Transcript The PRIME Theory of motivation and its application to

Smoking cessation treatment for people with
alcohol and substance use disorder
Robert West
University College London
June 2013
1
The big question
Should people attending drug and alcohol treatment
services routinely be offered support for quitting smoking?
No because:
Yes because:
The gains of stopping are too small
There’s not enough demand
It won’t work
It will worsen their other problems
It’s not practicable
The benefits are significant
Many clients would take it up
Many will stop smoking as a result
It may mitigate their other problems
It can be made to work
2
Outline
What are the likely benefits from stopping smoking?
What are the chances of people in these groups quitting?
What is the likely take-up of offer of help with quitting?
How effective is smoking cessation support likely to be?
Will the offer of help have adverse effects on their drug or
alcohol use?
How can the offer of help with quitting be made routine?
3
Benefit of stopping smoking: smokers
in general
Six hours of increase in life expectancy for every day of
smoking prevented after early adulthood
Improved health and functioning
Greater happiness and life satisfaction
Possible benefit to mental health
More disposable income
4
Benefits of stopping smoking
5
Doll et al 2004 BMJ
Benefits of stopping smoking: A/SUD1
smokers
Health gains greater because heavier smokers
Health gains reduced because masked by harms from
A/SUD
1 Alcohol
or substance use disorder
6
Quitting: smokers in general
Approximately 1-2% of smokers stop permanently each
year
More women try than men; success rates are similar
People who are anxious or depressed are more likely to try
to stop; success rates are worse
Half the rate succeed in social grade E as social grade AB
but the same proportion try
7
Rapid review: search strategy
Sources
Search terms
Selection
• Pubmed
• Web of Science
• Google Scholar
• Alcohol or substance
• Use disorder
• Smoking cessation
• Prevalence
• Efficacy and implementation
• Effects
8
Quitting: A/SUD smokers
Study
Finding
Bobo 1988 Add Beh 12
209
People with more severe AUD appear to be less
likely to be successful at stopping smoking when
they try
Covey 1993 Am J
Psychiatry 150 1546
Recovering alcoholics appear to have equal
success at stopping smoking as other smokers but
AUD with depression appears to be associated with
lower success rates
Martin 1997 J Cons Cl
Psy 65 190
Recovering alcoholics appear to have equal
success at stopping smoking as other smokers
9
Quitting: A/SUD smokers
Study
Finding
Marks 1997 J Subs Ab
Treat 14 521
Nicotine dependence is greater in smokers with
AUD
Hays 1999 Ann Beh Med Past and current AUD appears to be associated with
21 244
lower chances of short-term success at stopping in
smokers treated with NRT
Dawson 2000 Drug Alc
Dep 59 235
People with AUD are less likely than those without
to stop smoking
10
Quitting: A/SUD smokers
Study
Finding
Kalman 2001 J Subs
Abuse Treat 20 233
Success rates appear very low in smokers
undergoing inpatient treatment for AUD treated with
limited behavioural support and NRT, whether
treatment is started immediately or delayed
Karam-Hage 2005 Addict Stopping smoking unaided following treatment for
Beh 30 1247
AUD is not uncommon and is more likely in those
who were abstinent from alcohol at the end of
treatment
Richter 2005 J Addict Dis Long-term smoking abstinence rates may be
24 79
reasonable after motivational interviewing and
pharmacological treatment for smoking cessation in
SUD patients
11
Quitting: A/SUD smokers
Study
Finding
Agosti 2009 Soc
Psychiat Psychiat Epid
44 120
Remission from A/SUD is associated with higher
rate of smoking cessation
MacKillop 2009 Drug &
Alc Dep 104 197
Delayed reward discounting predicts worse smoking
cessation treatment outcome in heavy drinking
smokers
Kahler 2010 N&TR 12
781
Among heavy drinkers in cessation treatment, even
moderate alcohol use is associated with increased
risk of smoking, with heavy drinking further
increasing the risk
12
Quitting: A/SUD smokers
Study
Finding
Sonne 2010 Am J Add
19 111
In treatment seeking substance users, baseline
depression is associated with lower smoking
abstinence rates following smoking cessation
treatment
Hays 2011 J Subs Abuse Long-term smoking abstinence rates in recovering
Treatment 40 102
alcoholics given behavioural support plus
varenicline may be similar to other patient groups
Khara 2011 Am J Addict
20 45
SUD treatment clients may succeed in stopping at
rates similar to general population of smokers if
given intensive tobacco dependence treatment
13
Interest in taking up offer of help: smokers in
general
In England 10% smokers who received offer of help
report having tried to quit as a result
Heavier smokers are just as likely to respond as lighter
smokers
Smokers from lower social grades are more likely to
respond
14
Brief physician advice
Ask
‘Can I check – are you still smoking at all?’
