes and behaviour through argument, imagery etc.
Inducements
Making the desired behaviour more attractive
Coercion
Making the undesired behaviour less attractive
Upskilling
Providing training or instruction on how to achieve the desired behaviour
Regulating access
Restricting opportunities to engage in the undesired behaviour
Empowerment
Making it easier to engage in the desired behaviour
West, R British Medical Bulletin, In Press

17. Policy options Price increases Smoke-free legislation
increase taxes
reduce options for cheap smoking
Smoke-free legislation
Increasing access to help with stopping
Mass media campaigns and media advocacy
Warning labels on tobacco packaging
Further work on restricting tobacco promotion
Decreasing youth access to tobacco
School-based programmes
See Framework Convention on Tobacco Control; Levy et al (2004)
Journal of Public Health Management and Practice, 10, ;
West, R British Medical Bulletin, In Press

18. Conclusions
Treatments to aid cessation have a small but important and reliable effect
The aim to work by suppressing the motivation to smoke or bolstering motivation not to smoke either temporarily or permanently
More work is needed to improve behavioural treatments using a more comprehensive model of smoking behaviour
Treatments to aid cessation must be just one part of a wider tobacco control strategy