Self-Help Interventions by the Smoker

and,฀more฀rarely,฀is฀also฀acted฀upon.฀Greater฀seriousness฀is฀attached฀to฀decisions฀that฀are฀ prompted฀by฀personal฀illness฀or฀by฀the฀illness฀or฀death฀of฀a฀family฀member฀or฀close฀friend.฀ From฀our฀own฀experience฀of฀counselling฀smokers,฀we฀know฀that฀even฀heavy฀smokers฀ 40–60฀cigarettesday฀can฀carry฀through฀such฀decisions฀without฀major฀effort.฀The฀6฀stud- ies฀published฀to฀date฀in฀which฀self-help฀interventions฀led฀to฀successful฀smoking฀cessation฀ for฀6–9฀months฀OR฀=฀1.08;฀CI:฀0.81–1.44฀or฀12฀months฀OR฀=฀1.0;฀CI:฀0.75–1.34฀are฀ of฀ limited฀ value฀ because฀ biochemical฀ variables฀ were฀ measured฀ in฀ only฀ isolated฀ cases฀ [12] .฀The฀support฀of฀a฀partner฀was฀described฀as฀an฀increasing฀successful฀aspect฀for฀quit- ting฀ in฀ only฀ 2฀ of฀ the฀ 6฀ studies฀ [12] .฀ Smokers฀ whose฀ partners฀ are฀ non-smokers฀ or฀ ex- smokers฀are฀more฀likely฀to฀be฀successful฀at฀quitting฀ [13,฀14] .฀Currently฀married฀smokers฀ have฀a฀higher฀chance฀of฀success฀than฀divorced,฀widowed฀or฀never฀married฀smokers฀ [15] .฀ The฀support฀of฀the฀spouse฀may฀be฀beneicial฀for฀success฀ [16,฀17] .฀If฀smokers฀are฀con- stantly฀ nagged,฀ face฀ complaints฀ about฀ their฀ behaviour฀ or฀ are฀ repeatedly฀ criticised฀ for฀ failed฀attempts฀to฀ quit฀smoking,฀then฀ their฀ position฀becomes฀entrenched฀ [18] .฀Studies฀ indicating฀the฀positive฀inluence฀of฀the฀spousepartner฀in฀this฀context฀are฀countered฀by฀ others฀which฀are฀critical฀of฀their฀role฀ [19,฀20] .฀Two฀systematic฀studies฀report฀the฀support- ive฀effect฀of฀a฀partner฀in฀achieving฀smoking฀cessation฀ [21,฀22] ,฀in฀one฀case฀including฀the฀ recommendations฀of฀the฀AHQR฀ [21] . However,฀ numerous฀ organisations฀ also฀ provide฀ self-help฀ manuals฀ designed฀ to฀ assist฀ smokers฀who฀wish฀to฀quit฀ [23,฀24] .฀Consulting฀a฀therapist,฀in฀addition,฀may฀enhance฀the฀ effectiveness฀of฀the฀method฀ [23] .฀Standard฀instructions฀have฀been฀found฀to฀be฀less฀effective฀ than฀personalised฀instructions฀tailored฀for฀a฀group฀of฀smokers฀OR฀=฀1.41;฀CI:฀1.14–1.75฀ [25] .฀Overall,฀instructions฀on฀smoking฀cessation฀are฀assessed฀as฀useful฀and฀more฀effective฀ than฀attempting฀smoking฀cessation฀without฀instructions. Sporting฀ activities฀ are฀ a฀ key฀ aspect฀ of฀ self-help฀ to฀ achieve฀ smoking฀ cessation฀ [26] .฀ Physical฀exercise฀has฀a฀beneicial฀effect฀on฀cravings฀ [27] ,฀depressed฀mood฀ [28] ,฀sleep฀dis- turbances฀ [29] ,฀feelings฀of฀tension฀ [30] ,฀stress฀situations฀ [31] ฀and฀on฀weight฀gain฀following฀ smoking฀cessation,฀an฀aspect฀that฀is฀especially฀important฀for฀women฀ [32–34] .฀Sport฀also฀ has฀a฀positive฀effect฀on฀relapses฀ [35] ,฀coping฀with฀the฀smoking฀problem฀ [36] ฀and฀self- esteem฀ [37] .฀Overall,฀of฀course,฀physical฀activity฀confers฀health฀beneits฀on฀the฀ex-smoker฀ [38] ;฀heavy฀smokers฀often฀already฀notice฀this฀just฀2฀or฀3฀weeks฀after฀stopping฀smoking฀and฀ they฀volunteer฀this฀information฀spontaneously฀during฀counselling฀sessions.฀Out฀of฀a฀total฀ of฀8฀studies฀of฀this฀aspect฀published฀to฀date,฀6฀could฀not฀be฀assessed฀because฀patient฀num- bers฀were฀too฀small.