Use specific behavioral modalities for smoking cessation, including physician advice, group behavior therapy, and self-help therapy.

• Advice:
  • Ensure that all smokers receive at least one episode of smoking cessation advice and encouragement from a physician, because doing so can reduce the smoking rate by 50%, equivalent to a 2% absolute increase in cessation rates by 6 to 12 months
  • Frequent encouragement can increase the smoking cessation rate to 5%
  • See table 5-Step Brief Interventions to Promote Smoking Cessation for the counseling framework suggested in the Surgeon General’s Report
• Training physicians to provide advice:
  • Training physicians to provide smoking cessation advice does not appear to increase smoking cessation rates
• Format of therapy:
  • There does not appear to be an advantage of group therapy over individual therapy, nonspecific behavior modification over brief advice, or gradual cessation over abrupt cessation
  • Nursing interventions and well designed telephone counseling may assist smoking cessation
  • Brief intervention in hospital smoking cessation programs have had mixed results, and more intensive counseling may be needed in this setting
• Self-help therapy:
  • Self-help materials may increase cessation rates, although the magnitude of benefit is small

Evidence:

• Advice
  • In a systematic review examining smoking cessation therapies with at least 6-months follow-up, 17 randomized clinical trials included one episode of advice and encouragement from a physician. The summary absolute reduction in the rate of smoking was 2% (CI, 1 to 3). Ten trials of frequent encouragement found a reduction of 5% (CI, 1 to 8) (19)
  • A Cochrane review of RCTs examining smoking cessation advice from a medical practitioner found that brief advice increased smoking cessation rates. The OR for cessation was 1.69 (CI, 1.45 to 1.98) in favor of brief advice (20)
  • A randomized controlled trial of a brief intervention during hospital admission for smokers after myocardial infarction or bypass surgery found no significant difference in abstinence at 6 weeks and 12 months (21). A cluster randomized controlled trial of self-help for smoking cessation in pregnancy also showed no benefit (22). A Cochrane review found that intensive, in hospital, intervention programs (inpatient contact plus follow-up for at least 1 month) had significantly higher quit rate compared to control (OR, 1.82 [CI, 1.49 to 2.22]) (23).
  • A systematic review found insufficient evidence to suggest that more intensive counseling was better than brief counseling (20). However, the Public Health Service guideline makes the statement that “There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness.” In their review of the evidence they found an OR of 1.6 (CI, 1.2 to 2.0) for cessation with low-intensity counseling (i.e., 3 to 10 minutes) and an OR of 2.3 (CI, 2.0 to 2.7) with high-intensity counseling (i.e., greater than 10 minutes). It was also identified that eight or more sessions were of greater benefit than programs with 3 or fewer sessions. The OR of cessation with eight sessions vs. zero to one session was 2.3 (CI, 2.1 to 3.0), whereas for two to three sessions vs. zero to one session was 1.4 (CI, 1.1 to 1.7) (1)
• Training Physicians to Provide Advice
  • A systematic review of studies examining programs aimed at training health care professionals on smoking cessation found that these programs increased the likelihood that physicians would perform smoking cessation tasks; however, there was no strong evidence that this led to an increase in smoking cessation rates among their patients (24)
• Group Therapy
  • A Cochrane review of RCTs examining the benefit of group sessions on increased smoking cessation found an OR of cessation of 2.19 (CI, 1.42 to 3.37) in favor of group sessions. However, there was no evidence suggesting it was better than individual therapy (25)
  • Nonspecific behavior modification was no more effective than simple advice (2% [CI, 0 to 4], 3 trials). Gradual cessation was no better than abrupt cessation (19)
• Self-help Therapy
  • A systematic review comprised RCTs that examined the effect of self-help materials on smoking cessation. There was some benefit with self-help materials compared to control (OR, 1.24 [CI, 1.07 to 1.45]). Adding self-help materials to nicotine replacement therapy did not show any increase in smoking cessation (OR, 0.94 [CI, 0.67 to 1.31]). Personalized materials increased smoking cessation rates (OR, 1.36 [CI, 1.13 to 1.64]) (26)
