Smoking Cessation

Smoking rates have been on the decline since the 1970’s and much of this decline is due to quitting, rather than less people taking up smoking. The proportion of ex-smokers in Australia has increased steadily between 1974 and 1992, and have increased at similar rates for both sexes (Winstanley, Woodward and Walker, 1995).

Around 80% of Australian smokers have made attempts to quit (Cumming, Bartin, Fahey, et al, 1989). Cessation has immediate important health benefits for males and females of all ages. Former smokers live longer than continuing smokers, even if they quit at older ages. Cessation reduces the risk of cancer, heart attacks, strokes and other lung diseases (US Department of Health and Human Services, 1990).

While it is clearly important that we prevent smoking, continuing to encourage and support quit attempts is also important to prevent the health problems associated with long term smoking. It is particularly important that smoking cessation efforts encourage people to quit as early as possible, in order to minimise the health problems that occur because of smoking. In order to achieve goals and targets for reducing smoking prevalence it is necessary to accelerate successful cessation (Graham-Clarke, Nathan, Stoker et al, 1996).

Several reviews of the effectiveness of cessation strategies indicate that no one method of cessation is consistently superior to another (eg Mattick and Baillie, 1992; Schwartz, 1987). A combination of methods appears necessary.

The National Campaign Against Drug Abuse conducted a meta-analysis of 83 articles containing treatment-outcome data and made recommendations as to best practice interventions (Mattick and Baillie, 1992). The study recommends that a range of formal treatment interventions for smoking cessation should be maintained and promoted in new settings. It points out that although most smokers quit unaided they do so within a context of economic, social, psychological and health influences which support cessation.

Mattick and Baillie (1992) concluded that the type of intervention offered should depend on degree of dependence and the time available for intervention. Nicotine replacement therapy and more intense interventions such as cessation groups are recommended for the more heavily dependent. In settings where there is no time, such as some primary health care settings, quality self-help resources should be prominently available. In settings where there is only a small amount of time available brief interventions should focus on personalising the effects of smoking, providing advice to quit, providing self-help resources and, if motivation is high, setting a quit date. Intensive interventions such as cessation groups should also use these methods but in more detail, and should also address stress management and weight gain (Mattick and Baillie, 1992).

Similarly Richmond (1993), after a review of evidence, recommends an integrated combination of strategies, utilising stages of change (DiClemente and Prochaska, 1982). Least intensive strategies were recommended as the first option, with more intensive activities being tried later if necessary.

Researchers have identified a need to target our interventions to suit specific populations who have higher rates of smoking. These include youth (particularly disadvantages or marginalised youth), women, people of low socio economic status and certain groups from non-English speaking backgrounds. Glynn, Boyd and Gruman (1990) recommend that wherever possible existing programs be modified or adapted, rather than develop new programs.

Education and persuasion campaigns

As discussed in the marketing section, education and persuasion campaigns are able to reach a large proportion of the population, making them cost effective approaches. There appears to be no evidence that mass media campaigns on their own increase quit rates (Graham-Clarke, Nathan, Stoker et al, 1996). However campaigns can play a role in increasing knowledge and awareness and can enhance the value of other community based interventions (Reid, Killoran, McNeill and Chambers, 1992).

They are useful to promote cessation activities such as smoking cessation hotlines, self-help material and participation in smoking cessation programs. Mass media campaigns are noted to increase quit rates, when combined with other strategies, and to increase participation in programs (Graham-Clarke, Nathan, Stoker et al, 1996). Well designed media campaigns always include local and interactive components (Rissel, 1991).

Self-help

Self-help refers to those who quit without the aid of a formal program. Those who quit ‘on their own’ may have previously been subject to brief interventions or attended cessation clinics which have enabled them to gain the skills needed to successfully quit. As Mattick and Baillie (1992) point out, those who quit do so within a wider context that supports quitting.

Most smokers prefer self help to formal programs and more than 90% of people give up this way (US Department of Health Education and Welfare, 1979). Self help programs are recommended because they meet the clients’ needs, can potentially reach a large portion of the population and are cost-effective. Community campaigns and mass media campaigns are useful ways of disseminating information that may induce people to try to quit unaided.

Glynn, Boyd and Gruman (1990) note that many self help resources are targeted for the minority of smokers who are in the Action stage of change. There is a need to develop and evaluate resources for those in the Pre-contemplative and Contemplative stages as (Glynn, Boyd and Gruman, 1990).

Community based cessation groups or clinics

Cessation groups or clinics use a variety of methods and have varied outcomes. Most commonly the intervention chosen is a group behaviour modification program lead by an experienced group leader. More intensive programs have success rates ranging from 20% to 40% (Graham-Clarke, Nathan, Stoker et al, 1996). This is generally higher than other less intensive interventions (Richmond, 1993; Graham-Clarke, Nathan, Stoker et al, 1996).

