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I I I I I I I 1 I I I I I I I I I I I Pergamon cinoptan luw+i.iidr( .dn.r•\.. 41.j, \c : ^: '~ :-:ea. lo~;.+ Elsener X:en.e LW Prtnmsi n urnt Bnum 09[~dp,,o W S6 JO-J.UO 0959-8049(93)E0062-H Smoking Cessation Methods: Recommendations for Health Professionals. Advisory Group of the European School of Oncology A. Hirsch, K. Slama, A. Alberisio, G. Fowler, G. Lagrue, I. Malvezzi, M. Manley, R. Molimard and P. Tonnesen Smoking is the leading preventable cause of death. Approximately 40% of Europeans now smoke. Many smokers want to stop but do not make the attempt, and of those who try, most are unsuccessful. Primary care health providers can help their patients to stop by using brief behavioural and pharmacological interventions. Specialised smoking cessation clinics can support selected patients referred by primary care providers. This report reviews intervention techniques for health care providers, which, in combination with effective legislative and educational interventions, can significantly reduce the prevalence of smoking. EurJ Cancer, Vol. 30A, No. 2, pp. 253-263, 1994 INTRODUCTTON MASS IMPLEM£NTATION of effective smoking cessation inter- ventions that reach a large percentage of the population would save lives and be a major public health initiative in primary prevention. Smoking and disease: the burden ojillness Smoking is killing 8000 people a day, worldwide, by causing many of the most prevalent chronic degenerative diseases: 80-90% of chronic respiratory diseases, 80-85% of lung cancer, 25-43% of coronary heart disease [1]. Approximately 1/3 of all cancer deaths are caused by smoking [2]. Half of the people dying from smoking are under the age of retirement, in their 40s, 50s or early 60s, accounting for 50% of these premature deaths [3]. In Europe, smoking is considered responsible for an estimated 800000 deaths a year [4]. In all, smoking causes approximately one in six deaths [5]. The ill effects of environmental tobacco smoke are also becoming established: others' smoking can cause disease and death to non- Correspondence to K. Slama. A. Hirsch and K. Slama are at the Service de Pneumologie, Hopital Saint-Louis, 1 av. Claude Vellefaux, 75475 Paris Cedex 10, France; A. Alberisio is at the Responsabile Servizio di Psicologia, Istituto Nazionale per la Ricerca sul Cancro, Viale Benedetto XV, 10, 16132 Genova, Italy; G. Fowler is at the Dept of Community Medicine and General Practice, University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE, U.K.; G. Lagrue is at Inserm U. 139, Hopital Henri Mondor, 51, Av. du Mal de Lattre de Tassigny, 94010 Creteil Cedex, France; I. Malvezzi is at the Lega Italiana per Lotto Contro i Tumori, V. Venezian I, 20133, Milan, Italy; M. Manley is at the Smoking, Tobacco and Cancer Program, National Cancer Institute, Bethesda, Maryland, U.S.A.; R. Molimard is at the UER Biomedicale des Saints-Pbres, 45 rue des Saints-Peres, 75006 Paris, France; and P. Tonnesen is at the Rudolph Berghs Gadezo, 2100 Copenhagen e, Denmark. This study was supported by an educational grant from the EC "Europe Against Cancer" programme. smokers, who have been in environments where they breath in sidestream smoke. The U.S. Environmental Protection Agency has classified environmental tobacco smoke as a"gtnup A" or known human carcinogen [6]. In addition to causing discomfort and exacerbating respiratory and cardiovascular ailments, environ- mental tobacco smoke exposure is estimated to increase lung cancer risk among non-smokers by about 30% [7]. Tables 1 and 2 present a summary of the devastating health effects caused by smoking, Table 3 presents current knowledge about the health effects of environmental tobacco smoke, and Table 4 presents estimated risk reductions after cessation. In the European Community, as shown in Table 5, smoking among men 15 years of age and older ranged in the late 1980s from 38% in Ireland and Luxembourg to 61% in Greece; among women 15 years of age and older, from 12% in Portugal to 45% in Denmark [8], thus being a highly prevalent and visible behaviour. If we can provide effective interventions that encourage smoking cessation and abstinence, public health in the community can be enhanced, both in lowering health risks and in primary prevention: - The health risks created by smoking diminish progressively over time following cessation [1]; decreases in smoking preva- lence should be followed by reduced incidence of the numerous diseases caused or exacerbated by smoking. For example, recent drops have been registered in lung cancer mortality rates among men in those countries where men's smoking rates began declining in the 1960s and 1970s [9]. - Fewer smokers in the population means less exposure to environmental tobacco smoke and its sequelae. - Primary prevention can be facilitated. Decreased smoking prevalence among adults would enhance the possibility for prevention programmes among children and adolescents to have lasting effects. In Europe today, smoking is still a"notmal" behaviour. Young people who are searching for an alternative behaviour to signal a message about themselves are much more 253

