Transcript Barts and The London Presentation

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Achieving a Tobacco-free Aotearoa Together
600,000 smokers to go – how
to best get there?
Hayden McRobbie
Senior Lecturer, Auckland University of Technology
Senior Clinical Research Fellow, Wolfson Institute of Preventive Medicine, Queen Mary University of London
Consultant, Inspiring Limited
[email protected]
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Tobacco Free Aotearoa by 20205
• “Why not just
remove tobacco
from the market
place?”
• There is already some public support
for banning sales of tobacco
Edwards et al 2009 NZMJ 122:115-8
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Outright ban not feasible?
• We’re not talking about removing tobacco
from sale on 1st Jan 2011, but to be tobacco
free by 2025
• Isn’t this enough time to prepare people who
currently smoke for the future?
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Finland’s new tobacco law
• http://www.bloomberg.com/video/63416822
/
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Finland’s new tobacco law
http://www.bloomberg.com/video/63416822/
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Are we waiting for someone else to
make the first move?
Who needs to take action?
PM
Ministers
Community groups
Healthcare Workers
Aunty Pam
Hayden’s Dad
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What are we up against?
• The addictive nature of tobacco
• The tobacco industry
• Optimism and over confidence of smokers
– “It won’t happen to me”
– “I’ll be able to give up when the time comes”
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Steps to quitting
Level 12 – Ex-smoker
Level 11 – Quit and no use for 1 year
Level 10 – Quit and no use for 3 months
Level 9 – Quit and no use for 1 month
Level 8 – Quit for a week, but relapse / recycle
Level 7 – Quit for 24+ hrs, but relapse/ recycle
Level 6 – Quit but relapse within hours/ recycle
Level 5 – Not quit, but cut down
Level 4 – Set a quit date
Level 3 – Think about a quit date
Level 2 – Motivations for quitting
Level 1 – Feeling uncomfortable about
smoking
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Gap between planning and doing
• Four country ITC project
Reid et al 2010 Nicotine & Tobacco Research 12 (supl 1) S20-S33
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‘Lift’ to quitting
Level 12 – Ex-smoker
Level 11 – Quit and no use for 1 year
Level 10 – Quit and no use for 3 months
Level 9 – Quit and no use for 1 month
Level 8 – Quit for a week, but relapse / recycle
Level 7 – Quit for 24+ hrs, but relapse/ recycle
Level 6 – Quit but relapse within hours/ recycle
Level 5 – Not quit, but cut down
Level 4 – Set a quit date
Level 3 – Think about a quit date
Level 2 – Motivations for quitting
Level 1 – Feeling uncomfortable about
smoking
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Changing behaviour – 3Ts model
• Create motivational tension
• Apply triggers to create action
• be ready with immediate
treatment to assist with
maintaining the change
Slide courtesy of Professor Robert West, UK
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Motivation to change
Motivational ‘tension’
Change in internal
or external environment
Trigger
Action threshold
Low level of motivation
Rising motivational ‘tension’
Time
Action
Slide courtesy of Professor Robert West, UK
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The Behaviour Change Wheel
Behavioural
system
Policy
system
Environmental/
social planning
Intervention
system
Physical
Emot/
Habit
Psych
Psych/
Evaluatsocial
ion
Physical
Michie & West, 2010
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Policy and treatment
• ITC project: in first year after recruitment
UK
Australia
Canada
US
Visited a doctor or other HCP
55%
72%
68%
71%
Got advice to quit
55%
48%
57%
69%
Made 1 or more quit attempts
37%
41%
43%
39%
Got additional help
20%
6%
9%
10%
Got meds and behavioural support
19%
8%
9%
10%
• Odds of quitting for a month
Odds ratio
95% confidence interval
UK
Australia
Canada
US
1.0
0.59
0.72
0.51
referent
0.49-0.71
0.61-0.87
0.42-0.62
Reid et al 2010 Nicotine & Tobacco Research 12 (supl 1) S20-S33
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Tension, Triggers, Treatment
• Tension and triggers
– Maximising smokefree norms
– Raise the price of tobacco
– Restrict the supply
– Regulate tobacco
– Remove temptations to smoke
– Continue with fear arousing messages
– Populate the smokers’ world with QUIT NOW
messages
• Provide evidence based treatment
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Maximise smokefree norms
• Extended smokefree environments
– Smokefree cars
– Smokefree public areas (not just indoor)
• Smokefree role models
• Smokefree communities
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Raise the price
• By common consensus the intervention most
likely to reduce prevalence significantly is an
increase in price
• Next tax increase: 1st January 2011
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Restrict the supply
