Programme 10.00-10.15 10.15-10.45 10.45-11.15 11.15-11.45 11.45-12.15 12.15-13.00 Introduction Prof. Onno van Schayck Why do people smoke and find it difficult to stop? Prof. Robert West (University College London) What is the role of (primary) health care professionals in treating tobacco addiction? Prof. Jan Degryse (Catholic University Leuven) What are effective tobacco control measures to reduce smoking? Dr. Marc Willemsen (STIVORO, The Hague) Forum discussion with speakers and with Prof. André Knottnerus End of symposium and lunch 14.00-15.30 Confronting smokers with airflow limitation for smoking cessation PhD defence Daniel Kotz 1
Understanding tobacco addiction and improving smoking cessation strategies Onno van Schayck 21 november 2008 Tobacco is the only freely available product which, when used as intented, kills half of its dedicated users. 1
Smoking cessation R. Doll et R. Peto BMJ, 2004 2
The Tobacco Pandemic % of smokers among adults % of deaths caused by smoking 70 stage 1 stage 2 stage 3 stage 4 40 60 50 30 % male smokers % female smokers % male deaths % female deaths 40 30 20 20 10 10 0 20 40 60 80 100 Year The Tobacco Pandemic Those who die today are yesterday smokers and today smokers are tomorrow deaths. 3
Why do people smoke and find it so hard to stop? Robert West University College London November 2008 1 Outline 1. Why do people do anything? 2. Why do people smoke? 3. What does stopping doing something mean? 4. Why is it hard to stop doing anything? 5. Why is it hard to stop smoking? 2 1
Why do people do anything? We: act on impulse we do it without thinking about the consequences want or need something we seek a source of pleasure or satisfaction, or of relief think it is right or will serve a purpose we do what we consider best are following a plan we act on a prior intention And this motivation is stronger than any competing motivation present at the time 3 Example Faced with an apparent thief running towards us on the street: the impulse is to avoid physical contact ( flinch ) there may be anticipation of satisfaction from catching a criminal there may be anticipation of harm from being attacked there may be a belief that one should be a good citizen there may be a prior generalised intention to fight crime where possible Conflict between these different types of motivation will determine what action is taken in the moment 4 2
The requirement To develop a model that describes how different types of motivation interact and compete to generate responses in the moment 5 A solution A motivational system with 5 levels, with higher levels feeding into lower levels Responses starting, stopping or modifying actions Impulses vs inhibition Activation of CNS pathways underpinning actions, and competing pathways inhibiting them (urges) Motives Mental representations of future world states with feelings of anticipated pleasure or satisfaction (wants) or relief (needs) Evaluations Beliefs involving sense of what is useful/harmful (functional), right/wrong (moral), pleasing/displeasing (aesthetic) Plans Mental representations of future actions associated with feeling of varying degrees of commitment (intentions and rules) 6 3
The structure of the motivational system Five interacting subsystems providing varying levels of flexibility and requiring varying levels of mental resources and time p Plans r i m e Responses Impulses Motives Evaluations Higher level subsystems have to act through lower level ones where they compete with direct influences on these 7 Key points 1. Our behaviour is motivated at multiple levels from impulses, motives and evaluations to plans 2. Higher level motivations must work through lower level ones where they may come into conflict with other motivations at that level 3. Plans have a vital role to play in organising our behaviour and protecting our longer term interests in the face of immediate demands 4. But implementing them in the face of conflicting wants, needs and urges is effortful and uses up mental resources 8 4
Why do people smoke? They light up and puff on impulse much smoking is habitual, done without thinking They want or need to they expect to enjoy it; they experience a hunger for a cigarette after a period of not smoking They think it serves a purpose they expect it to help with stress, weight control and concentration They form plans to smoke they have a routine of going for a cigarette during coffee breaks These motivations are stronger than any competing motivations including a plan not to smoke 9 How does this arise? Nicotine hits from each puff of a cigarette binds to nicotinic acetylcholine receptors in the brain causing: dopamine release in the nucleus accumbens which: generates an automatic impulse to smoke in the presence of smoking cues provides pleasure and satisfaction associated with smoking makes other experiences associated with smoking more pleasurable changes the functioning of the brain region concerned so that when CNS nicotine levels are depleted there is need to smoke to restore those levels (nicotine hunger) other chronic changes to brain chemistry resulting in adverse mood and physical symptoms such as anger, depression and difficulty concentrating generate an additional need to smoke 10 5
