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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. ©

AUTHOR' S NOTE AND ACKNOWLEDGMENTS When I was 14 years old, my parents would leave me in charge of my younger sister. After she went to bed, I would listen to the radia When the Hit Parade came on, the announcer would extol the pleasures of cigarettes-"so smooth ... so refresh- ing ...... I then would search the house and clean out the ashtrays of my father's cigarette butts. The butts were foul smelling but once lit, they weren't too bad. I felt grown up and could enjoy the "smoothness" and "refreshment" of tobacco. I also remember watching my father light up when Johnny the bellhop sang out "CALL FOR PHILIP MORRIS" at the start of The-Edgar Bergen and Charlie McCarthy Show. When I was 16, my favorite cousin gave me a pipe and tobacco for my birthday. I remember taking a big puff and coughing, but I got used to it. I collected a half-dozen pipes that summer; my favorite was a corncob pipe. I couldn't wait for the first school foot- ball game to show everyone I smoked a pipe. At the game, I paraded in front of the stands smoking my pipe and puffing away for all to see. During World War II, I entered the Army at age 18. I had tried cigarettes but preferred my pipes. At Scott Field, IL, where I was inducted, I was given my free rations: three Hershey bars, a bar of soap, a package of razor blades, two packages of gum,_one roll of Life Savers, six packs of cigarettes, and two cigars. I asked if I could have more candy bars and less cigarettes but was told that the rations were the same for everyone. I sat on my bed with my trea- sures and looked around the barracks. Everyone else was smoking, so I opened a pack and began smok- ing. Later that night I tried one of the cigars. The cigar tasted better than the cigarettes. We generally had a "smoke break" every hour during basic training. The number of free candy bars and cigarette packs varied, but I always had more cigarettes than I could smoke. The major en- tertainment at night after movies was "playing craps." I often won a dozen packs of cigarettes. A year later, I was at Camp Carson, CO, training in a "night attack" outfit. This meant climbing up hills with a full pack. I grew up at the seashore and had never experienced high altitudes. I was gasp- ing for breath and decided to stop smoking cigarettes. When I was overseas, I traded my cigarettes for cigars and candy or gave my cigarettes to foreign civilians. After the war ended, cigarettes brought a good price on the black market. I relate my experience with smoking to indicate how pervasive cigarette smoking was when I was growing up. You were expected to smoke, and the free cigarettes, "smoke breaks," and advertising en- couraged it. As a public health researcher with an interest in health promotion, I became involved in quit- smoking methods in 1962. A result of these efforts was the funding in 1964 of the Smoking Control Research Project, which tried three cessation methods: group counseling, individual counseling, and pills (tranquilizers). During the project, I evaluated available quit smoking methods. A report of the evaluation of smoking control methods was supported by the Na- tional Clearinghouse for Smoking and Health and published in 1969. An update that evaluated ces- sation methods used from 1969 to 1977 was sup- ported by the Center for Disease Control and published in 1978. This review of smoking cessa- tion methods used from 1978 to 1985 serves as a current update. I would like to thank Dr. Joseph W. Cullen, Deputy Director, Division of Cancer Prevention and Control, National Cancer Institute (NCI), for sup- porting this review and evaluation. It was through Dr. Cullen's generous support that this review is more comprehensive than the former reviews. In ad- dition, chapters on maintenance and worksite smok ing control were added at Dr. Cullen's request. It has been a pleasure to work with Dr. Cullen. Marilyn M. Massey, M.P.H., of Prospect Associ- ates, the support services contractor for NCI's Smoking, Tobacco, and Cancer Program, handled the technical details of the subcontract arrange- ments for this effort. I thank her for her support and assistance that helped to ensure that the project proceeded smoothly. Dr. Margaret E. Mattson, Division of Cancer Prevention and Control, reviewed the manuscript for NCI. I thank her for her comments. Four outside experts were engaged by NCI to review and comment on the manuscript. Drs. Harry TIMN 293331

A. Lando (Ames, IA), Edward Lichtenstein (Eugene, OR), and C. Tracy Orleans (Lawrenceville, NJ) reviewed the manuscript, except the worksite chap- ter, while Russell E. Glasgow (Eugene, OR) reviewed the worksite chapter. Each of the reviewers submit- ted lengthy comments that improved the manuscript. In several cases, I included their com- ments directly into the text. I thank them for their efforts. I am grateful to Eileen O'Farrell (Davis, CA) for her careful editing of the manuscript and to Karen Jacob (Prospect Associates) for managing the production of the camera-ready document. Lastly, I wish to express appreciation to my wife, Joann, for her support and love throughout this project. Jerome L. Schwartz, Dr. P.H. Health Care Research Specialist Davis, California xiv TIMN 293332

1. INTRODUCTION In the April 1929 issue of The Dragnet Magazine, a popular pulp monthly featuring "detective and crook stories," there appeared five advertisements, the highest number advertising any single product, for mail-order remedies to banish the tobacco habit 1 One read in part: 'Ibbacco Redeemer will positively remove all craving for tobacco in any form in a few days. This we absolutely guarantee in every case or money refunded. Write today for our free booklet showing the deadly effect of tobacco upon the human system and positive proof that'Ibbacco Redeemer will quickly free you of the habit. Another said: Superba 'Ibbacco Remedy destroys all crav- ing for Cigarettes, Cigars, Pipes, Chewing or Snuff. Original and only remedy of its kind. Used by over 500,000 men and women. Perfectly harmless. Full treatment sent on trial. Costs $1.50 if it cures. Costs nothing if it fails. Write today for complete treatment. Cigarette consumption has declined very slow- ly despite widespread dissemination of the "facts" about smoking, the initiation of educational and media programs, the introduction of warning labels on cigarette packages (July 1966), the ban- ning of cigarette advertisements from television (January 1971), and the development of a variety of methods aimed at helping cigarette smokers break their habit. Per capita cigarette consump- tion in the United States declined in early 1964 but rose to nearly its former level by the end of that year; it declined again in late 1965, only to rise once more in 1966 and 1967.2 Starting in late 1967, however, when the annual consumption of cigarettes was 549.5 billion, a slow decline began that continued during 1968 and 1969. Consump- tion decreased by 3.5 billion cigarettes in 1968 and by an additional 16.7 billion in 1969, lowering per capita consumption to 1958 levels.3 Per capita consumption of cigarettes increased slightly during the early 1970's4 and peaked in 1973 at 4,112 cigarettes annually.g In 1979, per capita consumption of cigarettes approximated that in 1952.4 Per capita consumption fell to 3,731 cigarettes in 1982 and to 3,447 in 1983.5 The Federal ZYade Commission (FTC) reported In June 1985 that cigarette sales were falling for the first time since 1969 despite an increasing population and record advertising expenditures by tobacco companies.5 Cigarette sales fell from 636.5 billion cigarettes in 1981 to 632.5 billion in 1982 and 584.4 billion in 1983. Spending on cigarette advertising climbed, however, to nearly $2.7 billion in 1983, the highest ever, which was up from $1.9 billion in 1982. SMOKING AS A HEALTH PROBLEM6 The 1979 Surgeon General's report on smoking and health revealed that cigarette smoking is far more dangerous than supposed in 1964 when the first Surgeon General's report was published.7 The Surgeon General reported that the health damage resulting from cigarette smoking costs this Nation an estimated 325,000 premature deaths each year and $27 billion in medical care, absenteeism, decreased work productivity, and accidents. Cigarette smoking is the most important prevent- able environmental factor contributing to illness, disability, and death in the United States. Overall Mortality Life expectancy at any age is significantly short- ened by cigarette smoking. A two-pack-a-day smoker between the ages of 30 and 35 years has a life expectancy 8 to 9 years shorter than that of a nonsmoker of the same age. Prospective studies indicate that cigarette smokers have approximate- ly a 70-percent greater chance of dying from disease than do nonsmokers.8 Mortality ratios are proportional to the amount smoked and to the years of cigarette smoking and are higher for those who initiated smoking at younger ages and for those who inhale. Former cigarette smokers experience declining mortality ratios as their years of nonsmoking 1 TIMN 293333

