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Behavioral Tobacco Cessation Treatments: Yesterday’s News or Tomorrow’s Headlines?

From the H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL.

Address reprint requests to Thomas H. Brandon, PhD, Tobacco Research and Intervention Program, H. Lee Moffitt Cancer Center and Research Institute, 4115 E. Fowler Ave, Tampa, FL 33617; email: brandont{at}moffitt.usf.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION REFERENCES

 
ABSTRACT: This article reviews behavioral treatments (broadly defined) for tobacco use, discusses cessation treatments for cancer patients, and predicts the future direction of behavioral interventions. During the past decade, progress in behavioral treatments for tobacco use has not kept pace with progress made in the development of pharmacotherapies. Nevertheless, the efficacy and cost-effectiveness of behavioral treatments compare favorably with the pharmacotherapies. Intensive behavioral interventions with empirical support are reviewed, and the difficulty of attracting smokers to intensive smoking clinics is discussed. Because there has been little research on tobacco cessation interventions designed specifically for cancer patients, clinicians should follow the Five A’s suggested in the recent Clinical Practice Guidelines: Ask, Advise, Assess, Assist, and Arrange. The future of behavioral treatments will likely emphasize both minimal interventions (via telephone, Internet, and written materials) designed for broad impact and intensive interventions targeted to particular subgroups of smokers with the need and motivation for them (eg, the heavily nicotine-dependent, pregnant women, depression-prone smokers, and medical patients). A blurring of the distinctions between behavioral interventions, pharmacotherapies, and community-oriented approaches is also likely as multidimensional cessation strategies are developed.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION REFERENCES

 
THE 1990S WERE exciting and productive times for the field of tobacco control. These times included some of the first legal decisions against the tobacco industry, state and national settlements with the tobacco industry, evidence that the multifaceted tobacco control programs in California and elsewhere were working, and renewed attention to preventing tobacco initiation among adolescents. In the area of tobacco cessation, the last decade saw the ascendancy of pharmacotherapies as the most widely used aids for quitting smoking. Nicotine replacement therapies, first introduced in the mid-1980s, now include nicotine chewing gum, nicotine patch, nicotine nasal spray, and nicotine inhaler. The first nonnicotine product, bupropion hydrochloride, received Food and Drug Administration approval late in the decade. These products are now used by millions of smokers, and additional pharmacotherapies remain under development.

Despite these advancements during the 1990s—or perhaps because of them—one component of tobacco control has stagnated: behavioral tobacco cessation treatments. (In this article, a broad definition of behavioral treatment is used that covers nonpharmacologic treatments delivered directly to individual smokers. That is, it excludes only the pharmacologic and community-oriented interventions covered by the other two articles in this series.)

The stalled progress of behavioral treatment development has been noted before,^1,2 and it most likely has several causes. The first, and probably most important, is that the new pharmacotherapies excited and attracted the attention of tobacco researchers away from the development of behavioral interventions, which had previously been the only form of treatment. Moreover, in contrast to the pharmacotherapies, there has never been much, if any, economic incentive or reward for developing behavioral interventions. Traditionally, a newly developed treatment is described in a peer-reviewed journal article and enters the public domain. Likewise, there are few resources for efficient and broad dissemination of new behavioral treatments. Finally, funding for the research and development of behavioral interventions has been hard to come by. Without industry support, researchers rely primarily on the National Institutes of Health for funding. But, until recently, it has been difficult to acquire federal funding for early stage behavioral treatment development through existing funding mechanisms.³

EFFICACY OF BEHAVIORAL TREATMENTS
An alternative explanation might be that progress in behavioral treatments stalled because the existing treatments were ineffective or less effective than the new pharmacotherapies. However, this explanation is not born out by the empirical literature. The recent Clinical Practice Guideline published by the United States Public Health Service was based on a meta-analysis of clinical trials published between 1975 and 1999.⁴ The Guideline includes the odds ratios (ORs) for a variety of interventions. The ORs for the five Food and Drug Administration–approved pharmacotherapies ranged from 1.5 (for nicotine gum) to 2.7 (for nicotine nasal spray). This is consistent with previous reviews that concluded that pharmacotherapies tend to double abstinence rates after cessation attempts.⁵ The Guideline also reported ORs for some behavioral interventions. These included intratreatment social support (OR, 1.3), extratreatment social support (OR, 1.5), general problem-solving (OR, 1.5), rapid smoking (OR, 2.0), and other aversive smoking (OR, 1.7). It is important to note that these strategies are usually included as components within multicomponent behavioral treatments. For example, a typical behavioral-oriented smoking clinic might be administered in a group format, providing both social support and didactic help with acquiring and using coping skills to deal with nicotine withdrawal and urges to smoke. Despite this piecemeal evaluation of behavioral treatment components, the ORs generated for these components were in the same range as for the pharmacotherapies.

