Dr Subrina Ahmed
Senior Executive, Clinical Development, Incepta Pharmaceuticals Ltd
2017-08-12 13:13:40
Tobacco smoke is the leading cause of preventable premature mortality worldwide. Despite 6 million deaths being linked to tobacco use on an annual basis, an estimated 1 billion people worldwide continue to smoke. For every death related to smoking, 20 additional individuals will suffer from at least one serious smoking-related illness. (1)
Life expectancy and health-related quality of life indices have been shown to reduce in a dose-dependent manner when the number of cigarettes smoked increases.
Tobacco smoking is a learned behaviour that results in a physical addiction to nicotine for the majority of smokers. (2,3) Accordingly, stopping smoking can be difficult for many individuals. Seventy per cent of smokers want and intend to stop smoking at some point, yet only 12% are ready to stop in the next month. (4,5) To date, smoking cessation interventions have typically been targeted at individuals who want to stop and are able to provide a firm commitment to quit on a “quit day.” However, many smokers have tried unsuccessfully to quit this way. Recent evidence demonstrates that gradually reducing the number of cigarettes smoked before eventually quitting and quitting abruptly, with no prior reduction, produce comparable quit rates. (5,6)
Why psychological interventions are needed?
Psychosocial interventions can improve a smoker’s chance of making a successful quit attempt. The greater the number of professionals involved in the smoking cessation intervention, the greater the likelihood of success.
Who can provide psychological intervention?
The effectiveness of smoking cessation interventions delivered by providers did not significantly differ when it was delivered by providers from different professional disciplines, such as smoking cessation specialists, practising clinicians, and health care administrators. Recent research shows that pharmacists can also provide meaningful psychosocial interventions that significantly help individuals to quit smoking. (7)
What is the goal of Psychosocial Interventions?
The goal of psychosocial interventions is to improve one or more of the following outcomes: to reduce the impact of stressful events and situations; decrease distress and disability; minimize symptoms; improve the quality of life; reduce risk; improve communication and coping skills; and/or enhance treatment adherence. (8)
Types of Psychosocial Interventions
Group Therapy
Group behavioural therapy, or group counselling, is found to be more effective in helping smokers quit than self-help materials alone.(9) Group therapy based around the stages of change assists individuals establishes awareness and motivation to change their behaviour. In group therapy, a smoker can learn behavioural techniques (i.e. modelling and reinforcement) for aiding in their quit attempt and foster mutual support. Ideal groups include 4-8 individuals with one therapist or 9-15 individuals with two co-therapists. Group therapy sessions should ideally take 1 hour for a group with less than 12 individuals and 2 hours for a group with more than 12 individuals. Group therapy is most efficient when used in conjunction with other forms of treatment and intervention (e.g. nicotine replacement therapy, telephone counselling, self-help materials). (10)
Individual Counseling
The effectiveness of individual counselling on smoking cessation is related to the intensity of the treatment, or the amount of face-to-face contact with the client. An ideal individual treatment program might include four to seven sessions lasting at least 20 to 30 minutes. During these sessions, a provider can offer problem-solving, skills training, and support that is tailored to each client to increase smoking cessation rates. Treatment also includes encouragement, reinforcement for quitting attempts, and discussions of coping strategies for situations that increase the temptation for smoking.1 Furthermore, repeated contact is important in individual counselling to help maintain motivation. One study showed that individuals who completed three counselling sessions (5-10 minutes) with a pharmacist were significantly more effective at helping individuals quit smoking than one session of counselling. (7)
Adjuvant Interventions
The following are examples of interventions that are designed to enhance smoking cessation when combined with psychological interventions and/or nicotine replacement therapy:
Audiotapes & Relapse Prevention Clients are provided with computer-controlled audiotaped therapeutic messages called “digital therapists,” and they are encouraged to listen to the recording any time they may feel tempted to smoke. This treatment appears to predict the use of post-treatment coping skills, especially for clients that showed negative affect prior to treatment. It does not, however, promote stronger abstinence rates than interventions alone. (11)
Scheduled & Non-scheduled Smoking These methods help clients to reduce their smoking, thereby preparing them to begin nicotine replacement therapy and also demonstrating that they have control over their own smoking patterns. Non-scheduled smoking is gradual, with the goal of reaching a reduced number of cigarettes per day (i.e., down to half a pack) and at certain hours of the day, over time.3 Scheduled smoking is a more fixed program of incrementally increasing the time that passes in between cigarettes and has shown better abstinence rates than non-scheduled tapering off and the “cold turkey” approach to quitting. (11)
Multi-Media Interventions Text messages, emails, and the Internet are now being used as mediums for psychosocial interventions in smoking cessation. Ecological Momentary Interventions (EMIs) are contacts made to the individual throughout the day through text messages, email, phone, and/or the Internet to help the person stay engaged in quitting smoking. Research has shown that psychosocial interventions that included EMIs significantly increased smoking quit rates. (12)
Self-Help Interventions
For smokers who wish to quit privately or on their own, the following methods have been developed. From a public health perspective, they are cost-effective and have the potential to help many people quit.