A 254 A. Hirsch et al. I I I I I I I I I I I I I I I I Table 1. The health risk of smoking,j) Diseases causally linked to tobacco Coronary heart disease Artherosclerouc peripheral vascular disease Lung cancer Oral cancer Laryngeal cancer Oesophygeal cancer Chronic obstructive pulmonary disease (COPD) Cerebrovascular disease (stroke) Fetal effects causally linked to tobacco Probably causally linked to tobacco Unsuccessful pregnancies Increased infant mortality Peptic ulcer disease Diseases for which smoking is a contributing factor Bladder cancer Pancreatic cancer Kidney cancer Cervical cancer Intrauterine growth retardation Low birthweight Passive smoking effects on children and adults Increased risk of lung cancer Increased respintorv infections Source: U.S. Surgeon General's Report. Reducing the Health Consequences of Smoking. 25 Years of Progress. DHHS Pub (CDC) 89-8411, 1989, Rockville, Maryland, U.S.A. likely to choose to smoke themselves when they have an example to follow (10). This report Smoking cessation programmes are a vital component of any smoking control strategy. But they can only be supplementary to 'whole population' approaches which include regular tobacco tax increases, legislation (banning direct and indirect advertis- iag, restricting smoking in public places to identifiable "smoking zones", regulating strong health warnings on cigarette packaging), media campaigns and public information education programmes, and self-help cessation materials. A global, com- prehensive approach can influence consumption trends and the social acceptability of tobacco use, which in turn encourages spontaneous as well as aided cessation. Most ex-smokers report that they stopped smoking unaided [11]. However, the rate of new, sustained cessation in the population remains low, and usually occurs only after repeated efforts over time. Unless concerted efforts continue to be made to promote smoking cessation, the prevalence of smoking will not significantly decrease, because of the high levels of uptake among adolescents. This report will not attempt to deal with the effects of legislation, mass campaigns, self-help materials or prevention campaigns, but will assume that these methods should exist and serve as a backdrop to more therapeutic methods for smokers that desire and ask for help or for smokers in the general population who can be motivated to stop on their own. The scope of this report is limited to the smoking cessation methods offered by health professionals. Most evaluated results come from smoking cessation clinics or specialist consul- tations, or from trials in general practice; medical doctors or therapists being the principal agents of change. However, this Table 2. The health risk of smoking (11). Relative risks of mortality as a result of smoking (Data from ACS 50-state study) Underlying cause of death Non-smoker's risk Smoker's risk Miles/females Ex-smoker's risk Males/females All auses 1 2.34 / 1.90 1.58 / 1.32 Coronary heart disease (35-65) 1 2.81 / 3.00 1.75 / 1.43 Cerebrovascular lesions (35-65) 1 3.67 / 1.84 1.38 / 1.06 Other circulatory diseases 1 4.06/4.80 2.33/1.41 COPD 1 9.65/ 10.47 8.75/7.04 Cancer: lip, oral cavity, pharynx 1 27.48 / 5.59 8.80 / 2.88 Cancer: oesophagus 1 7.60 / 10.25 5.83 / 3.16 Cancer: pancreas 1 2.14/2.33 1.12/1.78 Cancer: larynx 1 10.48 / 17.78 5.24 / 11.88 Cancer: lung 1 22.36 / 11.94 9.36 ! 4.69 Cancer:cerviu uteri 1 / 2.14 / 1.94 Cancer: kidney 1 2.95 / 1.41 1.95/1.16 Cancer: bladder, other urinary 1 2.86 / 2.58 1.90 / 1.85 Source: U.S. Surgeon General's Report. Reducing the Health Conseqvenca of Smoking. 25 Years of Progreu. ~ DHHS Pub (CDC) 89-8411, 1989, Rockville, Maryland, U.S.A.

I I I I I I I I I I I I I I I I I Smoking Cessation Methods: Recommendations for Health Professionals Z55 Table 3. The health risks of smoking Suspected effects of - pasnve smoking Increased lung cancer risk: 20-30% of cases of iung cancer among non- smokers caused by passive smoking Risks: L'nexposed non-smoker 1 Non-smoking woman married to smoker 1.34 Smoker < 10 cigarettesrday 2.3-4.6 Increased risk of death from heart disease (disputed) Increased incidence of childhood respiratory diseases and respiratory tract infections Pneumonia Trachecitis Bronchitis Asthma Otitis Tonsillectomy Adenoidectomv More frequent childhood admissions to hospital Reduced lung function Increased fetal risks caused by tnaternal smoking Reduced birthweight Natal mortality Spontaneous abortion Possible effects: Neo-natal mortaliry Source: Hirsch A. Chancteristics and consequences of passive smoking. Aerobiologiea 1990, 6, 75-78. report wishes to encourage the entire health profession, and proposes actions that can be considered not only by general practitioners and medical specialists, but also by nurses, dentists, pharmacists and other professionals in the health field such as psychologists and social workers. DEFINITION OF THE PROBLEM Current knowledge about smoking and smoking cessation Tobacco smoking is a complex behaviour to which psychologi- cal, social and pharmacological factors contribute [12]. The acquisition of the habit in childhood or adolescence is largely determined by the desire for experimental, rebellious behaviour which is perceived as adult and which is encouraged by peer group behaviour [9]. The relatively low cost and high availability of tobacco products underpin the overall legitimacy of tobacco use. The highly visible pEev_alence of smoking among certain groups, including people in the entertainment industry and young adults, provides constant reinforcement and modelling for continued smoking. As a psychological device, smoking becomes a powerful component of coping for many smokers, and physical responses rapidly develop alongside psychological needs. Pharmacological addiction frequently becomes the major factor determining persistence of the behaviour. Nicotine, poss- ible other pharmacological mechanisms, social, psychological and behavioural factors can all help to explain the difficulties