‘Have you managed to stop smoking?’
‘Do you ever smoke these days?’
Advise
‘What you do is of course up to you but I can tell you that he
best way of stopping is with a combination of support and
one of the stop-smoking medicines that are now available.
It’s always worth having ago however long you last because
every day you don’t smoke gives you an extra 6 hours of life’
Assist
‘I can refer you to an excellent stop-smoking specialist who
can talk to you about the options. Is that something that
would interest you?’
‘If you think you’d just like to try one of the medicines, then I
can prescribe that for you’
‘Even if you do not feel ready to stop, we now know that
using one of the nicotine replacement products to help you
cut down can be an important step along the way’
15
Stead et al 2008, Cochrane
• Very brief advice: N=13,724
• More extensive advice: N=1,254
• 95% confidence intervals from
meta-analyses
↑ % abstinent >6m
Brief advice: efficacy
12
10
8
6
4
2
0
Very brief advice
More extensive
advice
Aveyard et al 2012, Addiction
• Advice only increased quit attempts by 24% (95% CI: 16-33%)
• Offering behavioural support increased quit attempts by 117% (95%
CI: 52-210%)
• Offering prescription increased quit attempts by 68% (95%CI: 48-89%)
16
Response to brief GP offer by social grade
Percent
trying to stop as a result of GP
offer
14
12
10
8
6
4
2
0
A/B
C1
Source: Smoking Toolkit Study N=3,311
C2
D
E
17
Response to brief GP offer by age
Percent
trying to stop as a result of GP
offer
12
10
8
6
4
2
0
16-24
25-24
35-44
45-54
55-64
Source: Smoking Toolkit Study N=3,311, p=0.02 for difference
65+
18
Interest in stopping smoking in A/SUD
Study
Finding
Ellingstad 1999 Drug Alc
Dep 54 259
A majority of smokers in treatment for AUD would
probably be interested in help with stopping either
during or after AUD treatment
Clarke 2001 Am J Addict
10 159
There is at least a moderate level of interest in
stopping smoking in injecting drug users, more so in
those who are older, engaged in methadone
maintenance programmes and without AUD
Stotts 2003 Drug Alc
Dep 24 1
Smokers in treatment for AUD appear to be more
motivated to abstain from alcohol than to stop
smoking and those who are motivated to do both
may be more likely to drop out of treatment
19
Interest in stopping smoking in A/SUD
Study
Finding
Joseph 2003 J Add Dis
22 87
There is considerable interest in smoking cessation
in alcohol dependent treatment populations
Joseph 2004 Am J
Addict 13 405
Patients being treated for AUD with a history of
depressive disorder or depressive symptoms are
less interested in stopping smoking
Flach 2004 Addict Beh
29 791
In people undergoing treatment for AUD who smoke
there may be lower interest in stopping smoking
than in alcohol abstinence
20
Interest in stopping smoking in A/SUD
Study
Finding
Nahvi 2006 Addict Beh 2
127
There is at least a moderate interest in quitting
among injecting drug users in methadone
maintenance programmes
Ramo 2010 Drug & Alc
Dep 106 48
Young people undergoing treatment for SUD
typically show at least moderate interest in stopping
smoking
Bowman 2012 Drug Alc
Review 31 507
Only 15% of clients on methadone maintenance had
tried to stop in the past year and only 10% of eversmokers had stopped
21
Behaviour change framework for aiding
smoking cessation
Michie et al 2011 Implementation Sci
22
Behaviour change framework for aiding
smoking cessation
Build capacity for self-regulation
Help understand benefits of cessation
Inform about best ways of quitting
Persuade that quitting is worthwhile
Foster desire to quit
Tackle urges to smoke
Provide easy access to support
Minimise exposure to smoking cues
Develop norms around quitting
23
Effectiveness of support: smokers in
general
Optimal treatment (behavioural support plus medication)