฀In฀the฀inal฀analysis,฀therefore,฀only฀1฀study฀provided฀positive฀evi- dence฀of฀the฀effect฀of฀vigorous฀exercise฀in฀terms฀of฀smoking฀cessation฀OR฀=฀2.36;฀CI:฀ 0.97–5.70฀ [39] ,฀with฀a฀deinite฀increase฀in฀continuous฀abstinence฀compared฀with฀controls฀ 11.9฀vs.฀5.4;฀p฀=฀0.05฀ [39] . To฀determine฀whether฀exercise-based฀interventions฀alone฀or฀combined฀with฀a฀smoking฀ cessation฀programme฀are฀more฀effective฀than฀a฀smoking฀cessation฀intervention฀alone,฀ Ussher฀searched฀the฀Cochrane฀Tobacco฀Addiction฀Group฀specialized฀register฀for฀studies฀ including฀ the฀ terms฀ “exercise”฀ or฀ “physical฀ activity”฀ and฀ MEDLINE,฀ EMBASE,฀ PsycINFO,฀ CINAHL,฀ Dissertation฀ Abstracts฀ and฀ SPORTDiscus.฀ Randomized฀ trials฀ which฀compared฀an฀exercise฀programme฀alone฀or฀an฀exercise฀programme฀as฀an฀adjunct฀ to฀a฀cessation฀programme฀with฀a฀cessation฀programme฀recruiting฀smokers฀or฀recent฀quit- ters,฀and฀with฀a฀follow-up฀of฀6฀months฀or฀more฀were฀included฀in฀the฀ [40] .฀Eleven฀trials฀ were฀identiied,฀six฀of฀which฀had฀fewer฀than฀25฀people฀in฀each฀treatment฀arm.฀They฀var- ied฀in฀the฀timing฀and฀intensity฀of฀the฀smoking฀cessation฀and฀exercise฀programmes.฀Three฀ studies฀showed฀signiicantly฀higher฀abstinence฀rates฀in฀a฀physically฀active฀group฀vs.฀a฀ control฀group฀at฀the฀end฀of฀treatment.฀One฀of฀these฀studies฀also฀showed฀a฀beneit฀for฀ exercise฀vs.฀control฀on฀abstinence฀at฀both฀the฀3฀month฀and฀12฀month฀follow-up฀points.฀ One฀study฀showed฀signiicantly฀higher฀abstinence฀rates฀for฀the฀exercise฀group฀vs.฀a฀con- trol฀group฀at฀the฀3฀month฀follow–up,฀but฀not฀at฀the฀end฀of฀treatment฀or฀at฀12฀month฀fol- low-up.฀The฀other฀studies฀showed฀no฀signiicant฀effect฀for฀exercise฀on฀abstinence.฀The฀ study฀concluded฀that฀only฀one฀of฀the฀11฀trials฀offered฀evidence฀for฀exercise฀aiding฀smok- ing฀cessation.฀All฀but฀one฀of฀the฀other฀trials฀were฀too฀small฀to฀conclude฀that฀the฀interven- tion฀was฀ineffective,฀or฀included฀an฀exercise฀intervention฀which฀was฀insuficiently฀intense฀ to฀achieve฀the฀desired฀level฀of฀exercise.฀Trials฀are฀needed฀with฀larger฀sample฀sizes,฀suf- iciently฀intense฀exercise฀interventions,฀equal฀contact฀control฀conditions฀and฀measures฀of฀ exercise฀adherence฀ [40] . The฀ effectiveness฀ of฀ telephone฀ counselling฀ has฀ been฀ investigated฀ in฀ 23฀ studies,฀ the฀ results฀of฀which฀are฀extremely฀heterogeneous.฀In฀4฀studies,฀telephone฀counselling฀was฀fol- lowed฀by฀face-to-face฀counselling.฀However,฀telephone฀counselling฀can฀help฀to฀prevent฀ further฀relapses฀or฀stabilise฀smoking฀cessation฀ [41] .฀Since฀telephone฀counselling฀is฀usually฀ performed฀on฀an฀individual฀basis,฀it฀is฀preferable฀to฀group฀counselling,฀a฀modality฀that฀is฀ often฀rejected฀by฀smokers฀ [42] .฀Counselling฀then฀becomes฀a฀hotline฀to฀request฀a฀wide฀range฀ of฀ information.฀ Counselling฀ services฀ have฀ been฀ set฀ up฀ speciically฀ for฀ smokers฀ e.g.฀ QuitlineAustralia,฀ QuitEngland,฀ Heidelberger฀ TelefonGermany฀ or฀ they฀ may฀ operate฀ within฀the฀broader฀framework฀of฀an฀integrated฀smoking฀cessation฀support฀service฀ [43] .฀ Similarly,฀the฀Erfurt฀Smoker฀Counselling฀Centre฀provides฀free฀information฀and฀advice,฀but฀ also฀offers฀individual฀treatment฀free-of-charge฀over฀a฀period฀of฀weeks฀or฀months฀with฀the฀ goal฀of฀achieving฀smoking฀cessation฀see฀Appendix.