COST-EFFECTIVENESS
The utility of an intervention must be judged not only by its efficacy but also by its cost-effectiveness. A 1997 study⁶ calculated the cost-effectiveness ratios of various smoking cessation treatments based on the previous edition of the Clinical Practice Guidelines published by the Agency for Health Care Policy and Research.⁷ For each treatment, the cost per life-year saved was calculated. It is again instructive to compare behavioral counseling with pharmacotherapies. For example, nicotine gum therapy with only minimal counseling (ie, < 3 minutes with the clinician) reportedly cost $6,135 per life-year saved, and nicotine patch therapy cost $3,246 per life-year saved. These are quite respectable cost-effectiveness ratios compared with many health promotion and disease prevention interventions that we take for granted.⁸ Yet the same analysis found that the cost per life-year saved for intensive group counseling without pharmacotherapy was only $1,496. When nicotine and patch therapies were each examined in combination with varying intensities of counseling, the general pattern emerged such that, as amount of counseling increased, the cost-effectiveness of the combined interventions improved. The overall conclusion from both the efficacy and cost-effectiveness literatures is that a combination of pharmacotherapy and intensive counseling produces the best smoking cessation outcomes.

SMOKING CESSATION FOR CANCER PATIENTS
Patients diagnosed with cancer represent a special population of smokers who have a particularly strong rationale for quitting smoking. Depending on the type of cancer, the prevalence of smoking may be quite high among cancer patients, exceeding 50% among lung cancer patients.⁹ Not surprisingly, many patients spontaneously quit smoking on receiving their diagnosis. But the intensity of nicotine dependence is such that a significant number of patients continue to smoke despite receiving diagnoses of serious smoking-related illnesses.

Given the unique motivations and circumstances of cancer patients, one would expect to find smoking cessation interventions targeting this population of smokers. However, a recent literature review identified only four published clinical trials of smoking treatments focusing on cancer patients.⁹ In each of these trials, smoking cessation counseling was delivered by either surgeons or nurses, and counseling began in the hospital and continued after discharge. Unfortunately, three of these trials suffered from inadequate sample sizes,^10-12 and the fourth had an inappropriate control group.¹³ Thus, despite obtaining respectable absolute abstinence rates, differences between conditions were not statistically significant.

Because there is not yet any empirically supported smoking cessation treatment explicitly designed for cancer patients, clinicians with cancer patients who smoke are best advised to follow the recommendations of the Clinical Practice Guideline.⁴ The basic heuristic for intervening with the patient who smokes is the Five A’s, which is consistent with a variety of other published strategies.

1. (1) Asking the patient if he/she uses tobacco;
   
2. (2) Advising the patient to quit tobacco use;
   
3. (3) Assessing the patient’s willingness to quit tobacco use;
   
4. (4) Assisting the patient in his/her quit attempt; and
   
5. (5) Arranging follow-up contacts and relapse prevention.
   

Every clinician needs to get into the habit of asking patients about tobacco use and advising them to quit. Given the importance of tobacco use as a health risk, such assessment and advice constitute only the minimal standards for ethical clinician behavior. Tobacco use status should be considered a vital sign requiring regular assessment.¹⁴ Nevertheless, studies continue to find that assessment of tobacco use and advice to quit smoking are inconsistently practiced by clinicians.¹⁵

After asking and advising, the third step is to assess the patient’s willingness to quit. For the patient unwilling to quit at this time, the clinician should help increase quitting motivation by discussing the immediate and long-term risks of continued smoking, benefits of quitting, and the patient’s perceived barriers to quitting (eg, weight gain, withdrawal symptoms). The clinician should take care to make the discussion personally relevant to the patient, and include risks and benefits in addition to those related to health, if appropriate (eg, economic benefits, role modeling for children, improved sense of taste).

