0025-7125/92 $0.00 + .20

CIGARETTE SMOKING

METHODS OF SMOKING CESSATION Jerome L. Schwartz, MBA, DrPH

People who quit smoking live longer than those who continue to smoke. Quitting smoking decreases the risk of lung cancer and many other cancers, heart disease, stroke, chronic lung diseases, and respiratory illness. 97 Ex-smokers have better health status than do current smokers. Ex-smokers have fewer days of illness, fewer health complaints, better self-reported health status, and reduced rates of bronchitis and pneumonia. 97 About 40 million adult Americans have quit smoking, representing nearly half of all living adults who have ever smoked. Cigarette smoking, however, remains a difficult habit to break. The results of early studies indicated that many smokers must try several times before they can successfully quit. 86 Although most people who quit smoking do so without the use of professional help or an organized program, many smokers are unable to stop on their own and seek assistance in quitting. In response to this need, a wide variety of smoking cessation methods have been developed. Early Programs

The first public tobacco withdrawal clinics were started in Stockholm in 1955. 15 These early clinics combined medications with educational lectures, pamphlets, and physician counseling over a 10-day course. During the 1960s, more than 100 different smoking cessation programs were described in the United States, Canada, Europe, Japan, Formerly from the University of California at Davis, Davis, California, and currently retired MEDICAL CLINICS OF NORTH AMERICA VOLUME 76' NUMBER 2 • MARCH 1992

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and Australia. HO During the 1970s, about 300 cessation programs were reported.82, 87 Over the past four decades, there has been a change in the emphasis of cessation methods. s2 In the late 1950s, methods were primarily educational or based on medication. 80 The leading programs in the 1960s and 1970s were five-day plans, group discussion, and conditioning-based procedures, such as rapid smoking and satiation. SI, 87 Other popular treatments in the 1970s were self-help, group therapy, counseling, hypnosis, and self-management approaches. 84, 87 By the 1980s, self-help, multiple programs, hypnosis, acupuncture, physician advice and counseling, nicotine chewing gum, skills training/relapse prevention, and mass media and community programs were emphasized. 82 Current Approaches

Although some methods have changed very little over the past 25 years, others have gotten more sophisticated. Methods have been specifically developed for certain population groups (e.g., pregnant women, blacks, Hispanics, youth, heavy smokers, blue-collar workers)Y The total environment of both the smoker and nonsmoker has become involved in treatment, and the focus has shifted to community approaches. In this article, cessation methods are discussed under eight categories: self-care, clinics and groups, medication, behavioral methods, physician advice and counseling, hypnosis, acupuncture, and mass media and community programs. The discussion of physician methods and medication is limited because these topics are covered in other articles in this issue. CESSATION METHODS Self-Care

A variety of aids have been produced to assist smokers in stopping smoking. 81, 82, 87 The earliest materials were lobeline, filters, stop-smoking books, and quit kits. Later audiotapes, correspondence courses, and smokeless cigarettes were marketed. More recently, videos and computer programs have become available. Several dozen quit-smoking books, guides, and pamphlets have been produced by voluntary organizations, government agencies, insurance companies, and funded smoking projects. 82 Some of these materials are described below. The American Cancer Society (ACS) has developed a variety of motivational pamphlets. The I Quit Kit consists of instructions for quitting and tips on how to remain off cigarettes. Tips for quitting are also available in an ACS booklet, Smart Move. A pamphlet to be used

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in conjunction with the Great American Smokeout covers tips, exercise, and diet (How to Stay Quit Over the Holidays). The National Cancer Institute (NCI) designed the Helping Smokers Quit Kit, containing materials for the smoker and the physician. NCI updated this kit with Quit for Good. Kits were developed for pharmacists, dentists, respiratory therapists, and other health professionals. 84 The American Lung Association (ALA) produced two manuals for people who wish to quit on their own: a 64-page cessation guide, Freedom from Smoking in 20 Days, and a 28-page maintenance booklet, A Lifetime of Freedom from Smoking. The cessation guide includes part of the Self-Test, identifies smoking triggers, and offers information about controlling weight, handling smoking situations, deep-breathing, and relaxation exercises. The maintenance booklet supports the ex-smoker after quitting. These manuals are well designed and have proven to be very popular. Shortened versions are available under the titles Freedom from Smoking for You and Your Family and Freedom from Smoking for You and Your Baby. The ALA also produced a home video, In Control. Several "how to quit smoking" books have been written, primarily by ex-smokers and psychologists. Glasgow et al compared the ACS I Quit Kit with two behavioral self-help books. 39 Under self-help conditions, the ACS manual came out best. Glasgow et al postulated that smokers who receive relatively complex behavioral programs for cessation have great difficulty in following them. 37 When a therapist led the treatment using the same materials, the behavioral books came out better than the ACS manual. 39 An early aid to quitting, still marketed today, is a filter that reduces the tar and nicotine levels, permitting the smoker to be weaned from the chemical addiction. 82 Teledyne Water Pik's "One Step at a Time" consists of four reusable filters that progressively reduce the nicotine content. Each filter is supposed to be used for 2 weeks. As with any cessation method that does not address the psychological addiction of smoking, evaluations of filters alone have shown little long-term success. A new filter system is being marketed by Vipont Pharmaceuticals. "Kick The Habit" consists of three "nicotine fading" filters to be used over 21 days.84 The package addresses the psychological addiction by including a deck of cards aimed at overcoming this dependence and offering coping tips to be used after quitting. Lando and McGovern added "Kick the Habit" filters to clinics consisting of 16 sessions held over 9 weeks. 60 At 1 year, 30% of the filter subjects were abstinent, compared with 23% of subjects who were assigned to brand switching. E-Z Quit, a smokeless cigarette, is intended to simulate the taste of tobacco smoke. It consists of a plastic cigarette with three mentholflavored capsules. The Food and Drug Administration (FDA) has ruled that products such as filters and smokeless cigarettes are medical devices that have not provided data to demonstrate their effectiveness. 29 Other self-help cessation aids are quitting by mail, taped telephone messages, telephone hotlines, cigarette holders and dispensers, videotapes, and several types of computer-based methods. 82

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A national survey of adult smokers in the United States found that about 90% of successful quitters use self-care methods rather than an organized program. 24 Of 17 million who reported that they attempted to quit in 1986, 2 million used organized programs. 24 Heavy, more addicted smokers are more likely to participate in an organized cessation program than people who smoke less. Fiore et al conclude that organized programs play an important public health role by serving heavier smokers, those most at risk of tobacco-related morbidity and mortality.24 Evidence from 10 prospective studies of people who attempted to quit on their own indicates that self-quitters' success rates, for a single attempt to quit, are no better than those reported for treatment programs. lO An NCI expert panel concluded that self-help strategies may be the preferred means by which smokers stop and can produce success rates approaching those of formal programs at lower cost and with greater access to relevant populationsY The panel recommended that self-help/minimal intervention programs include information about the health and social consequences of smoking and specific strategies and exercises for successful quitting, maintenance, relapse prevention, and recycling. We found out a long time ago that smokers would rather quit on their own but with help from aids and guides. 85 A variety of self-help materials have been developed to assist smokers who want to quit on their own. Self-help techniques appear to be cost-effective in terms of their minimal use of professionals and programs. But, to be successful, self-help packages must pay attention to both the physical and psychological dependencies of smoking. Also, if maintenance is included in the method, long-term success rates increase. Clinics and Groups

Following the lead of clinic programs in Europe, formal cessation methods were developed in the United States. Local units of cancer, lung, and heart associations and the Seventh-day Adventist Church initiated clinic programs that are available in many localities. 87 Voluntary Agencies. Clinic methods generally use an educational or a group counseling format. ACS Helping Smokers Quit clinics were an educational approach standardized throughout the United States by use of selected guides, printed materials, and trigger films presented by extensively trained volunteers. These ACS clinics spread to its 58 divisions and 3100 local units. 87 In the 1980s, the ACS revised its clinic program. Its new program, FreshStart, consists of four I-hour small-group sessions aimed at understanding why people smoke, handling withdrawal symptoms, practicing stress management, and providing tips to help the individual refrain from smoking. The ALA has also provided clinic guidelines to local units, but individual chapters formulate their own programs. In the 1980s, they