smokers face in stopping smoking. Although the balance between psychosocial factors and phar- macological addiction vaires from smoker to smoker, research has increased awareness of the importance of nicotine addiction. The powerful nature of this addiction had been emphasised by comparing it to such drugs as heroin and cocaine [ 13]. As a drug, nicotine has many of the characteristics of other drugs of addiction, including the development of tolerance and experi- ence of withdrawal effects after stopping smoking. However, as spontaneous addiction to pure nicotine has never been docu- mented, other still unknown pharmacological dete inants of tobacco addiction might exist. Despite these psychosocial and pharmacological factors, people can and do stop smoking. It may be useful to consider smoking cessation as a process, with identifiable stages of precontemplation (not yet thinking about stopping), contem- plation (awareness of the issues), decision (personal reasons for stopping), action and maintenance [14]. A conceptual model of this process is presented in Fig. 1. While the majority of smokers now acknowledge that smoking creates additional risk, there is evidence that only those who are closest to a decision to stop smoking are likely to feel personally vulnerable to the risks [15]. However, although 65% or more of smokers pass beyond the stage of precontemplation [16], few are able to pass through all of the stages. Using this conceptual model, techniques for smoking cessation have evolved to respond to the barriers of passage from one stage to the next. Depending on the stage of their cessation, smokers may need increased motivation to move towards the decision to act, techniques to facilitate action or strategies to maintain their abstinence. In some populations receiving cessation aid, there may be a high percentage of smokers who stop smoking initially, with a majority relapsing, in large numbers at first and decreasing numbers over time as shown in Fig. 2. In other populations the relapse curve will be similar, but the initial cessation may be much smaller. Table 4. The health risk of smoking (IV). Risk reduction after smoking cessation Short term Long term Coronary heart disease 50% less risk at 1 year Non-smoker rate at 10-15 years Cerebrovascular disease Non-smoker rate at < 1 yr ~ Peripheral vascular disease Halts progression immediately ~ Lung cancer 60% less risk at 5 years 50-90% less risk at 15-20 years ~ ealcanar laryn Non-smoker rate at 10-15 years g ~ Oral cavity cancer Decreased risk after 6 years Non-smoker rate at 16 years ~ Bladder cancer Non-smoker rate at 15 years Respiratory disease Slow decline 50% less risk at 20 years ~ Source: Fielding JE. Smoking: health effects and control. N Er+gl J Med 1985, 313, 491Jt98. 1

1 256 A. Hirsch er al. I I I I I I I I I I I V I I I I I "Contented" smokers Table 5. Proporticm of smokers (cigarettes, pipes, cigars) bv sex and age in the EC' accumulated results of four surUevs 1987 to 19891 - Males Females Total Age 15-24 25-39 40-54 55- Total 15-24 25-39 40-54 55- Total populauon 0i6 % 016 0/0 0/0 % 0/0 0/0 11i0 11/0 0i6 Denmark 33 39 50 47 46 44 49 46 40 45 45 Greece 59 72 67 47 61 35 45 21 09 26 43 Netherlands 38 49 55 46 47 41 47 38 21 37 42 Spain 51 64 61 38 53 49 50 13 04 28 40 France 51 57 49 28 44 46 38 20 10 29 36 Belgium 38 51 50 37 44 32 43 25 13 28 36 U.K. 30 45 42 41 40 29 32 35 30 32 35 Ireland 32 43 37 39 38 31 38 31 25 31 35 W. Germany 31 55 46 38 43 26 43 20 17 27 34 Luxembourg 28 45 39 35 38 37 37 29 14 30 34 Italy 31 45 42 35 39 24 40 25 16 26 32 Portugal 52 57 42 28 46 26 22 03 01 12 28 Community 39 53 47 37 44 34 40 26 17 28 36 'Here the countries are arranged in order of the decreasing percentage of smokers of both sexes in the total population (15 years or over ). Weighted average. Source: Comission of the European Communities (1989b), from Bosanquet N & Trigg A. Smoke-free Europe in the Year 2000: Wishful Thinking or Realistic Strategy? Health Policy Unit Discussion Paper 4. Chichester: Carden Publication Limited, 1991. Deciding Thinkin.~ to try `---N b a out Trying to stopping stop Stopp g Relapsing / Staying stopped Fig. 1. Stopping smoking as a process. Source: Raw M. Help Your Patient Stop. London, BMA, ICRF, UICC, WHO, 1988. (00 ~ y ~ ¢ 50 90 80 70 60 E 40 30 20 10 Point prevalence \ Q_ ~ ---- ~ I f I 3 6 9 12 Months Methodologu:al issues Motivation to stop smoking and confidence in the ability to do so are important predictors of success [17]; method of recruitment is, therefore, an important variable and those partic- ipating in studies in specialist smoking cessation clinics will generally be more motivated than those in primary care studies. Analysis of results should be on an 'intention to treat' basis, those not followed-up being assumed to be continuing smoking, rather than excluded from analysis. Relapses are common after cessation, but most people who do relapse do so in the first year [10]; 1 year follow-up is, therefore, a good measure of long-term success. Point prevalence cessation at 1 year includes not only those who have achieved sustained abstinence since the inter- vention, but also those who have stopped recently and are likely 100 90~- 80yF! 70 10 Sustained abstinence \ , \ . -------- .fl •p ................ q I f f I t 0 3 6 9 12 Months Fig. 2. Examples of point prevalence and sustained abstinence curves for tbree smoking cessation therapies. Source: Laado HA, et a/. .y Comparative evaluation of American Cancer Society and American Lung Association smoking cessation clinics. Am j PnWic Xeah61990, 80, ~ 554-559.