can lead to long-term (>1 year) abstinence in >20% of
cases
Cost around $500 per course of treatment (behavioural
support plus medication)
24
Medication options
NRT
• transdermal patch, gum, inhaler, lozenge, nasal spray,
mouthspray
• use for >8 weeks
• varying doses
• can be used in combinations (‘dual form’)
• not contra-indicated in CVD
• no increased risk of serious adverse events
• low addictive potential
Varenicline
• partial agonist binding with high affinity to 42 nAch
receptor
• targets craving and blocks nicotine reward
• increase dose over 7 days then 1mg twice daily for >11
weeks
• not contraindicated in CVD
• mixed findings on potential CVD risk
• no clear evidence of other serious adverse events
• main adverse events: nausea, disturbed dreams
25
Stead et al 2008, Cahill et al 2012,
Cochrane
• Varenicline: N=6,166
• Single NRT: N=51,265
• Dual NRT: 4,664
• NRT for ‘reduce to quit’: N=3,429
• 95% confidence intervals from
meta-analyses
↑ % abstinent >6m
Medications: efficacy
20
15
10
5
0
Varenicline Single form Dual form
NRT
NRT
NRT for
'reduce to
quit'
26
Specialist behavioural support
Individual
• 6+ sessions starting before the quit date
• Use specific ‘behaviour change techniques to boost
resolve, reduce motivation to smoke, avoid and cope with
smoking urges, make optimum use of stop-smoking
medication
• Key elements include: measuring expired-air CO
concentrations, getting commitment to a definite quit date,
emphasising the ‘not a puff’ rule, advising on ways of
avoiding smoking triggers
Group
• 6+ sessions starting before the quit date
• As above but with additional focus on using group
processes to maintain motivation not to smoke
Self-help
• Websites, text messaging, written materials
• Significant heterogeneity
• No proven programmes currently generally available
27
Stead et al 2012, Cochrane1
• Individual vs brief advice: N=7,855
• Group vs self-help: N=4,375
• Internet vs nothing: N=2,960
• Text messaging versus control
messages: N=9,110
• Written materials: N=15,117
• 95% confidence intervals from
meta-analyses
↑ % abstinent >6m
Behavioural support: efficacy
10
8
6
4
2
0
See caveats on previous slide
Available as evaluated through the NHS
1Updates
about to be published
28
52-week abstinence rates for selected
methods of stopping smoking
30
% abstinent
25
20
15
10
5
0
Unaided
Mono NRT Dual NRT Rx Varenicline Mono NRT + Dual NRT Varenicline +
Rx only
only
Rx only
specialist
+specialist
specialist
support
support
support
Based on treatment as directed in guidelines
West and Owen 2012 www.smokinginengland.info 29
Effectiveness of support: A/SUD smokers
Study
Finding
MMWR 1997 Morb Mort
Wkly Rep 46 1114
Brief counselling without medication does not
appear to be effective in helping smokers with AUD
to stop
Prochaska 2004 J Cons
Clin Psy 72 1144
(Review)
Smoking cessation treatment appears to have shortterm effects in people during or following A/SUD
treatment but effects may not be sustained longer
term
Joseph 2004 J Stud Alc
65 681
In patients treated for AUD, concurrent smoking
cessation treatment is not more effective than
delayed treatment
Bankole 2005 Arch Int
Med 165 1600
Topiramate may be effective in aiding smoking
cessation in AUD smokers at least up to 12 weeks
30
Effectiveness of support: A/SUD smokers
Study
Finding
Hurt 2005 J Stud Alc 66
506
Attempting high level nicotine replacement through
nicotine patches was followed by at least moderate
short-term smoking abstinence in stable recovering
AUD patients but success was not associated with
degree of nicotine replacement achieved
Kalman 2005 J Subst
Abuse Tr 30 213
High dose nicotine patch was not more effective
than standard dose in promoting smoking cessation
in recovering AUD patients
Diehl 2006 Int J Clin
Pharm Ther 44 614
The acetylcholinesterase inhibitor, galantamine,