• Decreasing youth access to tobacco
– ↑ age of purchasing could help if sanctions to
vendors increased
• Tobacco on prescription
• The Sinking Lid strategy
– A forced supply reduction strategy
– Legislation would introduce regular reductions in
the allowable amount of tobacco reduced to
consumers
• E.g. 5% reduction every 6 months
Laugesen NZ Med J. 15 June 2007; 120 (1256); Laugesen et al. NZ Med J 2010
Thomson et al 2010 Tobacco Control 19: 431-435
Price per cigarette
Tobacco released for sale
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Sinking lid
2010
2012
1014
2020
2016
2018
Thomson et al 2010 Tobacco Control 19: 431-435
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Nicotine Regulation
NRT
(safe)
Cigarettes
(harmful)
Least
Harmful
Very Highly
Regulated
Most
Harmful
Minimal
Regulated
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Control constituents of tobacco
• Tobacco companies add numerous substances
to tobacco to enhance flavour, palatability and
nicotine absorption
• Removing these would make smoking less
enjoyable
• Nicotine content could also be reduced
making tobacco less rewarding
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3 policy options to reduce nicotine
1. Mandated sinking nicotine content, all brands
together
2. Mandate increase in very low nicotine cigarettes
(VLNCs) share of sales by 20% p.a.
3. Nicotine tax makes VLNCs cigarettes a smart way
for smokers to avoid paying more for their smoking.
Murray Laugesen and Nick Wilson, APACT, Syndey 2010
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Removing temptation
• Selfcontrol is
weakened
in a ‘state
of arousal’
Thaler & Sunstein 2009 Nudge – Improving descisions about health, wealth and happiness
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Resisting temptations
• Shmueli &
Prochaska 2009:
101 smokers
resisting tempting
sweets or less
tempting
vegetables
Self-restraint uses up mental • Those exposed to
energy
sweets were more
likely to smoke
during break
Shmueli and Prochaska, Health Psychol 2009,28,300-306
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Removing temptation
• Retail display bans
– Hoek et al (2009) reported that removing point of
sale advertising displays would
• Decreased smoking initiation in young people
• Promote greater consistency of the smokefree message
• Assist those trying to quit smoking
• Plain packaging
Hoek et al 2009 Tobacc Control 19(4) 334-7
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Fear arousing messages
• Need to communicate the addictive
potential of tobacco and the
consequences of its use
– Media
– Healthcare workers
– Warning labels
• Indirect evidence (e.g. on awareness and attitudes) of
effects of pictorial warnings
• Need to believe that it could happen to
them
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Policy is the Governments business
• True – many policies need to be implemented
at a national level, but could more be done at
the community level? e.g.
– Small communities with with few outlets for
tobacco could request that
• tobacco displays are removed
• NRT is made available
– Increase in smokefree public places
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‘Quit Now’ messages
• Media campaigns
– e.g. No Smoking Day, generate immediate
increases in markers of quitting such as NRT use.
• Warning labels
• Healthcare workers
• Health target
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No Smoking Day
• UK Charity that co-ordinates an annual UKwide campaign to encourage smokers to quit
• Data from the English ‘Smoking Toolkit Study’
showed that the rate of quit attempts was
2.8% higher in the months following NSD
• Gives an estimated additional 0.07% of 8.5
million smokers quitting permanently
– that’s about 6000 smokers
• £85 per life year saved
Kotz et al Tobacco Control 2010
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Innovative campaigns
• http://www.youtube.com/watch?v=UZvXTzDK68
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Innovative campaigns
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The Tobacco Health Target
• “Eighty percent of smokers
will be provided with advice
and help to quit by July
2010; 90 percent by 2011;
and 95 percent by July 2012.
A similar target for primary
care will be introduced from
July 2010 or earlier, through
the PHO Performance
Programme”
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Health Target Results
Wairarapa
New Zealand District Health Boards
Waikato
Southland
Tairawhiti
Hawke's Bay
Canterbury
Lakes
West Coast
Whanganui
Bay of Plenty
Q4 Results
Otago
Q1 Results (%)
Nelson Marlborough
MidCentral
Auckland
Northland
South Canterbury
Capital & Coast
Counties Manukau
Taranaki
Waitemata
Hutt Valley
0
10
20
30
40
50
60
70
80
Percent provided with advice and/or help to quit
90
100
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Following the herd
• We like to conform
– Conformity experiments show that people
conform 20-40% of the time
• We could use this as an advantage, e.g.