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produced the excellent quitting and maintenance manuals that emphasized self-help. The ALA developed a clinic program based on education and behavior modification principles. The clinic uses the Freedom from Smoking manual in a seven-session format. The method offers a systematic approach aimed at reducing the stress of quitting. The ALA has enlisted interested corporations to sponsor their programs utilizing the self-help and clinic modes. The ACS and ALA formats and materials have been modified and adopted for cessation programs sponsored in communities, the workplace, industry, hospitals, the military, health departments, medical groups, and schools. Methods vary in length from 3 to 8 weeks. Several agencies run active cessation clinics based on their own treatments, such as the American Health Foundation in New York City, Roswell Park Memorial Institute in Buffalo, and the Kaiser Foundation Health Plan in California. 82, 87 The Seventh-day Adventist Church launched the Five-day Plan in 1960. 68 The format consisted of five consecutive sessions of 90 to 120 minutes each. Groups varied from 15 to several hundred people. For the first several years there were no follow-up treatment sessions, but maintenance sessions have been added. Physical fitness, restrictions on coffee and alcohol, exercise, balanced diets, hot and cold showers, deep breathing, and a "buddy system" were encouraged. Sessions discussed the physiologic effects of smoking, and actual lung specimens were displayed. Clergymen, psychologists, or physicians presented lectures and conducted counseling. The plan enrolled more smokers than any other program and was widely copied in modified form by professionals and lay people. 82 In 1985, the Seventh-day Adventist Church introduced the BreathFree Plan as an update to the Five-day Plan. Breath-Free consists of eight sessions with an emphasis on behavior modification techniques. Sessions include printed materials, group discussion, lectures, and videos. A survey was conducted of 268 program directors to evaluate the acceptance of the new plan. 66 Although generally viewed as a helpful system, Breath-Free was criticized because it lacked a systematic followup program to prevent relapse. Commercial Programs. Proprietary groups began offering cessation methods to smokers in the late 1960s. At first, most companies were local, but several national companies developed. Some of these companies were commercially successful, with SmokEnders and Schick emerging as the most prominent national firms.82, 87 SmokEnders started in New Jersey in 1969. This company uses community facilities (churches, schools, hotels) instead of their own buildings. In terms of acceptance and marketing, SmokEnders has been the most successful commercial stop-smoking program. SmokEnders is a highly structured, systematic technique emphasizing positive reinforcement and changing attitudes. The format consists of six weekly meetings, with quit day after the fourth session. 82 All moderators are graduates of the program. Schick Centers for the Control of Smoking started in Seattle in

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1971. All centers are owned and operated by the company. Schick has invested in building facilities and television promotion. Because of lagging public interest, Schick closed its Eastern United States units and concentrated in five Western states. The Schick method consists of aversive conditioning (low-grade shocks and smoke satiation) for 5 days, followed by 6 weeks of group meetings. 82 Two other national organizations with similar treatment programs were formed in the 1980s. Smokeless and Smoke Stoppers license their programs, mainly to hospitals and businesses. These organizations conduct training programs and provide materials to licensees. The Smokeless and Smoke Stoppers systems are educational, intensive, and highly structured. Attractive pamphlets guide the smoker through the program. Use is made of stress management, positive rewards and reinforcements, food management, and negative smoking practices. Four classes are held the first week, designed to enable smokers to quit, followed by 2 or 3 weeks of maintenance sessions. 82 A review of the telephone yellow pages from over 200 US cities for the years 1976 and 1977 revealed that stop-smoking programs were available in most major cities and in many smaller communities. 87 A similar review for the years 1984 and 1985 of the 47 largest US cities found an increase in listings from 112 to 385. 82 What was striking about the differences between the two periods was that commercial programs, which made up about 50% of the listings in the first survey, accounted for only 20% in the later survey. Hypnosis made up 17% of the listings in the earlier survey but almost 33% in the second survey. Medication

General Pharmaceutical Agents. Two general categories of pharmaceutical agents have been used to help people quit smoking: agents developed specifically to help smokers break the habit and drugs prescribed to overcome withdrawal symptoms. Smoking deterrents have been available since before 1900. Early deterrents consisted of herbs, spices, and mouthwashes that produced a disagreeable taste for the smoker. 80 These preparations create their deterrent effect by irritating the oral and nasal mucosa. Other products aim at diminishing the sensory drives or creating a dry mouth. In 1982, an FDA panel concluded that drug products such as mouthsprays, chewing gum, and tablets containing silver acetate are not effective as smoking cessation aids. 28 Use of lobeline as a treatment for smoking, combined with educational programs or dispensed through withdrawal clinics, was a popular method during the 1960s. 8o Lobeline was considered to be a nicotine "substitute" and was dispensed in the form of tablets, lozenges, and chewing gum and by injection. Lobeline-based products are still sold over the counter (e.g., Bantron, Nikoban, and CigArrest). Lobeline has irritating effects in the mouth and stomach. It has been contended that

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lobeline sulfate satisfies the craving for nicotine and thus helps the smoker quit. There is no scientific evidence, however, to support this contention. 28 ,53 The second category of pharmaceutical agents includes those that attempt to reduce the physiologic and psychological withdrawal symptoms related to quitting. Some have a relaxing effect whereas others are intended to help the patient sleep, prevent weight gain, or overcome nervousness or fatigue. Drug types include sedatives, anticholinergics, tranquilizers, sympathomimetics, anticonvulsants, and nicotine replacements. Prior to nicotine chewing gum, pharmacologic agents to aid in smoking cessation had not been shown to be advantageous. Jarvik and Gritz reviewed the literature in 1977 and concluded that drug therapy was not particularly useful in overcoming the smoking habit. 53 Clonidine, however, a drug used to treat hypertension, has been found to reduce the urge to smoke. It is speculated that clonidine may relieve nicotine withdrawal symptomsY A clonidine transdermal patch is currently being tested as a smoking cessation aid. 96 Other agents, including mecamylamine, are currently undergoing testing as quitsmoking aids. 49 , 75 Nicotine Replacement Therapy. Since nicotine and psychological dependence are the two key components of tobacco addiction, Ferno advanced the idea of providing an alternate source of nicotine. In this way, individuals wishing to stop smoking could focus on combating their psychological dependence while nicotine replacement addressed the acute physiologic effects of nicotine withdrawa1. 21 Research under Ferno's direction led to the development of nicotine polacrilex gum, marketed as Nicorette. Nicotine polacrilex is a prescription drug in the form of chewing gum containing 2 mg of nicotine, which is bound by an ion-exchange resin to allow for slow release of nicotine when chewed. Proper chewing for 20 to 30 minutes can result in the release of 90% of the nicotine. 22 Patients are advised to use the gum for at least 3 months. Some smokers, however, continue to chew the gum beyond the 6 months of recommended use. Lakeside Pharmaceuticals, a Division of Merrell Dow, undertook a massive promotional campaign in 1984 after the FDA approved Nicorette. As a result of this campaign, Nicorette became one of the fastestselling prescription drugs ever introduced. Sales were 42 million dollars in 1984 and reached 60 million dollars in 1987. 96 Surveys have shown that 66% of the prescriptions for Nicorette were initiated by patients rather than physicians. 96 The availability of nicotine polacrilex may have encouraged physicians and dentists to become more active in advising their patients to quit smoking because they now have a specific medical intervention to offer. There are indications, however, that most physicians do not provide proper instructions on the use of the gum. Moreover, Sachs has cautioned that physicians must explain to patients the limitations of nicotine polacrilex. 79 Without counseling or therapy, success rates

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with the product are low. 82, % Practitioners experienced in the use of nicotine gum who provide instructions and additional advice and counseling have achieved good results with nicotine gum. 17, 30, 48, 52, 56, 82, 96 New approaches to nicotine replacement are citric acid spray,62 nasal nicotine solution,54 a nicotine vapor,78 and nicotine transdermal patches. 1, 51, 69, 76 Of these, the nicotine patch appears most promising and has recently received FDA approval (see Addendum on page 472). One study reported that the percentage of people who continued to abstain from smoking 6 months after wearing a nicotine patch was significantly greater than for those who were assigned to a placebo patch. 76 Daughton claims that nearly 40% of nicotine-patch users were able to abstain after 2 weeks, compared with 13% for placebo-patch users.

