Directory UMM :articles:
Underst anding individual
sm okers’ behaviour and CDTS
Robert West
Cancer Research UK and UCL
Sept em ber 2005
Sm oking t rends in t he UK
140
120
Rat e of decline
in prevalence is
now t oo slow
100
80
60
40
20
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020
Men total ('000 deaths)
W omen total ('000 deaths)
Male smokers ('00,000)
Female smokers ('00,000)
Sm oking cessat ion in t he UK: 2004
Smokers
Sources:
1 ONS October/November 2004
2 Hughes et al, Tob Con 2003, 12, 21-27
3. Shiffman et al, 2002, Addiction, 97, 505-512
33% Attempt to quit 1
4. Addiction supplement March 2005
5. Hughes et al, 2004, Addiction, 99, 29-38
OTC means from shop or pharmacist
21% use treatment 1
4% use prescription only1
10% buy NRT OTC1
Quit for at least
12 months
8% 2
0.8%
=
12% go ‘cold turkey’
7% use a smokers’ clinic1
8% 3
+
0.32%
2.65% stop smoking
15% 4
+
1.05% +
4% 5
0.48%
Sm oking cessat ion in t he UK: 2004
Smokers
We need t o double
t his figure t o get
annual prevalence
reduct ion up t o 1%
33% Attempt to quit 1
21% use treatment 1
Quit for at least
12 months
8% 2
0.8%
=
12% go ‘cold turkey’
4% use prescription only1
10% buy NRT OTC1
7% use a smokers’ clinic1
8% 3
+
70% ‘want t o st op
sm oking’
0.32%
2.65% stop smoking
15% 4
+
1.05% +
4% 5
0.48%
Why do sm okers not t ry t o st op
m ore oft en?
PRI ME Theory
A new, com prehensive t heory of m ot ivat ion t hat
int egrat es choice, im pulse, ident it y, habit , selfcont rol, and drive int o a single descript ion of t he
‘m ot ivat ional syst em ’
This syst em is ‘chaot ic’ in t he sense used by ‘Chaos
Theory’
For an act ion t o occur som et hing has t o
happen at t hat t im e t o t rigger it :
Beliefs about what is good or bad have no effect
unless t hey creat e desire
Desires have no effect unless t hey generat e im pulses
The basis of all behaviour change is: t ension and
t riggers
West R ( 2006) Theory of Addict ion. Oxford Blackwells
What is ‘t ension’?
‘Mot ivat ional t ension’ involves a feeling of
dissat isfact ion wit h t he st at us quo
I t has t he following feat ures:
1. I t is only present when it is ‘brought t o m ind’
I t can oft en put ‘out of m ind’
I t is m ore responsive t o changes in
circum st ances t han st eady st at es
2. I t involves a com parison wit h som et hing ‘bet t er’
which is achievable
There is a st rong t endency t o m ake ‘upward
com parisons’
Denying t hat som et hing is achievable can
reduce t he t ension
What are t riggers?
Triggers are event s in t he int ernal or ext ernal
environm ent t hat generat e im pulses t o act t hat are
st rong enough t o overcom e inert ia and com pet ing
im pulses
I nt ernal t riggers
Persist ence of or increases in drive st at es
Recollect ion of int ent ions or plans
Ext ernal t riggers
Rem inders
Cues
‘Provocat ions’
‘Models’
‘Calls t o act ion’
Mot ivat ion t o st op
Mot ivat ional ‘t ension’
Act ion t hreshold
Tim e
Low level of m ot ivat ion
Rising m ot ivat ional ‘t ension’
Trigger
Cut t ing down
Tension can be reduced by ‘cut t ing down’ or ot her
harm m inim isat ion act ivit ies
Approxim at ely 50% of sm okers are at t em pt ing t o
rest rict t heir sm oking at any one t im e
New dat a from Sm okers Toolkit Pilot ( N= 84) indicat e
t hat sm okers who say t hey are ‘t rying t o cut down on
how m uch t hey sm oke’ have only slight ly lower
nicot ine int ake ( saliva cot inine of 331ng/ m l versus
370ng/ m l)
But previous research shows t hat sm okers who report
t hat t hey are ‘cut t ing down in preparat ion for quit t ing’
are m ore likely t o have quit one year lat er t han t hose
who do not ( West et al, 2001)
So cut t ing down in it self m ay be of lit t le benefit , but if
it is successful it m ay prom ot e cessat ion
Tension, t riggers and sm oking
Tension
Worries about healt h, feeling of disgust ,
em barrassm ent , sham e, dissat isfact ion wit h t he
cost , feeling t hat st opping is possible
Triggers
Healt h scares
Ot her people st opping