I I I I I I I I I I I I Smoking Cessation Methods: Recommendations for Health Professionals 257 to relapse. Abstinence immediately following the intervention and maintained for 1 year is the most reliable measure of long-term success and self-reporting needs to be validated by biochemical tests such as exhaled carbon monoxide (CO) level or blood, urine or saliva cotinine, because deception is common. STATE OF THE ART, PART 1: PROGRAMMES FOR GENERAL. PRACTICE PA'I`IENTS There is important evidence of the efficacv of smoking cessation interventions in primary care and much of this evidence comes from rigorous evaluation by randomised controlled trials [22, 23]. Implementation of smoking cessation interventions Despite the clear public health mandate to reduce the preva- lence of smoking in the community, health professionals outside the realm of cessation clinics have been reticent to offer smoking cessation interventions. Existing health care delivery systems vary throughout Europe, but within each context, health pro- fessionals can use their exemplary role and their access to a large number of smokers to provide advice and treatment. General practitioners and medical specialists may not feel confi- dent about their skills in treating smokers, since their medical training focuses on curative procedures rather than preventive techniques [ 18]. They may be reticent to significantly increase such procedures which are often not accepted clinical procedures for fee payment or reimbursement. General practitioners may not be aware of the significant impact that their actions can have on prevalence in the community, nor the clear mandate that smokers attribute to them for providing treatment, as shown in Table 6. Other health professionals (dentists, pharmacists, nurses, etc.), and those working in health delivery systems, such as psychologists and social workers, may face even larger disincentives to action, as little research has been undertaken to demonstrate what techniques they could adapt to their working practices and the impact such action would have on smoking cessation efforts. Opportunities for advice, however, are plentiful [ 19, 20]. The combination of advice and the possibility of treatment coming from a maximum number of sources is essential for undermining the social legitimacy of smoking and for aiding smokers through the various stages of cessation (21]. This committee emphasises the importance of the problem and the desirability of putting into place means for advising smokers to stop at every contact with the existing health delivery system. Table 6. Smokers' attitudes to GP detection of their smoking and predicted reactioru to the offer of specific advice % of patients % of raying they smokers would saying that change to I % of smokers they would another GP change to in relation expecting another GP to I this from because of their GP this preventing hypertension Initial detection 91% 0% 2% Health warning 96% 2% 7% I Advice to stop smoking 78% 7% Smoking cessation strategies 78% 2% Strategies for reducing hypertension 1% I Prescription of medicinal aid 44% 0% 3% I Source: Slama KJ, Redman S, Cockburn J, Sanson-Fisher RW. Com- muniry views about the role of general practitioners in disease preven- tion. Family Practice 1989, 6, 203-209. Brief advice An overview [23] of the effect of brief smoking cessation advice, given by doctors in consultations about other matters, indicates achievement of about 5% long-term cessation, com- pared with less than 1% in non-intervention control groups; following such advice, about one in 20 can, therefore, be expected to stop smoking for good. GPs can be influential even for those who are in the early stages of the process of cessation, and help smokers move towards a decision to stop smoking. Any action on the part of the GP increases the number of cessation attempts by 10% [17]. Although the evidence of efficacy of brief advice in primary care almost entirely relates to doctors, advice from nurses seems likely to have an effect too, especially if supplementary to a doctor's advice (24). In the following text, health professionals are given advice based on results from general practice. Basic procedure for health professionals In light of the scientific evidence of the efficacy of.smoking cessation interventions in primary care, it is possible to outline a procedure which could be adopted by all health. professionals. The US National Cancer Institute has proposed a programme of four steps as a guideline for helping patients to become motivated to stop and helping motivated patients succeed at cessation attempts. The four steps are: (1) ASK all patients about smoking (2) ADVISE smokers to stop (3) ASSIST their efforts with self-help materials, a quit date, and possibly nicotine replacement (4) ARRANGE follow-up 1. ASK about smoking at eaery opportunity. The health pro- fessional should seek opportunites to raise the issue of smoking in any consultation, especially in the context of smoking-related symptoms, pregnancy and forthcoming operations--and also discussing parental smoking in the context of respiratory ill- nesses in infants and children. Medical records should include information about whether the patient is a smoker or not. 2. ADVISE (motivate) all smokers to stop. The health pro- fessional should ask if the patient is interested in stopping smoking and provide information and advice, reinforcing pati- ents' own motivation where possible and emphasising the bene- fits of stopping. There is no set procedure for giving advice and stopping smoking, but a prescriptive approach should be avoided. Eliciting the patient's own knowledge and beliefs, reinforcing the smoker's own reasons for wanting to stop and boosting motivation and confidence are useful approaches. Emphasis on possible immediate benefits will often mean more to the smoker than long-term advantages. For those patients who presently do not want to stop, nagging is rarely of benefit. Health professionals must accept the patient's decision, make sure the patient is making an informed decision, and attempt to maintain the patient's trust and confidence, so that smoking can be discussed at future visits. If the conversation is noted in the medical records, it can be referrsd to in future discussions. 2046399556 t