What does stopping doing something mean? Self-consciously stopping doing something typically means: 1. forming a rule (plan) not to do it, or 2. forming a rule (plan) that one will try not to do it Applying that rule in relevant situations which generates a want or need not to do it 11 Why is it so hard to stop doing anything? To stop ourselves doing something that is habitual or we want or need to do, our rule must generate more powerful competing wants and needs This is difficult if: the impulse, want or need to engage in the behaviour is at least sometimes strong and/or our capacity to generate competing wants or needs when required is weak 12 6
Why is it so hard to stop smoking? The impulse to smoke Many smokers experience powerful cue-driven impulses in situations in which they would normally smoke The want to smoke Many smokers enjoy and get satisfaction from smoking The need to smoke Nicotine hunger, adverse effects of abstinence Positive beliefs about smoking Stress relief, aid to concentration, weight control The routine of smoking Strong over-learned plans to smoke at certain times 13 Rates of attempting to stop smoking Rate of attempts to stop decreases with age Data from 4374 adults aged 16+ who smoked in the past year in Smoking Toolkit Study, surveyed in 2008 Percent 50 40 30 20 10 Rate of attempts to stop in past year 0 15 25 35 45 55 65 75 Age 14 7
Success rates of unaided quit attempts Relapse curve Prognosis curve Percent still abstinent 100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 Weeks since quit date Percent who will succeed long term 100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 Weeks since quit date The need to smoke decreases rapidly after the first week, but can re-emerge months or years later Weekly relapse rate 100 90 80 70 60 50 40 30 20 10 0 Weekly relapse rate 0 10 20 30 40 50 Weeks since quit date 15 Wanting and needing to smoke Wanting to smoke appears to deter attempts to stop while needing to smoke leads to relapse once an attempt is made Percent 90 85 80 75 70 65 60 55 50 Urges to smoke Did not attempt Relapsed Data from 1479 smokers in Smoking Toolkit Study, followed up 6 months after ratings or enjoyment and urges were made to find out whether: had attempted to stop and if so had relapsed Percent Enjoyment of smoking 100 95 90 85 80 75 70 65 60 55 50 Did not attempt Enjoy Relapsed Not enjoy Strong urges No urges 16 8
Tackling the problem at all levels: reducing motivation to smoke Reduce the impulse medication during smoking to break the smoking-reward link reduce exposure to smoking cues Reduce the want and need medication during smoking and abstinence to make smoking less satisfying and reduce nicotine hunger and adverse symptoms control exposure to events that provoke wanting and needing Change beliefs convince smokers that smoking does not confer benefits Change plans change routines that involve smoking 17 Tackling the problem at all levels: increasing motivation not to smoke Generate competing impulses set up competing habitual responses to smoking cues Increase the want and need not smoke use extrinsic rewards and punishments (e.g. social approval, disapproval, vouchers) maintain salience of negative feelings about smoking (e.g, disgust, anxiety) foster intrinsic rewards for not smoking (e.g. achievement) Change beliefs foster negative beliefs about smoking and positive non-smoker identity Establish firm, coherent plans Establish clear not a puff rule as part of new identity Establish clear if-then rules to minimise wants, needs and urges 18 9
Conclusions 1. Our actions are controlled by multiple levels of a motivational system (PRIME) with higher levels (plans) having to work through lower levels (impulses and inhibitions) 2. At every moment there may be conflict between motivations arising from the same or different levels 3. Stopping doing something involves forming a rule (plan) which has to generate sufficiently strong wants and needs to overpower more immediate wants, needs and urges rising at a lower level 4. Stopping smoking is hard because of powerful urges, wants and needs arising from the actions of nicotine in the brain 5. The optimum solution requires attending to all levels of the motivational system to minimise the motivation to smoke and maximise the motivation not to at all times 19 10
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What is the role of primary health care professionals in treating tobacco addiction? Jan Degryse MD PhD University of Leuven (KUL/UCL) 3 4
Overview What evidence is available? Implementation problems Research agenda 5 Advice to quit smoking Physicians Counsellors Nurses Telephone advice Self help materials 6
A brief advice during a routine consultation by a physician improves quit rates Stead LF et al (2008) Physician advice for smoking cessation. Cochrane library 7 Intensive advice sligthly improves quit rates compared with minimal advise (RR 1,37 CI 1,20-1,56) Individual counseling of at least 10 minutes by professionals trained in smoking cessation (social work, psychology, psychiatry, health education and nursing) increases the rate of quitting (OR 1,64 95% CI 1,33-2.01) Self-help materials without face to face contact slightly improved smoking cessation compared with no intervention ( OR 1,24 CI 1,07-1,49) 8
