1. Providing smoking cessation treatment: opportunities and challenges Robert West Durham May 2007

2. Statement of competing interests • I undertake research and consultancy for companies the manufacture smoking cessation medications including Pfizer, GSK and Novartis

3. Outline • The national smoking cessation picture • Goals of smoking cessation treatment • Treatments available and their effectiveness • Encouraging smokers to continue to try to stop using effective treatments until they succeed • The importance of accurate performance data • Response from attendees

4. The national picture (England) • Approximately 45% try to stop each year, many of them several times • Approximately 5% of attempts involve the NHS stop smoking services • Approximately 35% of quit attempts involve NRT bought over the counter • Approximately 2.5% (250,000) of smokers (10 million) stop permanently each year • The behavioural support element of the NHS Stop Smoking services probably contributes about 0.13% to this figure (13,000 smokers) at a cost of £3800 per permanent ex-smoker or less than £1000 per life year gained (undiscounted) • See www.smokinginengland.info

5. Conflicting motivations during a quit attempt

6. Motivation to smoke Smoking Habit/instinct Impulse to smoke Cues/triggers Choice Anticipated enjoyment Desire to smoke Need to smoke Nicotine ‘hunger’ Unpleasant mood and physical symptoms Anticipated benefit Reminders Positive evaluation of smoking Smoker ‘identity’ Beliefs about benefits of smoking

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

8. The goals of smoking cessation treatment • To engage as many smokers as possible who could benefit from the treatment • Maximise the number of smokers who know about the treatment available • Make the treatment options as attractive as possible to smokers without compromising effectiveness • Maximise the frequency of triggers that prompt smokers to engage with the treatment service • To maximise the chances of permanent cessation with every treatment episode • Maximise the numbers of smokers that engage with the most effective treatment options • Ensure that the treatment options are implemented optimally

9. Treatments available and their effectiveness • Clients strongly motivated to stop smoking • NRT, Zyban or Champix plus: • Multi-session group-based behavioural support provided by smoking cessation professionals or • Multi-session individual behavioural support provided face-to-face or by telephone by smoking cessation professionals • Brief or single session behavioural support provided by health professionals with limited training for whom smoking cessation is a small part of their role and weakly motivated clients Champix is more effective than Zyban and probably more effective than NRT when used as normally directed but the course is longer. It is more expensive but the cost-per life year gained is similar

10. Continuing engagement with treatment • Smokers who use NRT for one quit attempt are very likely to use it again for subsequent quit attempts • Re-engagement with NHS services appears to be less common but does occur • Smokers who attempt to stop within 3 months of a failed quit attempt are less likely to be successful, other things being equal • One study in Leeds (by Maria Spelacy) has found those who are prompted to re-engage with treatment after a gap of 12 months or more have broadly similar success rates (to be presented at the UKNSCC)

11. The importance of accurate performance data • Any operation, whether it be a business or a public service, needs timely access to accurate data on its performance so that it can adjust to changing circumstances and maintain or improve its operations • A minimum requirement is regular information on: • Awareness of the service in the target population • Attractiveness to the target population • Numbers of enquiries • Numbers of clients • Satisfaction rates • Success rates • Re-engagement rates • For each of the elements of the service provided: • Management units • Individual advisors • Types of provision

12. What are success rates? • Start with every smoker who sets a quit date and attends at least one session (N) • Four or more weeks after the target quit date find out using a method that minimises bias how many have smoked at all, even a puff, in the past 2 weeks and have an expired air CO at the time of testing of less than 10ppm (S) “Have you smoked at all, even a puff on a cigarette, in the past 2 weeks?” No, Just a few puffs, One or more cigarettes • Count the number of clients who you know have moved away or cannot attend the 4-week session for a good reason (D) • The success rate is S/(N-D)

13. Factors that promote service development • Collecting and sharing timely and accurate performance data at all the levels necessary • Acting in a timely manner on evidence that performance is slipping • Willingness to be objective about favoured treatment approaches that might not be optimal • High morale

14. What about ‘smoking reduction’ • A majority of smokers are trying to cut down at any one time • About 25% of these are using NRT to do so • We do not know whether this is successful and in itself reduces health risk but there is evidence that a structured programme of major reduction assisted by NRT leads some smokers to stop • It is not known whether it would be cost-effective for SSSs to include this option for smokers who are not ready to stop but in certain very difficult target groups it is worth considering further

15. Questions and responses to the points raised