I nst ruct ion from an aut horit y
‘New hope’ m essages
‘I nj ect ions of urgency’
Cut Down Then St op ( CDTS)
Successful ‘cut t ing down’ m ay
increase t ension by increasing t he
feeling t hat st opping is possible
The pharm acological com ponent of
t he drive t o sm oke m ay be reduced
so t hat when cessat ion is at t em pt ed it
is m ore likely t o be successful
Evidence used by Pfizer t o support
CDTS
Nicotine gum
or inhaler %
(N)
Total N
% (N) who had reduced
their smoking by 50% at
4 months
Odds ratio
1215
1209
15.9% (193)
6.7% (81)
2.63
18.5% (15/81)
1.89
4.5% (54)
2.02
% (N) of those who had by 30.1% (58/193)
50% at 4 months who
were abstinent at
12 months
Percent (N) of smokers
who were abstinent at 12
months
Placebo gum
or inhaler
% (N)
8.6% (105)
I m plicat ions of CDTS
Uncert ain whet her it will increase quit at t em pt s or
det ract from abrupt cessat ion
Possibilit y t hat will weaken t he ‘not a puff’ m essage
for sm okers in clinics
Clinics should not be expect ed t o help sm okers reduce
– no evidence t hat t his is effect ive
GPs should probably prescribe NRT for CDTS in cases
where st opping is m ore urgent e.g. COPD but it is
clear t hat t he sm oker will not st op abrupt ly
Could be t he st art of a blurring of t he boundaries
bet ween cigaret t e use and nicot ine use leading t o
sm okers get t ing nicot ine from m ore t han one source
Conclusions
CDTS m ay increase t he rat e at which quit at t em pt s
are m ade and t he use of NRT in t hose quit at t em pt s
The effect on prevalence depends on how far it
subst it ut es for abrupt quit s
I t is unlikely in it self t o achieve t he t arget of doubling
quit rat es. For t hat we need m ore t ension and m ore
t riggers:
1. 20p levy on a pack of cigaret t es funding a t obacco
cont rol program m e run by an independent Tobacco
Cont rol Task Force
2. Com plet e ban on sm oking in indoor public places
3. Mass m edia cam paigns and advocacy t hat focus m ore
on t ension and t riggers: addressing t he sm oker’s
ident it y, inj ect ing m ore urgency and m ore act ionorient ed m essages
sm okers’ behaviour and CDTS
Robert West
Cancer Research UK and UCL
Sept em ber 2005
Sm oking t rends in t he UK
140
120
Rat e of decline
in prevalence is
now t oo slow
100
80
60
40
20
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020
Men total ('000 deaths)
W omen total ('000 deaths)
Male smokers ('00,000)
Female smokers ('00,000)
Sm oking cessat ion in t he UK: 2004
Smokers
Sources:
1 ONS October/November 2004
2 Hughes et al, Tob Con 2003, 12, 21-27
3. Shiffman et al, 2002, Addiction, 97, 505-512
33% Attempt to quit 1
4. Addiction supplement March 2005
5. Hughes et al, 2004, Addiction, 99, 29-38
OTC means from shop or pharmacist
21% use treatment 1
4% use prescription only1
10% buy NRT OTC1
Quit for at least
12 months
8% 2
0.8%
=
12% go ‘cold turkey’
7% use a smokers’ clinic1
8% 3
+
0.32%
2.65% stop smoking
15% 4
+
1.05% +
4% 5
0.48%
Sm oking cessat ion in t he UK: 2004
Smokers
We need t o double
t his figure t o get
annual prevalence
reduct ion up t o 1%
33% Attempt to quit 1
21% use treatment 1
Quit for at least
12 months
8% 2
0.8%
=
12% go ‘cold turkey’
4% use prescription only1
10% buy NRT OTC1
7% use a smokers’ clinic1
8% 3
+
70% ‘want t o st op
sm oking’
0.32%
2.65% stop smoking
15% 4
+
1.05% +
4% 5
0.48%
Why do sm okers not t ry t o st op
m ore oft en?
PRI ME Theory
A new, com prehensive t heory of m ot ivat ion t hat
int egrat es choice, im pulse, ident it y, habit , selfcont rol, and drive int o a single descript ion of t he
‘m ot ivat ional syst em ’
This syst em is ‘chaot ic’ in t he sense used by ‘Chaos
Theory’
For an act ion t o occur som et hing has t o
happen at t hat t im e t o t rigger it :
Beliefs about what is good or bad have no effect
unless t hey creat e desire
Desires have no effect unless t hey generat e im pulses
The basis of all behaviour change is: t ension and
t riggers
West R ( 2006) Theory of Addict ion. Oxford Blackwells
What is ‘t ension’?