I I I I I I I I I I I I I I I I i 258 A. Hirsch et al. 3. ASSIST tke patient in stopp:ng. For those patients who express a sincere desire to stop smoking, the health professional should help them to pick a specific date for this action. There is evidence that patients who set a "quit date" are more likely to make a serious attempt to stop [25]. The data should usuallv be within 4 to 6 weeks, but not immediately, giving the patient the necessary time to prepare to stop. Once a patient has selected a specific date to stop, information must be provided so that he or she can prepare for that date. Preparing to stop by planning a strategy, including involving a spouse or friend, avoiding smoking situations, etc., will be a matter of individual style. Since consultation time is limited, self-help leaflets are useful adjuncts. Effective self-help material (brochures, cassette or video tapes, etc. ) provide the patient with necessary information about smoking cessation (symptoms and time course of withdrawal, tips about stopping, good reasons for stopping, answers to common questions, etc.). With this information, the patient can leave the office with a concrete plan for stopping, including a quit date, and information about preparing for that date and successfully stopping. Medical practitioners can include nicotine replacement ther- apy as an adjunctive aid, where appropriate. Results from placebo-controlled trials of nicotine patches in the primary care setting are encouraging [26-28). For example, a recent study among highly motivated heavy smokers in general practice found sustained cessation at 12 month follow-up of 9.3% for brief advice and active patches compared with 5.0% for brief advice and placebo patches (28). Readers are referred to the section on pharmacological tratments for more details about nicotine gum or patches. ' 4. ARRANGE jollou~up visets. When patients know their progress will be reviewed, their chances of successfully stopping are improved. This monitoring may include a letter or phone call just before the quit date reinforcing the decision to stop. In addition, clinical trials strongly suggest that a return visit after a patient has stopped smoking is extremely important to the patient's ability to remain a non-smoker [ 17]. Merely scheduling the visit may help the patient by providing a short-term goal that appears more manageable than "forever". Most relapses occur in the first 6 weeks after cessation [29), and a person who returns after being a non-smoker for 1 to 2 weeks has a much improved chance of *Y**+aining abstinent. Follow-up visits consist of an assessment of the patient's pro- gress, discussion of any problems encountered or anticipated, and discussion of nicotine gum use, if prescribed. It is also useful to consider a second follow-up visit 1 or 2 months later. Studies show that the quit rate improves as the number of follow-up visits increases [30]. Incorporating smoking cessation advice into routine operating procedure Some simple changes in office procedures will significantly increase the health professional's effectiveness in treating pati- ents who smoke. A policy of including a patient's smoking history, including cessation attempts, in his or her medical records encourages the doctor's continued implementation of routine advice, and has been shown to increase cessation rates [31). Every practice is different, so the exact procedures adopted will vary somewhat, but the goal is to ensure that all patients who smoke are routinely identified, monitored and appropriately treated. A smoke-free office makes a powerful statement about the health professional's strong_commitment to non-smoking. Steps for making an office tobacco.;free include posting no-smoking signs, removing ashtrays, displaying tobacco cessationipreven- tion information prominently and eliminating tobacco advertis- ing from the office, by subscribing to magazines that do not carry this advertising [30]. The single most important cessation strategy is the involve- ment of primary care physicians. Workplace programmes and specialist smoking cessation clinics have a part to play, as do other health professionals. A coordinated approach with liaison between all agencies involved is highly desirable [32]. Specialist smoking cessation clinics have a limited role as they can only serve limited numbers of smokers [33], but their value in supporting general practitioners may have been underestimated [34]. Recommendations (1) The primary care health system is the logical setting to provide smoking cessation services to most smokers. These interventions should be a routine part of primary care. (2) All health care professionals need to acquire the appropriate knowledge and skills to provide these services, and be encouraged to use them. (3) Payment should be made for providing smoking cessation services in primary care. STATE OF THE ART, PART II: SPECIALIST SMOMG CESSATION CLINICS CIinics, hospitals and university laboratories can offer special assistance to smokers with a promise of expertise in aiding cessation. As mentioned previously, dependence on smoking varies across individuals, and although subjects who attend smoking cessation programmes usually are the more heavily dependent subjects, these smokers are generally more motivated to stop, but have sought help in stopping smoking and staying abstinent. Results both in initial and sustained cessation are, therefore, higher than results in general practice, where smokers with lower and varying motivation to quit smoking are recruited. For this reason, results from cessations clinics should not be compared with those of general practice. Individuals who attend smoking cessation clinics vary in their needs; most clinics, therefore, offer multicomponent pro- grammes to respond to the complex mix of behavioural, psycho- logical and pharmacological factors in smoking dependence. The 1988 US Surgeon General's Report "Nicotine Addiction", drawing on research in the treatment of tobacco dependence, concluded that tobacco dependence can be treated successfully, that effective interventions include behavioural approaches alone and behavioural approaches with adjunctive pharmacological treatment, that behavioural interventions are most effective when they include multiple components, and that nicotine replacement can reduce tobacco withdrawal symptoms and may enhance the efficacy of behavioural treatments [13J. Behavioural, psychological approaches The most effective behavioural techniques correspond to elements from behavioural modification therapy which attempt to establish a better understanding of the environmental and physical cues to smoking so as to enable the smoker to more successfully modify his or her response to these cues, and to analyse fears and difficulties involved in abstinence from smoking, so as to prepare adequate but non-smoking strategies for coping. 20463995-57