Behavioral Methods

Behavior modification therapies entail two divergent approaches to behavior change. One approach uses punishment, including aversion therapy, and the other uses positive reinforcement, including selfmanagement procedures. Among the self-management therapies are stimulus control, contingency contracting, restricted environmental stimulation therapy, relaxation, and desensitization. These procedures have had only limited success in the area of smoking cessation and are not discussed here. The reader is referred to reviews of behavioral methods for additional information. 37, 64, 72, 81, 82, 87 Aversive Techniques. Aversion therapy has been used to treat a wide assortment of disorders. Early studies included electric shock, desensitization training, breath holding, overexposure to stale smoke, and covert sensitization. 8o Use of electric shock as a punishing stimulus to eliminate smoking behavior has had limited success. The most promising techniques use a form of smoke aversion such as satiation or rapid smoking. With satiation treatment, subjects are required to increase the number of cigarettes smoked and the rate at which they are smoked. Satiation has generally been combined with other procedures. Lando 38 and Best et al 4 have designed successful multicomponent smoking cessation programs that include satiation. Rapid smoking requires the subject to inhale from a cigarette once every 6 seconds for the duration of the cigarette or until nauseated. Danaher's review showed that rapid smoking produced relatively good results. 14 There was concern that rapid smoking created a risk to the cardiopulmonary system, but serious consequences have not been observed. Nevertheless, care should be taken to screen subjects and monitor them closely during treatment. Multicomponent treatments including rapid smoking have also shown good long-term successY, 72, 82 Self-Management Techniques. Strategies for quitting smoking through self-management encompass a variety of techniques, some of

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which are used with aversive methods. 46 These techniques are generally directed by leaders or therapists. Self-Monitoring. Most cessation programs require participants to keep records of the number of cigarettes smoked to assess baseline smoking, progress in treatment, and outcome. Requirements for selfmonitoring programs have ranged from counting cigarettes smoked for just 1 day to elaborately recording the time, place, activity, mood, and desire level when smoking each cigarette for 1 or more weeks. McFall demonstrated that when an individual begins to closely monitor his or her smoking behavior, this behavior is likely to change, even though change may not be intended or desired. 67 Glasgow comments that self-monitoring can be useful provided that the self-monitoring assignments are not overly complex, are varied, and are not required for a lengthy period. 37 Nicotine Fading. Slowly reducing nicotine intake by changing to brands with lower nicotine content (brand fading) or cutting down the number of cigarettes smoked (tapering) are ways of gradually withdrawing from nicotine. Tapering results have not been very positive. 82 As cigarettes are reduced, each remaining cigarette can become more reinforcing. With nicotine fading, however, individuals can continue to smoke the same number of cigarettes while lowering nicotine intake. Some investigators have shown good results with nicotine fading. 82 Nicotine fading by changing brands was introduced by Foxx and Brown, who advocated reductions in nicotine content of 30%, 60%, and 90% over a 3-week period. 31 Some investigators have used a different schedule, and most include other procedures in the treatment. Attesting to the interest in nicotine fading, many trials were conducted in the 1980s. Brown and Lichtenstein combined nicotine fading with relapse prevention training/ whereas Lando and McGovern used it with smoke holding. 59 Both studies showed good results, but Lichtenstein's group was not able to replicate the findings when combining nicotine fading with relaxation techniques. 3 Other studies of nicotine fading have produced variable outcomes. 82 For those smokers who choose to reduce their physiologic dependence on nicotine gradually, nicotine fading offers that opportunity, but training in coping strategies and relapse prevention appears to be necessary to achieve and maintain abstinence. Multicomponent Behavioral Programs. Many investigators combine several procedures in their methods. Often there is no theoretical reason for the combination. Sometimes, however, the combinations are intended to increase motivation, break the habit, or help the client to refrain from smoking. Some investigators have taken a "cafeteria" approach by offering a multitude of procedures and leaving it to clients to select the techniques that best suit them. Almost all multiple treatments include some form of self-control procedures (e.g., nicotine fading, abstinence training, relaxation). Many multicomponent programs also include smoke aversion as a way of breaking the habit and self-control to maintain nonsmoking. 4 Hall,46

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Killen,55 and Lando 58 have headed multiple programs that have achieved excellent results. Most multicomponent programs include relapse prevention training that emphasizes the interacting role of coping strategies and commitment in maintaining change in addictive disordersY Relapse prevention has been added to nicotine gum treatment. 30, 55 Multiple programs have achieved the highest quit rates at I-year follow-ups of any behavioral procedure. 82 In a review of behavioral treatment manuals, Glasgow and Rosen noted the potential superiority of multicomponent behavioral approaches. 38 Lichtenstein and Brown64 and Glasgow3? caution that more is not always better. Too many procedures may confuse smokers trying to quit and make it difficult for counselors to provide an integrated treatment. Lichtenstein and Brown comment that multicomponent treatments remain attractive because these programs deal with the multiple factors maintaining smoking as well as the considerable differences among smokers.64 Physician Advice and Counseling

Roles of Physicians. National surveys have indicated that a high proportion of physicians believe that it is their responsibility to help their patients to stop smoking. 9 Wechsler's survey of Massachusetts primary care physicians found that although 93% thought it was very important to eliminate smoking among their patients, physicians had little confidence in their ability to help their patients quit.98 It has been demonstrated, however, that physicians can influence their patients to change their smoking behavior. 63 There are indications that physicians,13, 24, 40, 73 as well as nurses,44 dentists,34 dental hygienists,88 pharmacists/o and respiratory therapists,77 can assist their patients in smoking cessation. Pederson has summarized the findings regarding the impact of a physician's advice to quit smoking on pregnant women and pulmonary and cardiovascular patients. 73 Quit rates among pregnant women range from 1% to 35%. The presence of pulmonary or cardiac problems added credence to the physician's message, resulting in higher quit rates for these patients. Quit rates for pulmonary patients ranged from 10% to 76%, with a median I-year abstinence rate of 31.5%.82 For cardiac patients, quit rates ranged from 11 % to 73%, with a median I-year abstinence rate of 43%.82 Schwartz summarized the findings of 28 physician-based smoking cessation trials with at least a 6-month follow-up, reported between 1965 and 1984. 82 The trials were grouped into those that provided simple advice and counseling and those that included more intensive treatment. The 15 trials with simple advice showed quit rates of 3% to 13% and a median rate of 5%. The 13 interventions with more intensive treatment had quit rates ranging from 13% to 40% and median rates of

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29% (6-month follow-up) and 22.5% (I-year follow-up). In these studies,

simple counseling was enhanced by procedures such as strong messages, warnings, record keeping, follow-ups, a compliance contract, or a demonstration of exhaled air carbon monoxide level. Kottke et al recently conducted a meta-analysis of 39 controlled smoking cessation trials. They found that a team of physicians and nonphysicians using multiple intervention modalities to deliver individualized advice on multiple occasions produced the best result. 57 They concluded that cessation rates could be further improved by increasing the number and intensity of patient contacts and by providing followup visits or contact. The physician can also offer nicotine gum to smokers who are motivated to quit. But, as noted earlier, nicotine gum alone, without the counseling of a physician or smoking cessation specialist, produces few long-term ex-smokers. Glynn and Manley suggest that physicians can reduce smoking among their patients by routinely asking them about their smoking; strongly and sincerely advising them to stop smoking; assisting the patient by setting a quit date, providing self-help material, and prescribing nicotine replacement therapy if appropriate; and arranging follow-up visits (see article by Manley et al).40, 42 Today the physician has many resources to assist patients, such as physician kits/guides and self-help materials. These materials are readily available through the National Cancer Institute, the American College of Chest Physicians, the American Academy of Family Physicians, the National Heart, Lung, and Blood Institute, and others. In addition, there are numerous outlines of procedures that physicians can follow in counseling patients. 70 Recently, Glynn and Manlet2 produced an excellent manual for physicians, derived primarily from the experience of five physician-based smoking cessation intervention trials funded by the National Cancer Institute.4o, 91 This manual is available free of charge by calling I-800-4CANCER Importance of Physician Advice. Physician advice and counseling encourage many patients to make an attempt to quit smoking. The proportion of patients who succeed in quitting after a brief message or warning is small, but the yield when applied to a physician's practice is large. When the physician enhances the advice with a stronger message, gives tips on how to quit, provides self-help materials, and schedules follow-up visits, the results improve. The quit rates for patients with pulmonary or cardiac disease who are advised or counseled to stop smoking are substantial. Although the role of physicians in helping patients to stop smoking cannot be underestimated, other health professionals who have daily contact with patients can also influence them to quit. Success in breaking the habit depends on both the smoker and the method. Smokers must be committed to stopping in order to succeed. This commitment is stronger in people who believe that the dangers of smoking are personally relevant. This is why the role of the health professional can be instrumental in motivating a patient to stop smoking.

