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. , Review and Evaluation of SMOKING CESSATION ~ METHODS: • • The United States and Canada, 19?8-1985 , ~ , ,... U.S. DEPARTMENT OF $EALTH AND HUMAN SERVICES Public Health Service National Institutes of Health

Review and Evaluation of SMOKING CESSATION METHODS: The United States and Canada, 1978-1985 Jerome L. Schwartz, Dr.P.H. Health Care Research Specialist Davis, California Published by Division of Cancer Prevention and Control National Cancer Institute U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health NIH Publication No. 8 7-2940 April 1987 TIMN 293322

TIMN 293323 For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402

CONTENTS Page TABLES ...................................................................... vii PREFACE ..................................................................... ix FOREWORD ................................................................... xi AUTHOR'S NOTE AND ACKNOWLEDGMENTS ...................................... xiii 1. INTRODUCTION ............................................................ 1 SMOKING AS A HEALTH PROBLEM ............................................ 1 Overall Mortality ........................................................... 1 Morbidity ................................................................. 2 Lung Cancer .............................................................. 2 Other Cancers .............................................................. 2 Cardiovascular Disease ...................................................... 2 Nonneoplastic Bronchopulmonary Disease ....................................... 2 Peptic Ulcer ............................................................... 3 Effects of Smoking on Pregnancy .............................................. 3 Smoking and Occupational Exposure ........................................... 3 Summary of the Consequences of Smoking ...................................... 3 SMOKING HABITS IN THE UNITED STATES AND CANADA ......................... 3 Smoking Levels in the United States ........................................... 3 Smoking Levels in Canada ................................................... 4 SUMMARY OF 1969 REVIEW .................................................. 4 SUMMARY OF 1969-1977 REVIEW ............................................. 6 METHODOLOGICAL WEAKNESS OF CESSATION EVALUATIONS .................... 7 VALIDATING SELF-REPORTS BY PHYSIOLOGICAL MEASUREMENTS ................ 9 2. CLASSIFICATION OF SMOKING CESSATION CATEGORIES .......................... . 11 METHODS INCLUDED IN THE REVIEW ......................................... 11 CRITERIA USED FOR EVALUATION OF CESSATION METHODS ..................... 11 WORKSITE SMOKING POLICIES AND CONTROL PROGRAMS ....................... 13 3. SMOKING CESSATION METHODS ............................................... 15 SELF-CARE ................................................................ 15 Self-Help Books ............................................................ 16 Aids to Quitting ............................................................ 18 Quitting by Mail .......................................................... 19 Summary and Comment ..................................................... 20 EDUCATIONAL APPROACHES, CLINICS, AND GROUPS ............................ 21 Nonprofit Programs ......................................................... 21 Educational Activities ...................................................... 21 Educational Techniques .................................................... 23 Cessation Programs in Schools .............................................. 23 Educational Quit Programs ................................................. 23 Five-Day Plan ........................................................... 24 In-Residence Treatment ................................................... 25 Withdrawal Clinics and Groups .............................................. 26 Summary of Group Methods ................................................ 30 Comment ................................................................ 30 iii TIMN 293324

Page Commercial Programs .......................................................... 30 Review of Telephone Yellow Pages .............................................. 30 Proprietary Methods ......................................................... 32 Comment .................................................................. 34 MEDICATION ................................................................ 34 NICOTINE CHEWING GUM ....... . ............................................. 35 Side Effects and Contraindications of Nicorette ..................................... 36 Use of Nicorette .............................................................. 36 Evaluation of Nicorette ........................................................ 37 Summary and Comment ..................................... ,................ 40 Concluding Comment ........................................................ 41 HYPNOSIS ................................................................... 42 Single Individual Session ....................................................... 43 Multiple Individual Sessions .................................................... 43 Group Hypnosis .............................................................. 44 Aspects of Hypnotic Treatment .................................................. 45 Summary and Comment ....................................................... 46 Concluding Comment ........................................................ 47 ACUPUNCTURE ............................................................... 48 Evaluation .................................................................. 48 Summary and Comment ................................ ...................... 50 PHYSICIAN COUNSELING ............................................... ........ 50 Trends in Physician Counseling About Smoking .................................... 50 Summary of Findings on Patients' Compliance ..................................... 52 Pregnant Women ............................................................ 52 Pulmonary Patients .......................................................... 53 Cardiac Patients ............................................................. 54 Physician Advice and Counseling During Routine Patient Visits ........................ 55 Physician Interventions Including More Than Counseling ............................. 56 Physician's Efforts in Smoking Cessation ........................................... 56 Summary ............................................... :.................... 58 Comment Regarding Counseling by Nurses, Pharmacists, and Dentists .................. 58 Comment Regarding Physician Counseling ........................................ 59 RISK FACTOR PREVENTIVE TRIALS ............................................. 59 Background ................................................................. 59 MRFIT ..................................................................... 60 Summary and Comment ....................................................... 61 MASS MEDIA AND COMMUNITY PROGRAMS ....................................... 62 Background ................................................................. 62 Mass Media Programs ......................................................... 63 Use of the Telephone .......................................................... 66 Great American Smokeout ..................................................... 67 Smoke-Free Days in Australia and Great Britain .................................... 67 Doctors Ought to Care ......................................................... 67 Community Programs ......................................................... 68 San Diego Community Laboratory .............................................. 68 Lloydminster Community Project ............................................... 68 Stanford Three-Community Study .............................................. 68 Recent U.S. Community Studies: Stanford, Minnesota, and Pawtucket .................. 69 Community Programs in Australia, Switzerland, and Finland ......................... 71 Summary and Comment ....................................................... 72 BEHAVIORAL METHODS ....................................................... 74 Aversive Procedures ........................................................... 74 Rapid Smoking ............................................................. 75 Other Smoke Aversion Procedures .............................................. 78 Covert Sensitization .......................................................... 80 iv TIMN 293325

