National Working Group for ACTTION

July 28, 2010

Simon Chapman has written about the neglect of “unassisted cessation.”  In a recent article, he said he meant by unassisted cessation “approaches that involve none of these interventions [pharmacotherapy or any individual or group behavioural or cognitive intervention] but instead include interventions such as changes in tobacco tax, smoking restrictions, or public awareness campaigns designed to stimulate cessation.”  ActionToQuit asked Dr. Steve Schroeder of the Smoking Cessation Leadership Center for his views on this issue.*

ActionToQuit:
What do you see as the role for unassisted cessation?

Steve:
There are two important components to the quitting process:  attempts at quitting and the proportion of attempts that are successful.  As Simon Chapman correctly notes, the majority of quit attempts are spontaneous, unaided by counseling or medications.  We can assume that attempts at quitting are motivated by a variety of reasons, depending on the smoker.  These would include concerns about health, social stigma, the costs of purchasing cigarettes, prodding from family and friends, and occupational pressures.  We do know that a variety of policies can stimulate quit attempts: raising the price of tobacco products through taxes; clean indoor air laws; countermarketing; population-wide increased cessation coverage; and sufficiently graphic warning labels on tobacco products.  I assume that direct-to-consumer advertising of smoking cessation medications may stimulate unassisted quit attempts, although I have not seen direct proof of that.  We also know that quit attempts are more successful if accompanied by the advice of clinicians, by counseling, and by medications.  The increase in aided quit attempts in published studies is much higher than the spontaneous quit rate of about 3%.  It is likely, however, that the real world quit rate is lower than the published reports of between 15% and 30% of one year abstinence because these studies of necessity enroll motivated smokers and the subjects receive more intense counseling than exists in the real world.  In summary, I favor anything that can be done to encourage quit attempts, and to increase the odds that those attempts will be successful.

ActiontoQuit:
What about 5 A’s (Ask-Advise-Assess-Assist-Arrange)? or brief 3 A’S? (Ask, Advise, and Refer)?  Can any of the A’s—ask and advise for instance—be part of unassisted cessation?

Steve:
That depends on how “unassisted” is defined.  If it includes advice to quit, then that refers to the first two A’s.  Counseling without medication is not usually thought of as unassisted, whether that counseling is done as part of the 5 A’s model, or through telephone quitlines via the Ask, Advise, Refer model.  There is excellent evidence that quitlines increase the probability of quitting, both through counseling alone, as well as counseling and the provision of medications.

ActionToQuit:
What do you see as the role for Nicotine Replacement Therapy (NRT) or medication? 

Steve:
Smokers should have a choice as to how they wish to quit.  Medications—either NRT, bupropion, or varenicline—either alone or in combination, work best in smokers who smoke at least 10 cigarettes daily.  They are also a good option for those who have tried to quit and have failed.  There are many pathways to smoking cessation and it seems to me that we should keep as many options open as possible.

ActionToQuit:
What about quitlines?  What do you see as the role of quitlines given that only about 1.4% of U.S. smokers have called them—and the amount of resources they consumer? 

Steve:
Studies show that quitlines are preferred over face-to-face contact by 85% of smokers attempting to quit.  Quitlines are free, convenient, take place in the comfort of one’s place of residence, and afford anonymity, thus reducing stigma.  But the tragedy is that most clinicians and smokers are unaware of their existence.  The Smoking Cessation Leadership Center at the University of California, San Francisco works with many clinical organizations to encourage them to get their members do a better job at helping smokers quit.  We have found that only a relatively small number of clinicians are willing to become 5A experts, but that many more are willing to adopt the AAR model in which the clinician asks about smoking, advises quitting, and refers smokers to the quit line.  We have called this strategy, “Take 30 Seconds and Save a Life.”  There are two ways by which smokers learn about quit lines.  The first is through marketing, and unfortunately state marketing budgets for quit lines have been severely curtailed because of spending reductions.  The second way is through the efforts of clinicians.  In California, the number of calls to quitlines have remained relatively constant over the past 4 years, but the proportion coming from clinicians has increased from 31% to 56%.  It would be great to do more marketing of quitlines so that this effective and convenient cessation aid could reach more smokers.

ActionToQuit:
What is your view of the messages that Simon Chapman thinks smokers should get about cessation?  He says that they should be told that in many countries there are more ex-smokers than smokers; unaided cessation is the most common method used by most ex-smokers (as many as ¾); a serious quitting attempt need not involve NRT, drugs, or professional support; failure is part of the process; pharmaceuticals and counseling may help, but are not necessary.

Steve:
I have no quarrel with these messages, but would caution that they not be framed as antagonistic to professional support.  Those working in public health have long been suspicious about the perils of medicalizing health issues.  A major reason for this suspicion is the fear that scarce dollars will be siphoned from public health budgets into medical budgets.  But the essential issues for both public health and medicine are that young persons not start to smoke and smokers try to quit and are successful in doing so. 

ActionToQuit:
What messages do you think smokers should get about cessation?

Steve:
I like the way Simon Chapman explains those messages in the previous question.  I would just add that smokers should understand that using counseling and medications will increase their chances of quitting.

ActionToQuit:
How do you measure success?  What time frame do you use to define long term abstinence?  Do you distinguish between rates of successful quitting and absolute numbers of successful quitters, and why? 

Steve:
The ultimate measures of success are the number of smokers, the intensity with which smokers quit, the number of quit attempts, the proportion of successful quitting, the number of people exposed to second hand smoke, and the population rate of tobacco consumption.  Long term abstinence is usually defined as being smoke-free for a year or more.  Both measures—rates of quitting and the number of successful quitters are important.  As mentioned earlier, quit attempts are driven by a variety of measures.  Successful quitting occurs much more frequently in the unassisted mode, but the rates of quitting are higher with assistance.  Given the huge health toll from smoking, we should not have to choose between efforts to promote quitting and efforts to make quitting more successful.  Both are essential.

ActionToQuit:
What do you think about the possibility of reducing the emphasis on cessation campaigns that use pharmaceuticals and counseling and adding the possibility of unassisted cessation?  Do you think the emphasis on assistance holds smokers back from trying to quit? Should there be more flexibility in the Public Health Service Clinical Guidelines?

Steve:
As mentioned earlier, I think this is a bogus issue given the importance of smoking.  If there were a clear zero sum budget situation, then we would need evidence as to which strategies work best.  In most countries however, the public health and clinical budgets are separate, and savings from one do not automatically flow to the other.  The marketing efforts of pharmaceutical companies, which serve to stimulate some unassisted as well as assisted cessation attempts, constitute an entirely separate budget category.

*Neither Dr. Schroeder nor the Smoking Cessation Leadership Center at UCSF receives funds from the pharmaceutical industry.