increase. It takes about 15 years for mortality ratios of former smokers to approach those of nonsmokers.9 Provided that the person has not quit because of illness, cessation diminishes an in- dividual's risk. Coronary heart disease is the chief contributor to the excess mortality among cigarette smokers, followed by lung ca.ncerr and chronic obstructive lung disease. Morbidity Data from the National Health Interview Survey show that current smokers have more acute and chronic conditions than do persons who have never smoked 1O Current smokers report more chronic bronchitis, emphysema, chronic sinusitis, peptic ulcer disease, and arteriosclerotic heart disease than do persons who have never smoked. Gastric ulcer is also linked to smoking. The age- adjusted incidence of acute conditions for men who had ever smoked was 14 percent higher and for women was 21 percent higher than for those who never smoked. The 1974 survey data revealed that there are more than 81 million excess work days lost and more than 145 million excess days of bed disability per year because of smoking in the U.S. population. Current and former smokers report more hospitalizations than do nonsmokers. Lung Cancer The causal relationship between smoking and lung cancer is well established. Lung cancer ac- counts for 25 percent of all cancer deaths in the United States; it is estimated that 85 percent of lung cancer cases are due to cigarette smoking 11 Overall, smokers are 10 times more likely to die from lung cancer than are nonsmokers, and heavy smokers are 15 to 25 times more at risk. Lung cancer mortality in women is increasing more rapidly than in men, and it is expected that lung cancer will be the leading cause of cancer deaths among women in the next decade.12 Certain occu- pational exposures (e.g., asbestos) can act synergistically with smoking to increase the in- cidence of lung cancer. Ex-smokers experience decreasing lung cancer mortality that approaches the rates of nonsmokers after 10 to 15 years of not smoking. Other Cancers 'Ibbacco use has been linked to cancers of the larynx, oral cavity, esophagus, bladder, kidney, and pancreas lg-l4 An estimated 50 to 70 percent of oral, laryngeal, and esophageal cancer deaths are associated with smoking. The use of alcohol in conjunction with smoking acts synergistically 2 to increase greatly the risk of these cancers. There is a strong association between cigarette smoking and cancers of the bladder and pancreas, and smokers are twice as likely as nonsmokers to die of these diseases. The risk of pancreatic cancer in- c--eases with the number of cigarettes smoked; a two-pack-a-day smoker has five times the risk of a nonsmoker. Quitting smoking reduces one's cancer risk substantially. The more years that one does not smoke cigarettes, the greater the reduc- tion in excess cancer risk. Cardiovascular Disease Smoking is an important risk factor for coronary heart disease and acts synergistically with other risk factors such as hypertension and hypercholes- terolemia 15•16 Smoking increases the probability of the recurrence of myocardial infarction, and smoking cessation reduces the risk of mortality from coronary heart disease. Smoking is a major risk factor for arteriosclerotic peripheral vascular disease. In persons with angina pectoris or inter- mittent claudication of peripheral vascular disease, smoking reduces the established thresh- old for precipitation. Smoking is a key factor in circulatory problems of the arms and legs, which frequently lead to gangrene. This danger is partic- ularly strong for diabetics who smoke. Women who smoke and use oral contraceptives are at a higher risk than are others of experienc- ing myocardial infarction and thromboembolism. Cigarettes and oral contraceptives have a synergis- tic effect; the risk of their combined use is much greater than the sum of the dangers posed by either alone. The risk of nonfatal myocardial in- farction among women during the childbearing age is increased twofold by the use of estrogen- containing oral contraceptives and tenfold if users also smoke?''ls It is unlikely that a "safe cigarette" can be developed that will reduce cardiovascular risk.20 Data indicate that smokers of low-yield cigarettes do not have a lower risk of myocardial infarction, coronary disease, or decline in lung function than do consumers of higher yield cigarettes.2l Numerous studies have shown that those who quit smoking cigarettes experience a substantial decrease in coronary heart disease mortality and an improvement in life expectancy.22 For those who continue to smoke, there is no "safe" level of cigarette consumption.23z4 Nonneoplastic Bronchopulmonary Disease Smokers have more respiratory symptoms and greater pulmonary function abnormalities than do TIMN 293334

nonsmokers.25 Respiratory infections are more common in smokers, who take longer to recover. Respiratory symptoms decrease and pulmonary function improves when a person quits smoking. Cigarette smoking acts independently of and synergistically with the other risk factors that contribute to bronchitis. Peptic Ulcer There is a positive dose-response relationship between smoking and the incidence of peptic ulcer disease. The risk of dying from peptic ulcer is, on the average, twice as high for smokers as nonsmokers.26 Although not proved, cigarette smoking probably retards the healing rates for both stomach and intestinal ulcers. A smoker who develops an ulcer should therefore stop smoking. Effects of Smoking on Pregnancy Cigarette smoking during pregnancy has a significant and adverse effect on the well-being of the fetus, the health of the newborn baby, and the future development of the child.27 Mothers who smoke increase substantially their risk of spontaneous abortion, premature birth, and death of the infant during the first days of life. There is evidence that children of mothers who smoke may be deficient in physical growth and intellectual and emotional development.27 Smoking and Occupational Exposure Smoking and physical and chemical agents interact to produce adverse health effects on certain occupational groups. Both cigarette smoking and exposure to certain occupational hazards increase the risk for chronic lung disease.28 These risks can occur independently or may combine to produce a greater degree of lung injury than would have occurred from either exposure separately. Thus smoking can act synergistically with toxic agents to increase disease, and inhaling can serve as a vehicle for toxic agents in the workplace. Chemicals can contaminate tobacco products and thus enter the body through inhalation, ingestion, or skin absorption. Workers can run a higher than usual risk of exposure when the same toxic chemicals in cigarette smoke occur at their jobs. Smoking also has been found to contribute to industrial accidents. Summary of the Consequences of Smoking Cigarette smoking is linked to many of the leading precursors of disease and disability such as coronary heart disease, lung cancer, bronchitis, emphysema, and peptic ulcers. 'Ibbacco use increases the hazards associated with certain types of occupational exposure and the use of oral contraceptives and has an adverse effect on the fetus. Cigarettes also may interact with certain drugs and alter the results of some diagnostic tests.29 Smokers who give up cigarettes can improve their health, while those who continue to smoke live shorter lives and are at a higher risk of developing diseases. This is why it is important to discourage young people from starting to smoke and to encourage those who smoke to stop. Most smokers want to quit, but there are those who believe that they cannot quit on their own. The availability of treatment programs may encourage quit attempts in individuals who would not otherwise attempt cessation. It is for this reason that smoking cessation methods have been developed. The material that follows will review and evaluate cessation methods that were used from 1978 to 1985. SMOKING HABITS IN THE UNITED STATES AND CANADA Smoking Levels in the United States In 1983, a total of 34.8 percent of U.S, males 20 years of age and older smoked *3O This represents a decrease of 17.3 percent since 1965, when the percent of adult male smokers was 52.1. In the same period, smoking among U.S. females 20 years of age and older declined from 34.2 to 29.5 percent. Between 1980 and 1983, the percentage •Cited here are statistics on cigarette smoking as reported by Federal Government sources. A Gallup Poll in June 1986 reported that cigarette smoking had declined to its lowest level in the poll's 42-year findings.31 Interviews with 1,004 scientifically selected adults. 18 years and older, revealed that 31 percent reported having smoked during the week before the interview. Similar polls in 1983 and 1985 found that 38 and 35 percent, respectively, reported that they smoked. More men (35 percent) than women (28 percent) were smokers in 1986, and more blacks (34 percent) than whites (31 percent) were smokers. Education is closely related to whether people smoke. In the current audit, only 23 percent of college graduates were cigarette smokers. The proportion rose to 35 percent among high school graduates and to 45 percent for those without a high school diploma. The following regional differences were reported for percent smokers: East-31. Midwest-29, South-35, and West-29. Smokers under 30 years tended to be lighter smokers. In this age group, 58 percent claimed to smoke less than one pack of cigarettes per day, compared with 39 percent of smokers over 30 years. The majority of smokers in all population groups would like to quit, including 75 percent nationally. 3 TIMN 293335

of males who smoked declined at all ages except for those 65 years and over; among females, the percentage of smokers increased in the age group 20 to 34 years but declined for senior citizens.3O About 35 million Americans have quit smoking, but the picture of teenage smoking is particularly discouraging. Although the percentage of children under 19 years who are regular smokers declined between 1974 and 1979, smoking prevalence among females 17 to 19 years increased during that period and now exceeds that of males.32 Whereas smoking among boys 17 to 19 years declined from 31.0 percent in 1974 to 19.3 percent in 1979, smoking among girls of that age increased from 25.9 to 26.2 percent during the same period. Among girls 15 to 16 years, there was a decrease between 1974 and 1979 in the percent of regular smokers from 20.2 to 11.8; for boys, the decrease was from 18.1 to 13.5 percent. Smoking among white males declined from 51.3 percent in 1965 to 37.1 percent in 1980 and among white females from 34.5 to 30.0 percent.33 A similar pattern was seen among black adults- a decline for males from 59.6 to 44.9 percent and for females from 32.7 to 30.6 percent. The proportion of the white adult male popula- tion who have stopped smoking increased between 1965 and 1980 from 21.2 to 31.9 percent, and for white females the increase was from 8.5 to 16.3 percent.33 A similar trend was observed among blacks: the percentage of former smokers among adult males increased from 12.6 to 20.6 percent, and for adult females the increase was from 5.9 to 11.8 percent. Most national data on the smoking behavior of adults indicate that blacks, as com- pared to whites, are more apt to smoke yet smoke fewer cigarettes per day, smoke cigarettes of higher tar and nicotine content, and are less apt to quit smoking.34 Although the numbers of people who smoke have declined, those who continue to smoke have increased their daily consumption from 20.0 cigarettes in 1970 to 21.7 cigarettes in 1980.35 Daily consumption was heaviest among those aged 35 to 64 years. Only 11.4 percent of the smokers in 1970 reported consuming 40 or more cigarettes per day, but by 1980 the percentage had risen to 16.8 38 Those smoking fewer than 20 cigarettes per day declined from 39.8 percent in 1970 to 33.8 percent in 1980. The kind of cigarettes that Americans smoke has changed dramatically. In 1984, 94 percent of the cigarettes smoked were filter tipped, up from 1 percent in 1950.37 Low-tar, low-nicotine ciga- rettes were heavily promoted by manufacturers, resulting in a 60-percent share of the market in 1980. Grise reports a movement back to full- flavored cigarettes with the market share of low- tar, low-nicotine cigarettes dropping to 53 percent in 1984.37 4 Adults with the lowest and highest educational levels have a lower prevalence of smoking. There is less smoking among adult males with higher family incomes, while the prevalence of adult female smoking increases with family income. Separated or divorced persons have the highest smoking rates; married persons have higher rates than single or widowed persons. Smoking among professionals is relatively low; managers, ad- ministrative personnel, and blue-collar workers have higher rates of smoking.38 Data in 1978 from the National Center for Health Statistics showed that 59 percent of the smokers had tried to quit.39 In the previous year, 30 percent of the smokers attempted to quit, and 20 percent of those who tried reported that they succeeded. A higher proportion of black smokers than white smokers attempted to quit (39 to 30 percent), but a lower proportion of blacks than whites succeeded (10 to 21 percent). Smoking Levels in Canada In December 1983, 5.8 million Canadians 15 years of age and older, an estimated 31 percent of the adult population, were regular smokers.40 Oc- casional smokers represented 3.3 percent of the population, and pure pipe or cigar smokers 1.6 per- cent. The proportion of nonsmokers in the popula- tion appears to be rising. Nonsmokers represented 64.0 percent of the adult Canadian population in 1983 of which 18.6 percent were former smokers and 45.4 had never smoked. The results of a 1983 survey showed that regular smoking among the adult male Canadian popula- tion declined from 48.9 percent in 1970 to 34.0 percent in 1983 and among women declined from 32.4 to 28.3 percent.4O The percent decline in smoking prevalence between 1979 and 1983 was consistent in all age groups for both sexes, although males accounted for the largest share of the decline. The percentage of teenage Canadian females who smoked regularly increased from 24.9 percent in 1970 to 26.7 percent in 1977 and then declined to 20.3 percent in 1983. Between 1970 and 1983, the percentage of teenage males regularly smok- ing declined from 35.7 percent to 20.3 percent. The data indicated that 40 percent of all Canadian smokers made an attempt to quit smoking in the year preceding the survey. SUMMARY OF 1969 REVIEW This monograph reviews U.S. and Canadian smoking cessation programs reported in the litera- ture between 1978 and 1985. It is intended as an TIMN 293336