– Schools could promote the proportion of parents
that are smokefree
– Local authorities could promote the proportion of
the population that are smokefree
– Churches could promote the proportion of their
congregation that are smokefree
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Changing the language
85% of parents
smokefree
Our annual student survey now shows that
85% of parents are smokefree. If you
would like help in becoming smokefree
we are offering free support that will
help you stop smoking for good. Give us
a call on 2386524.
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We tend to think smokers know
more than they do
• We found that they actually know less than we think
they do
– And less than they think they do
• They always initially think they can quit by
themselves
– Only gradually after failing several times do they try other
options
• They don’t research the market
– So much as try out the new methods they come across
– Attracted by stories of success!
From Market Research on the NHS SSS undertaken by ‘The Nursery’
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Treatment
We have
ways of
making you
stop!
Gulp..
.
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Increased access to treatment
• Current access to treatment to aid cessation
– Prescription and OTC medication
• Increases long-term quitting by 5%
• If 30% of smokers use it each year the prevalence would
decrease by some 0.4% per year
– Stop smoking services (SSS)
• An added benefit over medication of 5%
• If 5% of smokers use it each year the prevalence would
decrease by about 0.06% per year
– Total effect: 0.46% per year
• Potential for the future
– Increasing medication usage to 40% and SSS usage to 8%
could reduce prevalence by a further 0.16% per year (total
0.62% per year)
Slide courtesy of Professor Robert West, UK
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Will Power
• MOTIVATION IS NOT KING!
– It is important, but it is not the only factor
– Also factors that motivate a quit attempt are probably
irrelevant for maintenance
• Borland et al 2010 measured motivation variables
(e.g. wanting to quit, frequency of stubbing out cigs,
concerns about cost of smoking)
• All were associated with making a quit attempt, but
not with maintenance. In fact the measures
predicted relapse
Borland et al 2010 Nicotine & Tobacco Research 12 (supl 1) S4-S11
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Why the strange findings?
• Smokers that relied more on motivation might
have neglected other strategies for quitting
• More motivated smokers might also be more
dependent
Whilst motivation is important we need to supplement
it with effective smoking cessation treatments
k If you have the will, we have the way!
Borland et al 2010 Nicotine & Tobacco Research 12 (supl 1) S4-S11
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‘Hard core’ smokers?
• Borland et al (2010) suggested that western
countries, which have had good tobacco
control policies in place for some 40 years,
might be seeing a rise in smokers that find it
difficult to stop
• Therefore there is a need for
– New policies
– More intensive and effective cessation services
Borland et al 2010 Nicotine & Tobacco Research 12 (supl 1) S1-S3
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Effect of socioeconomic status
• More likely to intend to quit if you are
– More highly educated
– Have a higher income
• More likely to make a quit attempt if you are
– More highly educated (income level did not
matter)
• More likely to succeed in quitting if you are
– More highly educated
– Have a higher income
Reid et al 2010 Nicotine & Tobacco Research 12 (supl 1) S20-S33
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Obstacles to stopping smoking
Acknowledgement: Peter Hajek, UK
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Getting over the first key barrier
Acknowledgement: Peter Hajek, UK
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Behavioural Support
• Advice, discussion, and encouragement designed to
–
–
–
–
maximise motivation to remain abstinent
minimise motivation to smoke
maximise the skills and capacity for self-control
optimise effective medication use
options
face-to-face (in
groups or
individually)
by telephone
Used for at least 4 weeks
by internet
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Meta-analysis*: Effectiveness of and Estimated Abstinence
Rates for Various Intensity Levels of Session Length
Number of arms
Estimated odds
ratio (95% CI)
Estimated
abstinence rate
No Contact
30
1.0
10.9
Minimal counseling
(<3 minutes)
19
1.3 (1.01 – 1.6)
13.4 (10.9 – 16.1)
Low intensity
counseling
(3-10 minutes)
16
1.6 (1.2 – 2.0)
16.0 (12.8 – 19.2)
Higher intensity
counseling
(>10 minutes)
55
2.3 (2.0 – 2.7)
22.1 (19.4 – 24.7)
Level of Contact
*N = 43 Studies
Treating Tobacco Use and Dependence: 2008 Update
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Text to Quit
• Cochrane Review – Mobile phone interventions for
smoking cessation (Whittaker et al 2009)
• 4 studies, Increased short-term abstinence rates
(RR=2.18; 95%CI: 1.80-2.65)
• No effect on long-term abstinence rates
• A large UK study is underway
• Could the NHS SSS utilise text messaging?
