Recent studies of clinical significance
Robert West
University College London
June 2011
1
Topics
The challenges facing UK Stop-Smoking Services
1. demonstrating the importance of clinical services
2. providing guidance how best to configure the services
3. ensuring quality of provision
Relevant studies
1. Real world effectiveness of aids to cessation and impact of the
services
2. What makes for an effective service and an effective
practitioner
3. Criteria that need to be in place when commissioning providers
2
The place of smoking cessation interventions
in tobacco control
Reduce total harm from tobacco use
Reduce prevalence
Reduce uptake
Promote cessation
Reduce harm from use
3
The First Law of Smoking Cessation
The number of
ex-smokers
E=NxS
The number of
smokers trying to quit
The chances of
success of each attempt
4
What does this mean?
1. Motivate as many smokers to try to quit as
possible
2. Ensure that they have access to the best
possible help if they wish to use it
3. Motivate them to use the most effective method
available
5
The Second Law of Smoking Cessation
• The best chance of success at stopping smoking
is by using a combination of:
– a) stop-smoking medication
– b) professional advice and support
6
The role of clinical services
• Stop-smoking services provide highly costeffective life-preserving treatment for an
addictive
disorder
for thosethose
people
who want to
Failure
to provide
services
use it is an abdication of responsibility
• The services
need to of
bethe
accessible
to all
and betrayal
principles
of
smokers and promoted
that smokers can see
the so
NHS
the benefits
• The extent of the provision must be
commensurate with demand
7
Promoting cessation
Promote cessation
Promote quit attempts
Aid quit attempts
Pharmacological treatment
Behavioural support
8
Pharmacological treatment
Reduce urges to smoke
Reduce ‘nicotine hunger’
Reduce acute cue-driven craving
Block nicotine reward
9
Effectiveness versus efficacy
• Efficacy
– Effect of an intervention compared with a comparator
in an experimental study
• Effectiveness
– Effect of an intervention in the ‘real world’
10
Percentange increase in success
Efficacy of medication options: 12 months’
sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo
continuous abstinence rates; all medications used with some behavioural support
11
Percentange increase in success
Efficacy of medication options: 12 months’
sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo
continuous abstinence rates; all medications used with some behavioural support
12
Percentange increase in success
Efficacy of medication options: 12 months’
sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo
continuous abstinence rates; all medications used with some behavioural support
13
Percentange increase in success
Efficacy of medication options: 12 months’
sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo
continuous abstinence rates; all medications used with some behavioural support
14
Percentange increase in success
Efficacy of medication options: 12 months’
sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo
continuous abstinence rates; all medications used with some behavioural support
15
Percentange increase in success
Efficacy of medication options: 12 months’
sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous
abstinence rates; all medications used with some behavioural support
16
Percentange increase in success
Effectiveness of medication options
20
18
16
14
12
West et al (2007) Thorax, 62, 998-1002
10
Brose et al (2011) Thorax, 66, 924-6
8
Smokers using NRT have better success
rates than those not using it
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
17
Percentange increase in success
Effectiveness of medication options
20
18
16
14
Brose et al (2011) Thorax, 66, 924-6
12
Smokers using bupropion have better
success rates than those using nothing
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
18
Percentange increase in success
Effectiveness of medication options
20
18
16
14
12
10
Brose8et al (2011) Thorax, 66, 924-6
Bauld 6et al (2012) Addiction, in press
4 using varenicline are more likely to
Smokers
succeed
2 than those using no medication or
NRT or
0 bupropion
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
19
Percentange increase in success
Efficacy of different forms of NRT
25
20
15
10
5
0
Gum
Patch
Nasal spray
Inhaler
Lozenge
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous
abstinence rates; all medications used with some behavioural support
20
Percentange increase in success
Efficacy of different ways of using NRT:
efficacy
25
20
15
10
5
0
Patch + faster acting
form vs patch alone
Starting patch before
quit date vs on quit date
NRT for reduction vs
placebo
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous
abstinence rates; all medications used with some behavioural support
21
Percentange increase in success
Efficacy of different ways of using NRT:
effectiveness
25
20
Brose et al (2011) Thorax, 66, 924-6
15
Smokers using dual form NRT have higher
success rates than those using single form
NRT
10
5
0
Patch + faster acting
form vs patch alone
Starting patch before
quit date vs on quit date
NRT for reduction vs
placebo
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous
abstinence rates; all medications used with some behavioural support
22
Percentange increase in success
Efficacy of different ways of using NRT:
effectiveness
25
20
Beard et al (2012) Drug & Alcohol
Dependence, in press
15
Beard et al (2012) Tobacco Control, in press
10
Smokers using NRT for smoking reduction
are more likely to go on to quit, even after
adjusting for possible confounding variables
5
0
Patch + faster acting
form vs patch alone
Starting patch before
quit date vs on quit date
NRT for reduction vs
placebo
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous
abstinence rates; all medications used with some behavioural support
23
Behavioural support
Behaviour Change Techniques ...
