Group Behaviour Therapy Programmes

to฀be฀broken฀down฀in฀stages฀by฀recording฀them.฀Key฀aspects฀of฀the฀treatment฀strategy฀are฀ the฀ initial฀ boosting฀ of฀ motivation฀ non-smoking฀ is฀ better,฀ increased฀ self-observation฀ documenting฀cigarette฀consumption฀to฀make฀smoking฀habits฀transparent฀and฀developing฀ individual฀techniques฀for฀coping฀with฀cravings.฀Smokers฀must฀gradually฀realise฀that฀absti- nence฀is฀attractive฀and฀they฀must฀be฀prepared฀for฀the฀possibility฀of฀relapses.฀The฀system฀ also฀enables฀smokers฀to฀learn฀a฀relaxation฀technique฀that฀should฀always฀be฀used฀when฀crav- ings฀arise.฀Since฀the฀possibility฀of฀weight฀gain฀can฀undo฀the฀beneit฀of฀cessation,฀quitting฀ smokers฀should฀be฀prepared฀for฀this฀eventuality฀ Chap.฀11 ,฀Sect.฀ 11.5.3 .฀It฀is฀important฀to฀ develop฀new฀behaviours฀and฀to฀set฀rewards฀for฀goals฀achieved.฀However,฀since฀the฀physi- cal฀dependence฀also฀has฀to฀be฀treated,฀adjunctive฀NRT฀also฀alleviates฀the฀symptoms฀of฀ withdrawal฀see฀ Chap.฀11 ,฀Sect.฀ 11.1.1 . The฀treatment฀uses฀elements฀of฀behavioural฀therapy฀sanctions฀or฀“punishments”฀[for- merly฀also฀learning฀aversive฀responses฀such฀as฀nausea฀and฀vomiting],฀identifying฀alterna- tive฀actions,฀support฀measures฀for฀quitting฀smoking฀and฀may฀be฀conducted฀individually,฀ in฀a฀group฀or฀with฀a฀self-help฀manual.฀In฀13฀studies฀comparing฀a฀group฀programme฀with฀a฀ self-help฀programme,฀there฀was฀an฀increase฀in฀smoking฀cessation฀with฀a฀group฀programme฀ OR฀=฀2.10;฀CI:฀1.64–2.70.฀Group฀programmes฀were฀more฀effective฀than฀no฀intervention฀ or฀minimal-contact฀interventions฀OR฀=฀1.91;฀CI:฀1.20–3.04.฀There฀was฀no฀evidence฀that฀ manipulating฀the฀social฀interactions฀between฀participants฀in฀a฀group฀programme฀had฀an฀ effect฀on฀outcome฀ [70] .฀In฀every฀case,฀however,฀biochemical฀markers฀should฀be฀included฀ when฀assessing฀success.฀Overall,฀interpretation฀of฀results฀is฀rendered฀dificult฀because฀the฀ study฀objectives฀were฀very฀differently฀deined.฀Behavioural฀therapy฀can฀be฀implemented฀in฀ weekly฀group฀sessions฀10–15฀smokers,฀particularly฀since฀individual฀treatment฀is฀far฀too฀ personnel-intensive฀ and฀ will,฀ therefore,฀ fail.฀ For฀ the฀ most฀ part,฀ a฀ 5–10-week฀ course฀ of฀ treatment฀is฀required฀ [71,฀72] .฀Shorter฀treatments฀often฀leave฀the฀ex-smoker฀to฀cope฀alone฀ with฀the฀late฀symptoms฀of฀withdrawal.