update of Schwartz's 1969 review41 and Schwartz and Rider's 1977 report.4z The 1969 review evaluated smoking cessation programs conducted in the United States, Canada, Australia, England, Scandinavia, and other parts of Europe during the years 1957 through 1968. The report covered 97 methods in 62 trials and evaluated their results in terms of following up on how many persons remained nonsmokers. Cessa- tion methods were classified in six general headings and a miscellaneous category. The six headings were Lobeline, Other Medication and Clinics, Five-Day Plan, Desensitization-Aversion Therapy, Physician Counseling, and Group Discus- sion and Therapy. Of the 62 studies reviewed in 1969, 34 had a followup after 6 months, 15 had a followup after less than 6 months, and 13 did not have a followup. Only 12 reports based the followup on all persons in the study; 8 others based their followup on at least three-fourths of the participants. Most in- vestigators calculated outcome rates only for per- sons who completed treatment. 'liventy programs used untreated controls or placebos. Of the 13 medication trials, 2 showed better results, 8 showed the same, and 3 showed worse results for the drug than for a placebo. In 18 experiments in which treated subjects were matched with controls, the method of treatment was better in 8, similar in 3, and worse in 7. The "better" results were not always statistically significant. A method often showed better initial results than did the control but also had high rates of recidivism, so that placebos achieved equal or better long-term success. Results at the end of treatment varied among the studies in the listing, with reported highs of 89 and 85 percent for two withdrawal clinics and 84 per- cent for a method using the threat of monetary loss among college students. No success was recorded in one aversive trial, only 10-percent suc- cess using electric shock, and 4-percent success for tranquilizers. Evaluations were done of 38 American, 14 English, 5 Scandinavian, and 2 Canadian pro- grams and 1 each from 3 other countries. Of the U.S. studies, 9 were in Pennsylvania, 6 each were in New York and California, 4 were in Oregon, and 13 were in 12 other states. The uses of medication, group therapy, the Five-Day Plan, and aversion therapy, in that order, were the popular methods prior to 1969. The earlier review contained only two reports of hypnosis, indicating perhaps that hypnotherapists were not reporting their results. Students of Lichtenstein began their work with aversive methods in the mid-1960's, and three of their trials were reported in the review.43 A number of studies reviewed in 1969 achieved between 20- and 38-percent success at followup. Some of the most significant U.S. studies prior to 1969 were those of Lawton, who began group pro- grams in Philadelphia around 1960 and reported a 4-year followup success of 16 percent.44 An im- portant study by Ross reported from 6- to 27-percent success at followup with an overall rate of 17 percent using medication and educational methods at a large-scale clinic at Roswell Park Memorial Institute in Buffalo, NY.45 The Smoking Control Research Project, conducted in northern California, used seven combinations of tran- quilizers, placebos, groups, and individual counseling with 1-year success rates of from 8 to 31 percent and 20 percent overall.46 The 1969 review stated that the combined ac- tivities of smoking cessation methods had con- tributed to the antismoking campaign, which would influence nonparticipating smokers and youths who had not taken up the habit. The review concluded the following: In summary, many investigators have tried "methods" to help smokers give up ciga- rettes but few have shown high success rates.... Part of the reason why success has not been better might be partially ex- plained by results of a survey in which it was found that the most commonly offered meth- ods of stopping are the ones least acceptable to smokers who wish to quit.47 Thus, the high dropout rates experienced by many methods may be due to low acceptance of the method. Smoking is a difficult habit to break. The results of the Smoking Control Research Proj- ect indicate that many smokers must try several times before they can quit. For them, the smoking clinic is one step closer to total success .... The studies reviewed indicate that they have served their purpose by show- ing that people can be helped to stop smok- ing by a variety of techniques. They have also demonstrated that drugs,... such as lobeline and tranquilizers are not effective in assisting smokers to give up the habit. Conditioning methods are both ineffective and impractical as they reach only limited numbers of per- sons.. . . The problem now is to explain the process of cessation and recidivism and to explore the possibility of applying mass media ap- proaches to reach large numbers of smokers. The potential of new and original smoking cessation techniques, presented on in- dividual, group, or mass media bases, has not been fully explored. However, too much should not be expected from any one ap- proach, no matter how ingenious, since no TIMN 293337 5

single method can be counted on to produce high rates of long term success. Most methods achieve their maximal success at the end of the treatment program but recidivism occurs sharply during the next few months. Thus, even if highly successful m°thods were de- vised, these techniques themselves cannot be expected to maintain the burden of keeping people off cigarettes once abstinence is achieved. This task must necessarily be re- served for societal and environmental in- fluences.. . . The action of voluntary and governmental agencies, increased efforts by physicians to counsel patients in their offices, and the applica- tion of research findings about the psychosocial factors involved in smoking cessation, are help- ing to create the environmental conditions which will aid smokers to quit permanently.`'8 SUMMARY OF 1969-1977 REVIEW Methods summarized in the 1977 review were those employed in the U.S. and Canadian pro- grams over a 9-year period.42 (Some English studies were included in the evaluation.) About 400 reports were reviewed. The monograph also contained a list of 66 doctoral dissertations com- pleted during the years 1970-1976 that related to smoking control methods. Smoking cessation was examined from several viewpoints: the intervention techniques of self- care, medication, and hypnosis; the service packages delivered by nonprofit institutions, health professionals, and commercial enterprises; the counseling and research trials offered by medical sponsors; the behavior modification techniques; and the mass media and community programs. Evaluations during this period revealed that many methods lacked proper design and followup. A recurrent problem was that of validating whether the subject had really quit smoking. Validation of abstinence by physical measure- ments was starting to be used primarily by pro- grams associated with a laboratory. Some pro- grams claimed success based on reduction of the number of cigarettes smoked rather than on com- plete cessation. Many programs failed to conduct followups at least 6 months after the termination of the program. It was during this period that a consensus of scientists recognized cigarette smoking as being addictive. Nicotine was identified as the chemical basis of the addiction, so a number of studies ex- amined the strength and effects of nicotine. Development of nicotine chewing gum by Swedish investigators progressed to the stage of clinical trials. Organized clinics examined their clientele and surmised that they tended to attract the ad- dicted smokers. 6 Many methods during the period had excellent end-of-treatment success rates with up to 80 per- cent of the subjects quitting smoking for at least a short time. In the long run, however, even these methods showed only fair results. Of 67 trials con- ducted in the United States and Canada between 1969 and 1977 with at least 6 months followup, two-fifths had quit rates of at least 35 percent of the participants, one-fifth had quit rates between ' 22 and 34 percent, and two-fifths had rates below 22 percent. Twenty-seven percent of the programs scored at least 40-percent success at 6 months, and 18 percent achieved 50-percent success. A few investigators claimed 67- to 88-percent quit rates at followup. The best results were for programs employing group counseling, hypnosis, and the rapid- smoking aversion technique. Rapid smoking showed mixed results, but the rates were improved when this procedure was combined with social support and good maintenance practices. Many of the developments in aversive methods, including rapid smoking, came from Lichtenstein's clinic in Eugene, OR. Other investigators involved in a good deal of behavioral testing were Lando in the United States, Best and Pederson in Canada, and Russell in England. Group support methods were more popular than individual counseling primarily because treating a group of people is more economical. During the review period, hypnosis gained in popularity as a cure for smoking. Spiegel introduced the self-hyp- nosis technique for smoking cessation. Success rates were contradictory for hypnosis with some hypnotists claiming high quit rates and others reporting poor success. In the 1970's, the American Cancer Society took a prominent role in smoking cessation with their extensive withdrawal clinics, development of a quit kit, initiation of the Great American Smokeout na- tionally, and sponsorship of the International Con- ference on Smoking Cessation.49 In Canada, the Ministry of National Health and Welfare began a national effort to reduce cigarette smoking that included support for cessation pro- grams. The Canadian Council on Smoking and Health was organized in 1974 to coordinate smok- ing activities among voluntary organizations. The American Health Foundation (AHF) in- itiated a large-scale smoking cessation program in 1972. The AHF treated over 5,000 smokers dur- ing a 5-year period. Methods varied from minimal self-care to combined therapies. Other noteworthy developments were the in- troduction of mass media and community cam- paigns through the Stanford and San Diego pro- grams. The Multiple Risk Factor Intervention Zi-ial (MRFIT) was initiated in 1972; its 2-year followup results showed 47-percent success. TIMN 293338