Page Shock Therapy ............................................................ 81 Summary of Aversive Procedures ............................................. 81 Self-Management Techniques ................................................. 81 Self-Monitoring ............................................................ 82 Nicotine Fading ......... ..................... 83 Stimulus Control .......................................................... 84 Contingency Management .................................................... 86 Systematic Desensitization and Relaxation ........................... . . . . ....... 87 Restricted Environmental Stimulation Therapy .................................. . 87 Self-Control Packages ....................................................... 88 Comment on Self-Management Techniques ........................ . ............. 90 4. WORKSITE SMOKING POLICIES AND CONTROL PROGRAMS ........................ 93 BACKGROUND ............................................................. 93 Health Risks .............................................................. 93 Costs of Smoking .......................................................... 94 WORKPLACE ANTISMOKING POLICIES ......................................... 95 Results of Surveys on Policies and Programs ..................................... 95 Examples of Company Smoking Policies ........................................ 96 WORKSITE SMOKING INTERVENTION STRATEGIES .............................. 99 Educational Campaigns ..................................................... 100 Incentives for Quitting ................ . ..................................... 101 Cessation Programs ......................................................... 103 Self-Care ................................................................107 Educational Methods, Clinics, and Groups ...................................... 108 Nicotine Chewing Gum ..................................................... 110 Hypnosis ................................................................110 Physician Advice and Counseling ............................................. 110 Behavioral Methods ........................................................ 111 SUMMARY AND COMMENT ................................................... 112 5. LONG-TERM MAINTENANCE ................................................... 117 PROFILE OF CONTINUING SUCCESSES AND RECIDIVISTS ......................... 117 Relapse Situations .......................................................... 119 MAINTENANCE STRATEGIES ................................................. 120 Social Support ............................................................. 120 Support From Family, Friends, and Coworkers .................................. 120 Buddies .................................................................121 Followup Support ............:............................................121 Other Support Measures .................................................... 122 Coping Skills ..............................................................122 Cognitive Approaches ....................................................... 123 COMMENT .................................................................124 6. SUMMARY AND CONCLUDING COMMENTS ....................................... 125 HIGHLIGHTS OF THE FINDINGS .............................................. 125 COMPARISON OF QUIT RATES BETWEEN METHODS ............................. 129 TRENDS IN SMOKING CESSATION ............................................. 130 CONCLUDING COMMENT .................................................... 131 REFERENCES .................................................................133 APPENDIX A-COMPREHENSIVE TABLE OF SMOKING INTERVENTION METHODS AND FOLLOWUP QUIT RATES .................................................... 157 APPENDIX B-DOCTORAL DISSERTATIONS RELATING TO SMOKING CESSATION, 1977-1984 .................................... 195 v TIMN 293326

