7.15 Individual and group-based cessation assistance

 

Last updated: April 2020

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.15 Individual and group-based cessation assistance. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from: http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-15-methods-services-and-products-for-quitting-mo

 

Smokers who are motivated to quit sometimes seek intensive cessation support, such as individual counselling or group programs. Such interventions are more limited in their reach than phone and internet-based services, and may be less accessible or desirable to smokers due to time and money constraints.1 Nonetheless, as shown in Table 7.15.1, evidence-based behavioural support can increase quit rates and help people to stop smoking.

Table 7.15.1 Effectiveness of behavioural support for smoking cessation

Behavioural support

Relative effect (95% CI)

Individual counselling2

 

                 Versus minimal contact (brief advice, usual care, or self‐help materials)

1.57 (1.40 to 1.77)

                 In addition to pharmacotherapy (vs. pharmacotherapy alone)

1.24 (1.01 to 1.51)

                 More intensive versus brief counselling

1.29 (1.09 to 1.53)

Group therapy3

 

                 Versus self-help program

1.88 (1.52 to 2.33)

                 Versus brief support from a health care provider^

1.22 (1.03 to 1.43)

                 Versus no intervention^

2.60 (1.80 to 3.76)

                 Versus face‐to‐face individual intervention

0.99 (0.76 to 1.28)

                 In addition to pharmacotherapy (vs. pharmacotherapy + brief support alone)

1.11 (0.93 to 1.33)

Workplace interventions4

 

                 Group therapy versus no intervention/control

1.71 (1.05 to 2.80)

                 Individual counselling versus no intervention/control

1.96 (1.51 to 2.54)

                 Self-help intervention versus no intervention/control

1.16 (0.74 to 1.82)

                 Pharmacological intervention versus no intervention/control

1.98 (1.26 to 3.11)

                 Incentives versus no intervention/control

1.60 (1.12 to 2.3)

                 Multiple interventions versus no intervention/control

1.55 (1.13 to 2.13)

Note: High-quality evidence; Moderate-quality evidence; ^Low-quality evidence.
Italics indicate interventions for which there was no evidence of benefit over comparison group.

 

For interventions delivered by healthcare professionals see Section 7.10, or for interventions delivered in mental health settings, see Section 7.12

7.15.1 Individual counselling

In 2020, the US Surgeon General concluded that behavioural counselling increases smoking cessation compared with self-help materials or no treatment.5 An earlier Cochrane review similarly concluded that there is high-quality evidence that individually-delivered smoking cessation counselling can assist smokers to quit.2 More intensive counselling appears to be more effective than a brief counselling intervention.2 Behavioural counselling is independently effective in increasing smoking cessation; however, it is even more effective when used in combination with pharmacotherapies5 (see Section 7.16.5).

7.15.1.1 Cognitive behavioural therapy

Individually delivered smoking cessation counselling can assist smokers to quit.2 Such counselling has traditionally been based on the principles of cognitive behavioural therapy (CBT), which also forms the basis of Quitline counselling. CBT for smoking cessation aims to break the situational and emotional connections that have been established with smoking. 6 Behavioural strategies target the pleasurable associations and situational cues that reinforce and maintain smoking, while cognitive strategies target the cognitions and emotions that may also play a role in the person’s tobacco use (for example, the person may believe he or she does not have any control over smoking, or that it relieves stress). 7 Treatments based on CBT techniques have been found to be highly effective in smoking cessation, 5 both for quitting and for preventing relapse.8 One small study found that progressive muscle relaxation—a behavioural technique used to reduce stress by concentrating on achieving muscle relaxation—reduces cigarette craving, withdrawal symptoms, and blood pressure in smokers who have recently quit.9

7.15.1.2 Acceptance and commitment therapy

An emerging body of research suggests that acceptance and commitment therapy (ACT) is another effective form of counselling for smoking cessation. ACT focuses on increasing willingness to experience physical cravings, emotions, and thoughts that trigger smoking (i.e., acceptance) while making values-guided behaviour changes (i.e., commitment). 10 Promising evidence, albeit with some methodological limitations, suggests that face-to-face ACT for smoking cessation has 30%–35% quit rates at one year follow-up.11-13 Small studies have found that ACT is also feasible to deliver by phone or by smartphone application, and shows higher engagement and promising quit rates compared with usual care.10, 14