Address motivation
Enhance self-regulation
Promote adjunctive activities
Support the process
24
Behavioural support: efficacy
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
25
Behavioural support: efficacy
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
26
Behavioural support: efficacy
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
27
Behavioural support: efficacy
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
28
Behavioural support: efficacy
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
29
Behavioural support: effectiveness
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
West et al (2012)
www.smokinginengland.info
Face-to-face
individual
Face-to-face
group
Smokers who receive behavioural
support plus medication have
higher success
rates than those
Pro-active
Text
telephone
obtainingmessaging
medication on
prescription only
30
Optimum service provision
• Brose et al (2011) Thorax, 66, 924-6
– Varenicline or dual form NRT
– Provide specialist support
– Offer group-based support
• West et al (2010) Nic & Tob Res, 12, 742-7
• West et al (2011) Nic & Tob Res, 13, 1316-20
– more sessions
– treatment manuals that focus on:
• additional foster ex-smoker identity
• CO monitoring
• elicit client views
• give options for support
• betting game
• communicating group member
identity
• advise on medication
• advise on changing routine
• advise on coping with cravings
• advise on changing routine
31
Key commissioning requirements
1. Only pay for ex-smokers above a threshold (e.g. 25%
4-week quitters) – but pay for them appropriately
2. Pay more for more dependent smokers
3. Only commission providers who:
a. offer all evidence-based treatments
b. employ staff who are certified, trained, supervised and have
appropriate continuing professional development
c. follow evidence based guidelines in delivery of behavioural
support
d. use a rigorous standardised procedures for assessing
abstinence according to the Russell Standard
e. use a fully independent service to audit claimed successes
West (2011) Addiction, 106, 1730-2
32
100
90
80
70
60
50
40
30
20
10
0
McDermott et al (2012) BMC Hlth Serv Res, 12, 121
Targets for
reducing
smoking
prevalence
Commissioners
specify service
type
Varenicline
available
Offer groups
Percent
Current practice
33
Should be 100%
100
90
80
70
60
50
40
30
20
10
0
McDermott et al (2012) BMC Hlth Serv Res, 12, 121
Targets for
reducing
smoking
prevalence
Commissioners
specify service
type
Varenicline
available
Offer groups
Percent
Current practice
34
Not generally
appropriate
McDermott et al (2012) BMC Hlth Serv Res, 12, 121
Targets for
reducing
smoking
prevalence
Commissioners
specify service
type
Varenicline
available
100
90
80
70
60
50
40
30
20
10
0
Offer groups
Percent
Current practice
35
Key points
• Clinical studies show:
– effectiveness as well as efficacy of the recommended
model of smoking cessation support in England
– important components of treatment both in terms of
medication and behavioural support
– some deficiencies in the current commissioning
process that may undermine effectiveness for some
services
36