TABLES Table Page 1 Summary of Followup Quit Rates of 18 Self-Help 'IYials, Reported 1980-1984 ............ 20 2 Stop-Smoking Clinics Offered by 8 Hospitals ..................................... 24 3 Summary of Followup Quit Rates of 19 Educational Trials, Reported 1962-1984 ......... 24 4 Summary of Followup Quit Rates of 18 Five-Day Plan Trials, Reported 1964-1984 ........ 25 5 Summary of Followup Quit Rates of 46 Group Z3rials, Reported 1962-1984 .............. 30 6 Comparison of Yellow Page Listings Under "Smokers' Information and 'IYeatment Centers,' 1976-1977 and 1984-1985 ...................... .............. 31 7 Summary of Followup Quit Rates of 19 Medication TYials, Reported 1959-1977 .......... 35 8 Summary of Followup Quit Rates of 28 Nicotine Gum Trials, Reported 1973-1986 ........ 38 9 Summary of Followup Quit Rates of 31 Hypnosis Trials, Reported 1964-1984 ............ 46 10 Summary of Followup Quit Rates of 13 Acupuncture Trials, Reported 1975-1985 ......... 49 11 Studies Comparing "Correct" and "Incorrect" Acupuncture Sites for Smoking Cessation .. 49 12 Physician Opinions Regarding Helping People Quit Smoking ......................... 51 13 Summary of Followup Quit Rates of Patients With Pulmonary or Cardiac Disease, Reported 1969-1984 ......................................................... 53 14 Summary of Followup Quit Rates of 28 Physician Intervention Trials, Reported 1965-1984 ................................................................ 55 15 Self-Reported and Adjusted Quit Rates for MRFIT at Years 1, 3, and 6 ................. 61 16 Summary of Followup Quit Rates for 7 Risk Factor Trials ........................... 62 17 Summary of the Results of Media and Community Studies ......................... 72 18 Summary of Followup Quit Rates of 49 Rapid Smoking Z3-ials, Reported 1968-1985 ....... 77 19 Summary of Followup C,. uit Rates of 23 Satiation Smoking ZYials and 16 Regular Paced Aversive Smoking ZYials, Reported 1968-1985 ...................... 78 20 Summary of Followup Quit Rates of 23 Nicotine Fading ZYials and 13 Contingency Contracting Trials, Reported 1967-1985 ............................. 84 21 Summary of Followup Quit Rates of 30 Multiple Program Trials, Reported 1973-1985 ..... 90 22 Followup Quit Rates of Worksite Cessation Programs, Reported 1974-1986 .............. 104 23 Summary of Followup Quit Rates of 416 Smoking Cessation Trials by Method, Reported 1959-1985 .......................................... 130 Comprehensive IbLble of Smoking Intervention Methods and Followup Quit Rates ............ 158 TIMN 293327 vii

PREFACE Since the first Surgeon General's report on the health consequences of smoking was issued in 1964, an overwhelming body of evidence-more than 50,000 studies from dozens of countries-has established that smoking is the largest preventable cause of premature death and disability in the United States. Despite awareness of the serious health risks of smoking, many individuals persist in this risk-taking behavior, and the rates of smoking-related diseases continue to rise for many segments of the population. Although some encouraging changes have oc- curred in smoking behavior since 1964-the num- ber of smokers in the population has dropped from 42 percent to about 30 percent-some 53 million Americans still smoke. The burden that they place upon the health care system, their families, and themselves is enormous. There are hopeful signs, however. Recent surveys of smoking among adults indicate that the beliefs, .attitudes, and intentions of smokers have changed for the better. Ninety percent of smokers indicate that they know smoking is hazardous to health and express a desire to quit if they could find a way; 60 percent have even tried to quit. Helping people to stop smoking and to avoid other forms of tobacco use continues to be a major challenge for public health and preventive medi- cine. The need for knowledge about innovative and effective ways to help individuals to quit smoking and to address possible physiological dependence and the maintenance of cessation is clear. Three years ago, I announced the goal of making the United States a smoke-free society by the year 2000. I did not know then if this smoke-free millen- nium could be achieved. However, seeing the strong response across this country by the major volun- tary and professional organizations plus literally millions of ordinary citizens over the past 3 years has reassured me that we indeed can achieve our goal. 1b handle effectively the problem of smoking over the next decade and a half, we must swiftly define solutions that are based on good science and aggres- sively apply them on a wide-scale basis. This comprehensive review and evaluation of smoking cessation methods that the National Cancer Institute (NCI) has commissioned is a critical ele- ment in this strategy. It analyzes the entire spec- trum of cessation approaches and provides an in- valuable resource for practitioners who already work in smoking cessation and for those who desire to learn more about the field. I applaud NCI's sponsorship of this vast under- taking and join the reviewers of this document In commending Dr. Jerome L. Schwartz for an out- standing evaluation. It represents a critical mass of knowledge that can assist the health community to identify and take advantage of the most appropri- ate smoking cessation interventions and to ensure that these interventions are woven into each facet of the smoker's natural environment-the health care setting, the workplace, the school, the media, the community, and the home. C. Everett Koop, M.D. Surgeon General U.S. Public Health Service ix TIMN 293328