Telephone Counseling Cessation rates for home-based clients given self-help materials alone are surpassed by those receiving pre-treatment telephone counselling, and even greater by those receiving several follow-up telephone sessions. The more intense the provider contact during quit attempts, the lower the relapse rate, especially within the first week after the quit attempt.11 Research has shown that even one 10-20 minute phone assessment and an individually-tailored letter based on the phone assessment can significantly help smokers to quit smoking and stay abstinent from smoking.13
Personalized Self-Help In addition to self-help materials and telephone counselling, clients can be provided with feedback on their home computers. A program based on the client’s stage of change, decisional balance, coping behaviours, and temptations have shown improved abstinence rates.4 Another program based on the client’s stage of change, self-efficacy, intrinsic motivation, and smoking/quitting history has shown improved initial cessation rates. Individually-tailored letters, based on responses to a questionnaire, can significantly help individuals stop smoking and remain abstinent from smoking.14 Self-help programs based on the stages of change help to personalize the intervention and increase the chance that the individual will quit smoking, compared to generic self-help programs. (15)
Telephone Follow-Up
Research has shown that even a single, 5-10 minute follow-up phone call from a smoking cessation counsellor, made three weeks after self-help materials were mailed, significantly increased smoking cessation rates. 10 A meta-analysis of callbacks found that individuals who received phone callbacks (average of 2-3 calls, though the specific number was not significant) were significantly more likely to quit smoking than individuals who did not receive a telephone follow-up.16 The phone calls encouraged individuals to continue to be abstinent from smoking and allowed the individual to voice any concerns or difficulties in quitting smoking. (10,16)
Three kinds of psychological intervention are used in smoking cessation treatment: psychoeducational interventions, behavioural skill training, and cognitive-behavioural 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. Behavioural skill training includes behavioural prescriptions, such as monitoring smoking situations and practising skills in the treatment setting and in the natural environment. Examples are a rehearsal of cigarette refusal skills and relaxation practice. Cognitive-behavioural 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 progressing 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-behavioural intervention than in a control psychoeducational intervention, but only when the psychoeducational intervention provided fewer contact hours than the cognitive-behavioural 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 pre-contemplation, a stage at which the smoker has no interest in quitting, to contemplation, to prepare for action, to the 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 behavioural 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.
Clinical Studies:
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.
The 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. The 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 smoke* and cessation or absit*. 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 behavioural 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
References:
1. World Health Organization. Report on The Global Tobacco Epidemic, 2011: Warning About The Dangers Of Tobacco. Geneva, Switzerland: World Health Organization; 2011.
2. Royal College of Physicians. Nicotine Addition in Britain. London, United Kingdom: Royal College of Physicians; 2000.
3. Hunt W. Learning Mechanisms In Smoking. New Brunswick, NJ: Transaction Publishers; 2007.
Office of National Statistics. Smoking-related Behaviour and Attitudes, 2008/09. Kew, United Kingdom: Office for Public Sector Information; 2009.
