Effectivenesswasgreaterthaninnon-pregnantwomenundergoingthesameprocedure. Highersuccessrateswererecordedin7studiesinpregnantwomenwithself-helpinstruc-
tions9;p=0.01thanin11similarstudiesinnon-pregnantwomenTable 10.2
. Hospital-basedinterventionsforsmokingcessationarenotnecessarilymoresuccessful
thaninterventionsoutsideahospitalsetting,eventhougha30increaseinsmokingces- sationhasbeenachievedOR=1.09;CI:0.91–1.31
[44] .However,wheretheseinterven-
tionsarecombinedwithafter-care,amarkedriseineffectivenessisreportedOR=1.82; CI:1.49–2.22
[44] .
Cliniciansachieveda35successrateingroupsessionswithhigh-riskpatientswith coronaryheartdiseasewhohadsurvivedamyocardialinfarction
[45] .Evenhighersuc-
cess rates were recorded in one uncontrolled study [46]
. In 4 further studies where counsellingwasmadeavailabletohigh-risksmokerswithnohistoryofinfarction
[47– 49]
, differing success rates for smoking cessation were achieved range: 7–31.3. Wheresmokersweresimplycounselledtostopsmoking,successwasnoworseincom-
parisonwiththeother3studieswithadditionalinterventionssuchasrepeatedreminders oftheriskofinfarction,supportforsuccessfulsmokingcessation,etc.
[47–49] 21
successrate;p0.001.Achangeinsmokinghabitscigar,pipewasreportedin1 study
[50] .
Individualcounselling [51–55]
ismoreeffectivethannocounsellingatallOR=1.55; CI:1.27–1.90andtheextentofcounsellingdoesnotappeartobedecisivebecausebrief
informationOR=1.17;CI:0.59–2.34aswellasgroup-counsellingsessionsOR=1.33; CI:0.83–2.13haveproveduseful
[56] .Follow-uptelephonecontactwithpatientshas
beenshowntobebeneicial [54]
. AstudybyPicardietal.assessedtheeffectivenessofabehaviouralgroupinterven-
tionforsmokingcessation,whichincludedtherecommendationtoparticipatewitha relativeorclosefriendasitsmostoriginalfeature
[57] .Inthisstudy,atotalof1,060
subjects took part in the programme, which consisted of nine group sessions over a periodof5weeks.TheinterventionconsistedofamodiiedversionoftheFive-Day
Plan,themaindifferencesbeingtheuseofbehaviouraltherapytechniquesandsmall groupwork,andtheadditionof4weeklyboostersessions.Abouttwo-thirdsofthepar-
ticipantscamewitharelativeorclosefriend.Long-termabstinencefromsmokingwas assessedwithfollow-uptelephoneinterviews.Itwasalsofoundthatveryfewsubjects
were lost to follow-ups 9.2 at 6 months, 9.7 at 1 year, 10.8 at 2 years. The observedquitrateswere42.6at6months,35.5at1yearand32at2years.When
consideringassmokersallsubjectswhowerelosttofollow-ups,quitrateswerealso satisfactory38.7at6months,32.1at1yearand28.6at2years.Themainpredic-
tors of a good outcome were being male, smoking 20 cigarettesday, having started smokingafter18yearsofage,havingmadepreviousquittingattempts,nothavingahis-
toryofunsuccessfulparticipationtosmokingcessationinterventionsandattendingthe sessionswitharelativeorclosefriend.Fromthisstudy,itwasconcludedthatalthough
somelimitationsinherentinthedesignofthestudysuggestedcautionininterpretingthe resultsandinmakingcomparisons,thelong-termeffectivenessoftheinterventionwas
satisfactory.Theinclusionofarelativeorclosefriendappeareduseful.Thissimpleand inexpensive strategy may deserve recommendation, though in the future it should be
testedincontrolledtrials [57]
.
10.5 Nursing Involvement
Since nurses constitute a very much larger professional body than doctors worldwide, trainingeffortsarewarrantedtoqualifynursingstaffforinvolvementinsmokingcessation
programmes,giventheenormityofthetask.Theeffectivenessofphysiciancounsellingfor smokingcessationiswell-established
[58,59] .Bycontrast,counsellingbynursingprofes-
sionalsisreportedtobelesseffective [60]
.Thedifferent [61,62]
studiesshouldberegarded assuccessfulOR=1.50;CI:1.29–1.73,thoughsomeinvestigatorsusedNRTtopromote
smoking cessation see Chap. 11
, Sect. 11.1
. Nevertheless, counselling delivered by nursesandrespiratorycaretherapistsetc.isviewedasuseful
[63] .Followingtheexample
oftheUSA,thisactivityshouldbeincorporatedintonurseeducationprogrammesworld- wide
[64] .Onerecentanalysis
[65] summarising17studiesindicatesthattheoddsofquit-
ting are increased by nursing intervention OR = 1.43; 95 CI: 1.24–1.66 and this improvedeffectivenesswasfoundforbothintensiveOR=1.39;CI:1.19–1.64andless
intensiveinterventionsOR=1.67;CI:1.14–2.65.Wherepost-infarctionpatientstook partinnurse-managedprogrammesinacardiologyclinic,effectivenesswasverymuch
higherOR=2.14;CI:1.39–3.31 [33,60,66]
.In1study,theeffectivenessofnurse- managedcounsellinginnon-hospitalisedpatientswithcardiovascularhealthproblemswas
verylowOR=0.19;CI:0.08–0.46 [61]
.However,thisstudyshouldbeviewedcritically inasmuchasthecontrolgroupincludedmorecoronaryarterybypassgraftpatientswho
alsoquitsmokingwithoutcounselling.Inafurther8studies,an80increaseineffective- ness was reported in non-hospitalised patients OR = 1.81; CI: 1.39–2.36
[67, 68] .