– Additional support?
– Assessing smoking status?
– Encouraging people to come back to treatment?
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Internet Cessation
• Little relevance for face-to-face services, but may be a
useful tool for those who don’t want face-to-face
services
• Shahab & McEwen (Addiction, 2009)
– Found 11 randomised trials
– Tailored or interactive web-based interventions were more
effective than untailored booklets or emails (RR=1.8; 95%
CI: 1.4-2.3)
• Etter (J Health Commun 2009) however showed that
tailoring did not make any difference to early relapse
• What does the ideal web-site look like or do?
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The right mix of support
• Number and timing of sessions
– Contact within the first week after the quit date is
important
• Face-to-face versus phone/text/email etc
• What are the effective components of
behavioural support?
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Behavioural support
• Is essentially advice, discussion and materials aimed at
helping smokers to stop
• Four components (MASS):
1.
Addressing motivation
• Maximising motivation to remain abstinent and minimising motivation to
smoke
2.
Promoting optimal use of adjunctive activities
• Helping smokers to make best use of medication or other quitting aids
3.
Maximising capacity for self-regulation
• Helping smokers avoid, minimise or resist urges to smoke
4.
Activities that support the above
• Establishing rapport, undertaking assessment, engaging the smoker,
tailoring the support plan to the smoker’s needs
Slide courtesy of Professor Robert West, UK
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Addressing motivation
• Deal with ambivalence
• Elicit commitment
• Use CO monitoring
• Explain importance of a good start
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The importance of a good start
‘Not a single puff rule’
Hajek et al 2009
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Self-regulation strategies
• ‘The Doer’ versus ‘The Planner’
TOBACCO WITHDRAWAL
SYNDROME AND ITS
MODIFICATION
Thesis submitted in part fulfilment of the requirements
for the degree of PhD in Medical Psychology
University of London
Hayden James McRobbie
Barts and The London
Queen Mary’s School of Medicine and Dentistry
2007
Thaler & Sunstein 2009 Nudge – Improving descisions about health, wealth and happiness
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Self-regulation strategies
• Incentives
– ‘Carrot’ – money to be made
– ‘Stick’ – money to be lost
• Buddies
• Changing routine
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It does get easier…
• Continuation of a new behaviour are often
contingent on the perceived benefits
• Withdrawal symptoms are the first hurdle
• Yong et al 2010 measure posting quitting
experiences
Yong et al 2010 Nicotine & Tobacco Research 12 (supl 1) S12-S19
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Post-quitting experiences
Change in capacity to enjoy simple pleasures of life
Improved
Same
Worse
DAYS
Yong et al 2010 Nicotine & Tobacco Research 12 (supl 1) S12-S19
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Post-quitting experiences
Improved
Change in ability to calm down when you feel
stressed or upset
Same
Worse
100
DAYS
Yong et al 2010 Nicotine & Tobacco Research 12 (supl 1) S12-S19
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Post-quitting experiences
Improved
Change in ability to control anger,
grumpiness or annoyance since quitting
Same
Worse
182
DAYS
Yong et al 2010 Nicotine & Tobacco Research 12 (supl 1) S12-S19
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Post-quitting experiences & relapse
• Those who reported an improvement in
enjoyment in the simple pleasures of life were
less likely to relapse
• Those who experience an increase in negative
affect were more prone to relapse
• Poor impulse control was also related to
relapse
Yong et al 2010 Nicotine & Tobacco Research 12 (supl 1) S12-S19
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Using medications
Data from Cochrane reviews; bars represent 95% CIs based on risk ratios versus placebo (for
medications) or brief advice/no treatment (for BehSup)
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Emerging treatments
• Recently launched or under evaluation
– new or rediscovered medications
• vaccines, cytisine
– new variants of existing medications
• higher dose NRT patch, rapid delivery NRT, e-cigarettes
– new indications
• smoking reduction
61
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Providing support – Ask Aunty
• Potential use of ‘lay’
community members to
– Promote and ‘sign post
treatment
– Provide support
• ‘Buddies’
• Part of a support package
• Whole of support package
• Could work with
primary care
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Quality of treatment services
• Its not just about throughput, outcome is also
important
• Service user feedback and input
• Monitoring and improvement (as opposed to
evaluation)
• Minimum outcome standard in the UK = 35%
4-week self reported (25% CO val) quit rate
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One size does not fit all
• A range and form of support that best fits the
person (and the health care system)
• Need to maximize access
– Priority populations
– Go to where the people are
– People want choice and the service that fits THEM
• Innovative, effective, and safe ways to manage
tobacco dependence
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Routes to quitting
• UK NHS Stop Smoking Service is considering
implementing different options for smokers
– Abrupt quitting (status quo)
– Rapid reduction to quit
– Slow reduction to quit
– Harm reduction
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Choice
• How much choice should we give people who
want help in quitting?