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Hypnosis

The popularity of hypnosis as a smoking cessation method is supported by a survey of the telephone yellow pages which found that hypnosis was the most frequently advertised method. 82 Reports regarding the effectiveness of hypnosis as a smoking cure are contradictory. 50, 82 Numerous accounts describe the use of hypnosis with small numbers of patients, Only a limited number of reports are based on appropriate follow-up data or state whether patients actually quit smoking. Some hypnotists claim good results based on their own estimates or faulty evaluations, Hypnosis is not a method that can reach large numbers of smokers. Nevertheless, hypnosis can help some smokers to quit, particularly those who have tried other methods and need intensive individual attention to succeed, Orne has emphasized that, although hypnosis is not a potent means of changing behavior, it is uniquely effective in helping individuals to achieve what they already want to do.71 The patient must assume responsibility for changing his or her own behavior and must recognize that failure can be blamed only on himself, not on the therapist Simon and Salzberg described five approaches to hypnotic procedures: (1) giving smokers direct suggestions to change; (2) using hypnosis to alter the smoker's perceptions with regard to addictive behavior; (3) using hypnotherapy-hypnosis as an adjunct to verbal psychotherapy; (4) using hypnoaversion-hypnosis to help the patient develop an aversion to an addictive behavior; and (5) using selfhypnosis-as an adjunct to supplement hypnotic treatment 89 It should be noted that most hypnosis methods include behavioral adjuncts, such as imagery, suggestions, substitute behavior, desensitization, self-relaxation, aversive methods, positive and negative reinforcement, inconvenience ploys, and counseling. 82 Hypnosis can be delivered in a single individual session, several individual sessions, or a group session, Single Individual Session. Spiegel teaches his patients to hypnotize themselves. He provides one session of psychotherapy reinforced by hypnosis,92 The patient is instructed to use the technique 3 to 10 times per day, Spiegel maintains that hypnosis alone is not a deterrent to continued smoking but that, combined with patient motivation, it creates the expectant, receptive attention and aroused concentration that can lead to a new perspective regarding the smoking habit. Spiegel concentrates on respect and protection of the body and instructs the patient in meditation. Spiegel claims that this state of concentration or self-hypnosis increases the patient's receptivity to his own thoughts and helps imprint his new point of view-his commitment to his own well-being-which gives him the power to give up smoking, Spiegel conducted a follow-up study of 616 patients who underwent his hypnotherapy program, counting nonrespondents as failures. He found that 35% of the subjects had stopped smoking for 1 year, 93 Several other investigators have reported that 12% to 25% of their

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patients quit smoking following a single hypnosis session. Pederson et al added group counseling to a single hypnosis session with 17 subjects and raised their quit rate to 53%.74 Multiple Individual Sessions. Hall and Crasilneck provided four hypnotic sessions to 75 highly motivated patients referred by other physicians. 45 They used direct suggestions, telling their patients that they would be relatively free from excessive desire for tobacco. After treatment, patients were phoned daily for 1 month. Patients who relapsed to smoking were offered additional sessions. Based on all subjects, 57% were successfully abstinent at 1 year. Group Sessions. The best result for hypnosis was reported in 1970 by Kline based on a 12-hour marathon group hypnosis session. 56 He treated 60 smokers in groups of 10, with each patient being hypnotized individually for 15 minutes. The method included relaxation, imagery, and self-hypnosis. Kline claimed a success rate of 88% at I-year followup. Evaluation of Hypnosis. Spiegel has added some theoretical concepts regarding who benefits from hypnosis. He stated that patients with high trance capacity (high hypnotic induction profile) have high immediate smoking cessation rates (up to 80%) but also have very high recidivism rates (H. Spiegel, personal communication). Those who successfully stay off cigarettes appear to have encouraging families and social support that aid in their efforts to quit. Persons with low trance capacity have lower rates of initial quitting (about 40%); however, these people tend to be more independent and more frequently can remain off smoking (lower recidivism rates) without other support. The results of 19 individual and 12 group hypnosis studies were reviewed in terms of smoking cessation efficacy. 81 Most of these studies lacked biochemical verification of abstinence. Quit rates ranged from zero to 68% for individual hypnosis and from 8% to 88% for group hypnosis. Individual hypnosis programs involving multiple sessions resulted in higher quit rates than those using a single-session format. From a review of over 50 reports and critiques of the use of hypnosis to control smoking, it appears that hypnosis produces only modest results when used alone. However, when combined with other cessation methods, the success rates are enhanced. The skill and experience of the therapist are very important to the effective use of hypnosis. Although a single treatment is most cost-effective, multiple sessions appear to improve quit rates. Several studies of group hypnosis have reported high success rates, but this finding may be due to the adjunctive effects resulting from group therapy. As with any method of smoking cessation, counseling and follow-up support are needed to maintain abstinence. Acupuncture

A review of listings in the telephone yellow pages shows that acupuncture is becoming increasingly popular as a method to aid

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smokers in quitting. Although it is gaining in popularity, there are only a handful of studies on the long-term efficacy of acupuncture. Types of Acupuncture for Smoking Cessation. Cousin cites two methods of treating smokers by means of acupuncture-nasopuncture and auriculopuncture. lI Nasopuncture consists of selecting points on the surface of the nose so as to decongest the respiratory tract and generate a feeling of disgust toward tobacco in the patient. Cousin claims that one treatment of nasopuncture results in a 64% quit rate. Auriculopuncture, which is popular in the Far East, can be painful. It involves using a staple to perform acupuncture to the ear. In staple puncture, a surgical staple is used at fixed acupuncture needle points for the purpose of conducting frequent stimulation to the ear. Threads and beads are also implanted at appropriate body and auricular points. Cousin also claims that 50% of the patients quit with auriculopuncture, but he presents no follow-up dataY Electroacupuncture is also used in treatment for smoking. Practitioners at the University of Singapore have described the use of lasers on acupuncture points for smoking cessation. 94 Laser probes were directed at the ears, wrist, and nose. Unfortunately, no follow-up information was collected and their immediate results were based on a reduction in smoking rather than full cessation. Evaluation of Acupuncture. Scientifically valid evaluations of acupuncture as a smoking treatment method have not been completed. Some investigators claim very high rates of success based on their own estimates of success rather than on methodologically sound assessments. Many authors base their reports of quit rates on end-of-treatment results or on very limited follow-ups. Only one study validated abstinence by biochemical means. Generally, in the few studies that had methodologically sound designs, low quit rates were observed. In a study of the effectiveness of acupuncture as a smoking cessation aid, Choy et al claimed a 42% success rate at follow-up periods varying from 2 months to 2 years. s They provided a later report on 514 patients, of whom 339 completed the 4-week treatment and 297 quit smoking. 7 Based on all patients treated, these authors reported a quit rate of 30% at 2 years. In another study, Fuller reported that 95% of 194 patients stopped smoking after three acupuncture treatments. 32 Long-term follow-up assessment showed a successful abstinence rate of 41 % at 6 months and 30% at 2 years. Separate reports from France with 1 year of information reported successful quit rates ranging from 8% to 32%.83 Eight studies have compared the efficacy of acupuncture at the "correct" site for smoking cessation against an "incorrect" or "sham" site. s3 In only one study did the "correct" site show a clear advantage over a placebo or sham site. Gillams et al commented that acupuncture at any site might cause endorphin release, which in turn alleviates symptoms of smoking withdrawal,35 They concluded, however, that acupuncture is not as effective in helping smokers to quit as has been reported. Fuller concluded that acupuncture merely eases smoking with-

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drawal symptoms, and, if the patient's motivation is weak, relapse occurS. 33 He noted that recidivism is a continuing problem with all types of cessation techniques and pointed out that acupuncture can offer only temporary relief from the addictive effect of nicotine; thereafter, personal motivation must take over. Reported quit rates for acupuncture at I-year follow-up ranged from 8% to 40%.82,83 Median quit rate for 13 studies with at least a 6month follow-up was 25%. Only one study attempted to validate successful abstinence biochemically, and that study found that only 8% had quit smoking. There is no physiologic evidence that acupuncture relieves withdrawal symptoms. It has not been demonstrated that acupuncture alone promotes smoking cessation. Acupuncture may act as a "placebo procedure" to help the smoker handle the addictive component of smoking. For sustained abstinence, the psychosocial aspects of smoking must also be addressed. Needed along with acupuncture are counseling, skills training, or other adjuvant therapy to achieve efficacy. As with any method, motivation to quit is necessary for continued abstinence. Mass Media and Community Programs

An important way to motivate a large number of smokers to quit is through radio and television. Mass media communications have resulted in increasing public awareness of the serious health hazards of cigarette smoking. During the late 1960s, the Federal Communications Commission required networks to air antismoking advertisements to counter television advertisement. These advertisements apparently had a considerable impact, with per capita consumption of cigarettes declining from 1967 to 1971 and then climbing again when the advertisements were stopped. 87 Fielding has stressed that radio and television broadcasts can be helpful in making the public develop strong negative feelings about unhealthy behavior. 23 Mass Media Programs. Mass media programs regarding tobacco can be grouped into three categories: (1) those that seek to impart information or awareness; (2) those that seek to induce people to take particular actions (e.g., attempt to quit smoking, request a self-help kit); and (3) those that present smoking cessation programs on camera. Television interventions can differ widely in intensity. Some consist of brief public service announcements or segments during the evening news. Others may air a comprehensive smoking cessation program over many days or weeks. Few television and radio cessation programs have been evaluated. Most evaluations of media programs are based on self-selected respondents and have relied on self-reports. Flay has analyzed the major problems that beset the evaluation of mass media programs. 25 He notes that the diffuse nature of the target audience limits the identification of both people at risk and impact of the intervention.