For the patient willing to quit, the clinician should provide assistance, such as helping the patient choose a target quit date in the near future and appropriate pharmacotherapy, providing social support, advising the patient about the nature and timecourse of nicotine withdrawal, recommending behavioral and cognitive coping responses (eg, distracting activities and self-talk) to use when the patient experiences urges to smoke, and perhaps making a referral to an intensive behavioral counseling program (ie, a smoking cessation clinic). Thus, even if the patient does not desire or pursue intensive counseling, the conscientious physician will have at least touched on the essential elements of a behavioral intervention. There is a dose-response relationship between the amount of clinician contact and smoking cessation outcome. The Guideline reported a meta-analysis of 43 studies (120 arms), which found that outcomes improved as person-to-person contact time increased. Compared to no contact, the ORs for minimal counseling (< 3 minutes), low-intensity counseling (3 to 10 minutes), and higher-intensity counseling (> 10 minutes) were 1.3, 1.6, and 2.3, respectively. The estimated abstinence rates ranged from 10.9% for no contact to 22.1% for higher-intensity contact.⁴

The last of the Five A’s involves arranging follow-up contact. This strategy is also based on the evidence that total contact time predicts treatment outcome. Follow-up contact can take the form of additional office visits, telephone calls, or even written materials sent through the mail.¹⁶ Such contact communicates the importance of the cessation attempt, provides social support, and offers the opportunity to intercede if problems have developed (eg, medication complications, depression, or smoking relapse). Because the risk of relapse is greatest immediately after quitting, follow-up contact ideally should begin close to the target quit date.

Further elaboration and examples of the clinician’s role in motivating and helping the patient quit smoking can be found in the Clinical Practice Guideline⁴ and elsewhere.¹⁷

INTENSIVE BEHAVIORAL INTERVENTIONS
Despite the recent slowdown in the development of behavioral interventions for tobacco use, there are existing intensive behavioral interventions that have empirical support. These are briefly reviewed.

Multicomponent Coping Skills Training This treatment represents the generic intensive smoking cessation intervention and is the standard by which new treatments should be judged. It has many aliases, including coping response therapy, problem-focused treatment, relapse-prevention training, and cognitive-behavioral therapy.^18-20 The common elements of these treatments include social support; didactic information about nicotine dependence, withdrawal symptoms, and situations that are risks for relapse (eg, alcohol use, negative moods, or presence of other smokers); and in vivo training in the use of cognitive and behavioral responses to cope with urges to smoke that reduce the risk of relapse. There may also be instruction on how to recover from an initial smoking lapse without progressing to a full relapse. Pharmacotherapy is often integrated into multicomponent programs.

Rapid Smoking Aversive therapies for smoking cessation were developed in the 1970s. These were true behavioral interventions based on Pavlovian principles of counterconditioning.²¹ The most widely used technique was rapid smoking, which typically involved smokers in a controlled clinical setting who deeply inhaled on cigarettes at 6-second intervals. Up to nine cigarettes would be smoked per treatment session. Rapid smoking produced strong aversive reactions to cigarettes, and these conditioned responses predicted long-term abstinence.^19,22 As noted above, the meta-analyses for the Clinical Practice Guidelines found rapid smoking to be one of the most efficacious cessation strategies. However, its use greatly declined after the introduction of nicotine replacement therapies that did not require aversion yet were similarly effective.¹⁹ Interestingly, rapid smoking has recently been rediscovered and is being investigated as an aftercare strategy to reduce cravings and prevent relapse.²³

Scheduled Reduced Smoking There are two new behavioral treatments that bucked the aforementioned trend of stalled progress in behavioral interventions. The first, scheduled reduced smoking, involves 3 weeks of gradually reduced nicotine intake. In contrast with other smoking cessation strategies involving gradual reduction of smoking, the patient does not control when and where smoking will occur. Rather, an algorithm is used to determine when each cigarette is to be smoked based on the passage of time. The theoretical advantage of this strategy is that particular smoking-related situations and moods do not continue to be reinforced by nicotine intake. Yet the gradual reduction of smoking allows for an attenuation of withdrawal symptoms as the patient learns to cope with most situations without cigarettes. In effect, this treatment can be conceptualized as a variation of nicotine replacement therapy, with the nicotine provided by noncontingent cigarettes. Two studies have demonstrated the efficacy of this treatment,^24,25 and it has been included on a short list of cessation treatments with evidence of efficacy.²⁶