~ Smoking Ccssauon Mcthods: Recommendations for Health Professionals Z59 I Self-management (self-control) techniques are based primar- i1y on understanding one's smoking and the circumstances around it, and modifying them both in a controlled way with behavioural and cognitive (mental imagery) strategies. Within a wide range, these strategies, usually provided in a group context, produce 33% cessation rate (35]. Aversive strategies, on the other hand, attempt to eliminate the positive associations the smoker has with smoking and to replace them with negative associations, by enforcing an aversive context to the act of smoking. While early results of rapid smoking and satiation were impressive, replication has shown more modest results [36]. Concern about the potential harmfulness of methods which encourage an increase, even if only temporarily, in smoking [35], has led to utilisation of milder aversive techniques such as normal-paced aversive smoking or smoke holding, almost always in conjunction with self-management strategies. Within a wide range of results, these multicomponent programs produce 25% cessation [37]. Self-management and aversive techniques have often been assessed in research comparing treatment options in the absence of a control group, and without biochemical verification of abstinence. This means that comparison of results from behavioural therapy research with the results of nicotine replacement therapy is difficult. is used in adjunction with psychological support, active increases smoking cessation rate. gum I I I I I I I I I I I I I I Pharmacological treatments Several drugs have been tested in smoking cessation, but nicotine replacement therapy is the only one proven to be effective (13]. (ACTH and mecamylamine, a nicotine antagonist, are currently under investigation.) Antidepressive drugs which have been tested have shown negative effects. Several placebo- controlled trials of clonidine, as tablets or in a patch, have shown conflicting outcomes and sedative side-effects. (Clonidine might have a role in aiding women who do not tolerate nicotine replacement therapy, but further research is needed.) Nicotine substitution is the only drug therapy showing a significant increase in outcome in most studies. Nicotine chewing gum (nicotine polacrilex gum) and nicotine transdermal patches are the nicotine delivery systems most extensively tested; newer delivery systems such as nicotine nasal spray and nicotine vapour inhaler ("smokeless cigarettes") are currently under investigation. The rationale for nicotine replacement therapy (NRT) is that a switch from tobacco to NRT temporarily enables the smoker to tackle the psychosocial aspects of cessation first, while obtaining relief from nicotine withdrawal effects. Subsequently, by tailing off the pharmacological treatment, nicotine abstinence may be achieved and withdrawal effects minimised. Nicotine polacriltx gum Many rigorous, placebo-controlled trials have investigated the efficacy of nicotine chewing gum. In specialist smoking cessation clinics, specific efficacy of the gum has been clearly demonstrated [38, 39], but this has not been shown in the primary care setting [40, 41]. Nicotine gum as an option to treatment, however, has shown efficacy. Of 13 trials [39-51], the short-term outcome (during use of the gum) is significantly higher in the active nicotine group in nine of the trials [39, 41, 43-46, 48, 50, 51) with median values at 4 weeks of 60% cessation versus 37% for placebo. The long-term outcome is significant in only four studies [39, 42, 49, 50], with median values of 23 versus 17% for placebo. However, many of the studies were not designed to measure long-term success. Also, underdosing seems to be a major reason for conflicting findings in several clinical trials with the gum. When adequate gum dose Use of nicotine polacrilex (chewing gum): nicotine poiacri- lex should not be chewed like chewing gum, but instead chewed intermittently and then held in contact with the oral mucosa, where the nicotine is absorbed. Patients need careful instruction in the use of this unusual drug delivery system, or they will derive no benefit from it. When used appropriately, withdrawal symptoms are reduced. The use of this drug for 3 months is recommended followed by a gradual tapering. Use for more than 6 months is not recommended, although this is not rare among patients who successfully stop smoking. Nicotine skin patch Nicotine skin patches are now available in many countries and in several varieties. Their efficacy in special- ist smoking cessation clinics has already been clearly established [52]. Of 11 placebo-controlled trials [26, 53-62], median results show 48% cessation with the active patch versus 20% for placebo at 6 weeks, and 17% in active versus 6% in placebo groups at 12 months. Use of the nicotine transdermal patch: transdermal nic- otine patches deliver nicotine through the skin and may prove easier for patients to use. Nicotine patches are available in 24-h and 16-h delivery systems. All manufac- turers recommend a higher initial treatment dose followed by one or two weaning doses. Most also advise a lower starting dose for patients with a history of cardiovascular disease and for those weighing less than 45 kilos. The nicotine transdermal patch should be applied once every 24 h (usually in the morning) to a clean, dry and non- hairy site on the trunk, upper arm, or gluteal region. Application sites should not be reused for at least 48 hours to decrease skin irritation. The evidence clearly indicates that nicotine replacement ther- apy helps people to stop smoking. The benefits of nicotine gum depend on adequate compliance and lack of this at least partly explains the failure to demonstrate efficacy in