– “It is particularly hard for people to make good
decisions when they have trouble translating the
choices they face into the experiences they will
have” Thaler & Sunstein (p83)
• Perhaps we should be more clear in
recommending the best option for THEM?
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We thought NHS Support would be
an easier sell
• But its unfocussed offering and range of services not
a compelling proposition
– Quitters don’t want options
– They want a programme that promises success
• Those who have had good experiences don’t credit
the NHS
– But rather the specific method used (i.e. NRT)
• Those who have had bad experiences blame the
bureaucracy of the system
– NHS Support gets the bad feedback for waiting times
– But not the success stories
From Market Research on the NHS SSS undertaken by ‘The Nursery’
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Harm Reduction
Should we be exploring this as an option for
smokers who cannot quit or do not want to
quit?
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Harm reduction
• People engage in risky behaviours
• An alternative to a ban is an effort to make the
behaviours less risky. This is called harm reduction
• Uncontroversial in driving and risky sports (safety
belts, improved skis and parachutes)
• Source of passionate controversies where behaviours
have moral connotations, e.g. drugs and sex
–
–
–
–
Methadone maintenance for heroin users
Needle exchange
Condoms in schools
Legalised prostitution
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Do we have a clean nicotine
delivery device available now?
• Current nicotine replacement treatments have
limited reach and efficacy but could be used
• Swedish snus (a less risky oral tobacco
product) has been suggested as a potential
product
• Newer and novel products may have a role to
play in the future
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Tobacco products or NRT
Swedish Snus
Nicotine Pouch
• Pouch and snus were shown to be superior to
nicotine gum in reducing urges to smoke and
had fewer side effects
Caldwell et al 2010 Nicotine & Tobacco Research 12(2) 179-83
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What do smokers think?
• There is little knowledge of smokeless tobacco
and its relative harm
• However, when asked to assume that
smokeless tobacco is less harmful than
smoking 34% said that they’d be interested in
trying
• Maori were significantly more interested
Wilson et al 2009 Nicotine & Tobacco Research 11(12) 1467-73
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NRT as an alternative to smoking
• New measures to support
those smokers who are
unwilling or unable to
quit tobacco
A Smokefree Future. A Comprehensive Tobacco Control Strategy for England. Department of Health. February 2010.
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New inhalator indication
• ‘Safer Option to Smoking’ strategy
• Indications for use now include:
– To aid smokers wishing to quit
– To aid smokers to reduce the amount of
cigarettes they smoke prior to quitting
– To assist smokers who are unwilling or
unable to quit smoking by replacing some
cigarettes with the inhalator for a safer
option to smoking
Nicorette® Inhalator SPC
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Coming from it at all angles
• Tobacco use is not just an ‘health issue’
• Therefore it is not only the responsibility of the
Ministry of Health and Healthcare Workers
• The whole of civil society needs to be involved in:
– Promoting smokefree norms
– Encouraging and supporting people to quit
– Promoting effective treatment
• Involves schools, workplace, religious groups,
community clubs (e.g. Lions) etc
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Concluding remarks – let us…
Adopt new policies that continue to create
tension and triggers
Continue to motivate and support healthcare
workers to encourage quitting and use of
effective treatments
Look critically at the treatment we currently
provide and monitor and improve outcomes
Involve service users and the community in
which they live
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Let us
Be Tobacco Free
2025
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Thank you
[email protected]
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Back up slides