Nascholing Kwaliteitsregister Stoppen met Roken 17

Nascholing Kwaliteitsregister Stoppen met Roken
17 september 2015
Paul van Spiegel
Kwaliteitsregister SmR 17.9.2015
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SRNT Europe 2015
 Multidisciplinaire kennistransfer
 Basiswetenschappen
 Addictiebehandeling
 Public health & tobacco control
 Keynote:
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Jacqueline Vink: Genetica rookgedrag
Paul Aveyard: Non-adherence in SmR behandeling
Robert West: Optimaliseren gedragsm. ondersteuning
Amanda Amos: Sociale ongelijkheid en roken
Paul Cairney: Politiek van tobacco control
Kwaliteitsregister SmR 17.9.2015
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SRNT-E 2015
 Vink: Beyond the genetics of smoking behavior
 Van tweeling en familieonderzoek (nurture or nature)
 Genoombrede associatiestudies in internat.consortia
 initiation/cpd/dependency (erfelijkhd 2-40%)
 2010 meta-analyse fenotypen rokers: gencluster Chr15
 Interactie genet. vulnerabiliteit en omgevingsfactoren
Individuele genetische varianten verklaren maar
klein deel van totale variatie rokersgedrag
Genfarmacologie; polymorfismen in
nicotinemetabolisme en neurobiologie
Kwaliteitsregister SmR 17.9.2015
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SRNT-E 2015 Clinical theme lecture
Aveyard: Non-adherence in smoking cessation
Rx-noncompliantie inherent addictiebehandeling
algemene opvattingen over roken, stoppen en Rx
additionele info Rx en problem solving
Cochrane 2015 bescheiden effect
info over genotype verhoogt ervaren Tx effectiviteit
Kwaliteitsregister SmR 17.9.2015
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SRNT-E Behavioural Science Lecture
 West: What is the most we can achieve with behav.
support in smoking cessation.
 85% relapse <4w; 70% <1jr; 20-30% >1jr
 Relapse vooral aandrang tot roken bij verlies aan
controle.
 COM-B model voor gedragsveranderng
Kwaliteitsregister SmR 17.9.2015
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Addiction to cigarettes
I really want to
stop smoking: it’s
costing me money
and it will probably
kill me
Just
smoke!
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Addiction to cigarettes
Addiction to cigarettes involves the moment-to-moment
conflict between
• Cue-driven urges
• Nicotine hunger
• Nicotine withdrawal symptoms
and
• Concern about cost
• Worry about health
• Dislike of other aspects of smoking
What is needed for behaviour change: The
COM-B model
Physical and psychological capability:
knowledge, skill, strength, stamina
Michie et al (2011) Implementation Science
The COM-B model of behaviour
change
Reflective and automatic motivation:
plans, evaluations, desires and
impulses
Michie et al (2011) Implementation Science
The COM-B model of behaviour
change
Physical and social opportunity:
time, resources, triggers, concepts
Michie, van Stralen & West (2011) Implementation Science
What is required for smoking
cessation?
Motivation to stop
• Desire to quit and hope for success versus concern
about lost benefits of smoking and fear of failure
Ability to stop
• Ability to maintain self-control in the face of
immediate urges, need and desire to smoke
Opportunity to stop
• Protection from smoking triggers
• Exposure to stopping triggers
QUIT ATTEMPT:
Balancing URGE vs RESOLVE
Abstinent
Smoking
Resolve (motivation
and ability to resist
urges)
Urges to smoke
Time
The treatment may have chronic or short-term effects on either or both curves
The role of treatment is to keep these lines as far
apart as possible
Urge to smoke
Time
Resolve
Strength of urge
Support for smoking cessation
 Behavioural support
 Advice, discussions, exercises designed to address social
and psychological aspects of the problem
 Pharmacotherapy
 Medicines (including nicotine products) designed primarily
to reduce craving and withdrawal symptoms
Licensed medicines and e-cigarettes
NRT
• transdermal patch, gum, inhaler, lozenge, nasal spray,
mouth spray, and oral film in varying doses and in
combinations
• can be used for smoking reduction
• use for ≥8 weeks possibly starting before quit date
Varenicline
• partial agonist binding with high affinity to α4β2 nAch
receptor
• increase dose over 7 days then 1mg twice daily for ≥11
weeks or 23 weeks
Bupropion
• unknown mechanism of action
• use for 8 weeks starting 1 week before quit date
E-cigarettes
• Multiple variants from 1st generation ‘cigalikes’ to ‘3rd
generation refillable, rechargeable bespoke devices
• Variable nicotine delivery
The role of pharmacotherapy
1. Reduce the strength, duration or frequency of urges to
smoke
2. Reduce unpleasant withdrawal symptoms
3. Reduce the pharmacological reward from smoking
FRONT RUNNERS: COMBINATION NRT
VARENICLINE
NEVER WITHOUT BEHAVIORAL SUPPORT
LONGER TREATMENT; LESS RELAPSE; BETTER OUTCOMES
How might psychological problems inhibit
cessation?