reduced smoking in recently detoxified AUD patients
enrolled regardless of willingness to stop smoking
31
Effectiveness of support: A/SUD smokers
Study
Finding
Grant 2007 Alcohol 41
381
Adding bupropion to NRT did not improve smoking
cessation rates in smokers with AUD but success
rates overall were similar to what is found in general
population
Hays 2009 Nic & Tob
Res 11 859
In recovering alcoholic smokers, providing
bupropion up to 52 following 8 weeks of treatment
with nicotine patches did not improve abstinence
rates
Okoli 2010 J Subs Abuse Few studies evaluating smoking cessation treatment
Treat 38 191 (Review)
in methadone maintained patients; success rates
are low and there is little evidence of effectiveness
32
Effectiveness of support: A/SUD smokers
Study
Finding
Kalman 2011 Drug Alc
Dep 118 111
Adding bupropion to NRT appears to be no more
effective than NRT alone in promoting smoking
cessation in patients who have received treatment
for AUD.
Karam-Hage 2011 Am J
Drug Alc Abuse 37 487
Bupropion may help smoking cessation in AUD
patients (very small pilot RCT)
Bernstein 2012 J Subst
Abuse Tr epub
Behavioural support plus medication increased
long-term smoking abstinence in A/SUD patients
attending an emergency department
33
Effectiveness of support: A/SUD smokers
Study
Finding
Tuten 2012 Addiction
107 1868
Incentives for reduced breath CO may reduce
cigarette consumption in methadone maintained
pregnant smokers
Carmody 2012 Drug Alc
Dep
High intensity behavioural support plus dual form
NRT for 26 weeks in AUD smokers led to short-term
but not long-term smoking abstinence; there was no
difference in alcohol outcomes
34
Stopping smoking effects on A/SUD
Study
Finding
Bobo 1988 Add Beh 12
209
Stopping smoking in recovering alcoholics appears
not to jeopardise sobriety
Covey 1993 Am J
Psychiatry 150 1546
Stopping smoking in recovering alcoholics does not
appear to precipitate relapse to alcohol
Martin 1997 J Cons Cl
Psy 65 190
Stopping smoking does not appear to precipitate
relapse in recovering alcoholics
35
Stopping smoking effects on A/SUD
Study
Finding
McIlvaine 1998 Am Fam
Physician 15 1869
(Review)
Treatment to aid smoking cessation may promote
alcohol abstinence in patients with AUD
Bobo 2002 Addiction 93
877
Low intensity tobacco cessation support in people
following AUD treatment resulted in improves AUD
outcomes but not improved smoking cessation
outcomes
Joseph 2004 J Stud Alc
65 681
In patients treated for AUD, concurrent smoking
cessation treatment may lead to worse alcohol
outcomes than delayed treatment
36
Stopping smoking effects on A/SUD
Study
Finding
Myers 2006 Alc Res Hlth
29 221 (Review)
What little research there is suggests that smoking
cessation treatment may be beneficial for
adolescents with A/SUD disorders
Grant 2007 Alcohol 41
381
Stopping smoking in a trial of smoking cessation
treatment in AUD patients was associated with
improved alcohol outcomes
Hall 2007 Am J Prev
Med 33 S406 (Review)
What little research there is suggests that smoking
cessation treatment could be beneficial and not
adversely effect A/SUD outcomes
Myers 2008 Subst Abuse Participation in smoking cessation treatment
21 81
programmes may help reduce substance use in
adolescents
37
Stopping smoking effects on A/SUD
Study
Finding
Kalman 2010 Clin Psy
Rev 30 12 (Review)
Treatment for tobacco dependence does not
jeopardise alcohol abstinence in those undergoing
treatment for AUD
Nieva 2011 Eur Add Res
17 1
Participation in a smoking cessation programme
does not impair alcohol outcomes, at least during
the first 6 months
Tsoh 2011 Drug Alc Dep
114 110
Stopping smoking within 1 year of treatment for
A/SUD predicted alcohol and substance use
outcomes up to 9 years later
38
How can stop-smoking support be made
routine?