Depression-Focused Counseling The second new treatment developed during the past decade, and also cited on the same short list, targets smokers with a history of major depressive disorders. Incorporated into a standard coping skills treatment are cognitive-behavioral therapy techniques developed and validated for treating major depression. There is a strong, probably bidirectional association between tobacco smoking and vulnerability to negative moods up to and including major depression.^27,28 Individuals with such a vulnerability have particular difficulty in successfully quitting smoking, so it is logical that treatments for depression might benefit smoking cessation. This is the same logic that led to the testing of antidepressants, including bupropion, as smoking cessation aids. The most direct evidence to support this treatment approach was derived from research by Sharon Hall and her colleagues,^29,30 but other studies have also shown that treatments can be developed with differential efficacy for depression-prone smokers.^19,31 Unfortunately, neither depression-focused counseling nor scheduled reduced smoking have been well-disseminated yet, so it would be hard to find local programs that offer these treatments.

LIMITATION TO INTENSIVE BEHAVIORAL TREATMENTS
It is important to acknowledge a serious drawback to traditional, clinic-focused, face-to-face behavioral treatments: Smokers do not want them. It is often noted that only 5% to 10% of smokers quit smoking with such an intervention,³² but today the percentage is most likely even lower. The declining interest in cessation clinics can probably be traced to the availability of pharmacotherapies that are perceived as alternative rather than complementary treatments. There is also some evidence that, because so many smokers quit during the past 20 years, the remaining smokers may be less interested in quitting and more difficult to treat.^33,34 Regardless of their high efficacy and cost-effectiveness, without smokers walking through their doors, even the best clinic-based interventions will have negligible public health impact.

CURRENT TRENDS AND FUTURE DIRECTIONS
Given the reality of limited access by patients to traditional behavioral-focused smoking cessation clinics, there are two trends that have begun and are likely to accelerate in the near future. Progress in behavioral treatments (in terms of both treatment-development and public health impact) should be most pronounced in the areas of minimal interventions and targeted intensive interventions.

Minimal Interventions Because smokers, as a whole, do not want to commit to intensive interventions, there has been a substantial increase in the development of minimal interventions. These interventions might be delivered via telephone hot-lines, the Internet, or written literature. A characteristic of many of these recent interventions is that they are either targeted to particular subgroups of smokers (eg, pregnant women), or they are tailored to the characteristics of individual smokers. A unique approach of one minimal intervention was to target former smokers in an effort to reduce smoking relapse.¹⁶ Participants received eight theory-based relapse-prevention booklets over the course of a year, which reduced relapse among recent quitters during that period by approximately two thirds, at a cost of only $126 per year of abstinence gained. Interventions tailored at the level of the individual have produced some encouraging initial findings,^35,36 but fully controlled studies have yet to be conducted. It is likely that, for minimal interventions to be successful, they will need to be based on sound theory and empirical research, which has not always characterized health promotion materials.

Targeted Intensive Interventions Although it may be tempting to give up on intensive interventions due to their limited overall public health impact, this would be a mistake. There are subgroups of smokers who should particularly benefit from intensive behavioral counseling and who may continue to be motivated to seek it out. Examples of these subgroups include heavily nicotine-dependent smokers who have been unable to quit via less intensive interventions, depression-prone smokers, as discussed above, pregnant and postpartum women, and patients with smoking-related medical disorders, such as cancer patients. Although the proportion of smokers who both need and want intensive interventions may be a fraction of the total smoking population, it is vital that such interventions remain available to them. Moreover, as patients and clinicians become more realistic about the effectiveness of pharmacotherapies, behavioral interventions may regain attractiveness for many smokers. If behavioral interventions are to show notable improvements in efficacy, however, researchers will need to build new treatments on a solid base of theory and research from areas such as learning, communication, and behavior change.¹

In summary, the future of tobacco cessation interventions is likely to involve a blurring of distinctions between behavioral, pharmacologic, and community-oriented interventions. The most potent interventions are likely to continue to be multicomponent intensive behavioral interventions that include pharmacotherapy, yet the greatest public health impact may be produced by community-oriented minimal interventions that draw on behavioral theory and research. Although this eclectic trend will probably not make headlines, its cumulative effect on the prevalence of tobacco use, and thus, the population’s health, may be substantial.

	ACKNOWLEDGMENTS

 
Supported by grant no. CA 80706 from the National Cancer Institute and grant no. DA 10484 from the National Institute on Drug Abuse.

	REFERENCES

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This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Brandon, T. H. Search for Related Content PubMed PubMed Citation Articles by Brandon, T. H.