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The format of media-based cessation programs generally consists of advance publicity asking participants to request kits, materials, and record cards. The cessation program itself usually includes information about the risks of smoking and the benefits of quitting, instructions on how to beat nicotine addiction, and tips on how to maintain nonsmoking status. Sometimes local personalities quit along with the audience or present testimonials regarding the effectiveness of the media program. Flay and his colleagues have conducted several televised cessation programs. In Los Angeles in 1982, an innovative television cessation program was coordinated with a school smoking prevention program. 27 The investigators used a school-based program to motivate smoking parents to participate in a cessation program. Prevention segments of 5 minutes were aired nightly during the local news over a 2-week period. A self-help quitting kit was provided with additional instructions on how to break the habit. A total of 400,000 smokers (22% of smokers in the area) viewed at least one of the cessation segments. Of a random sample of smokers who viewed at least one segment, 90% selected for evaluation remained quitters for 1 year. In the Chicago area, Flay et al compared the effectiveness of four different self-help and social support conditions provided in conjunction with a televised smoking cessation program. 26 An American Lung Association manual was also provided to 50,000 smokers who attempted to quit during this program. A 10% sustained cessation rate for 1 year was observed for smokers in the televised program plus ALA manual group. This was considerably better than the cessation rate observed among individuals receiving the ALA manual alone. Since many smokers prefer to quit on their own, a media-based program addresses this preference by offering kits and suggestions about quitting for individuals to use at home. The Great American Smokeout is a media event that has been extremely successful as an aid to smoking cessation. The Smokeout was first sponsored nationally by the American Cancer Society in 1977. The event urges smokers to "take a day off from smoking" and has spread to other countries. In 1988, the World Health Organization initiated a "World No Tobacco Day." Organized in a similar manner, these "Smoke out" days are given extensive press and television coverage, and many smokers have used these as their quit date. A Gallup Poll conducted in 1989 reported an 85% awareness of the Great American Smokeout. 36 More than 30% of the nation's 50 million smokers participated in the Smokeout by quitting or cutting down for at least 1 day. Community Programs. A number of programs have involved all or part of a community in an antismoking campaign. McAlister provides a comprehensive review of such community programs. 65 Some of the programs also aim to reduce cardiovascular disease and other risk factors. Stanford Three-Community Study. To determine whether community-wide health education programs can reduce the risk of cardiovas-

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cular disease, a field study was conducted in three northern California communities by the Stanford Heart Disease Prevention Program. 20 In two of these communities there were extensive mass-media campaigns. The third community served as a control. The mass-media campaign consisted of about 50 television spots, 3 hours of television programming, more than 100 radio spots, radio programming, newspaper columns and advertising, billboards, and mailed messages. Smoking cessation assistance included information on the harmful effects of smoking, advice on how to stop, booklets with instructions on self-control skills, and small group meetings for 10 weeks. Within treatment communities, there was a substantial (20% to 30%) decrease in cardiovascular risk. In the control community, the risk of cardiovascular disease increased over the study period. In addition to the overall risk reduction, a subgroup of smokers who received intensive cessation instruction exhibited a 32% smoking quit rate measured 3 years after the intervention. The investigators concluded that a media campaign combined with face-to-face instruction was more successful than mass media alone in increasing communitywide awareness of cardiovascular risk factors and in motivating and maintaining health behavior changes among individuals. 19 Recent US Community Studies. Three recent community projects aimed at reducing risk of cardiovascular disease (CVD) are the Stanford Five-City Project, the Minnesota Heart Health Program, and the Pawtucket Heart Health Project. These studies are assessing the effects of education and health promotion programs as well as community-wide interventions. The projects are designed to run about 10 years, and each has a smoking cessation component. One limitation of these studies is that the intervention and control communities were not chosen randomly. The Stanford Five-City Project is testing whether a communitywide intervention that results in decreased cardiovascular risk would lead to a decline in morbidity and mortality from CVD.19 In this study there are two intervention and three control communities. The study includes a 6-year health education campaign to encourage people to make lifestyle changes in smoking, weight, blood pressure, and nutrition. A broadcast media campaign was used to provide information, to support community programs, to increase knowledge, to change attitudes and behavior, and to recruit smokers into cessation programs. Farquhar et al have reported that, in the intervention communities, the overall risk of CVD was reduced 16%, including a reduction in smoking of 13% .18 There was also a modest decline in smoking in the control communities. The Minnesota and Pawtucket Heart Health Programs are still in progress. Both are designed to reduce the risk of CVD by providing community health education and enhancing the community climate to support healthy behaviors. The Minnesota project is studying three pairs of communities located in Minnesota, North Dakota, and South Dakota. s The communities were chosen to represent three different

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types: small towns, larger free-standing cities, and large metropolitan areas. The Pawtucket Program differs from the Stanford and Minnesota projects in that it relies on volunteers recruited from the community to deliver the behavioral change programs. 61 The project is continuing in two Rhode Island cities. Value of Mass-Media and Community Programs. Large numbers of people are reached by mass-media quit programs such as the Great American Smoke out, and many smokers are encouraged to try quitting. 2 Community programs have shown mixed results when intervention and control communities are compared. Outside factors, such as a national antismoking campaign, activities of local cessation programs, new antismoking laws, price increases in cigarettes, the death of a wellknown person from a smoking-related illness, or the release of a new report on smoking and health, can influence quitting in both the intervention and control communities. It appears that a combination of mass media and intensive individual instruction is more successful than a media campaign alone. As with any method, the smoker needs to be motivated to quit. A mass media campaign can increase motivation, but the quitter must still cope with addiction as well as personal, environmental, and social problems. Support and skills training are important treatment adjuvants, and intensive individual instruction can provide these elements. COMPARISON OF QUIT RATES BETWEEN METHODS

A number of problems make it difficult to compare the success rates of various smoking cessation methods. Self-reporting of smoking behavior is limited by reporting bias and inaccuracy of recall; whenever possible, success should be validated by biochemical methods. The definition of success may differ between programs or may be measured differently; cessation rates at 1 year should be determined whenever possible. Multiple quit attempts may also influence the success rates of an individual program or intervention. For these reasons, comparison of quit rates (Table 1) should be made with caution. Of the trials shown in Table 1, 185 had at least a 6-month followup and 231 had at least a I-year follow-up. The rates were based largely on self-reports and were supplied by investigators whose follow-up procedures may have differed. The highest median quit rates for trials with I-year follow-ups were scored by physician intervention with cardiac patients and by multiple programs. Seventeen multiple program trials had I-year follow-ups, and 11 (66%) of these achieved at least a 33% success rate. Cardiac patients are also highly successful in their smoking-cessation attempts because their life-threatening illness markedly increases motivation level. Other methods whose median quit rates reached 30% (I-year follow-up) were physician intervention with pulmonary patients, risk

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Table 1. SUMMARY OF QUIT RATES (PERCENTAGES) OF 416 SMOKING CESSATION TRIALS, BY METHOD, REPORTED BETWEEN 1959 AND 1985

Intervention Method Self-help Educational Five-day plan Groupt Medication Nicotine chewing gum Nicotine chewing gum and behavioral treatment or therapy Hypnosis, individual Hypnosis, group Acupuncture Physician advice or counseling Physician intervention, more than counseling Physician intervention, pulmonary patients Physician intervention, cardiac patients Risk factor Rapid smoking Rapid smoking and other procedures Satiation smoking:j: Regular-paced aversive smoking:j: Nicotine fading:j: Contingency contracting:j: Multiple programs:j:

Quit Rate (At Least 6-Month Follow-up)

