The PRIME Theory of motivation and its application to smoking ...

What does evidence-based behavioural support for smoking cessation look like? Robert West University College London UK Centre for Tobacco Control Studies National Centre for Smoking Cessation and Training June 2013 1 2 Essential features of a stop smoking service 1. It is for smokers who want help with stopping 2. It combines behavioural support and pharmacotherapy Behavioural support

multiple sessions provided by a trained specialist taking the smoker through the first 4 weeks of abstinence at least Pharmacotherapy NRT, bupropion or varenicline for 8-12 weeks 3. It is monitored using information on smokers treatment provided outcomes (using Russell Standard) 3 What a good stop smoking service delivers Per 5,000 smokers treated

A benefit of: 1,000 long-term ex-smokers 2,000 healthy life years 16 million in savings to society per year For an outlay of: 1.25 million including medicines There is almost no other public service that can provide this scale of benefit at so little cost 4 Performance of the services 2001-2012 816444 900,000 Number

800,000 700,000 600,000 500,000 400,000 288612 300,000 200,000 84501 100,000 0 2001/2 2002/3

2003/4 Throughput 2004/5 2005/6 4-week quitters 2006/7 2007/8 2008/9 2009/10

2010/11 2011/12 Impact (4-week quitters created) 5 Relative success rate in England by route to quit NHS support and medication Medication on prescription Significantly better than no aid adjusting for confounding variables, p<0.001

NRT over-the-counter No medication or support (reference) 0 0.5 1 1.5 2 2.5 3

Odds ratio (relative to no aid) Data from www.smokinginengland.info; based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=11,584 6 CO-verified success rates by PCT 2011-12 0.60 Proportion of smokers quit at 4 weeks 0.50 0.40

0.30 0.20 0.10 0.00 Primary Care Trust 7 Optimal service configuration Data from 126,890 treatment episodes in 24 stopsmoking services were used to assess the association between intervention characteristics and 4-week CO verified success rates adjusting for key smoking characteristics Major independent predictors of success were:

specialist treatment rather than primary care group rather than one-to-one use of varenicline or combination NRT rather than single NRT 8 Relative medication effectiveness varies across services Brose et al, 2013 9 Optimal components of behavioural support Examined behaviour change techniques specified in treatment manuals of 43 stop-smoking services and associated inclusion of each of these with success rates BCTs found to be linked to success rates were:

Strengthen ex-smoker identity Measure CO Reward abstinence Advise on changing routine Advise on coping with cravings Advise on medication use Ask about experiences when

using medication Give options for additional support Elicit client views 10 Differences in effectiveness between practitioners Data from 46,237 one-to-one treatment episodes delivered by stop-smoking specialists were used to assess differences in 4-week CO verified success rates between them adjusting for all other factors Differences between practitioners accounted for 7.6% of the variance in success rates, a larger differences than is typically found between active and placebo NRT

11 Variation in 4-week success rates between practitioners Brose et al, 2012 12 Why specialists get better success rates than non-specialists Data from survey of 573 specialists and 466 nonspecialists were used to identify factors mediating the differences in success rates Factors found to be important were:

greater use of abrupt rather than gradual cessation approach stronger emphasis on medication use number of days training received number of sessions observed when starting out better supervision 13 What does evidence-based behavioural support look like? 1. Schedules at least 6 weekly sessions starting before the quit date 2. Strongly recommends (and provides) varenicline or combination NRT 3. Strongly recommends abrupt cessation

4. Includes a set of evidence-based behaviour change techniques 5. Delivered by advisors who are well trained, supported and supervised 14 A new book for smokers on how to stop Most smokers want to stop but do not know the best ways of doing it There are a few very popular self-help guides; these put forward a particular method which is not evidence-based (e.g. Allan Carrs Easy Way) There is a need for a book will can act as the trusted source for smokers on how best to stop The book must communicate the science of stopping smoking to the widest possible readership in a way that is engaging and 15

accessible Bringing the science of stopping smoking to smokers A new book for smokers Launch date December 2013 16

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