'Paking medication for smoking cessation did not produce an average of even 20-percent abstinence in the short run, much less over time. The Five- Day Plan was widely available, but its long-term success rates were low. On the other hand, the Five-Day live-in program sponsored by the St. Helena Health Center achieved 35-percent abstinence at a 1-year followup. The monthly pro- gram at St. Helena treated over 2,000 smokers dur- ing an 8-year period. The yellow pages of the telephone books of over 200 cities in 1977 identified 116 different types of smoking cessation programs as follows: Type Number Proprietary and commercial firms ... 32 Medically sponsored .............. 12 Voluntary groups ................. 9 Used hypnosis ...................35 Used psychological or behavioral techniques ..................... 20 Used acupuncture ................ 8 Of the 27 cities in the United States with popula- tions greater than half a million, all but New Orleans had smoking cessation programs listed in the yellow pages. Some of the concluding comments from the 1977 review follow: ... Many smokers simply are not suscepti- ble to intervention; this is largely because no single method is available that can work uniformly well with large numbers of in- dividuals. And this is so because people dif- fer in personality, emotions, and personal satisfactions. Also people differ in their smok- ing habits, particularly how and why they use cigarettes, whether or how strongly they are addicted to cigarettes, and whether they have motivation and determination to quit smok- ing.... It is for these reasons that many dif- ferent smoking methods are needed in- cluding multicomponent methods. Several ingredients are necessary for suc- cessful treatment: an acceptable method, dedicated leaders, and well-planned maintenance procedures. Longer treatments usually reinforce commitment to cessation, especially when extended by maintenance efforts.. . . Proprietary methods have become widely available, and their fees provide added incen- tive to remain abstinent. It has been very dif- ficult, however, to obtain valid survey data on the quit rates of commercial clinics. Many claim excellent success rates that are based only on persons who go through the entire program and stop smoking.... Commercial clinics do attract smokers who wish to quit to their programs, and this contributes to the public awareness of quit clinics and provides a resource where smokers can be referred.... The most efficient, widest-reaching penetration is apt to occur through mass media promotion of cessation methods and a continued acceleration of positive govern- ment action against smoking. An example of a large scale attempt to increase awareness of health and to effect behavior change is the Canadian Operation Lifestyle program which reached nearly two-thirds of the population. The use of radio and television as cessation approaches has a great potential. Most physi- cian counseling treatments suffer from poor maintenance. Physicians lack the time and commitment to provide long-term support. In studies where physicians do discuss the pa- tients' smoking habits and encourage quit- ting, however, results show that the influence is important.. . . A review of smoking control programs con- ducted during the last few years leads the authors to conclude that certain conditions improve success: (1) the use of multiple cessa- tion methods which can deal with different types of people or different uses of cigarettes; (2) payment, as in the commercial programs which intensifies commitment; (3) the presence of illness or risk factors which enhance motivation to quit; and, (4) good maintenance procedures which continue to support the ex-smoker. Once the smoker abstains, a myriad of forces act upon the individual influencing him to return to smoking. These forces in- clude environmental, sociai, and internal fac- tors, such as mass media, smoking of peers, and stress.. . . When the smoker breaks his habit he still has to contend with the effects of his former addiction. This is why maintenance is impor- tant. This review found that those programs with well planned long-term maintenance reduce recidivism and increase their eventual success rates. Programs that tailor their followup efforts to the individual's situation or to special problems will improve their effectiveness. ... gO METHODOLOGICAL WEAKNESS OF CESSATION EVALUATIONS Although there have been improvements, cessa- tion evaluations continue to be deficient in design and methodology. These deficiencies were de- cribed by Bernsteing' and Schwartz41 in 1969 and later by others, notably Lichtenstein and TIMN 293339 7

Danaher52 and McFall.53 There are seven problem areas, although some progress has been made in three of these areas over the last several years. The problems are discussed below. (1) Validity of self-reports of smoking behavior remains the leading problem in the evaluation of cessation results. By the use of physiological measurements, numerous investigators have shown that up to one-fourth of the people claim- ing abstinence were not telling the truth g4-g' For- tunately, this is the area in which the most prog- ress has been made with the availability of physiological tests to validate abstinence. More and more programs are making the effort to use these tests to check self-reports, but it is still in- convenient and costly for community programs and individual investigators to use them. Some in- vestigators have used informants or observers to corroborate self-reports, but their value has been questioned.56 All investigators, as well as practi- tioners, should consider the use of physiological measures to validate self-reports. (2) Some investigators continue to evaluate their results in terms of reduced numbers of cigarettes smoked rather than cessation of smoking. Because most smokers who merely reduce their consump- tion return to higher levels of smoking and because stopping smoking is the primary goal of cessation programs, abstinence is the criterion that should be used to measure success. There also has been much progress in this area. Psychologists and students doing doctoral research remain primarily the ones using reduc- tion in smoking as a way to evaluate their results. This is because it is not difficult to demonstrate significant differences between treatments based on reduction using a small number of subjects. These significant differences, however, have little meaning when abstinence is considered. All pro- grams, except those concerned with controlled smoking, topography, or nicotine dependence, should use abstinence for evaluation purposes. Those investigators who insist on using reduction in smoking should also report abstinence data so that their results can be evaluated and compared to other programs. (3) There are three problems with followups: they are sometimes based only on those who (a) complete treatment or (b) reply to followups; (c) often the followup period is too short. Some pro- grams even base their success rates entirely on people who quit by the end of treatment. A 1-year followup is best, but 6 months is acceptable. Less than 6 months has questionable value. Progress has been made over the last several years in the length of the followup with most programs now do- ing a 1-year followup. There is no progress on the other two aspects, as many programs continue to 8 do partial followups. It is desirable to present results on all subjects, not just on those com- pleting treatment or reached at followup. Some programs (particularly many hypnosis and acupuncture trials) do not describe how they did their followup, which makes it difficult to deter- mine if their claimed cure rate is valid. (4) Methods, procedures, subjects, followups, and other aspects of the program are often poorly described. The overriding objective of clinical evaluation is replicability, which is only possible when the method is adequately described (e.g., recruitment, type of subjects, procedures, materials, type of leader, length of treatment, number of sessions, and contact with program) and when it does not contain nonreproducible ex- traneous aspects.58 Space limitations for journal articles sometimes pose restrictions on authors, but there is available space to describe briefly treatment methods. Perhaps authors can indicate that further methodological details are available on request. (5) The need for control or comparison groups and tighter designs has been detailed by Bern- stein.51 Controls are especially needed by research programs and experimental trials. Community clinics do not need control groups, but if they use several procedures, they should systematically test them to find out each procedure's contribution to success. (6) It is often difficult to determine what "method" was actually used as some programs in- clude three or four methods as part of treatment. This makes it impossible to determine what worked or did not work and diminishes the chance to compare methods. For example, Orleans and Rotberg provided a consultation service for pa- tients referred by physicians.59 Some patients received physician advice to quit smoking, motiva- tional counseling, and written guidelines for set- ting an abrupt quitting date. In addition, they were given the American Lung Association self-help manual, signed a compliance contract, and were monitored in a 4-week nicotine fading program. (7) The last problem deals with the difficulty of making comparisons between methods. Sometimes a single method is subject to vast dif- ferences of execution. For example, physician counseling can consist of a warning to quit, various amounts of advice on how to quit, or a careful followup program. Group counseling can be vastly different depending on whether the leader is a lay person, a psychologist, or a physi- cian. Such differences, unless explained, can make comparisons tenuous. Other factors that make comparisons difficult are the differences in subjects (men vs. women, volunteers vs. chronically ill patients vs. randomly TIMN 293340