FOREWORD In 1982, the National Cancer Institute (NCI) initiated a wide-scale smoking intervention research effort through its Smoking, Tobacco, and Cancer Program (STCP). STCP was designed to achieve part of the prevention objectives of the goal that the NCI Director, Dr. Vincent DeVita, established to reduce the cancer mortality rates 50 percent by the year 2000. Although smoking-related cancer rates for men in the United States are already decreasing, much remains to be done. For example, ethnic minorities, particularly blacks and Hispanics, either are ex- periencing lung cancer rates that far exceed those for whites or are smoking at rates that will lead to increased lung cancer mortality in the coming decades. Furthermore, although more than 30 million people have stopped smoking since the first Surgeon General's report on smoking and health in 1964, over 50 million Americans continue to smoke, and there are more heavy smokers today than ever before. STCP's strategy to reduce smoking and other forms of tobacco use calls for an intensive and con- certed effort by all sectors-local, state, Federal, and private-to establish a system of antitobacco meas- ures that is effective, acceptable to the public, cost- efficient, and self-perpetuating. It is expected that a wide range of strategies implemented through a variety of agents and channels and directed to a number of selected target populations will be necessary to reduce the prevalence of tobacco use. NCI recognizes that there are many agents and channels through which to influence the reduction of tobacco use in this country. However, they need information on what intervention strategies will work and how best to implement such strategies. NCI commissioned Dr. Jerome L. Schwartz to undertake a comprehensive review and evaluation of smoking cessation methods in the United States and Canada for the years 1978 to 1984. Actually, Dr. Schwartz was asked to update a similar review that he formerly had carried out under the auspices of the Centers for Disease Control for the years 1969 to 1977. The intended scope of the monograph is to evaluate nonprofit, commercial, community, and research programs, as well as self-care approaches and practitioner methods. Special sections on work- site control programs and long-term maintenance also are provided. Dr. Schwartz includes important methodological issues affecting the reliability of results and variation across studies and provides evaluative and interpretive commentary regarding the cessation methods identified. Several specialists with backgrounds in smoking research reviewed the monograph for STCP, and they agree with our assessment that Dr. Schwartz has produced an accurate and valuable document. Selected reviewers' comments include: In many respects this draft represents an im- pressive scholarly work.... A number of studies are cited with which I had no previous familiarity. I think it is especially noteworthy that the review deals with methods as diverse as acupuncture rather than being limited to topics such as behavior modification. This monograph is superior to any other I have seen in bringing together the highly diverse smok- ing cessation literature into a single volume. As such it should serve as an extremely valu- able and almost encyclopedic resource. The extended reference listing is itself a major con- tribution to those either working in smoking cessation or desiring to learn more about the field. Also quite useful is the appended listing of doctoral dissertations. I am extremely impressed by the breadth of the review-the amount of work involved in collecting, let alone organizing and reviewing this now vast literature is itself awesome. My hat's off to the author for such an ambitious and conscientious undertaking.... The re- view (of self-care) is thorough and interesting- describing for many readers unfamiliar with self-help guides their contents and general ap- proach. The section on filters and lozenges is very helpful and exists nowhere else.... This section [on nonprofit programs] is im- pressive for the range of studies reported, and for evidence of the great lengths to which the author went to find studies not usually re- viewed in the smoking cessation literature. ... The review of the smoking cessation pro- grams listed in the Yellow Pages provides a fascinating anthropological view on the forms xi TIMN 293329

[16W of treatment the lay public is offered .... I found this a very readable history of and ra- tionale for the development of Nicorette, a good description of the product and the contrain- dications for its use, and a very complete sum- mary of the international literature. Overall, this is an impressive monograph un- paralleled in scope or comprehensiveness. Probably no one else but Jerry Schwartz could have undertaken this and brought it off. His long immersement in smoking cessation work and his methodological astuteness are reflected throughout. It is interesting and provocative to have a single-authored analysis of the entire spectrum of cessation approaches .... I think some of the qualitative sections and subjective analyses are especially interesting and useful ... For example, the content analysis of telephone books and the descriptions of var- ious commercial programs are unique. One can't find this sort of information anywhere else and I think it is quite informative .... In conclusion, I want to repeat that this is a her- culean effort that will be very useful to staff chapter indicates that more employers are estab- lishing smoking policies that restrict smoking and many employers are offering smoking cessation programs. In addition to employers, there has been an increase in smoking control programs that are offered by public and private agencies and practi- tioners. It is my pleasure to share with you Dr. Schwartz' comprehensive assessment of smoking cessation methods. This effort supports NCI's goal of produc- ing information on the effectiveness of intervention strategies for cancer control. To be vigilant in the opportunities to promote cessation among large numbers of smokers, it is imperative that NCI stimulate the movement from science to the appli- cation of research results whenever that is feasible. It is my hope that this review and evaluation will encourage practitioners, organizations, employers, communities, researchers, and public health specialists to design and offer smoking cessation programs in a manner that will contribute to the goal of the Surgeon General of the United States, Dr. C. Everett Koop, that we achieve a smoke-free society by the year 2000. ©