7.15.1.3 Motivational interviewing

Motivational interviewing is a is a person-centered, goal-oriented style of counselling, which aims to elicit and strengthen people's own motivation and commitment towards behaviour change by helping them resolve their ambivalence and evoking their reasons for change. 15 This approach is widely used to help people to quit smoking. 16 Common components of motivational interviewing include: exploring ambivalence, decision balance (i.e., weighing pros and cons), assessment of motivation and confidence to quit, eliciting ‘change talk’ (i.e., statements that indicate the person has the desire, motivation, and/or commitment to change their behaviour), and supporting self-efficacy.16  

A 2019 Cochrane review evaluating the efficacy of motivational interviewing for smoking cessation concluded that there is not enough evidence to show whether or not it is effective compared with no intervention, as an addition to other types of behavioural support, or compared with other types of behavioural support for smoking cessation. It was also unclear whether more intensive motivational interviewing was more effective than less intensive motivational interviewing. There is almost no evidence on whether motivational interviewing for smoking cessation improves mental wellbeing. Overall, more higher quality research is needed.17

7.15.1.4 Mindfulness

A growing body of research supports the effectiveness of mindfulness-based interventions for smoking cessation. The concept of mindfulness has roots in Buddhist and other contemplative traditions. It is often described as the state of being attentive to and aware of what is taking place in the present.18 Mindfulness is an inherent human capability that can be learned and trained, and its practice has been linked with a range of improved health outcomes.19 It allows people to increase their positive affect, and improve their overall wellbeing.20 Smokers, especially female smokers, have lower levels of mindfulness and wellbeing than non-smokers, leading researchers to suggest that mindfulness-based interventions may help smokers to deal with treatment and abstinence by increasing their level of wellbeing.20

Mindfulness strategies for managing nicotine cravings involve present-moment, non-judgemental awareness of cravings without acting on them.21 A review of addiction research found that exercises aimed at increasing self-control, such as mindfulness meditation, can decrease the unconscious influences that cause cigarette cravings. For example, one study showed that mindfulness meditation training led to a subconscious reduction in smoking; that is, although participants who had completed the training reported smoking the same number of cigarettes, an objective measure of carbon dioxide percentage in their lungs suggested a 60 per cent reduction in the amount smoked over two weeks after the study.22 Researchers in the US found that mindfulness training led to significantly higher abstinence rates among a group of socioeconomically disadvantaged smokers.23 Mindfulness practice appears to reduce negative affect, craving, and cigarette use among smokers who are trying to quit,24 and may also be particularly effective for promoting recovery from lapses.25 A 2015 systematic review concluded that mindfulness-based interventions show promise for the treatment of smoking, especially for cessation, relapse prevention, number of cigarettes smoked, moderating the relationship between craving and smoking, and the development of coping strategies to deal with triggers to smoke. The positive effects of mindfulness on mental health might contribute to the maintenance of tobacco abstinence.26 Findings from a 2016 meta-analysis of randomised controlled trials of mindfulness-based interventions for smoking cessation showed that about one quarter (25.2%) of participants remained abstinent for more than 4 months in the mindfulness group, compared to 13.6 percent of those who received usual care.27

7.15.1.5 Positive psychotherapy

Given the importance of affect to the success of quit attempts, incorporating strategies from positive psychology has been suggested as a means of addressing moods in smoking cessation treatment. 28 Positive psychology interventions aim to enhance positive feelings, behaviours, or cognitions, and a large body of research supports the benefits of positive psychology strategies for enhancing people’s wellbeing and functioning, and for reducing depressive symptoms. 29 One small study examining the effectiveness of positive psychotherapy for smoking cessation found that attendance and satisfaction with treatment were high, and most participants reported using and benefiting from the positive psychology interventions. Almost one-third of participants sustained smoking abstinence for 6 months. 28 Findings from a pilot randomised controlled trial also supported incorporating positive psychotherapy into smoking cessation treatment. 30 Another small study found that a smartphone app using happiness exercises to aid smoking cessation was well received by nondaily smokers, and may therefore be a feasible cessation intervention. 31

7.15.2 Group therapy  

Group therapy can provide people who smoke with the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with social support. A Cochrane review published in 2017 concluded that group therapy is more effective for helping people quit smoking than self‐help, and other less intensive interventions. However, there was not enough evidence to determine how effective it is in comparison to intensive individual counselling.3  Another review recommended that group treatment for tobacco dependence should be established and available in all behavioural health and medical settings, due to its effectiveness and utility.32 A large randomised controlled trial that compared group-based acceptance and commitment therapy (ACT) with cognitive behavioural therapy found that one-year cessation rates did not differ, suggesting ACT-based intervention is a reasonable alternative to CBT.33 A review of family-based smoking cessation interventions, however, did not find evidence that such interventions are effective.34

Fresh Start courses, a smoking cessation course developed by Quit Victoria, were run for several decades in settings such as workplaces, prisons, the community, and health centres. The group course was led by a trained educator, and typically had eight sessions of 60–90 minutes over a four-week period. There was also a short version of the course, which included the same content as the longer Fresh Start course, but was run in two three-hour sessions. Sessions were 2–3 weeks apart, with Quitline support in between.