assigned subjects, use of students, socioeconomic factors, and heavy vs. light smokers); definitions; followup periods; groups on which quit rates are based (all subjects vs. only those completing treat- ment); length of treatment; and maintenance factors. These seven problems should be kept in mind when reviewing the overall comparisons between methods presented in this report. It is worth repeating that more weight should be given to the results of those trials that validate abstinence and utilize sound evaluation procedures. Investigators and practitioners can go far in alleviating these prob- lems by basing quit rates on validated abstinence at a 1-year followup and a full description of methods, subjects, and procedures. VALIDATING SELF-REPORTS BY PHYSIOLOGICAL MEASUREMENTS The problem of incorrect self-reports by par- ticipants in smoking cessation methods was noted in the previous section 54,5' Various laboratory pro- cedures available for testing exposure to smoking are finding greater use over the last few years. These tests are based on analyses of carbon monox- ide levels in the blood or expired air samples; plasma, urinary, or sputum thiocyanate; and blood, urinary, or sputum nicotine or its derivative, cotinine. BenowitzeO and Orleans and Shipley81 pro- vide excellent reviews of these measures. Carbon monoxide (CO) displaces oxygen In the blood to form carboxyhemoglobin (COHb). Levels of COHb can be measured from blood samples or more easily from noninvasive breath samples. Alveolar air CO is directly related to the level of COHb, which is related to cigarette smoking. Levels of CO from expired air samples can be monitored by CO analyzers. (One representative instrument is the Ecolyzer, manufactured by Energetics Science, Inc., NY.) This method is limited by the short half-life of COHb (about 3 to 4 hours) and the effect on CO of other exposures, such as second- hand smoke and auto exhaust. Benowitz reports that the time of day, the length of time since smok- ing the last cigarette, and individual variability in- fluence carbon monoxide levels.6O Advantages of the expired air method are its low cost, nonin- vasiveness, and immediate feedback. Vogt et al. described the measurement of serum thiocyanate (SCN) concentration in smokers as a consequence of trace amounts of cyanide in tobac- co.BZ SCN can also be measured from urine or saliva. Prue et al. provide a discussion of collection, storage, and laboratory procedures . for SCN measurements.63•64 The biologic half-life of SCN is about 2 weeks. The main disadvantage of this ap- proach is the overlap in the distribution of SCN levels in smokers and nonsmokers. Leafy vegetables, some nuts, and beer influence thio- cyanate levels. Vogt et al.65 and Cohen and Bartsch86 report that smokers generally have higher levels of SCN than do nonsmokers, and Luepker et al. support the use of salivary concen- trations of SCN as a noninvasive biochemical marker of smoking among adolescents.87 The main advantages of this method are that SCN has a long half-life, it is not affected by the time of day, and it is inexpensive to measure. Nicotine and its derivative, cotinine, can be used to distinguish smokers from nonsmokers. Validation can be from blood, urine, or saliva samples. Nicotine has a very short half-life (about 30 minutes), so cotinine, which has a half-life of about 30 hours, is preferred as a marker of smoking. (In a recent study, Lynch reported an average half-life for cotinine of 15 to 19 hours.88) Although nicotine absorbed from smoking varies with the type of cigarette and how it is smoked, cotinine permits very accurate detec- tion of regular smokers.69,'2 Cotinine is even sen- sitive in detecting adolescent smokers, who tend to smoke at lower rates than do adults.79 Advantages of the use of cotinine are its relatively long half-life, its stability throughout the day, and its accuracy in marking smokers. The main disadvantage of using cotinine as a marker is its high cost. Whatever method is used to validate abstinence, it should be kept in mind that drawing blood is in- trusive, use of urine is less intrusive, and taking saliva or breath samples is least intrusive. Because of its long half-life, SCN cannot be used to check abstinence at the end of treatment but can be used as a marker of long-term nonsmoking. Several in- vestigators advocate the measurement of both thio- cyanate and carbon monoxide to test nonsmok- ing.82-74 Use of both tests reduces the false positive rate. Benowitz remarks that if only smoking ver- sus nonsmoking is being assessed, then either car- bon monoxide or thiocyanate is an inexpensive measure that provides adequate information.75 Haley et al. maintain that cotinine is better suited than is thiocyanate to determine smoking status in large-scale epidemiologic studies.76 It is clear that abstinence should be validated in cessation studies and that methods are available to serve this purpose. Cost savings might be re- alized by limiting followup biochemical assessment to a sample of those who claim abstinence. It has been pointed out that use of a minimally intrusive measure, such as the assessment of alveolar car- bon monoxide, may have reactive effects on smok- ing.77 Measurement also increases the accuracy of self- reports.78 TIMN 293341 9

2. CLASSIFICATION OF SMOKING CESSATION CATEGORIES METHODS INCLUDED IN THE REVIEW Smoking cessation methods can be classified in four major ways: (1) by type of approach (e.g., educational, medical, and behavior modification); (2) by type of investigator or leader (e.g., educator, psychologist, physician, smoking specialist, and lay person); (3) by type of organization (e.g., non- profit, proprietary, religious group, university, and medical group); and (4) by method (e.g., self-care, medication, groups, and hypnosis). For the purpose of this review, predominant categories and subcategories have been identified that encompass major trends in cessation ac- tivities. These trends involve the four major areas noted above (approach, investigator, organization, and method) that represent the current work in smoking cessation. The ten categories used are as follows: • Self-care. • Educational approaches, clinics, and groups: - Nonprofit programs. - Commercial programs. • Medication. • Nicotine chewing gum. • Hypnosis. • Acupuncture. • Physician counseling. • Risk factor preventive trials. • Mass media and community programs. • Behavioral methods. Several different methods are included within some of the categories (e.g., educational, Five-Day Plan, rapid smoking, and covert sensitization). Where appropriate, these methods are given separate attention. Many of the programs used several methods such as nicotine chewing gum plus group therapy, aversive conditioning plus physician consultation plus self-management, educational plus physician counseling, or self-help manual plus group clinic. Rather than classify combined methods into a multicomponent category, they are discussed under their major component. Thus if nicotine chewing gum or hypnosis was used with groups or counseling, the program would be discussed under nicotine chewing gum or hypnosis. The methods included in this review met the following criteria: • They were reported in 1978 or thereafter. This review is intended as an update of the 1969 and 1977 reviews.41•42 In some cases, methods prior to 1978 are noted for historical or background information (e.g., self- hypnosis and satiation). • They were conducted in the United States or Canada. In addition, to present a more com- plete summary of several methods (e.g., nicotine chewing gum, acupuncture, and physician counseling), programs from other countries are included (notably, England, France, Sweden, and Australia). • They were concerned with cessation of cigarette smoking. Thus reports pertaining solely to pipes, cigars, or smokeless tobacco are not included. • Their reports included results based on abstinence. Thus studies that reported results based only on reduction of smoking are not included. • Their results were based on at least six per- sons. Individual case studies are not included. • They reported followup results of at least 3 months. CRITERIA USED FOR EVALUATION OF CESSATION METHODS In addition to reviewing the smoking cessation literature since 1978, a comprehensive table is presented in appendix A that covers the results of cessation programs from the first trials in Sweden to recent program reports. This table presents a listing of the results of methods and is offered to the reader as a comprehensive overview of the cessation literature. Programs were included 11 TIMN 293342

if the purpose of the trial was to help people quit smoking cigarettes; their results reported the number or percent of subjects abstinent; and they reported followup results of at least 3 months. Some investigators compared two or three dif- ferent methods in the same study. In several cases, the different methods (e.g., hypnosis, educational, and behavior modification) were separated from the larger trial and shown in the comprehensive table under their individual headings. A few methods were listed twice (e.g., under nicotine chewing gum and under acupuncture). The reader is directed to the cautionary note that precedes the comprehensive table. Care should be taken to give more weight to those studies that used sound followup procedures. Summary tables are presented in this review for various methods intending to show the number of trials, median quit rates, range of results, and per- cent of trials that scored at least 33 percent abstinence. The tables also show how the methods have progressed over time. For these summary tables, only programs with at least a 6-month followup were included. The reader is, never- theless, cautioned that 6-month results are not equivalent to 1-year results, as recidivism occurs between 6 months and 1 year. We now know from several long-term followups (2 to 5 years) that some ex-smokers return to smoking even after 1 year. The standard in the field should be a 1-year followup. Although many subjects cannot be located after 1 year, when possible, 2-year followups should be conducted. When information was available, programs were evaluated based on their reports of abstinence results; whether all initial subjects were included in the followup results or just "graduates," quit- ters, or persons found at followup; and the length of the followup. In addition, note is made of pro- grams that validated results by physiological measurements. Good evaluation procedures call for including all enrollees who start treatment in the followup results. In the case of methods with complicated procedures that extend over several visits or a group method with multiple sessions, it is argued that someone who attends only the first session should not be included in the results. 7hking this argument into consideration, the guidelines by Berglund et al. defined a participant as a "smoker who registers for treatment and attends at least 15 % to 20 % of the sessions: '79 Using this guideline, attendance at 1 out of 5 sessions would qualify a participant for inclusion in results; of 6 to 11 sessions, attendance at 2 would qualify a par- ticipant for inclusion in the results; and for 12 or more sessions, 3 would suffice to meet the defini- tion of participant. 12 The American Cancer Society initiated a code of practice for evaluating cessation programs and protecting smokers seeking treatment, which was developed under the direction of the National Center for Health Education. The Code of Practice for Smoking Cessation Programs defines success as complete abstention from all forms of tobacco for 1 year following treatment.80 The code calls for including in the evaluation all persons attending the first treatment session. The code provides definitions of participant, attrition rate, and treat- ment success. Although a number of voluntary and commercial organizations have agreed to abide by the code, there are indications that some subscribing agencies are not following the stan- dards. One deficiency of the code of practice is the absence of a recommendation for biochemical validation of self-reports. (A companion code, Stan- dards for the Evaiuation of Group Smoking Cessation Programs, was also developed). The guidelines and the code are definite on one point: participants not located at followup or fail- ing to provide results should be counted as smokers. In addition to providing results on all par- ticipants, investigators can present data on sub- jects completing treatment and on those found at followup. Most of the studies reviewed based their results on those subjects who completed treatment or were located at followup. The behavioral in- vestigators, particularly those using rapid smok- ing, 'limited their followups to subjects completing treatment. Hypnosis studies likewise limited their followups. It was not possible to recalculate results for studies that did not include all participants. Some reports did not state the original number of subjects. Definition of followup also varied (e.g., Nicorette studies counted their followup period from the start rather than the end of treatment). Also, quit rates for some studies were based on abstinence for the entire followup period, while most studies measured abstinence at the followup point. The results, as given by the investigators, are presented in the comprehensive table. The reader should be aware that some results are based on all subjects and some are not. The cautionary note that precedes the comprehensive table com- ments further on these points. Most cessation programs achieve from 50- to 80-percent abstinence at the end of treatment. One-half or more of the quitters return to smok- ing, indicating that short-term success rates are unstable. This review will examine only followup quit rates as measures of success. The reader should keep in mind that a 4- to 6-month rate is less stable than a 1-year rate. In this monograph, the term "smoker" will mean cigarette smoker and "success" will refer to abstinence. TIMN 293343

In broad terms, there are basically five ways of breaking the cigarette smoking habit: doing it on your own or with minimal instructions; attending a quit clinic, class, or group; working directly with a professional; participating in a large research trial or community program; or being a subject in a behavioral laboratory. Several dozen methods used over the last 8 years, organized into 10 categories, are reviewed in the next chapter. WORKSITE SMOKING POLICIES AND CONTROL PROGRAMS Following the review of smoking methods, a chapter is devoted to smoking control at the workplace. Covered are health risks to the worker, costs to the employer, antismoking policies, and intervention approaches. Three intervention strategies are reviewed: educational campaigns, in- centives for quitting, and cessation programs. Many companies sponsor quit methods for their employees, but few evaluation reports are available. Although most cessation studies at the workplace are covered under their appropriate category in chapter 3, they are brought together in the worksite chapter so that their impact can be assessed. TIMN 293344 13