Individual counseling to minimal contact control Lancaster et al (2008) Individual behavioural counseling for smoking cessation. Cochrane library 9 Advice from a nurse increases the rate of quitting Rice et al (2008) Nursing interventions for smoking cessation.cochrane library 10
Prignot J (2000)Tob Control 9:113 11 The smoking cycles Relapse should be considerd as normal and inherent to the addiction. Only a minority of smokers quits after a first tentative. Primary care workers should be aware of this and not get demotivated or discouraged. Fiori MC & Baily WC (2000) JAMA 283:3244-45 12
Registering smoking habbits Only half of the primary care physicians register smoking behaviour Lack of time and lack of motivation are forwarded as main reasons for this Coleman et al (1996) Br J Gen Pract 46:87-91 Cornuz et al (2000) Fam Pract 17:535-40 Tremblay et al (2001) CMAJ 165:607 13 Termination Maintenance Relapse Action Contemplation Preparation Precontemplation Prochaska and DiClemente s Stages of Change Model Prochaska JO, Di Clement CC. (1983). J.Consult Clin Psychol 1983 14
Advising patients A well ment but uncareful intervention can compromise the doctor/patient relationship A (customised) advice should be given with empathy and the advice must be repeated. Buttler et al (1998). BMJ 316:1878-81) 15 Nicotine addiction Physical and psychological depency Auto-titration en compensatory smoking behaviour Retrieval symptoms Assessing physical dependency Fagerstöm test «Time to the first cigaret» 16
The five A s strategy Ask about smoking Advise patients to stop Assess motivation to stop and need for pharmacotherapy Assist in quit attempts with counseling, prescription (or referral) Arrange follow-up Fiori MC & Baily WC (2000) JAMA 283:3244-45 17 Minimal intervention strategy An extra consultation of at least 10 minutes dedicated to smoke cessation (minimum two contacts) Dependant on the health care system. Feenstra, T (2003) 18
Pharmacotherapy Nicotine replacement therapy (NRT) Comparaison of all types of NRT versus placebo: OR 1,77 (1,66-1,88) All forms of NRT are roughly equally effective. A patch + an acute form of nicotine replacement might be rational Stead LF et al (2008) Nicotine Replacement therapies in smpking cessation cessation. Cochrane library 19 Combining a patch with an acute form may be rational. Stead LF et al (2008) Nicotine Replacement therapies in smpking cessation cessation. Cochrane library 20
Pharmacotherapy Antidepressants Brupopion Doubles the cessation rates (OR 1,94 CI 1,72-2,10) Nortriptyline Effective (OR 2,324 1,61-3,41) Hughes R et al (2007) Antidepressants for smoking cessation.cochrane library Varenicline Abstinence at 12 months is approximately three times higher than for placebo (OR 3,22 CI 2,43-4,27) Cahill K et al (2007) Nicotine receptor partial agonist for smoking cessation. Cochrane library 21 Key recommendations Van Schyck O et al 2008) IPCRG Consensus statement: Tackling the smoking epidemic- practical guidance for primary care. Primary care respiratory journal 17 3:185-191 22
A Belgian case study Aim: to assess the success rate of smoking cessation with the «minimal intervention strategy» in general practice GPs in 15 practices screened during 12 weeks their practice population for smoking habits, degree of dependence on nicotine, and motivation to quit smoking. GPs followed a short training (4h course) in giving advice to quit smoking. Motivational interview/ Minimal intervention strategy, the 5A model/ the motivaitonal model of Prochaska and Di Clemente, Fagerstrom Nicotine Dependence Test On a population of 5590 patients, 1206 smokers were identified. Buffels J, Degryse J, Decramer M, Heyrman J (2006) Repiratory Medicine 100, 2012-2017 Buffels J, Degryse J (2006) Hoe goed geven huisartsen rookstopadvies? Implementatieonderzoek van de aanbeveling Stoppen met Roken Huisarts Nu vol:34 :6 314-319 23 Only in 34% of the current smokers and in 21% of the ex-smokers the smoking habits were already filed in the medical records 24
Smoking cessation advice can be readily incorporated in the daily practice of the Belgian primary care. Nearly 20% of all identified smokers undertook an attempt to quit smoking. The short training had a strong positive effect on the selfperceived ability of the physicians. This strengthens former findings that trianing primary care physicians in smoking cessation advice seems highly cost effective. 25 «The evidence clearly shows that what doctors say and do about smoking in consultations makes a huge difference to their patients it is a matter of life an death for many» Aveyard P & West R (2007) BMJ 335 37-41 26