10.7 Aversion Therapy

Aversion฀therapy฀is฀based฀on฀pairing฀the฀“pleasurable”฀event฀with฀an฀unpleasant฀physical฀ stimulus.฀It฀may฀be฀regarded฀as฀a฀form฀of฀behavioural฀therapy฀designed฀to฀correct฀certain฀ behaviours฀such฀as฀dependence฀e.g.฀on฀cigarettes฀or฀excessive฀eating฀ [73] .฀In฀this฀context,฀ the฀best-known฀technique฀is฀that฀of฀rapid฀and฀increased฀cigarette฀consumption฀ [74] ,฀the฀ target฀being฀one฀puff฀every฀6–10฀s.฀After฀3฀min,฀generally,฀the฀smoker฀reaches฀the฀point฀at฀ which฀nausea฀develops.฀Some฀smokers฀need฀three฀cigarettes฀in฀this฀period.฀This฀“mild”฀ nicotine฀overdose฀dizziness,฀nausea,฀vomiting฀is฀intended฀to฀develop฀aversion.฀These฀ methods฀are฀hardly฀used฀at฀all฀today฀and฀they฀may฀even฀be฀dangerous฀for฀patients฀who฀are฀ at฀risk฀coronary฀heart฀disease,฀etc.฀ [75] ,฀though฀the฀contrary฀view฀also฀exists฀ [9,฀26,฀76] .฀ As฀soon฀as฀the฀symptoms฀of฀overdose฀have฀resolved,฀the฀procedure฀may฀be฀repeated,฀with฀ 3–10฀such฀sessions฀being฀reported฀in฀different฀studies.฀As฀far฀as฀possible,฀smokers฀should฀ not฀ smoke฀ between฀ sessions.฀ One฀ summary฀ review฀ of฀ 35,000฀ smokers฀ who฀ have฀ been฀ treated฀with฀this฀technique฀did฀not฀detect฀any฀major฀negative฀effects฀ [30] .฀In฀10฀studies฀of฀ rapid฀smoking,฀compared฀with฀control,฀the฀overall฀odds฀ratio฀for฀abstinence฀was฀2.08฀CI:฀ 1.39–3.12฀ [77] .฀However,฀this฀inding฀should฀be฀interpreted฀cautiously฀because฀the฀funnel฀ plot฀of฀included฀studies฀was฀asymmetrical฀due฀to฀the฀relative฀absence฀of฀small฀studies฀with฀ negative฀results฀Table฀ 10.2 ฀ [77] .฀The฀single฀trial฀using฀biochemical฀validation฀of฀all฀self- reported฀cessation฀did฀not฀show฀a฀signiicant฀result. Other฀aversion฀methods฀e.g.฀application฀of฀electric฀shocks,฀intensive฀pufing,฀holding฀the฀ smoke฀in฀the฀mouth฀for฀longer฀periods฀while฀continuing฀to฀breathe฀through฀the฀nose,฀cough฀ stimulus฀provocation,฀taking฀bitter฀pills฀before฀smoking฀a฀cigarette,฀silver฀acetate฀chewing฀ gum฀are฀reported฀to฀be฀only฀marginally฀effective฀OR฀=฀1.19;฀CI:฀0.77–1.83฀ [77] .

10.8 Mass Media Communication Strategies

Over฀the฀past฀10–15฀years,฀several฀attempts฀have฀been฀made฀via฀the฀mass฀media฀to฀inlu- ence฀smoking฀behaviour฀among฀the฀wider฀population.฀The฀following฀media฀formats฀have฀ been฀utilised฀for฀this฀purpose:฀television,฀cinema,฀radio฀broadcasts,฀print฀media฀of฀all฀types,฀ posters,฀personal฀discussions,฀smoker฀helplines฀and฀even฀personal฀direct฀mailings.฀These฀ campaigns฀communicated฀factual฀information฀or฀they฀took฀the฀form฀of฀appeals;฀they฀also฀ employed฀a฀counter-advertising฀strategy,฀tantamount฀to฀a฀condemnation฀of฀the฀tobacco฀ industry’s฀marketing฀strategies.฀When฀assessing฀the฀usefulness฀of฀such฀methods,฀of฀course,฀ the฀decisive฀point฀is฀the฀achievement฀of฀smoking฀cessation฀or฀at฀least฀a฀deinite฀reduction฀ in฀smoking฀over฀a฀period฀of฀several฀months฀³6฀months. In฀citing฀a฀number฀of฀such฀campaigns฀from฀the฀past,฀attention฀here฀will฀focus฀primarily฀ on฀Australia฀and฀the฀UK฀ [78] : • ฀ “Every฀cigarette฀is฀doing฀you฀damage”฀Australia.฀This฀campaign฀gained฀international฀ recognition฀because฀it฀used฀hard-hitting฀TV฀adverts,฀in฀conjunction฀with฀radio฀broad- casts,฀billboards฀and฀full-page฀magazine฀adverts,฀to฀depict฀the฀adverse฀consequences฀of฀ tobacco฀consumption฀ [79] .฀The฀initially฀positive฀results฀were฀seen฀most฀clearly฀among฀ adolescents฀14–17-years฀old,฀even฀though฀this฀group฀was฀not฀part฀of฀the฀intended฀ target฀audience;฀nevertheless,฀67฀of฀them฀were฀motivated฀to฀quit฀smoking.฀The฀mean฀ national฀smoker฀prevalence฀was฀lowered฀by฀1.7฀from฀23.5฀to฀21.8.฀The฀campaign฀ was฀run฀again฀in฀Singapore฀with฀slight฀modifications฀ [80] . • ฀ The฀John฀Cleese฀Campaign฀featured฀this฀celebrity฀comic฀actor฀to฀stimulate฀the฀interest฀of฀ smokers฀between฀the฀ages฀of฀25฀and฀44฀years;฀it฀sought฀to฀promote฀smoking฀cessation฀by฀ presenting฀serious฀messages฀e.g.฀“Smoking฀can฀kill,”฀“Smoking฀harms฀your฀children,”฀ “Smoking฀is฀not฀the฀only฀way฀to฀enjoy฀yourself ”฀in฀a฀humorous฀way.฀The฀campaign฀was฀ supported฀by฀a฀telephone฀helpline.฀Following฀the฀campaign,฀smoking฀prevalence฀fell฀by฀ 1.2฀from฀28.0฀to฀26.8฀over฀a฀3-year฀period฀1992–1995฀ [78,฀81,฀82] . • ฀ The฀target฀group฀for฀the฀“Break฀Free฀Campaign”฀was฀smokers฀who฀were฀already฀seri- ously฀considering฀quitting฀smoking.฀The฀“You฀can฀be฀free”฀slogan฀was฀shown฀on฀TV฀