Quit Rate (At Least 1 Year Follow-up)

Number of Trials

Range

Number of Trials

Range

Median'

11 7 4 15 7 3 3

0-33 13-50 11-23 0-54 0-47 17-33 23-50

17 36 15 24 18 23 35

7 12 14 31 12 9 11

12-33 15-55 16-40 5-71 6-50 8-38 12-49

18 25 26 28 18.5 11 29

11 10 7 3

0-60 8-68 5-61 5-12

25 34 18 5

8 2 6 12

13-68 14-88 8-32 3-13

19.5 27 6

3

23-40

29

10

13-38

22.5

10

10-51

24

6

25-67

31.5

5

21-69

44

16

11-73

43

12 21

7-62 8-67

25.5 38

7 6 10

12-46 6-40 7-52

31 21 30.5

11 13

14-76 0-56

38 29

12 3

18-63 20-39

34.5 26

7 9

26-46 25-76

27 46

16 4

7-46 14-38

25 27

13

18-52

32

17

6-76

40

Median'

Note: Quit rates provided suggest overall trends. Most quit rates were based on self-reports without biochemical confirmation. Some quit rates were recalculated to include all subjects, but most quit rates were based on the reports of investigators. Some quit rates omitted subjects who did not complete treatment or persons who did not report to follow-ups, therefore overestimating the overall success rate. Definitions of follow-up may vary between trials. 'Median not calculated for fewer than three trials. tThree group trials had 5-month follow-ups. :j:Other procedures may have been used, and some trials may be included in more than one method. From Schwartz JL: Review and Evaluation of Smoking Cessation Methods: The United States and Canada, 1978-1985. Public Health Service, National Cancer Institute. NIH Publication No 87-2940, 1987.

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factor studies, and rapid smoking and satiation, particularly when combined with other procedures. Methods that had median quit rates just below 30% included group programs and nicotine chewing gum when these treatments were combined with behavioral treatment or therapy. With few exceptions, 6-month median quit rates were higher than I-year rates. One third of the trials involving 12 different intervention methods scored at least a 33% successful cessation rate. Nevertheless, one cannot select any single method as the "best." In fact, the quit rates did not vary markedly between programs, with most cessation methods resulting in a median success rate of 15% to 40%. Self-help, with no professional supervision, showed a respectable 18% median quit rate at 1 year. When physicians provided intervention involving more than just advice or counseling to patients, the median quit rates rose from 6% to 22.5% at 1 year. Nicotine chewing gum had an 11 % median quit rate at 1 year, but the rate increased to 29% when combined with other treatments. Of the behavioral treatments, rapid smoking and satiation showed good results when combined with other treatments. Hypnosis and acupuncture-popular quitting methods-were modestly successful, although many of these studies lacked careful follow-up evaluation in which abstinence was validated by biochemical measures. The same is true for many commercial programs. NCI-FUNDED INTERVENTION RESEARCH

The National Cancer Institute commissioned Schwartz to conduct a comprehensive review and evaluation of smoking cessation methods in the United States and Canada for 1978 through 1984. The review included worksite smoking control programs and long-term maintenance programs. The NCI has also funded 60 prevention and cessation smoking trials impacting 10 million people in 33 states and more than 200 communities. 12, 91 Interventions are through schools, physicians and dentists, self-help, and the mass media. Six high-risk groups were targeted for priority intervention research: blacks, Hispanics, heavy smokers, women, youths, and smokeless tobacco users. Cullen reported that smoking-related cessation research has now sufficiently identified interventions that have proven to be most effective. 12, 91 Besides funding individual projects, the NCI launched the Community Intervention Trial for Smoking Cessation (COMMIT), the largest smoking intervention trial in the world. 91 The project includes 11 pairs of matched communities. One community in each pair serves as the intervention site and one as the control site. Strategies for COMMIT include interventions offered through physicians and dentists, mass media, worksites, community organizations, and telephone hotlines. Changes in community smoking prevalence and adolescent smoking rates will be monitored by cross-sectional surveys at the beginning and end of the trial.

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Recently, the NCI and ACS launched a major tobacco control project called the American Stop-Smoking Intervention Study (ASSIST).16,91 The project is scheduled to start in 1992 and is due to last until 1998. It is designed to reach more than 20% of the US population, at least 15 million smokers in about 20 states. The goal of this project, with a budget of over $120 million, is to assist the NCI in achieving its goal of reducing cancer mortality rates by 50% by the end of the century. To meet this goal, smoking by the US population must be substantially reduced. SUMMARY

Smoking-cessation treatment consists of three phases: preparation, intervention, and maintenance. Preparation aims to increase the smoker's motivation to quit and to build confidence that he or she can be successful. Intervention can take any number of forms (or a combination of them) to help smokers to achieve abstinence. Maintenance, including support, coping strategies, and substitute behaviors, is necessary for permanent abstinence. Although most smokers who successfully quit do so on their own, many use cessation programs at some point during their smoking history. Moreover, many people act on the advice of a health professional in deciding to quit. Some are also aided by a smoking-cessation kit from a public or voluntary agency, a book, a tape, or an over-thecounter product. Still others receive help from mass-media campaigns, such as the Great American Smokeout, or community programs. Counseling, voluntary and commercial clinics, nicotine replacement strategies, hypnosis, acupuncture, and behavioral programs are other methods used by smokers to break the habit. Programs that include multiple treatments are more successful than single interventions. The most cost-effective strategy for smoking cessation for most smokers is self-care, which includes quitting on one's own and might also include acting on the advice of a health profession or using an aid such as a quit-smoking guide. 82 Heavier, more addicted smokers are more likely to seek out formal programs after several attempts to quit. 24 Many people can quit smoking, but staying off cigarettes requires maintenance, support, and additional techniques, such as relapse prevention. Physicians, dentists, and other health professionals can provide important assistance to their patients who smoke. Quit rates can be improved if clinicians provide more help (e.g., counseling, support) than just simple advice and warnings. Clinicians also play an important role in providing nicotine replacement products such as nicotine gum or transdermal patches. These products are particularly useful for smokers who show evidence of strong physiologic addiction to nicotine. Attitudes toward smoking have shifted dramatically. In the 1950s, fewer than 50% of American adults believed that cigarette smoking

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caused lung cancer. In 1986, this proportion had increased to 92%.96 A majority of the public favors policies restricting smoking in public places and worksites. Half of all Americans who ever smoked had stopped smoking by 1988. Of those who continue to smoke, more than 70% report that they would like to quit. By increasing their knowledge about smoking-cessation methods, health professionals can support and encourage the large majority of smokers who want to quit. ADDENDUM

The FDA has approved two skin patches: Nicoderm (Alza Corp., Palo Alto, CA, and marketed by Marion Merrell Dow) and Habitrol (Lohman, Germany, and marketed by Ciba-Geigy). The FDA is expected to approve two other skin patches in early 1992: Prostep (Elan Corp., Ireland, and marketed by Lederle Laboratories, American Cyanamid), and Nicotroll16 (Cygnus Therapeutic Systems Corp., Redwood City, CA, and marketed by Warner-Lambert). The patches are affixed to the upper body and left for 24 hours, or in the case of Cygnus' patch, 16 hours. The patches contain a reservoir of nicotine that is steadily released through the skin into the blood. Numerous clinical trials have found them to be highly efficacious as an aid to smoking cessation. The four companies are expected to aim for the 16 million Americans who attempt to quit each year. The marketing blitz for nicotine skin patches is likely to increase awareness among doctors about the need for smoking counseling. As with other cessation methods, counseling is necessary in conjunction with the patch to assist smokers to succeed in long-term abstinence. References 1. Abelin T, Buehler A, Muller P, et al: Controlled trial of transdermal nicotine patch in tobacco withdrawal. Lancet 1:7, 1989 2. Bal DC, Kizer KW, Felten PC, et al: Reducing tobacco consumption in California. Development of a statewide antitobacco use campaign. JAMA 264:1570, 1990 3. Beaver C, Brown RA, Lichtenstein E: Effects of monitored nicotine fading and anxiety management training on smoking reduction. Addict Behav 6:301, 1981 4. Best JA, Owen LE, Trentadue BL: Comparison of satiation and rapid smoking in selfmanaged smoking cessation. Addict Behav 3:71, 1978 5. Blackburn H, Luepker R, Kline FC, et al: The Minnesota Heart Health Program: A research and demonstration project in cardiovascular disease prevention. In Matarazzo JD, Weiss SM, Herd jA, et al (eds): Behavioral Health: A Handbook for Health Enhancement and Disease Prevention. New York, Wiley & Sons, 1984, p 1171 6. Brown RA, Lichtenstein E: Effects of a cognitive-behavioral relapse prevention program for smokers. Paper presented at 88th Annual Convention of the American Psychological Association, Montreal, 1980 7. Choy DS], Lutzger L, Meltzer L: Effective treatment for smoking cessation. Am J Med 75:1033, 1983 8. Choy DS), Pumell F, jaffe R: Auricular acupuncture for cessation of smoking. In Schwartz JL (ed): Progress in Smoking Cessation. Proceedings of the International Conference on Smoking Cessation. New York, American Cancer Society, 1978, p 329 9. Coe RM, Brehm HP: Smoking habits of physicians and preventive care practices. HSMHA Health Rep 86:217, 1971