10.4 Physician Advice for Smoking Cessation

Seventeen฀different฀studies฀used฀5-min฀standard฀interviews฀to฀point฀out฀the฀dangers฀of฀ smoking฀ and฀ issued฀ smokers฀ with฀ an฀ information฀ booklet฀ without฀ offering฀ any฀ further฀ consultation.฀Three฀of฀these฀17฀studies฀were฀conducted฀in฀a฀hospital฀setting.฀The฀studies฀ revealed฀no฀clear฀differences฀in฀terms฀of฀success,฀not฀even฀when฀biochemical฀markers฀were฀ measured฀plasma฀nicotine฀levels฀or฀CO. Where฀ the฀ studies฀ were฀ conducted฀ with฀ additional฀ physician฀ input฀ spirometry,฀ CO฀ measurement,฀oral฀or฀written฀medical฀counselling,฀post-cessation฀support฀or฀a฀combination฀ of฀interventions,฀different฀success฀outcomes฀were฀achieved฀p฀฀0.001,฀a฀fact฀that฀was฀ also฀attributable,฀among฀other฀things,฀to฀non-standardised฀methods฀and฀individually฀tai- lored฀physician฀input฀in฀the฀individual฀studies. Group฀sessions฀with฀a฀medical฀expert฀to฀discuss฀the฀health฀consequences฀of฀smoking฀ also฀showed฀no฀signiicant฀success.฀In฀pregnant฀women฀attending฀three฀sessions,฀success฀ was฀ reported฀ in฀ 9฀ independent฀ studies฀ in฀ which฀ biochemical฀ markers฀ were฀ measured.฀ Effectiveness฀was฀greater฀than฀in฀non-pregnant฀women฀undergoing฀the฀same฀procedure.฀ Higher฀success฀rates฀were฀recorded฀in฀7฀studies฀in฀pregnant฀women฀with฀self-help฀instruc- tions฀9;฀p฀=฀0.01฀than฀in฀11฀similar฀studies฀in฀non-pregnant฀women฀Table฀ 10.2 . Hospital-based฀interventions฀for฀smoking฀cessation฀are฀not฀necessarily฀more฀successful฀ than฀interventions฀outside฀a฀hospital฀setting,฀even฀though฀a฀30฀increase฀in฀smoking฀ces- sation฀has฀been฀achieved฀OR฀=฀1.09;฀CI:฀0.91–1.31฀ [44] .฀However,฀where฀these฀interven- tions฀are฀combined฀with฀after-care,฀a฀marked฀rise฀in฀effectiveness฀is฀reported฀OR฀=฀1.82;฀ CI:฀1.49–2.22฀ [44] . Clinicians฀achieved฀a฀35฀success฀rate฀in฀group฀sessions฀with฀high-risk฀patients฀with฀ coronary฀heart฀disease฀who฀had฀survived฀a฀myocardial฀infarction฀ [45] .฀Even฀higher฀suc- cess฀ rates฀ were฀ recorded฀ in฀ one฀ uncontrolled฀ study฀ [46] .฀ In฀ 4฀ further฀ studies฀ where฀ counselling฀was฀made฀available฀to฀high-risk฀smokers฀with฀no฀history฀of฀infarction฀ [47– 49] ,฀ differing฀ success฀ rates฀ for฀ smoking฀ cessation฀ were฀ achieved฀ range:฀ 7–31.3.฀ Where฀smokers฀were฀simply฀counselled฀to฀stop฀smoking,฀success฀was฀no฀worse฀in฀com- parison฀with฀the฀other฀3฀studies฀with฀additional฀interventions฀such฀as฀repeated฀reminders฀ of฀the฀risk฀of฀infarction,฀support฀for฀successful฀smoking฀cessation,฀etc.