Additionaltelephonecontactincreasedtheeffectivenessofsmokingcessationinterven- tionsinsomestudiesOR=1.40;CI:1.00–1.96
[59] .
Overall,counsellingbytrainednursingprofessionalsmayberegardedasuseful,with statistically signiicant though moderate effects having been achieved to date
[65] . In
selectedhospitalsandoutpatientdepartments,nursesshould,therefore,beincludedinthe systemofpatienteducationtopromotesmokingcessation
[59] .
10.6 Group Behaviour Therapy Programmes
Dependenceexpertsandpsychiatrists,inparticular,considerthatbehaviourtherapypro- grammesarealsoveryeffectivetopromotesmokingcessationOR=2.10;CI:1.64–2.70
[62,69] .Thehypothesisthatsmokingisalearnedandconsolidatedbehaviourbasedon
manyyearsofconditioninghaspromptedthedevelopmentoftreatmentstrategiesusing thesamepracticesto“unlearn”theresultantdependence.
Behaviourslearnedasaresultofsmokingsituationsinwhichthesmokerreachesfora cigarette;theactoflightingupandsmoking;automatisationandritualisationofsmoking
havetobeunlearnedinthecourseoftreatment.Self-monitoringofsmokingbehaviourfor example,bykeepingasmoker’sjournalisacommonlyusedmethodinwhichhabitshave
tobebrokendowninstagesbyrecordingthem.Keyaspectsofthetreatmentstrategyare the initial boosting of motivation non-smoking is better, increased self-observation
documentingcigaretteconsumptiontomakesmokinghabitstransparentanddeveloping individualtechniquesforcopingwithcravings.Smokersmustgraduallyrealisethatabsti-
nenceisattractiveandtheymustbepreparedforthepossibilityofrelapses.Thesystem alsoenablessmokerstolearnarelaxationtechniquethatshouldalwaysbeusedwhencrav-
ingsarise.Sincethepossibilityofweightgaincanundothebeneitofcessation,quitting smokersshouldbepreparedforthiseventuality
Chap.11 ,Sect.
11.5.3 .Itisimportantto
developnewbehavioursandtosetrewardsforgoalsachieved.However,sincethephysi- caldependencealsohastobetreated,adjunctiveNRTalsoalleviatesthesymptomsof
withdrawalsee Chap.11
,Sect. 11.1.1
. Thetreatmentuseselementsofbehaviouraltherapysanctionsor“punishments”[for-
merlyalsolearningaversiveresponsessuchasnauseaandvomiting],identifyingalterna- tiveactions,supportmeasuresforquittingsmokingandmaybeconductedindividually,
inagrouporwithaself-helpmanual.In13studiescomparingagroupprogrammewitha self-helpprogramme,therewasanincreaseinsmokingcessationwithagroupprogramme
OR=2.10;CI:1.64–2.70.Groupprogrammesweremoreeffectivethannointervention orminimal-contactinterventionsOR=1.91;CI:1.20–3.04.Therewasnoevidencethat
manipulatingthesocialinteractionsbetweenparticipantsinagroupprogrammehadan effectonoutcome
[70] .Ineverycase,however,biochemicalmarkersshouldbeincluded
whenassessingsuccess.Overall,interpretationofresultsisrendereddificultbecausethe studyobjectiveswereverydifferentlydeined.Behaviouraltherapycanbeimplementedin
weeklygroupsessions10–15smokers,particularlysinceindividualtreatmentisfartoo personnel-intensive and will, therefore, fail. For the most part, a 5–10-week course of
treatmentisrequired [71,72]
.Shortertreatmentsoftenleavetheex-smokertocopealone withthelatesymptomsofwithdrawal.
10.7 Aversion Therapy
Aversiontherapyisbasedonpairingthe“pleasurable”eventwithanunpleasantphysical stimulus.Itmayberegardedasaformofbehaviouraltherapydesignedtocorrectcertain
behaviourssuchasdependencee.g.oncigarettesorexcessiveeating [73]
.Inthiscontext, thebest-knowntechniqueisthatofrapidandincreasedcigaretteconsumption
[74] ,the
targetbeingonepuffevery6–10s.After3min,generally,thesmokerreachesthepointat whichnauseadevelops.Somesmokersneedthreecigarettesinthisperiod.This“mild”
nicotineoverdosedizziness,nausea,vomitingisintendedtodevelopaversion.These methodsarehardlyusedatalltodayandtheymayevenbedangerousforpatientswhoare
atriskcoronaryheartdisease,etc. [75]
,thoughthecontraryviewalsoexists [9,26,76]
. Assoonasthesymptomsofoverdosehaveresolved,theproceduremayberepeated,with
3–10suchsessionsbeingreportedindifferentstudies.Asfaraspossible,smokersshould not smoke between sessions. One summary review of 35,000 smokers who have been