7.15 Cessation assistance: low reach, intensive

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Smokers who are motivated may seek help from more intensive cessation support, such as individual counselling or group courses. More intensive cessation support may be relevant for particular sub-groups of smokers. Cost can be a major factor affecting the utilisation of intensive cessation assistance.¹

7.15.1 Group quit courses and cessation clinics

Group programs represent a significant increase in intensity from self-help and internet interventions. Evidence shows that group therapy is no more effective than a similar intensity of individual counselling but is better than self-help. There is limited evidence that attending more sessions and adding other forms of treatment, such as nicotine replacement therapy (NRT), adds extra benefit.² Courses that include strategies to increase cognitive and behavioural skills and avoid relapse appear to be more effective.³

In recent years there has been a decline in demand for group courses, possibly due to a greater range of quitting methods becoming available. One difficulty faced by group courses is ensuring they are accessible to people in rural and regional areas, and that they are conducted regularly so they are available at times when smokers are motivated to quit. They are more costly to run compared to other, less intense interventions. Despite these issues they have a role to play, such as for those who have particular needs or who have tried other methods and failed.

Quit organisations in Australia most commonly conduct the Fresh Start cessation course or variants of it. The courses are run in many settings, such as workplaces, prisons, the community and health centres. The group course is led by an experienced educator, and typically has eight sessions of 60–90 minutes over a four-week period. The course is designed for smokers who want to quit, cut down or learn to manage their smoking.

Participants may be required to pay to take part, depending on the setting. The early sessions cover understanding smoking and quitting, planning to quit and methods. Participants are encouraged to then set a quit date. Subsequent sessions support participants through making a quit attempt, dealing with withdrawal, problem solving for situations where tempted to smoke, lapses, and other issues in becoming a non-smoker. To help overcome the barrier of difficulty attending eight sessions, the Fresh Start Short Course was developed by Quit Victoria. It includes the same content as the longer Fresh Start course, but run in two sessions of three hours duration. Sessions are 2–3 weeks apart, with Quitline support between sessions.

Evaluation of the Fresh Start courses has found quit rates at one year of 23% (18% of the original sample).⁴ Evidence shows that such multi-session group programs are about twice as effective as self-help alone.³ However there have been relatively few trials that compare such programs with other forms of help. This may be partly because groups take considerable time and effort, while other, less demanding methods are now much more readily available and popular.

Group cessation courses have been offered by other commercial and community organisations. As a rule, these have not been well evaluated, so it is difficult to comment on their effectiveness. Programs claiming novel methods should be treated with caution until proven to work.

7.15.2 Workplace-based interventions

The workplace has the potential to reach large numbers of smokers to encourage smoking cessation. Studies show that workplace interventions for individual smokers, including groups, individual counselling and NRT, increase cessation rates compared to no treatment or minimal intervention. Self-help materials are less effective, as are programs applied to the workplace as a whole.⁵ These results are consistent with other settings. There is limited evidence that participation in workplace programs can be increased by competitions and incentives but lack of evidence regarding their cost-effectiveness.⁶

7.15.3 Peer support

The research into the effectiveness of peer or social support in assisting quitting is limited and the area itself is complex. In this context assistance ranges from general support to those trying to quit from friends, family and colleagues to more structured social support. Researchers have looked at both structural and functional aspects of support. Structural support is the existence of family/friends and other social networks and functional support deals with the quality of those relationships.⁷ Another relevant element to cessation is the smoking behaviour within an individual's social environment.⁷ Most research has focused on the possible influences of the smoking behaviour of family and friends and of the quality of support provided by family and friends. The results are inconsistent with a wide range of variables affecting outcomes.⁷ There is some evidence that non-smokers are very willing to seek help for smokers.⁸

Focusing on the support of another individual or 'buddy' may be more practical and effective. Some limited studies have found that use of a 'buddy' can help people quit, but the findings are again inconsistent.^7,9 A pilot study of a workplace-based website offering training to employees to encourage smokers to quit and to use effective methods found the approach feasible and well accepted.¹⁰

Internet-based social support groups can connect widely dispersed groups of people trying to quit smoking, are highly accessible and involve little cost. However, there is very limited research into this use of web-based support. One small study of the role of peer email support as part of a college smoking cessation website did show positive outcomes in terms of abstinence and reduction of smoking.¹¹ Another study of an online cessation support group found that peer responses to new users were rapid and therefore may be beneficial to smokers needing immediate support and suggested that the approach may be helpful for relapse prevention.¹²

Further good quality research is required to establish the effect of peer support on cessation especially as most interventions for smokers recommend its use.

7.15.4 Individual counselling

The number of people seeking individual counselling for smoking cessation has always been low. A review of the evidence on individual counselling concludes that it is more effective than minimal behavioural intervention, although the evidence available to date is insufficient to show that more intense counselling is superior to brief counselling.¹³ There is little evidence about the relative effectiveness of different psychological approaches.¹⁴ More sessions or longer sessions may improve quit rates, but the rates seem to plateau after 90 minutes or total counselling time.¹⁵ Helpful components of counselling include problem solving to help develop a plan and overcome barriers to quitting and providing social support as part of treatment.¹⁵ Combining counselling with quitting medications is more effective than either component alone.¹⁵ Motivational interviewing is a directive, patient-centred style of counselling designed to help people to explore and resolve ambivalence about behaviour change. It forms the basis of cessation assistance in some individual counselling. The evidence suggests that motivational interviewing may assist smokers to quit compared to brief advice or usual care, and is effective when delivered by primary care physicians in sessions longer than 20 minutes.¹⁶

7.15.5 Residential treatments

There are very few residential treatment centres for smoking cessation and very limited research as to their effectiveness and cost-effectiveness. Residential treatment may have an impact on psychosocial factors such as perceived stress, partner support and self-efficacy, all of which are associated with successful cessation.¹⁷ There is some evidence that residential treatment increases the likelihood of cessation at six months compared to outpatient treatment for those with higher nicotine dependence.¹⁸

References

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13. Lancaster T and Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of Systematic Reviews 2005. (2)DOI: 10.1002/14651858.CD001292.pub2 Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001292/frame.html

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17. Ames S, Croghan I, Clark M, Patten C, Stevens S, Schroeder D, et al. Change in perceived stress, partner support, decisional balance, and self-efficacy following residential nicotine dependence treatment. Journal of Addictive Diseases 2008;27(1):73–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18551890

18. Hays J, Croghan I, Schroeder D, Burke M, Ebbert J, McFadden D, et al. Residential treatment compared with outpatient treatment for tobacco use and dependence. Mayo Clinic Proceedings 2011;86(3):203-209. Available from: http://www.mayoclinicproceedings.com/content/86/3/203.long