general practice in placebo-controlled trials. Compliance with transdermal nicotine patches seems to be better. However, about 10% of people are unable to use nicotine patches because of skin reactions and a small proportion using 24-h patches experience sleep disturb- ance. We have no definitive way of estimating dependence on smoking or on nicotine. The Fagerstrom Questionnaire is cur- rently the most commonly used scale to determine nicotine dependency [63], but more precise measures are needed. We recommend the possibility of using nicotine replacement for subjects smoking 10 or more cigarettes per day, as this has been the minimum number for inclusion in trials that have shown efficacy for the nicotine patch. Laboratory studies have shown that the combination of nic- otine gum and nicotine patch might affect withdrawal symptoms at the same level as does smoking. The combination of the different forms of nicotine delivery should thus be tested in the clinic to increase outcome further. Basic principles in smoking ussation clinic treatrnerus There are some general rules and basic principles that are fundamental to smoking cessation programmes. Smoking cess- ation must be complete, as even one or two cigarettes per day 2046399558

I I I I I I I I I I I I I I I I I I I 260 A. Hirsch et al. will be followed_by relapse. Cessation among heavilv dependent Research in intervenrions bv_health professionals smokers can be doubled with nicotine replacement therapy. Social pressures for nQn::§moking, persistent anti-tobacco Follow-up must be included as a part of treatment, especially in messages from a variety of sources, and a tobacco-free environ- the first 3-6 weeks when risk of relapse is greatest. Subjects who ment greatly influence the success rates of smoking cessation do relapse should be recycled into other treatment after a period. treatments. Efforts should be maintained to keep these the Recotnmendations: major goals of tobacco control policy. Of the smokers who are influenced to stop, most will stop without any formal treatments; (1) Specialist smoking cessation clincs should be research- based and be the 1 for this reason general information about the reasons for stopping egitimate site for testing new treatment smoking and the most effective available strategies should be options. (2) Treatment in specialist smoking cessation clinics should take provided to the widest possible audience. One of the most logical access points is the health delivery system. Research is needed into account both behavioural and pharmacological aspects not only in continuing the search for the most effective inter- of smoking. vention tools, but equally, in discovering how to influence health professionals to incorporate such interventions systematically CONTROVERSIAL SMOKING CESSATION METHODS into their normal job functions. The role of nicotine replacement A number of methods which are claimed to be useful in therapy in general practice needs refining, and the feasability smoking cessation must be regarded as controversial because of and acceptability (both to the agents and to their patients/clients) the relative lack of scientific evidence regarding their efficacy. of smoking cessation interventions by other health professionals Compared with, for example, the substantial amount of evidence (dentists, pharmacists, social workers) is still to be determined. from rigorous scientific trials of the efficacy of brief advice, and Research should investigate how health professionals can of nicotine replacement therapies, there is little or no evidence mcrease motivation to stop smoking, and promote smokers' supporting these controversial methods either because appropri- passage from a desire to stop smoking to actual behaviour ate trials have not been conducted or because of the methodolog- change. The whole area of relapse prevention in the community ical inadequacies of such trials as have been attempted. should also be addressed: how can health professionals systemati- cally play a role in helping new ex-smokers? Hypnosis Treatment packages specific to each European health delivery This is widely regarded as a useful treatment strategy in system need to be designed and evaluated, and then made smoking cessation and there are many reports of successful available for distribution, to increase the feasibility of incorpor- cessation following hypnosis. Some individuals are highly sus- ation into everyday practice of smoking cessation interventions ceptible to hypnotic induction but others are unresponsive. by health professionals, and particularly by GPs. In conjunction Studies have found hypnosis better than non-treatment control ~~ the treatment packages, optimal training techniques should but these rely on short-term follow-up and self-reported cess- be found to encourage health professionals' participation. ation only. There is little evidence that hypnosis per se facilitates Precision of ineasurement smoking cessation [64]. However, although scientific evidence Currently, we have very crude measures of motivation, the does not justify the promotion of hypnosis for smoking cessation, measure of intention to stop smoking and the measure of susceptible individuals wishing to try it should not be discour- confidence that one can stop and remain abstinent being the aged. two most correlated to eventual stopping among motivational measures [10]. It would be helpful to have more accurate Acupuncture measures, to identify the actual role of motivation in successful This is also widely used and has become increasingly popular cessation. with the growth of interest in "alternative" or "complementary" Research should continue to develop more precise measure- therapies. Although there have been a number of trials, most ment of nicotine addiction with the objective of obtaining have suffered from serious methodological8aws, especially lack optimal results from nicotine replacement therapy. Monitoring of a proper control group. The scientific basis for acupuncture, of plasma nicotine would allow more individualised doses of as for hypnosis, is therefore weak. nicotine, and/or the recognition of optimal dosage. It is also important to determine the limits of the explanation Products without a:rredical liuhse (over the cmmur smoking nicotine dependence mechanisms can provide