  • Analyses presented in the Public Service Guideline were less supportive of the benefit of self-help interventions (1).
• Nursing Interventions
  • A Cochrane review of 16 randomized trials, with at least 6-month follow-up, found that nursing based interventions increased smoking cessation when compared to control/usual care groups (OR, 1.50 [CI, 1.29 to 1.73]) (27).
  • One study found that nurse/community health workers are effective in delivering evidence-based interventions to low-income underserved minorities (28).
  • One randomized trial showed that training nurse midwives to provide brief interventions increased cessation during and after pregnancy (29).
• Telephone Counseling
  • A Cochrane review identified 48 randomized controlled trials of telephone counseling for smoking cessation. Cessation rates were higher for groups randomly assigned to receive multiple sessions of call-back counseling (OR, 1.41 [CI, 1.27 to 1.57]). Phone counseling protocols with a greater number of calls tended to be more effective. Benefits of phone counseling were clearer for trials that recruited smokers who were motivated to quit. Phone counseling was effective as an addition to self-help materials, brief advice, or drug therapy (30).
  • A study of the effectiveness of the California Smokers Helpline randomized smokers to seven telephone counseling sessions or to telephone counseling on an as requested basis. In an intention to treat analysis the intervention group had an absolute increase in cessation of 2.2% at 1 year (P<0.001) (31).
  • A randomized controlled study of 837 smokers at Veterans Affairs medical centers showed that telephone care, combining phone counseling with provision of drug therapy, substantially increased long-term quit rates compared to primary care intervention (13.0% vs. 4.1%, P<0.001) (32).
  • Based on the evidence well-designed counseling may assist smokers in cessation.
• Exercise and Other Non-drug Therapies
  • A Cochrane review of the use of rapid smoking and other aversive methods to increase smoking cessation rates found insufficient evidence for the use of these approaches (33). However, the Public Health Service guideline meta-analysis suggested these techniques may be of benefit (OR, 1.7 [CI, 1.04 to 2.80]) (1).
  • A Cochrane review of the effectiveness of acupuncture vs. sham acupuncture on smoking cessation rates found insufficient evidence to support their use, in terms of cessation at 12-months follow-up (OR, 1.08 [CI, 0.77 to 1.52]) (34)
  • A Cochrane review of RCTs of hypnotherapy vs. behavioral therapy found no evidence for an improvement in 6-month cessation rates (35)
  • There is insufficient evidence to support the use of exercise therapy, acupuncture, aversive smoking, or hypnosis in smoking cessation.
  • A Cochrane review of exercise interventions to increase smoking cessation found only two trials with more than 25 patients per each arm. One trial observed a significant benefit in the intervention group (36).

Comments:

• Few smoking cessation studies have evaluated the benefit of various therapies on cessation after 1 year. This fact is important to consider, given that relapse can occur even after 1 year of cessation.
• Biological verification of smoking cessation is important in assessing the validity of relevant studies, because there is a high rate of misrepresentation of smoking status by persons enrolled in clinical trials (37).
• There is insufficient evidence to support the use of acupuncture, according to a systematic review (38), or hypnosis in smoking cessation. Some evidence exists to support the use of exercise therapy and aversive smoking.
• Current evidence provides some support for more intensive therapy compared to brief interventions to reduce exposure of children to environmental tobacco smoke (39).
• Some well-executed randomized trials have found that family-based intervention can reduce adolescent smoking. More high quality studies are needed to confirm these findings (40).
• According to a systematic review, although there is strong evidence to support behavioral and drug treatments to help smokers achieve abstinence, there is insufficient evidence to support inclusion of specific relapse prevention interventions to help smokers maintain abstinence as part of a smoking cessation program (41).