‘Mot ivat ional t ension’ involves a feeling of
dissat isfact ion wit h t he st at us quo
I t has t he following feat ures:
1. I t is only present when it is ‘brought t o m ind’
I t can oft en put ‘out of m ind’
I t is m ore responsive t o changes in
circum st ances t han st eady st at es
2. I t involves a com parison wit h som et hing ‘bet t er’
which is achievable
There is a st rong t endency t o m ake ‘upward
com parisons’
Denying t hat som et hing is achievable can
reduce t he t ension
What are t riggers?
Triggers are event s in t he int ernal or ext ernal
environm ent t hat generat e im pulses t o act t hat are
st rong enough t o overcom e inert ia and com pet ing
im pulses
I nt ernal t riggers
Persist ence of or increases in drive st at es
Recollect ion of int ent ions or plans
Ext ernal t riggers
Rem inders
Cues
‘Provocat ions’
‘Models’
‘Calls t o act ion’
Mot ivat ion t o st op
Mot ivat ional ‘t ension’
Act ion t hreshold
Tim e
Low level of m ot ivat ion
Rising m ot ivat ional ‘t ension’
Trigger
Cut t ing down
Tension can be reduced by ‘cut t ing down’ or ot her
harm m inim isat ion act ivit ies
Approxim at ely 50% of sm okers are at t em pt ing t o
rest rict t heir sm oking at any one t im e
New dat a from Sm okers Toolkit Pilot ( N= 84) indicat e
t hat sm okers who say t hey are ‘t rying t o cut down on
how m uch t hey sm oke’ have only slight ly lower
nicot ine int ake ( saliva cot inine of 331ng/ m l versus
370ng/ m l)
But previous research shows t hat sm okers who report
t hat t hey are ‘cut t ing down in preparat ion for quit t ing’
are m ore likely t o have quit one year lat er t han t hose
who do not ( West et al, 2001)
So cut t ing down in it self m ay be of lit t le benefit , but if
it is successful it m ay prom ot e cessat ion
Tension, t riggers and sm oking
Tension
Worries about healt h, feeling of disgust ,
em barrassm ent , sham e, dissat isfact ion wit h t he
cost , feeling t hat st opping is possible
Triggers
Healt h scares
Ot her people st opping
I nst ruct ion from an aut horit y
‘New hope’ m essages
‘I nj ect ions of urgency’
Cut Down Then St op ( CDTS)
Successful ‘cut t ing down’ m ay
increase t ension by increasing t he
feeling t hat st opping is possible
The pharm acological com ponent of
t he drive t o sm oke m ay be reduced
so t hat when cessat ion is at t em pt ed it
is m ore likely t o be successful
Evidence used by Pfizer t o support
CDTS
Nicotine gum
or inhaler %
(N)
Total N
% (N) who had reduced
their smoking by 50% at
4 months
Odds ratio
1215
1209
15.9% (193)
6.7% (81)
2.63
18.5% (15/81)
1.89
4.5% (54)
2.02
% (N) of those who had by 30.1% (58/193)
50% at 4 months who
were abstinent at
12 months
Percent (N) of smokers
who were abstinent at 12
months
Placebo gum
or inhaler
% (N)
8.6% (105)
I m plicat ions of CDTS
Uncert ain whet her it will increase quit at t em pt s or
det ract from abrupt cessat ion
Possibilit y t hat will weaken t he ‘not a puff’ m essage
for sm okers in clinics
Clinics should not be expect ed t o help sm okers reduce
– no evidence t hat t his is effect ive
GPs should probably prescribe NRT for CDTS in cases
where st opping is m ore urgent e.g. COPD but it is
clear t hat t he sm oker will not st op abrupt ly
Could be t he st art of a blurring of t he boundaries
bet ween cigaret t e use and nicot ine use leading t o
sm okers get t ing nicot ine from m ore t han one source
Conclusions
CDTS m ay increase t he rat e at which quit at t em pt s
are m ade and t he use of NRT in t hose quit at t em pt s
The effect on prevalence depends on how far it
subst it ut es for abrupt quit s
I t is unlikely in it self t o achieve t he t arget of doubling
quit rat es. For t hat we need m ore t ension and m ore
t riggers:
1. 20p levy on a pack of cigaret t es funding a t obacco
cont rol program m e run by an independent Tobacco
Cont rol Task Force
2. Com plet e ban on sm oking in indoor public places
3. Mass m edia cam paigns and advocacy t hat focus m ore
on t ension and t riggers: addressing t he sm oker’s
ident it y, inj ect ing m ore urgency and m ore act ionorient ed m essages