3. SMOKING CESSATION METHODS Although about 1 million Americans stopped smoking in each of the last several years, there re- main 50 million smokers. Survey data have shown that the majority of smokers have made at least one serious but unsuccessful attempt to stop smoking.81 Almost two out of five smokers have made three or more attempts to quit.82 Horn reported that between 1970 and 1975, 84 percent of U.S. smokers thought seriously about giving up smoking, and 68 percent of these smokers tried to quit.83 This chapter reviews cessation methods under 10 major categories. Where feasible, summaries of followup quit rates are presented for various in- terventions in tabular format. The reader should keep in mind that rates reported are largely unverified and that some followup procedures may be faulty. Reports that were received or identified late may not be included in the summary tables, but they are listed in the comprehensive table. Although most ex-smokers quit on their own after several attempts to break their habit, many smokers seek help in quitting. That is why cessa- tion methods are offered by health practitioners and voluntary and commercial organizations and are the subject of much laboratory research by social and behavioral scientists. It should be noted that the availability of smoking cessation pro- grams may encourage some individuals to attempt abstinence who otherwise would not do so. SELF-CARE Self-care means simply being able to do for yourself things that maintain your health. Self- care is being able to make personal choices based on one's own experience and knowledge.84 In smoking cessation, self-care consists of three modes: devising one's own way of quitting; receiv- ing brief instructions or advice on how to stop and then doing it; or utilizing an aid or a self-help guide to quitting such as a stop-smoking book, quit kit, instructional manual, record, cassette, filter, over- the-counter lozenge, or drug store preparation. In many cases, smokers stop temporarily when they have a nagging cough, throat irritation, or cold or when they experience alarming physical symp- toms such as loss of breath, chest pains, or weakness. No specific method is employed, but before long the smoker has quit.e5 Self-care is distinguished from self-management or self-control inasmuch as the latter are behavioral techniques, generally directed by psychologists, which include supervision or a variety of procedures that negate the self-care aspect. For example, Glasgow evaluated a self-help treatment manual by assigning subjects to "minimal contact self-control" that consisted of a 3-week treatment program (relaxation and stimulus control training, rapid smoking during six sessions, meetings with a therapist, and weekly telephone calls to check progress and answer ques- tions) or "high contact self-control" (the same pro- cedures with more direction and contact with the therapist).86 This is not meant as criticism of Glasgow, as his study was well done, but as an illustration that managing the subject so closely is not considered self-care. There is a bit of self-care in many cessation methods. Quitting after a warning or counseling from a physician to stop smoking or after viewing a televised quit program could be labeled "quitting on your own: " The difference is that the impetus was the physician's warning or counseling or the television program. The term "self-help" is often used to mean peo- ple helping each other through mutual support and is therefore part of self-care. There are 500,000 self-help groups, many of them organized around health, disease, or addiction. Smokers Anonymous is an organization that encourages smoking cessa- tion and offers support to those who have quit. The National Cancer Institute (NCI) defined self-help for a workshop on self-help strategies more broadly to include "an individual's or a group's efforts to quit smoking without the continued assistance of professionals, trained leaders, or organizations: 'B7 This definition included mass media approaches and contact with physicians. In this monograph, these other methods will be treated in separate categories. 15 TI-MN 293345

In cessation trials, those people who are as- signed to be controls and stop smoking have quit on their own. Although they may have filled out a questionnaire, they have received no instructions on how to quit. The following examples all had 1-year followups. The Smoking Control Research Project had two control groups: 17 and 19 percent, respectively, quit.88 In Seriff and Finkelstein's study, 10 percent of the controls quit.$a Ovhed (Sweden) reported that 14 percent of the controls quit.90 Guilford had controls sign "decision cards": 16 percent stopped smoking.91 In the final exam- ple, Suedfeld and Ikard encouraged controls to quit but offered no help: 17 percent gave up smoking.92 Self-Help Books A variety of self-help books and quit kits are available to guide smokers in their efforts to stop smoking. Unfortunately, there are only a few evaluations of these materials. The Self-T2?sting Kit, devised by Horn in the late 1960's at the National Clearinghouse for Smoking and Health, has been widely used and is included in most quit books and guides.93 A Teenage Self-Test was also developed by the Clearinghouse. The kits provide understanding of how one feels about cigarettes, how one uses them based on Silvan 'Ibmkins' theory94 the reasons for stopping, and factors that inhibit or assist the quitting effort. In 1969, the Clearinghouse broadcasted a television series of four programs that utilized the Self-Tbsting Kit. A followup of 207 persons who watched the program and used the kit showed that 23 percent were not smoking 1 year later.95 The U.S. Office on Smoking and Health provides smoking cessation pamphlets, such as Helping Smokers Quit and Calling it Quits: The Latest Ad- vice on How to Give up Ctgarettes. NCI designed the Helping Smokers Quit Kit containing materials for the smoker and the physician. In 1983, NCI issued a new cessation kit, Quit for Good, which replaced the earlier kit. The kit is designed for physicians and dental and other health professionals to use in counseling patients. The kit contains two patient brochures, Quit It and For Good, with cessation and maintenance tips. NCI recently developed a Helping Smokers Quit kit for pharmacists to use in counseling people on how to quit. NCI also offers Clearing the Air, a pamphlet that details methods and techniques for giving up smoking; a Spanish version is Despeo jan- do el Aire. NCI makes available a supplemental factsheet, You've Kicked the Smoking Habit-Fbr Good1, which provides a variety of tips for remain- ing a nonsmoker. In 1977, the American Cancer Society (ACS) developed the I Quit Kit consisting of seven items: 16 portions of the Self-Tbst; instructions for quitting over a 7-day period; a quitting calendar; a phono- graph record that contains experiences in quitting, a breathing exercise, songs, and skits; a poster; tips on how to quit and remain off smoking; and I Quit buttons. Glasgow, Schafer, and O'Neil96 used the I Quit Kit as a "minimal treatment control" in a test of two behavioral self-help books, one by Danaher and Lichtenstein97 and one by Pomerleau and Pomerleau.98 In the self-help trial, the ACS manual outscored the other two books: 27 percent success for the ACS manual at 6 months compared to 15 percent for the Danaher and Lichtenstein book and zero percent for the Pomerleaus' book. Glasgow reports that four-fifths of the subjects assigned to the ACS manual read it, while about one-half of the subjects assigned to the other two books read them.99 He postulates that self- administered subjects who receive relatively com- plex behavioral programs have great difficulty in following them. On the other hand, the less com- plex I Quit Kit was more easily followed. (In the same trial, when a therapist directed an 8-week group in which subjects used the same materials, the behavioral books came out better than the ACS book.) The Stanford University group evaluated the Quit Kit developed for their Five City Project 100 The Quit Kit consists of an explanatory flier, four two-sided sheets with behavioral tips for smoking cessation, and a 2-inch heart magnet. 'Iivo hun- dred and seven northern California smokers were assigned to either the Quit Kit, the Quit Kit plus audiotape with instructions on the focused smok- ing procedure, or delayed treatment. The analysis was "muddied" by combining the two quit kit groups, although over one-third of the audio sub- jects used the cassettes, and by not following the comparison group at the 6=month followup. At the 2-month followup, 13 percent of the quit kit sub- jects and 5 percent of the delayed treatment sub- jects were abstinent. At 6 months, the quit rate for quit kit subjects was 11 percent. Nonsmoking was verified by carbon monoxide assessments. The Quit Kit cost $1.75. The authors concluded that the kit is an inexpensive way to help motivated smokers to quit. The study also showed that most subjects will not use a self-administered aversion procedure. The American Lung Association (ALA) pro- duced 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 F7-eedom From Smoking lol The cessation guide includes part of the Self-Test, a cigarette record, and contracts to TIMN 293346

