Pshycological Intervntions for Tobacco Cessation - part 3
Three kinds of psychological intervention are used in smoking cessation treatment: psychoeducational interventions, behavioral skill training, and cognitive-behavioral interventions. Psychoeducational approaches include information about smoking and health, information about strategies for quitting and maintaining abstinence, and group discussion to further understand and implement these changes. Behavioral skill training includes behavioral prescriptions, such as monitoring smoking situations, and practicing skills in the treatment setting and in the natural environment. Examples are rehearsal of cigarette refusal skills and relaxation practice. Cognitive-behavioral interventions include changing thoughts about smoking and quitting smoking and related situations and emotions. Treatment programs often include a combination of these three intervention types. 17,18,19
- Matching Treatments to Diagnostic Groupings. There has been progress in matching patients to treatments. Specific populations with high smoking rates have been identified, including psychiatric patients, especially those with depressive disorders or psychosis, and patients with alcohol and other drug disorders. Smokers with major depressive disorder (MDD) have been the most extensively studied. For example, data indicate that smokers with a history of MDD were more likely to quit smoking in a cognitive-behavioral intervention than in a control psychoeducational intervention, but only when the psychoeducational intervention provided fewer contact hours than the cognitive-behavioral intervention.
These data suggest that increased therapeutic contact is helpful for smokers with a depression history. More than one therapeutic approach may be useful, and the best therapeutic content needs to be determined. Mechanisms of action underlying the increased effectiveness of more intensive, supportive treatments with depressed smokers have been suggested. Possibilities include increased or better sustained motivation or less increase in the poor mood that frequently accompanies quitting smoking.
- Matching Interventions to Special Subgroups of Smokers. Some data suggest that smokers differ widely in readiness to quit. These data are especially relevant to smokers diagnosed with substance abuse or psychiatric problems, since such samples probably contain a relatively high proportion of smokers who are not ready to enter a traditional treatment program for smoking cessation. Such programs usually require a high and sustained degree of motivation to quit.
Other data show that psychological interventions can be successfully tailored to the individual smoker's readiness to quit. Computerized expert system interventions have been developed that are targeted at a smoker's self-professed level of interest in quitting, which may range from precontemplation, a stage at which the smoker has no interest in quitting, to contemplation, to preparation for action, to action itself. In at least one study, expert systems developed by this group have shown efficacy in increasing readiness to quit and improving abstinence rates.
- Psychological Interventions and Pharmacotherapies. There is considerable evidence that combining psychoeducational or behavioral skill training interventions with nicotine replacement increases the abstinence rates found when smokers quit using nicotine replacement therapy alone. Several mechanisms have been suggested to explain this effect.
In summary, the following facts are known:
- In treatment-seeking smokers, psychological interventions for smoking cessation are more effective than no treatment.
- For at least one category of comorbid smokers, those with depressive disorder, psychological interventions increase abstinence rates.
- Psychological interventions targeted to smokers who express a readiness to quit increase abstinence rates in samples of smokers who have not yet made a commitment to abstinence.
- Psychological interventions increase abstinence rates when combined with nicotine replacement therapies.
- A 2 (medical management vs psychological intervention) × 3 (bupropion vs nortriptyline vs placebo) randomized trial was conducted with 220 cigarette smokers. Outcome measures were biologically verified abstinence from cigarettes at weeks 12, 24, 36, and 52.
Psychological intervention produced higher 7-day point-prevalence rates of biochemically verified abstinence than did medical management alone. With the use of point-prevalence abstinence, both nortriptyline and bupropion were more efficacious than placebo. On rates of 1-year continuous abstinence, the 2 drugs did not differ from each other or from placebo. Psychological intervention did not differ from medical management alone on rates of 1-year continuous abstinence.
Psychological intervention produces better abstinence rates than simple medical management. Both drugs, and psychological intervention, have limited efficacy in producing sustained abstinence. The data also suggest that combined psychological intervention and antidepressant drug treatment may not be more effective than antidepressant drug treatment alone. 20
- Seven electronic databases were searched from the start of the database to August 2003. Search terms were coronary or cardio or heart or cvd or chd and smok* and cessation or absti*. Results were supplemented by cross-checking references. More than 2,000 papers were screened in a first step. Eligibility of studies was assessed (by reviewer Jürgen Barth) and reasons for exclusion were coded. Abstinence rates were computed both according to an intention to treat analysis, and based on follow-up results only.
The objective was to conduct a systematic review of the efficacy of psychosocial interventions to quit smoking in patients with CHD.
19 randomized controlled trials were found, comparing a specific psychosocial intervention with “usual care,” with a minimum of 6-month follow-up. Interventions consist of behavioral therapeutic approaches, telephone support, and self-help material.
Smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient intensity with a minimum length of 1 month. Further studies should compare different psychosocial intervention strategies, or the combination of a psychosocial intervention strategy with nicotine replacement therapy or bupropion compared with nicotine replacement or bupropion alone. 21
- This pilot study investigated the benefits of adjunctive psychological intervention for smokers accessing standard smoking cessation interventions. Chronic obstructive pulmonary disease (COPD) smokers attending a smoking cessation service were offered up to 12 adjunctive clinical psychology sessions. Baseline data included demographics, smoking history, and disease severity. Outcomes included attendance and quit rate. In all, 59 patients with moderate COPD were referred. Of the 20 patients who attended training sessions, 7 (35%) were relapse prevention referrals and 13 (65%) were current smokers. Of the seven relapse prevention referrals, six (86%) maintained their quit, 2 of 13 (15%) of the current smoker group maintained a 28-day quit and 3 of 13 (23%) of current smokers reduced their tobacco intake. For COPD smokers with a heavy smoking history and multiple past quit attempts, there was insufficient evidence to show that additional psychological intervention leads to higher quit rates. Significant barriers to quitting and complex medical and psychosocial needs were identified in this group, suggesting that the current 'one-size-fits-all' approach to smoking cessation may not be sufficient to meet the needs of such a complex group
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