• Factors likely to be associated with provision of tobacco
cessation support
– Staff motivation and skills
– Management support
– Systems and access to treatment options
Michie 2011 Implementation Sci
39
Provision of stop smoking treatment
Study
Finding
Bobo 1995 Psychiat
Serv 46 945
Counsellors in AUD treatment services are more
likely to offer smoking cessation support if they are
non-smokers, know more about nicotine addiction
and have services that they can refer to
Bowman 2003 Drug Alc
Rev 22 73 (Review)
There is a need for research into improved systems
to offer smoking cessation support to patients with
A/SUD
Walsh 2005 Drug Alc
Rev 24 235
Only a quarter of Australian A/SUD treatment
services questioned had smoking cessation
intervention policies and one third had adequate
treatment programmes. Concerns over negative
effects and lack of client interest were reported as
significant barriers
40
Provision of stop smoking treatment
Study
Finding
Richter 2006 Subst
Abuse Tr Prev Pol 14 1
(Review)
Stop-Smoking treatment should be embedded in
A/SUD treatment programmes and involve
behavioural support and medication
Guydish 2007 J
Psychoactive Drugs 39
423 (Review)
Staff smoking prevalence in A/SUD treatment
centres is variable and not necessarily high. The
main barriers to providing smoking cessation
support appear to be staff smoking, lack of
knowledge and skills, concern about effect on
A/SUD outcomes
Knudsen 2010 J Subs
Ab Treat 38 212
Substance abuse counsellors are less likely to
provide brief tobacco interventions if they smoke,
had less knowledge of guidance, and perceived less
management support
41
Provision of stop smoking treatment
Study
Finding
Wye 2010 Aus NZ J Publ Recording of smoking status may be very low in
Hlth 34 298
psychiatric hospitals but higher for patients with
A/SUD than those without
Prochaska 2010 Drug
Alc Dep 110 177
(Review)
A/SUD treatment providers have an ethical duty to
provide nicotine dependence treatment
Knudsen 2011 Drug Alc
Dep 118 244
NRT availability in SUD treatment centres in the US
is low and decreasing
42
Provision of stop smoking treatment
Study
Finding
Huntt 2012 J Subst
Abuse Treat 42 4
A study of treatment provision found that provision
was rare and systems were non-existent
Knudsen 2012 Nic Tob
Res In Press
A high proportion of smoking cessation programmes
in SUD treatment centres fail to be sustained.
Management attitudes, low staff skills and
competing demands were associated with
discontinuation
43
Conclusions
 Stopping smoking will substantially increase life
expectancy and improve quality of life
 Demand for treatment will be broadly similar to the
general population at around 5-10% of clients
 The chances of clients stopping without support are
minimal. Limited support is unlikely to make a meaningful
difference but intensive support plus medication could
44
Conclusions
 Offering stop-smoking support is unlikely to damage
alcohol or drug-related outcomes and may improve them
 It is practicable to include treatment to promote
smoking cessation in alcohol and substance use services
and routinely offer support but all aspects of capability,
opportunity and motivation of staff need to be addressed
45