sign and identifies smoking triggers. It offers in- formation about controlling weight, handling smoking situations, and doing deep-breathing and muscle relaxation exercises. Tasks and informa- tion are offered for each of 20 days with the first 7 days considered preparation, the next 9 quitting, and the last 4 days reinforcement of nonsmoking. The maintenance booklet supports the ex-smoker by providing techniques for coping with urges to smoke. Diet information and suggestions for deal- ing with tension and social situations are em- phasized. These manuals are well designed and have proven to be very popular. David, Faust, and Ordentlich evaluated the ALA manuals in five cities of four states 1O2 The 1,237 participants were randomly assigned to four con- ditions: (1) the cessation guide; (2) the cessation guide plus maintenance booklet; (3) ALA leaflets; and (4) the leaflets plus maintenance booklet. A $20 fee was required. A 1-year followup showed that 15 percent of the subjects assigned to the cessation guide had quit, while those assigned to either con- dition that included the maintenance booklet (2 or 4) showed 18-percent success; the leaflets alone had a 12-percent quit rate. Ninety-five percent were located at followup; nonresponders and pipe or cigar smokers were counted as failures. Tvo local evaluations of the ALA manuals were conducted. O'Neal queried people who had re- quested the manuals in Arkansas.103 Of 68 responders, 32 percent reported that they had stopped smoking (unknown followup period). Perlstadt surveyed 1,500 persons who had received the manuals in Michigan within the previous 15 months.104 Of 300 persons who responded, one- third had quit There are dozens of "how to quit smoking" books; a few will be briefly summarized. Danaher and Lichtenstein's Become an Ex- Smoker views smoking as a learned behavior that has to be unlearned.97 They present aversive and nonaversive ways of quitting. Record keeping and combating urges to smoke are stressed. Muscle relaxation skills and self-rewarding techniques are suggested. Managing thoughts about smoking and weight con- trol are discussed. Pomerleau and Pomerleau base their book. Break the Cigarette Habit A Behavioral Program for Giving Up Cigarettes, on behavior modification techniques.98 Eight units lead the smoker through gradual reduction to abstinence. Stimulus control techniques are presented. Ways of dealing with problems and weight gain are discussed. Pederson and her colleagues conducted two studies of self-help books. In the first trial, 28 smokers were assigned to either the Pomerleaus' book or the Danaher and Lichtenstein book los At 6 months, quit rates were 33 percent for Pomerleaus' and 23 percent for Danaher and Lichtenstein. In the second trial, 69 smokers were advised to quit, and some of them were given the Pomerleaus' manual 1O6 Surprisingly, of those who received Pomerleaus', 17 percent reported abstinence at 6 months, while among those who were only advised to quit, 26 percent were successful. liwo other behavior modification volumes are Stop Smoking for Good107 and No More Butts A Psychologist's Approach to Quitting Cigarettes los Jackie Rogers of SmokEnders authored a book that emphasized careful preparation and develop- ment of the proper attitude for quitting109 Case histories and recommended activities (relaxation, diet, and exercise) are included. Burton and Wohl's book, The Joy of Quitting, is directed at teenagers.11O The effects of smoking are summarized, and excuses for not stopping are discussed. Methods for stopping and healthy eating habits are presented. Quit Smoking in 30 Days includes three phases: preparation, quitting, and maintenance 111 "Pat; ' an inner voice that fights nonsmoking by supplying a stream of "resumption thoughts; ' is a feature of this volume. Tips are provided on how to deal with "Pat," cope with withdrawal symptoms, control urges, avoid weight gain, and manage potential relapse situations. A number of quit books do not provide a single method to follow. Instead, they emphasize the hazards of smoking and the benefits of quitting. They describe a variety of available methods and cite sources where the smoker can turn for help. One example is Casewit's Quit Smoking.ll2 He discusses the psychology and physiology of cigarette use and describes ways of quitting. A book to be published in 1987 by Ferguson is aimed at smokers not committed to quitting. The Smoker's Book of Health: How to Keep Yourself Healthier and Cut Your Smoking Risk advises smokers how to improve their health and offers a variety of methods and tips to smokers who decide to quit 113 This volume contains useful information on eating, exercise, stress reduction, and social support. The final self-help book to be noted is The Stop Smoking Diet.il4 Nicotine is assumed to be the ad- dictive component of cigarettes. Diets containing acid-forming foods (meats, poultry, and fish) en- courage faster elimination of nicotine from the system, while base-forming foods (vegetables, fruits, and milk) result in slower release of nicotine. The base-forming smokers' diet (including grains) is in- tended to prevent weight gain and help the smoker to quit. The diet changes once abstinence is achieved. Some suggestions are potentially damag- ing, as the author proposes as "nicotine 17 TIMN 293347

alternatives" dry snuff, moist snuff, chewing tobacco, and a pipe or cigar. Nepps evaluated Johnson and Johnson Corpora- tion's Liue for Life Smoking Cessation Program Manual consisting of nine sequential modules that combined behavioral techniques 115•118 Smoke holding, nicotine fading, and self-control strategies were dispensed to employees who volunteered for the cost-free program. Originally, 36 workers started the modules, but only 19 returned for the second module, and 6 completed all 9 modules. Quit rates based on these 19 par- ticipants showed that 26 percent succeeded. Several audiocassettes provide quitting pro- grams. Three examples follow. The first, Smoke No More by Miller, is a set of two tapes that contain tips to strengthen motivation, provide stress reduc- tion and self-control skills, and describe relaxation and deep-breathing exercises. Miller stresses the need to replace smoking urges with positive im- ages and rewards until cigarettes are no longer needed. The second is a series of five audiotapes by Danaher and Lichtenstein called Comprehen- sive Smoking Cessation Program. In addition to muscle relaxation exercises and homework assignments, an aversive smoking procedure is outlined. Advice is offered on how to handle prob- lems associated with quitting. In 1985, the ALA produced In Control, a smok- ing cessation video program that individuals with VCR's can use at home.l 17 Nina Schneider (UCLA) and Steve Garvey (baseball star) host the 2-hour video program consisting of 13 segments to be shown over 13 days. Users also receive a 124-page Viewers Guide and a 20-minute audiotape with motivational and relaxation messages. A 14-day weight maintenance plan is included. The In Con- trol package sells for $60. Aids to Quitting A variety of aids are available to help smokers break their habit. Their effectiveness is ques- tionable, and those persons who quit after using these products may be considered actually to have quit on their own. The most popular aid is a filter that reduces the tar, nicotine, and carbon monox- ide levels, permitting the smoker to be weaned from the chemical addiction to cigarettes. Several filters are sold, one being Teledyne Water-Pik's One Step at a Time (in the United States and Japan, and sold under the MD-4 brand name in other countries). This filter system comprises four reusable filters that reduce the tar, nicotine, and carbon monoxide levels about 20, 50, 70, and 90 percent, respectively.118 The withdrawal system takes 8 weeks, as each filter is supposed to be used for 2 weeks. The suggested retail price is $11.95, 18 but it is discounted in some stores to $7.99. A re- quest to Tbledyne Water-Pik for validating data regarding quit rates was answered merely with data regarding the substance reduction capabili- ties of the filters. There have been two tests of 'Ibledyne Water- Pik's One Step at a Time 119 The first was a study by Miller of 67 people who purchased the filters in pharmacies in Erie County, PA120 Only persons who completed the procedures for using the filters were considered. None of the 67 people had quit at the end of the 8-week period. Followups 4 to 12 months later revealed that 10 percent had quit smoking. Most people remained on the fourth filter for many months and did not stop smoking. Some people compensated for the reduced nicotine by increasing their smoking. The second study was a carefully controlled evaluation of One Step at a Time. Hymowitz et al. assigned 130 subjects to use graduated filters, use placebo filters, or quit on their own lz1 At the end of 8 weeks, the quit rate for graduated filters was 26 percent, placebo filters 14 percent, and quitting on their own 21 percent. At the end of the year, the percent quitting on their own had swelled to 33 percent, while rates for graduated filters had declined to 22 percent and for placebos to 12 per- , } cent. The investigators concluded that the data fail ' to document the utility of the filter system for stop- ping smoking. Nonetheless, the success rate-22 percent at 1 year-is as good as that achieved by many more complex methods reported later in this volume. There are numerous over-the-counter products sold as aids to stopping smoking. Jeffrey Martin, Inc., sells Bantron, smoking deterrent tablets com- posed of lobeline sulfate, tribasic calcium phosphate, and magnesium carbonate. Lobeline sulfate is supposed to decrease the physical crav- ing for nicotine. Three tablets are taken each day with one-half glass of water each "until the goal is reached: " A package of 18 tablets costs $5. A re- quest for validating data brought no response. VITA Plus Industries markets Stop-Easy, a stop- smoking gum. The package states that the gum has been used successfully by thousands of peo- ple in Europe and the United States as a temporary aid to moderate smoking or stop altogether. The gum is composed of silver acetate, ammonium chloride, and carboxylase. Tablets are to be chewed every 4 hours with a 3-week program recom- mended. The cost for 12 tablets is $5. The tablets are supposed to interact with tobacco smoke to create an unpleasant taste. The package claims 10 years of clinical research. There was no response to a request for validating data. HEALTHBREAK, distributed by Lemar Labora- tories, consists of 24 medicated chewing gum TIM.N 293348