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10. Cohen S, Lichtenstein E, Prochaska JO, et al: Debunking myths about self-quitting. Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves. Am Psychol 44:1355, 1989 11. Cousin M: Tabagisme, acupuncture, nasopuncture et auriculopuncture. Gaz Med France 83:1973, 1976 12. Cullen JW: National Cancer Institute's Smoking, Tobacco, and Cancer Program. In Aoki M, Hisamichi S, Tominaga S (eds): Smoking and Health 1987. Proceedings of the 6th World Conference on Smoking and Health. Amsterdam, Excerpta Medica, 1988, p 155 13. Cummings KM, Giovino G, Sciandra R, et al: Physician advice to quit smoking: Who gets it and who doesn't. Am J Prev Med 3:69, 1987 14. Danaher BG: Research on rapid smoking: Interim summary and recommendations. Addict Behav 2:151, 1977 15. Ejrup B, Wikander PA: Fortsatta forsoktill avvanjing fran tobak medelst injektions behandling. Svenska Iakartidn 56:1975, 1959 16. Erickson AC, Pechacek TF: The American Stop Smoking Intervention Study for Cancer Prevention (ASSIST): Logic and strategies. In Durston B, Jamrozik K (eds): Tobacco and Health 1990. The Global War. Proceedings of the Seventh World Conference on Tobacco and Health, 1st-5th April 1990, Perth, Western Australia, p 214 17. Fagerstrom KO: A comparison of psychological and pharmacological approaches in smoking cessation. J Behav Med 5:343, 1982 18. Farquhar JW, Fortmann SP, Flora JA, et al: Effects of community-wide education on cardiovascular disease risk factors: Stanford Five-City Project. JAMA 264:359, 1990 19. Farquhar JW, Fortmann SP, Maccoby N, et al: The Stanford Five-City Project: An overview. In Matarazzo JD, Weiss SM, Herd JA, et al (eds): Behavioral Health: A Handbook for Health Enhancement and Disease Prevention. New York, Wiley & Sons, 1984, p 1154 20. Farquhar JW, Wood PO, Breitrose H, et al: Community education for cardiovascular health. Lancet 1:1192, 1977 21. Ferno 0: Nicotine chewing gum as an aid in smoking cessation. World Smoking Health 5:24, 1980 22. Ferno 0, Lichtneckert S, Lundgren C: A substitute for tobacco smoking. Psychopharmacology 31:201, 1973 23. Fielding JE: Health promotion-some notions in search of a constituency. Am J Public Health 67:1082, 1977 24. Fiore MC, Novotny TE, Pierce JP, et al: Methods used to quit smoking in the United States. JAMA 263:2760, 1990 25. Flay BR: Mass media and smoking cessation: A critical review. Am J Public Health 77:153, 1987 26. Flay BR, Gruder CL, Warnecke RB, et al: One year follow-up of the Chicago televised smoking cessation program. Am J Public Health 79:1377, 1989 27. Flay BR, Brannon BR, Johnson CA, et al: The television school and family smoking prevention and cessation project. 1. Theoretical basis and program development. Prev Med 17:585, 1988 28. Food and Drug Administration: Smoking deterrent drug products for over-the-counter human use; tentative final monograph. Fed Register 47:490, January 5, 1982 29. Food and Drug Administration: Smoking deterrent drug products for over-the-counter human use; tentative final monograph. Fed Register 50:27552, July 3, 1985 30. Fortmann SP, Killen JD, Telch MJ, et al: A placebo controlled trial of nicotine polacrilex and self-directed relapse prevention: Initial results of the Stanford Stop Smoking Project. JAMA 260:1575, 1988 31. Foxx RM, Brown RA: Nicotine fading and self-monitoring for cigarette abstinence or controlled smoking. J Applied Behav Anal 12:111, 1979 32. Fuller J: Acupuncture and smoking. In Santamaria J (ed): Proceedings of Seminars. Melbourne, Australia, St. Vincent's Hospital, May 1981, p 16 33. Fuller J: Smoking withdrawal and acupuncture. Med J Aust 1:28, 1981 34. Geboy MJ: Dentists' involvement in smoking cessation counseling: A review and analysis. J Am Dent Assoc 118:79, 1989

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35. Gillams J, Lewith GT, Machin 0: Acupuncture and group therapy in stopping smoking. Practitioner 228:341, 1984 36. Gilmore G: Incentives for change: An overview of the American Cancer Society's Great American Smokeout. In Jamrozik K (ed): Abstracts & Participants, Seventh World Conference on Tobacco and Health, 1st-5th April 1990, Perth, Western Australia, p 29 37. Glasgow RE: Smoking. In Holroyd K, Creer T (eds): Self-Management of Chronic Disease and Handbook of Clinical Interventions and Research. Orlando, FL, Academic Press, 1986, p 99 38. Glasgow RE, Rosen GM: Behavioral bibliotherapy: A review of self-help behavior therapy manuals. Psychol Bull 85:1, 1978 39. Glasgow RE, Schafer L, O'Neill HK: Self-help books and amount of therapist contact in smoking cessation programs. J Consult Clin Psychol 49:659, 1981 40. Glynn TJ: Relative effectiveness of physician-initiated smoking cessation programs. CA Bull 40:359, 1988 41. Glynn TJ, Boyd GM, Gruman JC: Essential elements of self-help/minimal intervention strategies for smoking cessation. Health Ed Q 17:329, 1990 42. Glynn TJ, Manley MW: How to Help Your Patients Stop Smoking. National Cancer Institute, NIH Publication No 89-3064, 1989 43. Glassman AH, Stetner F, Walsh T, et al: Heavy smokers, smoking cessation, and c1onidine: Results of a double-blind, randomized trial. JAMA 259:2863, 1988 44. Goldstein AO, Hellier A, Fitzgerald S, et al: Hospital nurse counseling of patients who smoke. Am J Public Health 77:1333, 1987 45. Hall JA, Crasilneck HB: Development of a hypnotic technique for treating chronic cigarette smoking. Int J Clin Exp Hypn 18:283, 1970 46. Hall SM: Self-management and therapeutic maintenance: Theory and research. In Karoly P, Steffan J (eds): Improving the Long-Term Effects of Psychotherapy. New York, Gardner Press, 1980, p 263 47. Hall SM, Rugg 0, Tunstall e, et al: Preventing relapse to cigarette smoking by behavioral skill training. J Consult Clin Psycho I 52:372, 1984 48. Hall SM, Tunstall C, Ginsberg 0, et al: Nicotine gum and behavioral treatment in smoking cessation. J Consult C1in Psychol 55:603, 1987 49. Henningfield JE, Miyasato K, Johnson RE, et al: Rapid physiologic effects of nicotine in humans and selective blockade of behavioral effects of mecamylamine. In Harris LS (ed): Problems of Drug Dependence, NIDA Research Monograph 43. National Institute on Drug Abuse, 1982, p 259 50. Holyrod J: Hypnosis treatment for smoking: An evaluative review. Int J Clin Exp Hypn 28:341, 1980 51. Hurt RD, Kottke TE, Dale Le, et al: Transdermal nicotine replacement therapy as an aid to smoking cessation. In Jamrozik K (ed): Abstracts & Participants, Seventh World Conference on Tobacco and Health, 1st-5th April 1990, Perth, Western Australia, p 210 52. Jarvik ME, Glick SO, Nakamura RK: Inhibition of cigarette smoking by orally administered nicotine. Clin Pharmacol Ther 11:574, 1970 53. Jarvik ME, Gritz ER: Nicotine and tobacco. In Jarvik ME (ed): Psychopharmacology in the Practice of Medicine. New York, Appleton-Century Crofts, 1977, p 493 54. Jarvis M: Nasal nicotine solution: Its potential with smoking cessation and as a research tool. In Ockene JK (ed): Pharmacologic Treatment of Tobacco Dependence. Cambridge, MA, Institute for the Study of Smoking Behavior and Policy, 1986, p 167 55. Killen JD, Maccoby N, Taylor CB: Nicotine gum and self-regulation training in smoking relapse prevention. Behav Ther 15:234, 1984 56. Kline MV: The use of extended group hypnotherapy sessions in controlling cigarette smoking. Int J Clin Exp Hypn 18:270, 1970 57. Kottke TE, Battista RN, DeFriese GH, et al: Attributes of successful smoking cessation interventions in medical practice. A meta-analysis of 39 controlled trials. JAMA 259:2883, 1988 58. Lando HA: Successful treatment of smokers with a broad-spectrum behavioral approach. J Consult C1in Psychol 44:361, 1977 59. Lando H, McGovern PG: Nicotine fading as a non-aversive alternative in a broadspectrum treatment for eliminating smoking. Addict Behav 10:153, 1985