4. Taylor T, Lader D, Bryant A, Keyse L, Joloza MT. Smoking-related Behaviours And Attitudes. 2005. London, United Kingdom: Office for National Statistics; 2005.
5. Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz N, Curry SJ. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville MD: US Department of Health and Human Services, Public Health Service; 2008
6. Costello, M., Sproule, B., Victor, J., Leatherdale, S., Zawertailo, L., & Selby, P. (2011). Effectiveness of pharmacist counselling combined with nicotine replacement therapy: a pragmatic randomized trial with 6,987 smokers. 7. Cancer Causes & Control: CCC, 22(2), 167-180.
Collaborating Centre for Mental Health (Great Britain)., & Institute for Health and Clinical Excellence (Great Britain). (2009).Schizophrenia core interventions in the treatment and management of schizophrenia in primary and secondary care (update).
8. Stead LF, Lancaster T. Group behaviour therapy programs for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001007.
9. Becoña, E., & Míguez, C. (2008). Group Behavior Therapy for Smoking Cessation. Journal Of Groups In Addiction & Recovery, 3(1/2), 63-78.
10. Skaar, K. L., Tsoh, J. Y., McClure, J. B., Cinciripini, P. M., Friedman, K., Wetter, D. W., & Gritz, E. R. (1997). Smoking cessation 1: An overview of research. Behavioural Medicine, 23, 5 -13.
11. Heron, K. E., & Smyth, J. M. (2010). Ecological momentary interventions: Incorporating mobile technology into psychosocial and health behaviour treatments. British Journal Of Health Psychology, 15(1), 1-39.
12. Borland, R., Balmford, J., & Hunt, D. (2004). RESEARCH REPORT The effectiveness of personally tailored computer-generated advice letters for smoking cessation. Addiction, 99(3), 369-377
13. Sutton, S., & Gilbert, H. (2007). Effectiveness of individually tailored smoking cessation advice letters as an adjunct to telephone counselling and generic self-help materials: a randomized controlled trial. Addiction, 102(6), 994-1000.
14. Travis, H. E., & Lawrance, K. G. (2009). Randomized Controlled Trial Examining the Effectiveness of a Tailored Self-Help Smoking-Cessation Intervention for Postsecondary Smokers. Journal Of American College Health, 57(4), 437-444.
15. Stead, L., Perera, R., & Lancaster, T. (2007). A systematic review of interventions for smokers who contact quitlines. Tobacco Control, 16 Suppl 1i3-i8.
16. Cinciripini, P.M.; Lapitsky, L.; Seay, S.; Wallfisch, A.; Kitchens, K.; and Van Vunakis, H. The effects of smoking schedules on cessation outcome: Can we improve on common methods of gradual and abrupt nicotine withdrawal. J Consult Clin Psychol 63(3):388-399, 1995.
17. Hall, S.M.; Reus, V.I.; Muñoz, R.F.; Sees, K.L.; Humfleet, G.; Hartz, D.T.; and Triffleman, E. Nortriptyline and cognitive behavioural therapy in the treatment of cigarette smoking. Arch Gen Psychiatry, in press.
18. Prochaska, J.O.; DiClemente, C.C.; Velicer, W.F.; and Rossi, J.S. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychol 12(5):399-405, 1993.
19. Sharon M. Hall, Gary L. Victor I. Reus. Psychological Intervention and Antidepressant Treatment in Smoking Cessation. Arch Gen Psychiatry. 2002;59(10):930-936.
20. Barth, J., Bengel, J. & Critchley, J. Efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease: a systematic review and meta-analysis ann. behav. med. (2006) 32: 10.
21. Yap SY, Lunn S, Pang E, Croft C, Stern M. A psychological intervention for smoking cessation delivered as a treatment for smokers with chronic obstructive pulmonary disease: Multiple needs of a complex group and recommendations for novel service development. Chron Respir Dis. 2015 Aug;12(3):230-7.