A research agenda What are the key characteristics of an effective brief intervention for smoking cessation? How effective (and cost effective) are brief interventions delivered by different professionals in various settings? Are additional «confrontational» approaches effective (spirometry, lung age) Should interventions be more «stratified» Influence of co-morbidity, polymedication, mental condition? A specific approach for special groups? Depressive patients, Multi-addiction, Lower socioeconomic groups, 27 A research agenda How effective can new technologies be used in primary care? Monitoring systems Tele-control systems Telephone counseling E-mail counseling 28
Epilogue The Old Market Square 'The greatest smoke-free bar of Western Europe' A perfect place to organize a training course? 30
What are effective tobacco control measures to reduce smoking? Symposium Understanding tobacco addiction and improving smoking cessation strategies Marc Willemsen, November 21, 2008 Maastricht Smoking is not very good 1/2 of all smokers will die of tobacco use. Of these, approximately 1/2 will die in middle age, losing on average 20 25 years of life expectancy. Peto, Lopez et al. (1994). Mortality from smoking in Developed Countries 1950-2000. 1
Percentage of all deaths caused by smoking (Peto et al., 2005) The tobacco use epidemic 2
Estimated number of tobacco deaths worldwide (cumulative) 520 Tobacco deaths (millions) 400 300 200 100 70 220 0 1950 2000 Year 2025 2050 World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80. Estimated number of tobacco deaths worldwide (cumulative) 520 Tobacco deaths (millions) 400 300 200 100 70 220 0 1950 2000 Year 2025 2050 World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80. 3
Who s problem is it anyway? the smoker? Do you intent to quit smoking in the future? 45 40 35 Yes, but not within Yes, within 12 12 months months % 30 25 20 15 10 5 0 No, never Source: Continuous Survey of Smoking Habits (STIVORO, TNS-NIPO, 2007); N=3,726 Smokers 4
Who s problem is it anyway? the doctor? Two perspectives on smoking cessation Clinical Goal is to help smokers to improve their odds of quitting Responsibility of change rests primarily within the person Method: behavioural and farmacological therapy Population Goal is to stimulate as many smokers as possible to quit (reduce prevalence) Responsibility of change rests within government. Method: policy change and mass media campaigns 5
Who s problem is it anyway? The government? National Tobacco Control Programme 2006-2010 Goal: 20% smokers in 2010. 6
National Tobacco Control Programme 2006-2010 Goal: 20% smokers in 2010. 40 35 30 25 27.5% 20 15 10 5 0 89 91 93 95 97 99 2001 2003 2005 2007 2009 Cessation in the population Quit attempt rate = % trying to quit Success Rate = % of these attempts that succeeded Quit attempt rate x success rate = annual cessation rate 7
Shu-Hong Zu s model (Washington, WCTOH 2006) All smokers 30% No Make Quit Attempt? Yes (Q) No (1 =H) Use evidence based help? Yes (H) Use of evidence based smoking cessation aids in the Netherlands 25 20 15 10 5 0 12341234123412341234123412341234123412341234123412341234123412341234 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total NRT Selfhelp Medication Behavioral Continous Survey of Smoking Habits (STIVORO, TNS-NIPO) 8
Shu-Hong Zu s model (Washington, WCTOH 2006) All smokers 30% No Make Quit Attempt? Yes (Q) 15% 85% No (1 =H) Use evidence Yes (H) X 0% based help? X 7% X 14% Annual cessation rate in Netherlands Q (0.14H + 0.07 (1-H)) = 0.07 Q (1 + H) = 0.024 (2.4%) This is 0.67% of the total population 9
Shu Hong s formula for Annual Cessation Rate 0.07 Q (1 + H) The number of annual quitters makes all the difference Quit Attempts Netherlands Percent Using Help Shu-Hong Zu. Increasing cessation in the population. 13th WCTOH, Washington 2005 10
WHO s solution M onitor tobacco use and prevention policies P rotect people from tobacco smoke O ffer help to quit tobacco use W arn about the dangers of tobacco E nforce bans on tobacco advertising, promotion, and sponsorship R aise taxes on tobacco 11
Impact of Tobacco Control Policies Price (25% increase) Smoking ban - Worksite - Bars & Restaurants Intensive media campaign (combined with other policies) Cessation Rate -2.1% -2.1% -0.9% -2.1% Level of evidence Strong Strong / Moderate Moderate Comprehensive advertising bans -1.2% Moderate / Low Increased treatment access, including broad reinbursement + more physician involvement Large graphic health warnings, supplemented with information campaigns < - 0.6% -0.6% Low Low SimSmoke simulation, Levy, Chaloupka & Gitchell (2004). Impact of Tobacco Control Policies Price (25% increase) Smoking ban - Worksite - Bars & Restaurants 2004 Intensive media campaign (combined with other policies) 2003 2008 Comprehensive advertising bans Increases treatment access, including broad reinbursement + more physician involvement Large graphic health warnings, supplemented with information campaigns -2.1% -2.1% -0.9% -2.1% 1991, 2000, 2004, 2008 2009?? Cessation Rate -1.2% < - 0.6% -0.6% Level of evidence Strong Strong / Moderate Moderate Moderate / Low Low Low SimSmoke simulation, Levy, Chaloupka & Gitchell (2004). 12
What next? Increase tobacco tax + media campaigns To quit or not to quit: that s the answer! Promotion of cessation treatments will have more population impact of this contributes to more quit attempts. 13