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60. Lando HA, McGovern PG: A comparison of brand switching and nicotine reduction filters. In Durston B, Jamrozik K (eds): Tobacco and Health 1990. The Global War. Proceedings of the Seventh World Conference on Tobacco and Health, 1st-5th April 1990, Perth, Western Australia, p 705 61. Lasater T, Abrams D, Artz L, et al: Volunteer delivery of a community-based cardiovascular risk factor change program: The Pawtucket experiment. In Matarazzo ]D, Weiss JA, Herd NE, et al (eds): Behavioral Health: A Handbook for Health Enhancement and Disease Prevention. New York, Wiley & Sons, 1984, p 1166 62. Levin ED, Rose JE, Behm F: Development of a citric acid aerosol as a smoking cessation aid. Drug Alcohol Depend 25:273, 1990 63. Lichtenstein E: Clinic based cessation strategies. In Ockene JK (ed): Pharmacologic Treatment of Tobacco Dependence. Proceedings of the World Congress. Cambridge, MA, Institute for the Study of Smoking Behavior and Policy, 1986, p 205 64. Lichtenstein E, Brown RA: Current trends in the modification of cigarette dependence. In Bellak AS, Hersen M, Kazdin AE (eds): International Handbook of Behavior Modification and Therapy. New York, Plenum Press, 1983, p 575 65. McAlister A: Community studies of smoking cessation and prevention. In US Department of Health and Human Services: The Health Consequences of Smoking: Chronic Obstructive Lung Disease. A Report of the Surgeon General. DHSS Publication No (PHS) 84-50205, 1984, p 501 66. McFadden DD, Butler TL: Perceptions of program leaders about a new smoking cessation program. In Jamrozik K (ed): Abstracts & Participants, Seventh World Conference on Tobacco and Health, 1st-5th April 1990, Perth, Western Australia, p 295 67. McFall RM: Effects of self monitoring on normal smoking behavior. J Consult Clin Psychol 35:135, 1970 68. McFarland JW, Gimbel HW, Donald WAJ, et al: The five-day program to help individuals stop smoking. A preliminary report. Conn Med 28:885, 1964 69. Medical Tribune News Service: Nicotine patch helps people kick habit. San Francisco Chronicle, April 17, 1991, P B5 70. Orleans CT: Understanding and promoting smoking cessation: Overview and guidelines for physician intervention. Ann Rev Med 36:51, 1985 71. Orne MY: Hypnosis in the treatment of smoking. In Steinfeld L Griffiths W, Ball K, et al (eds): Health Consequences, Education, Cessation Activities, and Social Action. Vol n. Proceedings of the 3rd World Conference on Smoking and Health, 1975. DHEW Publication No (NIH) 77-1413, 1977, P 489 72. Pechacek TF: Modification of smoking behavior. In Krasnegor NA (ed): The Behavioral Aspects of Smoking. NIDA Research Monograph 26. DHEW Publication No. 79-882, 1979, P 127 73. Pederson LL: Compliance with physician advice to quit smoking: A review of the literature. Prev Med 11:71, 1982 74. Pederson LL, Scrimgeour WG, LeFcoe NM: Variables of hypnosis which are related to success in smoking withdrawal programme. Int J Clin Exp Hypn 27:14, 1979 75. Pomerleau CS, Pomerleau OF, Majchrzak MJ: Mecamylamine pretreatment increases subsequent self-administration as indicated by changes in plasma nicotine level. Psychopharmacol 91:391, 1987 76. Rose JE, Levin ED, Behm FM, et al: Transdermal nicotine facilitates smoking cessation. Clin Pharmacol Ther 47:323, 1990 77. Roundtable Conference: Smoking cessation programs and the role of the respiratory care practitioner. Today's Ther Trends (Suppl 1), 1989 78. Russell MAH, jarvis MJ, Sutherland G, et al: Nicotine replacement in smoking cessation: Absorption of nicotine vapor from smoke-free cigarettes. JAMA 257:3262, 1987 79. Sachs DPL: Cigarette smoking-health effects and cessation strategies. Clin Geriatr Med 2:337, 1986 80. Schwartz JL: A critical review and evaluation of smoking control methods. Public Health Rep 84:483, 1969 81. Schwartz jL: Smoking cures: Ways to kick an unhealthy habit. In Jarvik ME, Cullen jW, Gritz ER, et al (eds): Research in Smoking Behavior. NIDA Research Monograph 17. DHEW Publication No (ADM) 78-581, 1977, P 308

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82. Schwartz JL: Review and Evaluation of Smoking Cessation Methods: The United States and Canada, 1978-1985. Public Health Service, National Cancer Institute. NlH Publication No 87-2940, 1987 83. Schwartz JL: Evaluation of acupuncture as a treatment for smoking. Am J Acupuncture 16:135, 1988 84. Schwartz JL: Recent trends in smoking cessation methods in North America. hI Durston B, Jamrozik K (eds): Tobacco and Health 1990. The Global War. Proceedings of the Seventh World Conference on Tobacco and Health, 1st-5th April 1990, Western Australia, p 613 85. Schwartz JL, Dubitzky M: Expressed willingness of smokers to try 10 smoking withdrawal methods. Public Health Rep 82:855, 1967 86. Schwartz JL, Dubitzky M: Requisites for success in smoking withdrawal. In Borgatta EF, Evans RR (eds): Smoking, Health, and Behavior. Chicago, AI dine Publishing Co, 1968, p 231 87. Schwartz JL, Rider G: Review and Evaluation of Smoking Control Methods: The United States and Canada, 1969-1977. Center for Disease Control, HEW Publication No (CDC) 79-8369, 1978 88. Secker-Walker RH, Solomon LJ, Haugh LD, et al: Smoking cessation advice delivered by the dental hygienist. A pilot study. Dent Hyg Chi 62:186, 1988 89. Simon MJ, Salzberg HC: Hypnosis and related behavioral approaches in the treatment of addictive behaviors. In Hersen M, Eisler RM, Miller PM (eds): Progress in Behavior Modification, Vol 13. New York, Academic Press, 1982, p 51 90. Smith MC, Fincham JE: The Role of the Pharmacists in Smoking Cessation Counseling. University of Mississippi, Bureau of Pharmaceutical Services. A special supplement to Drug Topics (undated) 91. Smoking, Tobacco, and Cancer Program: Smoking, Tobacco, and Cancer Program: 1985-1989 Status Report. US Department of Health and Human Services, National Cancer Institute. NIH Publication No 90-3107, 1990 92. Spiegel H: A single treatment method to stop smoking using ancillary self-hypnosis. Int J Clin Exp Hypn 18:235, 1970 93. Spiegel H: Termination of smoking by a single treatment. Arch Environ Health 20:736, 1970 94. Tan CH, Sin YM, Huang XG: The use of laser on acupuncture points for smoking cessation. Am J Acupuncture 15:137, 1987 95. US Department of Health and Human Services: The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General. DHHS Publication No (CDC) 88-8406, 1988 96. US Department of Health and Human Services: Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHSS Publication No (CDC) 89-8411, 1989 97. US Department of Health and Human Services: The Health Benefits of Smoking Cessation. A Report of the Surgeon General. DHSS Publication No (CDC) 90-8416, 1990 98. Wechsler H, Levine S, Idelson RK, et al: The physician's role in health promotiona survey of primary-care practitioners. N Engl J Med 308:97, 1983

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Methods of smoking cessation.

Smoking-cessation treatment consists of three phases: preparation, intervention, and maintenance. Preparation aims to increase the smoker's motivation...
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