Reducing
•
•
•
•
Motivation to quit
Hope for success in quitting
Ability to exercise self-control
Quitting triggers
Increasing
• Concern about lost benefits of smoking
• Immediate, urges, needs and desire to smoke
• Smoking triggers
Anxiety and depression appear not to
reduce motivation to quit
 Data from Smoking Toolkit Study
 N=1,330 smokers in general population in England
 Household survey
 Measures:
 number of quit attempts in the past year
 motivation to quit on 7-point scale (MTSS)
 Anxiety/depression (EQ5D)
 Age, gender, social grade
 Results:
 smokers with poor mental health are as motivated to quit and
try to quit at least as often as those with good mental health
 adjusted beta: 0.03, p=.31 for motivation; 0.06, p=0.05 for quit
attempts
People with anxiety and depression are
more likely to be offered quitting support
 Data from Smoking Toolkit Study
 N=1,301 smokers in general population in England
 Household survey
 Measures:
 GP advice to quit
 GP offer of support to quit
 Anxiety/depression (EQ5D)
 Age, gender, social grade
 Results:
 smokers with poor mental health are more likely to receive offer
of support
 adjusted beta: 1.44, p<0.001
 but this is only because they see the GP more often
Mood management in smoking cessation
 Gierisch et al (2011) JGIM, 27, 351
 Systematic review of RCTs of mood management
added to smoking cessation support
 5 trials with current depression or history of depression
 Interventions included CBT and Behavioural Activation
treatment
 Results suggestive of benefit
Mood management in smoking cessation:
current depression
 van de Meer et al (2013) Cochrane Database,
CD006102
 Systematic review of RCTs of mood management
added to smoking cessation support
 11 trials with current depression
 Interventions included CBT and behavioural activation
treatment
 Results showed benefit
Mood management in smoking cessation:
past depression
 van de Meer et al (2013) Cochrane Database,
CD006102
 Systematic review of RCTs of mood management
added to smoking cessation support
 13 trials with past depression
 Interventions included CBT and behavioural activation
treatment
 Results showed benefit
Robert West:
Take home messages
OPTIMALISEREN BEHANDELING:MANAGING URGE/RESOLVE
VERHOGEN RESOLVE:
WENS /STEMMING /MORAAL /IDENTITEIT/
RESPONSGEVOELIGHEID
REDUCEREN URGE:
CUE EXPOSURE /CUE SENSITIVITY /IMPACT LAPSE /ACCESS
INSPELEN OP GOED OF SLECHT VOELEN WERKT VAAK BETER
DAN OVERTUIGEN MET EVIDENCE BASED ARGUMENTEN
STEL DOELEN DICHTBIJ
FARMACA ONDERSTEUNEN DE GEDRAGSMATIGE AANPAK
Kwaliteitsregister SmR 17.9.2015
ROBERT WEST: ABRUPT OR GRADUAL QUIT
 Minderen naar stoppen verhoogt onttrekkingslast
 Afbouwen: compenserend roken
 Met NRT of varenicline lukt minderen goed
 Every smoker can do something: PLAN & ADVANCE
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Quit when ready with evidence based support
Set quit date in advance; do not cut down
If lapse: keep on going and recomit
If not ready to quit: cut down with NRT
Kwaliteitsregister SmR 17.9.2015
Wim van den Brink:
Importance of breaking free
 Historisch overzicht verslavingsconcept
 Nu: Chronische hersenaandoening met genetische
vulnerabiliteit, biologische risico factoren en
aantoonbare hersendysfuncties in cue reactiviteit en
reward system:
 Addictie: Hyperreactief beloningssysteem en een
deficient cognitief controle systeem.
Kwaliteitsregister SmR 17.9.2015
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SRNT-E: Inequalities in smoking
 Amanda Amos: Mind the inequality gap.
 Declining smoking prevalence but not social gradient
 Social inequality great driver of ill health
 TC policies have uncertain equity impact
 tax/RYO/smugling/reimbursement/chronic illness
 FM to RYO to tax evasion: GBP 600 – 2000/yr
Endgame ? Polluter pays
based on sales
goal tax funding the deprived & health care
Kwaliteitsregister SmR 17.9.2015
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SRNT-E 2015: e-Cigarette
 Onzekerheid
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Data snel verouderd: Eurobarometer Mei 2015
Effectief bij relapse?