An evaluation of the Fresh Start courses found that about one quarter (23%) of participants had quit at one year (18% of the original sample).35 Another evaluation found that quit rates fell from 23% at the end of the Fresh Start short course, to 17% at the 3- month follow-up and 16% at the 12-month follow-up (based on the assumption that participants who did not complete all follow-ups were still smoking). However, of respondents who completed the 12-month follow-up questionnaire, 30% had quit smoking.36

7.15.3 Workplace-based interventions

There are significant costs to the workforce associated with tobacco use, due to increased unproductive time, absenteeism, illness, and premature mortality among smoking employees.37 Smokers’ workplaces are a potentially useful and wide-reaching setting for delivering cessation interventions, particularly in blue collar occupations where smoking prevalence in substantially higher (see Chapter 1 Section 1.7). A Cochrane review of workplace interventions published in 2014 found strong evidence that some interventions, including individual and group counselling, pharmacological treatment, and multiple interventions targeting smoking cessation, increase the likelihood of quitting. All these interventions appear to be similarly effective whether offered in the workplace or elsewhere. The review also concluded that self-help interventions and social support are less effective.4 In regards to implementation, another Cochrane review found no clear evidence to identify effective strategies to improve the implementation of policies and practices targeting smoking cessation in the workplace. The authors suggested that policy makers and practitioners look to theory and evidence from other settings when designing interventions for the workplace environment.38 Research in NSW found that telephone-based coaching and group sessions designed using principles of cognitive behavioural therapy successfully assisted employees of the passenger rail network to quit smoking.39

A qualitative review of employees’ views of workplace interventions highlighted the importance of smokers’ readiness to change in quitting, and noted that employees’ expectations regarding employers’ support for, and enforcement of, interventions or restrictions might facilitate smoking cessation.40 Another evidence review concluded that interventions should target workers that actively want to stop smoking, use elements that workers have identified as useful, and/or focus on altering beliefs about smoking and the need to stop.41

Providing financial incentives in addition to a workplace-based smoking cessation group training program appears to increase long-term smoking abstinence,42 and social support from colleagues or a partner is also associated with quit success among employees who participate in a smoking cessation intervention in the workplace.43 A large study in Switzerland found that while smoking cessation training in a workplace setting can achieve reasonable long-term quit rates, younger and more addicted smokers may need additional support at the group or personal level.44

7.15.4 Peer support programs

Peer support programs aim to provide social support to people in a variety of settings. Peer support can take many forms, such as self-help groups, internet support groups, peer-delivered services, peer-run or operated services, peer partnerships, and peer employees or volunteers within traditional healthcare settings, such as peer companions, peer advocates, consumer case managers, peer specialists, and peer counsellors.45 Several reviews have concluded that more rigorous research is needed to support the use of this method for smoking cessation.46-48 A 2018 Cochrane review of interventions aiming to enhance partner support to improve smoking cessation concluded that such interventions do not appear to increase quit rates, nor do they appear to effectively increase partner support.49 Emerging evidence suggests that peer support programs may be of greater help to priority populations, such as economically and socially disadvantaged populations,50 and people with serious mental illness.48, 51 Peer mentoring may also be a useful addition to text-messaging programs for smoking cessation. 52

7.15.5 Residential treatments

Residential treatment program for tobacco dependence are rare and costly, but can provide intensive behavioural and pharmacological treatment, especially in early days of a quit attempt when people are more likely to relapse.53 One such program is run by the Mayo Clinic in the US, which runs for eight days and comprises a multidisciplinary treatment team consisting of physicians, nicotine dependence counsellors, psychologists, nurses, pulmonary therapists, and exercise physiologists.54 An examination of the effectiveness of the program found that it was associated with a significantly greater odds of 6-month smoking abstinence compared with outpatient treatment.53 Another study found that at the completion of the program, perceived stress was significantly lower, while partner support and self-efficacy were significantly higher among participants.54

  

Relevant news and research

For recent news items and research on this topic, click  here. (Last updated October 2020)

 

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