Cessation groups are questioned for a number of reasons. Firstly the vast majority of smokers who quit do so without external assistance and some research suggests that those who quit on their own are more likely to succeed. However this is thought to be a product of the fact that those who attend special programs are more likely to be heavily addicted (Fiore, Novotny, Pierce, et al, 1990). In addition cessation clinics are not a cost-effective strategy and have minimal impact on the overall population prevalence rates (Chapman, 1985).

Despite these criticisms, smoking clinics or groups remain a forum whereby people can learn techniques and skills to assist quitting. These skills may be useful in other unaided quit attempts, if quitting is not achieved by attending the group. Groups also offer social support in quitting, which is recommended to increase cessation rates (Mattick and Baillie, 1992). Cessation groups perform a service for the highly dependent heavy smoker who is unable to quit with the use of other less intensive methods (Richmond, 1993; Mattick and Baillie, 1992; Reid, Killoran, McNeill and Chambers, 1992).

However, because groups can only reach a small number of people and are not very cost effective, limited use is recommended. Cessation groups are particularly recommended for those unable to quit on their own such as highly dependent smokers to give them an improved chance of obtaining and achieving abstinence (Mattick and Baillie, 1992). Thus less intense, more cost effective services should be tried first.

In addition services need to consider other aspects of cost containment. Mattick and Baillie (1992) recommend that the programs do not extend beyond six sessions as longer programs lead to diminishing returns. Graham-Clarke, Nathan, Stoker et al (1996) recommend that each Area have only one cessation clinic operating at any one time.

For improved success rates, clinics should be made more accessible to the community through the use of community based settings, hospital inpatient services and worksite settings (Graham-Clarke, Nathan, Stoker et al, 1996; Mattick and Baillie, 1992).

Primary health care brief interventions

Many health professionals including GPs, dentists, pharmacists, nurses, midwives and drug and alcohol counsellors can assist smokers to quit (Reid, Killoran, McNeill and Chambers 1992). Australian research shows that smokers prefer advice and programs conducted through their doctor or other health professional (Owen and Davies, 1990).

GPs are in a particularly important position to provide advice and assistance to their patients. GPs see an enormous number of clients. 79.2 million attendances were recorded in 1988-89, and a higher proportion of these attendances would have been from smokers than non-smokers (Chapman, 1990). Doctors are generally highly regarded in Australia, and their advice taken seriously. In addition GP brief interventions can be very cost effective (Viney, Haas and Seymour, 1996).

A number of studies have shown increased cessation rates where doctors have, in the course of the consultation, given their patient brief advice about quit rates (eg Russell, Wilson, Taylor and Baker, 1979; Wilson, Wakefield, Steven, et al, 1990). Low intensity, minimal contact programs have been shown to produce cessation rates of between 5%-25% (Graham-Clarke, Nathan, Stoker et al, 1996).

In addition doctors are able to prescribe nicotine replacement therapy such as patches or gum. However such methods achieve best results in conjunction with some form of counselling or therapy and the combined approach is recommended (Graham-Clarke, Nathan, Stoker et al, 1996), particularly in cases of high dependence (Mattick and Baillie, 1992).

Kottke, Battista, DeFriese and Brekke (1988) found, after a meta-analysis of 39 studies that the most successful interventions were personalised smoking advice conducted by both GPs and other health professionals, repeated in different forms over a period of time. Follow up visits or phone calls after advice also increased quit rates. Richmond (1993) and Glynn, Boyd and Gruman (1990) note that there is a need for interventions which have multiple contact and target the different stages of change.

However few GPs detect smokers or regularly offer smoking cessation advice (Lowe, Wiggers, Leeder and Sanson-Fisher, 1989; Lowe and Del Mar, 1992). Mattick and Baillie (1992) suggest that health professionals are under utilised and recommend that all primary health care workers, including GPs, be encouraged to offer brief interventions on quitting, and encourage self help approaches. In addition more research is need to identify barriers to health professionals conducting brief interventions and to develop and evaluate strategies to overcome barriers.

Anecdotal evidence suggests that a barrier to the use of brief interventions by health professionals is smoking behaviour amongst the heath professionals themselves, particularly nurses. Given the efficiency and effectiveness of brief interventions, it may be worthwhile investigating if this is indeed a barrier and if so, strategically targeting health workers in smoking cessation interventions.

Worksites

Worksite smoking restrictions play a valuable role in reducing exposure to passive smoking, but there is no consistent evidence that they reduce smoking, due to compensatory behaviour among smokers (Richmond, 1992; Reid, Killoran, McNeill and Chambers, 1992). However it does appear that worksite based cessation programs offered in parallel with worksite smoking restrictions result in high quit rates