2 RCT’s negatief
Sara Hitchman: ITC real world smokers 2010-2013
 eC on last QA more effective than no medication or NRT
Kwaliteitsregister SmR 17.9.2015
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Aids used in most recent quit
attempt
50
45
Percent of smokers trying to stop
40
Increase in use of e-cigarettes for quitting has been
accompanied by a smaller reduction in use of other
aids except behavioural support
35
30
25
20
15
10
E-cigs
NRT OTC
NRT Rx
Champix
Beh'l supp
5
0
N=4,810 adults who smoke and tried to stop or who stopped in the past year
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Stop coach performance
 Emma Croghan:
 Advisor personality and client QR in SSS
 Extraverte stopcoach meer succes (OR 1,15)
 NCSCT Briefing 2012
 Dennis de Ruyter:
 Pilot Adherence to SC guidelines & needs for web-based
adherence support.
 Psychologische en praktische barrières
Kwaliteitsregister SmR 17.9.2015
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Barriers and facilitating factors for adhering to smoking cessation
guidelines in primary care: a qualitative study among Dutch practice
nurses
Dennis de Ruijter;
Eline Smit; Hein de Vries; Ciska Hoving
Background
Setting: Dutch general practice
Practice nurse (PN)
 Employed in 80% of general practices
 Prevention-related tasks
 Chronic disease consultations
Smoking cessation counseling
 Motivational Interviewing
 Evidence-based guidelines
 Such as the STIMEDIC guideline
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Based on Minimal Intervention Strategy (MIS)
STIMEDIC
7 counseling steps
Behavioral counseling
Pharmacological support
Support after quit date
Current situation
Smoking cessation counseling
− How adherent are PNs?
Sub-optimal adherence to guidelines
 Determinants of adherence unknown
 What are important barriers and facilitating factors for adherence?
Need for adherence support
 Do PNs want to be supported?
 What are important features of adherence support?
PNs’ guideline adherence
All PNs use a guideline
Difficulties adhering to
‘… they [patients] are not
internally motivated… Becoming
internally motivated often takes
longer than quitting itself.’
several steps
Motivating smokers to quit
Removing/discussing smokers’
barriers to quit
Organizing support after quit date
‘You call them [patients] or they
visit the practice and of course
you talk about their quit attempt,
but there is no specific plan [to
increase the odds of successful
quitting].’
Psychological barriers
Low self-efficacy
 Counseling is of minor influence
 Lack of confidence to increase
‘If a patient reports not to need
counseling, it [counseling] has
no effect. I am glad when they
[patients] agree to take home
some information.’
motivation
Shift responsibility to
‘Unmotivated patients should
first work on their motivation
themselves.’
smokers
 Becoming motivated
 Attending follow-up
‘Get them [patients] to return to
practice… it is their [the
patients’] own responsibility.’
Practical barriers
‘Online medication orders are
Policies of health care
insurers
not delivered on time, which
means that a well-prepared quit
attempt falls to pieces.’
Lack of high-quality
brochures
‘We often switch between
brochures. They [brochures]
could be more compact and filled
with practical information.’
‘Finding reliable information is
Staying up-to-date
very time-consuming and
sometimes leading to a lot of
confusion.’
Facilitating factors
Visual support
‘Visual overviews… if you quit
this will happen after 1 day, after
2 days, etcetera… See how
much you can still improve!’
‘A GPs’ advice could be
Quit advice by
general practitioner (GP)
motivation-enhancing for
patients, but it [GPs’ quit advice]
does not happen enough.’
PNs’ needs for adherence support
Experiences of peers
‘Experiences of others would be
interesting. Being able to read
about how they dealt with a
situation… so you know what
was successful and which
strategies did not work.’
Individually relevant
content
‘I want to browse through a
Practical applications
program and choose only those
things that I can personally apply
during counseling.’
Interview conclusions
PNs use smoking cessation guidelines
Adherence is suboptimal
Low self-efficacy
 To motivate patients
 To discuss barriers
Struggle with
 Organizing follow-up support
 Retrieving relevant & high-quality information
Need for tailored adherence support
 Free to (re-)visit at their convenience
Translation into practice
Computer-tailored e-learning program
 Personal feedback and tailored advice
 Always accessible via Internet
 Forum for peer-to-peer contact
 Printable patient material
 Up-to-date information
Work in progress…
E-learning program is being developed
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Integrated in project website
Tailored advice modules
Online discussion forum
Up-to-date information
Trial with PNs starts late 2015
 +/- 300 PNs
 2 groups: Intervention & Control
 3 measurements
 +/- 1200 smokers
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Kwaliteitsregister SmR 17.9.2015
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