in our understand- ces tion aids) ing of dependence, and to continue to examine the possibility of A number of products claiming to facilitate smoking cessation other pharmacological factors in tobacco dependence. are available through newspaper advertisements, pharmacists Research questions in specialist smoking cessarion clinics and other agencies. These include some nicotine tablets or We need continued research not only on optimal dosage and lozenges (and recently, skin patches) which have not been duration for each sort of nicotine replacement therapy, but formally evaluated. Other products available are non-nicotine also on the utility of combining different forms of nicotine and include herbal cigarettes, special filters, dummy cigarettes substitution delivery (e.g. gum + patch) and the concomitant and non-nicotine chewing gum or tablets. These have not been questions of dosage and duration of treatment. scientifically evaluated and their use should not be encouraged. Depression appears to inhibit successful smoking cessation. Research is needed to measure the magnitude of the role FUTURE RESEARCH NEEDS depression plays in the outcome of smoking cessation treatment. Following the advances research has made in our understand- It is well known that weight gain is a common result of ing of the evolution of smoking and the role of nicotine in smoking cessation. But there are few positive examples of weight tobacco dependence, there remain many areas for future research gain prevention techniques promoting successful outcomes in in smoking cessation methods. smoking cessation treatment. This merits further research. 2046399559

I I I I I I I I I I I I I I I I I I Smoking Cessation Methods: Recommendations for Health Professionals 261 Research is also needed for special populations: what are the optimal ueatments for pregnant women, people with smoking- related disease symptoms, worksite populations, adolescent smokers % Finallv, the relationship between smoking and other depen- dencies, or other maladaprive behaviours needs further study. SUGGESTED FUNDING PRIORITIES With 800000 deaths a year in Europe at the present time, smoking cessation should be a top priority. This priority should be reflected in the funding of research and the dissemination of results. Dissemination of existing knowledge Research to extend our knowledge about the phenomena of smoking cessation and relapse is not enough. We must know about the feasibility and implementation of existing knowledge. This can only be done by a clear policy favouring health promotion activities such as smoking cessation interventions by health professionals. Priority should be given to the evaluation of effective implementation and training of health professionals in cessation activities. Research Funding of research in the tobacco cessation field should give priority to the research questions developed in the preceding section. - Optimising the implementation of routine smoking cessation interventions in general practice, training for all health professions; and developing intervention packages for use with their patients. Optimising the treatments general practitioners and other health professionals have at their disposal. Discovering more precise measurement of dependence and of attitudinal measures of motivation. Optimising the treatment efficacy of nicotine replacement therapy through research on dosage, duration and combi- nation of forms of delivery. Searching for other pharmacological determinants of smok- ing and for new pharmacoloL,- -sl therapies. Discovering ways of preverr relapse. Deepening our knowledge =-out the needs of special sub- groups, about the effects of specific factors on smoking cessation and about predictors of outcomes. This research can and should come from a number of sources. Research in general practice and other health delivery sites needs to be encouraged, in particular for: - defining the optimal cessation and relapse avoidance inter- ventions for each health site. - Developing and evaluating the efficacy of both training and treatment packages for health professionals. As stated above, only a limited number of smokers can be treated by specialist smoking cessation clinics. But these clinics can also play an important role in developing and defining specific techniques in cessation, aid in disseminating this infor- mation, and support primary health care professionals. It is suggested that funding be made available to a network of cessation clinics throughout Europe to coordinate activites and serve as: - Information centres for scientific documentation and infor- mation for the media and the public. Cenues for collaborating and coordinating research, award- ing grants and fellowsktigs, and organising meetings. Centres for evaluating specific treatment therapies, parucu- larly nicotine replacement therapy and self-management strategies, and developing measurement of dependence. Teaching centres for GPs and other health professionals, psychologists and educators involved in smoking prevention or cessation. CONCLUSIONS Smoking is killing people in the prime of their lives; three times as many smokers die in middle age as non-smokers (65j. Many smokers can be motivated to become non-smokers on their own, others can stop and remain non-smokers if they are assisted. Along with persistent social, educational and legislative pressures for a tobacco-free society, smoking cessation activites must exist. Our commitment must be to continually search for the best ways to reach out and help the greatest numbers of these smokers. MESSAGE TO THE PUBLIC Individuals can safeguard their health by never becoming smokers. But the benefits of stopping for those who do smoke are important, and can be gained fairly quickly at any age, however much is smoked and whatever the duration of smoking. It is never too late to stop smoking. Many smokers succeed in stopping without any special aids or help and without any special support other than that of a spouse or friends. But for some, the help and support of a primary care doctor, or any health professional can be valuable. Smokers should not be reticent in requesting such help. Many doctors in many countries identify helping smokers to stop as an important part of their job. 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