฀ [47–49] ฀21฀ success฀rate;฀p฀฀0.001.฀A฀change฀in฀smoking฀habits฀cigar,฀pipe฀was฀reported฀in฀1฀ study฀ [50] . Individual฀counselling฀ [51–55] ฀is฀more฀effective฀than฀no฀counselling฀at฀all฀OR฀=฀1.55;฀ CI:฀1.27–1.90฀and฀the฀extent฀of฀counselling฀does฀not฀appear฀to฀be฀decisive฀because฀brief฀ information฀OR฀=฀1.17;฀CI:฀0.59–2.34฀as฀well฀as฀group-counselling฀sessions฀OR฀=฀1.33;฀ CI:฀0.83–2.13฀have฀proved฀useful฀ [56] .฀Follow-up฀telephone฀contact฀with฀patients฀has฀ been฀shown฀to฀be฀beneicial฀ [54] . A฀study฀by฀Picardi฀et฀al.฀assessed฀the฀effectiveness฀of฀a฀behavioural฀group฀interven- tion฀for฀smoking฀cessation,฀which฀included฀the฀recommendation฀to฀participate฀with฀a฀ relative฀or฀close฀friend฀as฀its฀most฀original฀feature฀ [57] .฀In฀this฀study,฀a฀total฀of฀1,060฀ subjects฀ took฀ part฀ in฀ the฀ programme,฀ which฀ consisted฀ of฀ nine฀ group฀ sessions฀ over฀ a฀ period฀of฀5฀weeks.฀The฀intervention฀consisted฀of฀a฀modiied฀version฀of฀the฀Five-Day฀ Plan,฀the฀main฀differences฀being฀the฀use฀of฀behavioural฀therapy฀techniques฀and฀small฀ group฀work,฀and฀the฀addition฀of฀4฀weekly฀booster฀sessions.฀About฀two-thirds฀of฀the฀par- ticipants฀came฀with฀a฀relative฀or฀close฀friend.฀Long-term฀abstinence฀from฀smoking฀was฀ assessed฀with฀follow-up฀telephone฀interviews.฀It฀was฀also฀found฀that฀very฀few฀subjects฀ were฀ lost฀ to฀ follow-ups฀ 9.2฀ at฀ 6฀ months,฀ 9.7฀ at฀ 1฀ year,฀ 10.8฀ at฀ 2฀ years.฀ The฀ observed฀quit฀rates฀were฀42.6฀at฀6฀months,฀35.5฀at฀1฀year฀and฀32฀at฀2฀years.฀When฀ considering฀as฀smokers฀all฀subjects฀who฀were฀lost฀to฀follow-ups,฀quit฀rates฀were฀also฀ satisfactory฀38.7฀at฀6฀months,฀32.1฀at฀1฀year฀and฀28.6฀at฀2฀years.฀The฀main฀predic- tors฀ of฀ a฀ good฀ outcome฀ were฀ being฀ male,฀ smoking฀ 20฀ cigarettesday,฀ having฀ started฀ smoking฀after฀18฀years฀of฀age,฀having฀made฀previous฀quitting฀attempts,฀not฀having฀a฀his- tory฀of฀unsuccessful฀participation฀to฀smoking฀cessation฀interventions฀and฀attending฀the฀ sessions฀with฀a฀relative฀or฀close฀friend.฀From฀this฀study,฀it฀was฀concluded฀that฀although฀ some฀limitations฀inherent฀in฀the฀design฀of฀the฀study฀suggested฀caution฀in฀interpreting฀the฀ results฀and฀in฀making฀comparisons,฀the฀long-term฀effectiveness฀of฀the฀intervention฀was฀ satisfactory.฀The฀inclusion฀of฀a฀relative฀or฀close฀friend฀appeared฀useful.฀This฀simple฀and฀ inexpensive฀ strategy฀ may฀ deserve฀ recommendation,฀ though฀ in฀ the฀ future฀ it฀ should฀ be฀ tested฀in฀controlled฀trials฀ [57] .