Physician Advice for Smoking Cessation

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] .

10.5 Nursing Involvement

Since฀ nurses฀ constitute฀ a฀ very฀ much฀ larger฀ professional฀ body฀ than฀ doctors฀ worldwide,฀ training฀efforts฀are฀warranted฀to฀qualify฀nursing฀staff฀for฀involvement฀in฀smoking฀cessation฀ programmes,฀given฀the฀enormity฀of฀the฀task.฀The฀effectiveness฀of฀physician฀counselling฀for฀ smoking฀cessation฀is฀well-established฀ [58,฀59] .฀By฀contrast,฀counselling฀by฀nursing฀profes- sionals฀is฀reported฀to฀be฀less฀effective฀ [60] .฀The฀different฀ [61,฀62] ฀studies฀should฀be฀regarded฀ as฀successful฀OR฀=฀1.50;฀CI:฀1.29–1.73,฀though฀some฀investigators฀used฀NRT฀to฀promote฀ smoking฀ cessation฀ see฀ Chap.฀ 11 ,฀ Sect.฀ 11.1 .฀ Nevertheless,฀ counselling฀ delivered฀ by฀ nurses฀and฀respiratory฀care฀therapists฀etc.฀is฀viewed฀as฀useful฀ [63] .฀Following฀the฀example฀ of฀the฀USA,฀this฀activity฀should฀be฀incorporated฀into฀nurse฀education฀programmes฀world- wide฀ [64] .฀One฀recent฀analysis฀ [65] ฀summarising฀17฀studies฀indicates฀that฀the฀odds฀of฀quit- ting฀ are฀ increased฀ by฀ nursing฀ intervention฀ OR฀ =฀ 1.43;฀ 95฀ CI:฀ 1.24–1.66฀ and฀ this฀ improved฀effectiveness฀was฀found฀for฀both฀intensive฀OR฀=฀1.39;฀CI:฀1.19–1.64฀and฀less฀ intensive฀interventions฀OR฀=฀1.67;฀CI:฀1.14–2.65.฀Where฀post-infarction฀patients฀took฀ part฀in฀nurse-managed฀programmes฀in฀a฀cardiology฀clinic,฀effectiveness฀was฀very฀much฀ higher฀OR฀=฀2.14;฀CI:฀1.39–3.31฀ [33,฀60,฀66] .฀In฀1฀study,฀the฀effectiveness฀of฀nurse- managed฀counselling฀in฀non-hospitalised฀patients฀with฀cardiovascular฀health฀problems฀was฀ very฀low฀OR฀=฀0.19;฀CI:฀0.08–0.46฀ [61] .฀However,฀this฀study฀should฀be฀viewed฀critically฀ in฀as฀much฀as฀the฀control฀group฀included฀more฀coronary฀artery฀bypass฀graft฀patients฀who฀ also฀quit฀smoking฀without฀counselling.฀In฀a฀further฀8฀studies,฀an฀80฀increase฀in฀effective- ness฀ was฀ reported฀ in฀ non-hospitalised฀ patients฀ OR฀ =฀ 1.81;฀ CI:฀ 1.39–2.36฀ [67,฀ 68] .฀ Additional฀telephone฀contact฀increased฀the฀effectiveness฀of฀smoking฀cessation฀interven- tions฀in฀some฀studies฀OR฀=฀1.40;฀CI:฀1.00–1.96฀ [59] . Overall,฀counselling฀by฀trained฀nursing฀professionals฀may฀be฀regarded฀as฀useful,฀with฀ statistically฀ signiicant฀ though฀ moderate฀ effects฀ having฀ been฀ achieved฀ to฀ date฀ [65] .฀ In฀ selected฀hospitals฀and฀outpatient฀departments,฀nurses฀should,฀therefore,฀be฀included฀in฀the฀ system฀of฀patient฀education฀to฀promote฀smoking฀cessation฀ [59] .

10.6 Group Behaviour Therapy Programmes

Dependence฀experts฀and฀psychiatrists,฀in฀particular,฀consider฀that฀behaviour฀therapy฀pro- grammes฀are฀also฀very฀effective฀to฀promote฀smoking฀cessation฀OR฀=฀2.10;฀CI:฀1.64–2.70฀ [62,฀69] .฀The฀hypothesis฀that฀smoking฀is฀a฀learned฀and฀consolidated฀behaviour฀based฀on฀ many฀years฀of฀conditioning฀has฀prompted฀the฀development฀of฀treatment฀strategies฀using฀ the฀same฀practices฀to฀“unlearn”฀the฀resultant฀dependence. Behaviours฀learned฀as฀a฀result฀of฀smoking฀situations฀in฀which฀the฀smoker฀reaches฀for฀a฀ cigarette;฀the฀act฀of฀lighting฀up฀and฀smoking;฀automatisation฀and฀ritualisation฀of฀smoking฀ have฀to฀be฀unlearned฀in฀the฀course฀of฀treatment.฀Self-monitoring฀of฀smoking฀behaviour฀for฀ example,฀by฀keeping฀a฀smoker’s฀journal฀is฀a฀commonly฀used฀method฀in฀which฀habits฀have฀ 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฀