tablets and a program booklet for $7.50 or 12 medicated lozenges for $6 called The Stop- Smoking Lozenge. A request for validating data brought no response. BAN SMOKE, a product made of benzocaine, is offered by Thompson Medical Co. This special for- mula gum comes in packages of 24 for $4. One or two pieces are to be chewed when the user gets the urge to smoke. The package states "Delicious, flavor-ful BAN SMOKE is the pleasant way to stop smoking: " The package cautions that "BAN SMOKE will help you only if you really want to cut down or stop smoking completely." There was no reply to a request for validating data. IN TROL, offered by Bonny Venture Service, is a "miracle" product aimed at controlling smoking and appetite easily. It is "a secret blend of natural ingredients, each individually effective in satisfy- ing cravings for tobacco." The product is dispensed through a small vaporizer (IN TROLATER) dis- guised to look like a cigarette. A 6-month supply of IN TROL costs $9. E-Z QUIT, the advertisement says, is "recom- mended by doctors to help you kick the habit- for good: " It is a cigarette substitute that "simulates the taste and pleasure of a ciga- rette .... The secret lies in the scientifically im- pregnated capsule inside the lifelike 'cigarette: " A package consisting of one smokeless cigarette and three capsules (lasts up to 4 months) is sold for $7 by Starcrest of California, Perris, CA. A smokeless cigarette named Favor is a plastic- coated cylinder with a nicotine-soaked filter.122 It is supposed to satisfy a smoker's nicotine desire without emitting a cloud of smoke. One stick is equal to five regular cigarettes. Ferguson reports that Favor is not advertised as a smoking cessa- tion device to avoid Food and Drug Administration (FDA) regulation 113 Favor is marketed in some cities in Texas, Colorado, Oklahoma, and New Mexico by Advanced 'Ibbacco Products of San Antonio.113 Jazz is a nonnicotine, tobacco-free product made from the Argentinian plant lactuca (similar to lettuce). It burns like a regular cigarette and smells like mild tobacco.122 Other cessation devices include several types of cigarette dispensers that unlatch a cigarette at predetermined intervals, mouthpieces that reduce nicotine levels, and a holder that produces an electrical shock. There is even a cigarette-holding device that discourages smoking by delivering a health risk message 123 The holder is equipped with treated filter paper that carries health risk messages that are. invisi- ble at the start of smoking but become clearly readable during smoking. The FDA is studying the effectiveness and safe- ty of smoking deterrents. An FDA panel of experts found that 43 of 45 active ingredients used in smoking deterrents are neither safe nor effective lz4 Lobeline and silver acetate are still under study. The FDA is expected to issue rulings concerning the sale of deterrents containing these ingredients. Quitting by Mail Three studies present evidence that it is possi- ble for smokers to quit through the receipt of materials via the mail. Brengelmann and Sedlmayr report as much as 45-percent success at 15 months for subjects who were treated through the mai1125 1l-eatment materials were mailed over a period of 12 weeks to persons who volunteered to quit. Subjects had to respond to mailouts. The followup was based on response from about one-half of the subjects. Jeffery et al. randomly assigned 29 subjects to three correspondence courses for quitting smok- ing 128 The three conditions were mail only, mail plus a signed monetary contract linked to suc- cessful completion of periodic homework assignments, and mail plus a contract plus daily progress reports to a telephone answering machine. A group method was used as a control. In addition to a manual, two audiotapes were pro- vided on relaxation and aversive smoking pro- cedures. Each participant deposited $50 as a per- formance deposit. At an 8-month followup, 20 of 29 subjects reported their abstinence results, which ran from 33 to 44 percent based on the sub- jects reporting. Schneider et al. sent computerized mail to treat smokers who did not wish to attend face-to-face therapy.127 Of 1,044 smokers who expressed in- terest in cessation treatment, 117 were willing to accept face-to-face treatment. Of the 509 assigned to the computerized program, one-fifth returned at least one mailing, and of these, two-fifths con- tinued to the final week. A 6-month evaluation of four conditions showed the following quit rates: single mailing of computerized material (N=214)-10 percent; single mailing of pamphlet (N=205)-12 percent; complete set of computer- ized mail (N =108)-13 percent; and face-to-face treatment (N=105)-18 percent. The results of the three mail studies are encouraging as they show that people can quit on their own when receiving instructions on how to do it without face-to-face contact. Several groups are developing microcomputer programs for quitting smoking. Investigators at Behavioral Health Systems, Staten Island, NY, and Massachusetts General Hospital, Boston, are designing online behavioral smoking cessation in- structions for computer users. Control Data Cor- poration offers two self-quit courses: How to Quit TIMN 293349 19

Smoking Self-Study Course and a computer-based program named PLATO. Both courses run 6 to 8 weeks and are intended for distribution by com- panies to employees. (Refer to the worksite chapter for cost and other information.) Summary and Comment We found out a long time ago that smokers would rather quit on their own but with the help of instructions, medicine, or guides. In a 1965 survey of male smokers belonging to the Kaiser Health Plan, the most popular quitting methods were instructions, followed by medicine, television programs, and a book.47 Public health clinics and groups were least popular. Three out of five respondents were willing ("yes" and "maybe" responses) to participate in methods that they could carry out by themselves (book or television programs). Only two out of five were willing to par- ticipate in methods that actively involved others. A Gallup Poll in 1974 confirmed our results.lz8 The variety of self-help aids-kits, pamphlets, manuals, books, audio cassettes, drug store preparations, cigarette substitutes, and cor- respondence courses-cater to the wishes of smokers for ways they can quit smoking on their own. Evaluations of self-care products and books reveal quit rates slightly lower than those of some other methods (table 1). The median quit rate was about the same for 6-month and 1-year followups. Evidence was presented that the less complex quit guides achieved higher success rates. Zbble 1 SUMMARY OF FOLLOWUP 9UIT RATES OF 1S SELF-HELP TRIALS Reported 1980-1984 Percent N Range Median 33% At Least 6-Month Followup 11 0-33 17 18 At Least 1 Year Foilowup 7 12-33 18 14 The general finding to emerge from the various types of self-quitting studies is that people who self-select to quit on their own appear to succeed 16 to 20 percent of the time in being abstinent at 1 year. This finding is supported by statistics from national samples (see page 4), which indicate that of those who try to quit, 20 percent report that they succeed.39 This may be used as a benchmark to measure results from interventions that include more than minimal guidance up to intensive treatment. Schacter points out that self-quitting appears to involve cumulative learning over repeated ef- forts 129 He contends that most smokers who really try to self-quit eventually succeed. Recent research 20 suggests that unaided quitters who succeed enjoy higher levels of motivation to quit, success expec- tancy, social support for quitting, and psychosocial assets and make greater use of particular self- change skills than do individuals who do not suc- ceed in quitting 13a19s DiClemente and Prochaska found that change processes discriminated self- quitters and therapy quitters 132 These studies were largely retrospective, so they may involve recall biases. For example, successful quitters may claim strong motivation as a recall. In a prospective study of self-quitters, it was found that recent quitters emphasized social sup- port, while long-term quitters emphasized coping strategies.ls4 Self-efficacy scores reliably discriminated smokers from nonsmokers and re- cent quitters from long-term quitters 135 Prochaska and DiClemente have found highly significant dif- ferences in the change processes that self- changers emphasize in five stages of change.ls4•138 They are using their findings to develop self-help materials. Research on self-care methods and the self- change process has increased.-NCI has funded 10 research projects that are either testing self-care materials or studying self-quitters. Several projects use ALA or ACS manuals, while others are developing their own materials. Three projects are being conducted at worksites; two groups use hotlines; one is testing a correspondence program; and several are using nicotine chewing gum. Maintenance and relapse factors, such as stress and social support, are being studied. These proj- ects will impact over 200,000 individuals and, hopefully, will identify useful self-care methods and provide more insight regarding self-quitting. Findings from these studies may instruct us in how to help treated subjects gain the motivations, resources, and skills of successful untreated subjects. Considering the great number of people trying self-aids and that many smokers try several times before they actually quit, one must conclude that the aids have led many smokers to the path of nonsmoking. More studies are needed to evaluate the drug store preparations. It appears that FDA is taking the first steps to evaluate the evidence regarding the safety and effectiveness of many in- gredients. Participation of health professionals and community programs can encourage more people to help themselves break the cigarette habit. Self-help guides have been used in conjunction with most cessation methods. The excellent ALA cessation and maintenance guides meet high stan- dards. They are attractive in appearance and design; they cover a variety of effective techniques; and they present a step-by-step program for quit- ting smoking that can be easily understood by the user. The maintenance manual provides advice TIMN 293350

and tips for the period after the smoker quits. On the horizon are other self-help aids that utilize new technologies, such as videotapes and personal computers. Self-help aids would appear to be cost- effective in terms of their minimal use of profes- sionals and programs. They are convenient for the user and satisfy the consumer's preference for quitting on his or her own. Needed is the develop- ment of new self-help techniques and research into how best to present these packages to smokers. Self-help techniques that are shown to effective can be distributed through medical and dental of- fices, health departments, the media, schools, public libraries, and places of work. This strategy will result in many more ex-smokers. EDUCATIONAL APPROACHES, CLINICS, AND GROUPS Nonprofit Programs Over the last decade there has been a notable in- crease in smoking control programs offered by public and private agencies, particularly hospitals. For example, a 1980 survey of state and local smok- ing programs found that in the United States, in ad- dition to those given by the state and local units of cancer, lung, and heart associations and the Seventh-day Adventist Church, smoking cessation programs were offered by at least 50 hospitals in 19 states, 30 health plans or clinics in 14 states, and health departments in 12 states.138 A similar survey conducted in 1985-1986 reported that cessation programs are now offered by 124 hospitals in 33 states, by 54 health plans or clinics in 28 states, and by 94 health departments in 36 states?3a Cessation programs are sponsored by a variety of other organizations, including schools, colleges, medical centers, research foundations, medical societies, interagency councils, military units, rural community and service agencies, labor unions, and exercise clubs, as well as private businesses at of- fices and factories. Many of these cessation efforts are based on the programs or materials supplied by the ACS, the ALA, and the Seventh-day Adven- tist Church, but some clinics offer biofeedback, hypnosis, behavioral approaches, or their own methods. Smokeless and Smoke Stoppers are popu- lar programs in hospitals. The most active organizations in smoking con- trol in the United States and Canada have been the cancer and lung associations and the Seventh-day Adventist Church. In Canada, the Council on Smoking and Health, the Heart Foundation, and provincial health departments have played leading roles in cessation. A number of private foundations, such as the American Health Foundation, have sponsored ongoing cessation programs. This sec- tion will discuss educational activities and pro- grams, the FYve-Day Plan, live-in programs, group methods, and withdrawal clinics offered by non- profit organizations. In general, nonprofit programs are characterized by low fees, nonprofessional leaders, and an emphasis on health education. Educational Activities The public health campaign waged by public and private agencies has stimulated cessation activities. The annual report of the Surgeon General, pre- pared by the Office on Smoking and Health (The Health Consequences of Smoking), and the announcements and publications by governmen- tal and voluntary agencies have provided the public with incentives and ways to quit smoking. The Surgeon General called for a Smoke Free Society by the Year 2000. In response to this call, 63 representatives of America's antismoking move- ment met in November 1984 to develop strategies for realizing this goal. The National Interagency Council on Smoking and Health organized the meeting. The Office on Smoking and Health (OSH) is the principal U S. agency concerned with the problems of smoking and its effect on health. OSH offers educational materials, bibliographic references, and scientific findings related to smoking and smoking cessation. The Self Test has already been men- tioned.93 OSH prepares the annual report on the health consequences of smoking and conducts systematic surveys of smoking habits and attitudes among adults, teenagers, and health professionals. OSH publishes the ongoing Bibliography on Smok- ing and Health, which summarizes the world literature on smoking and health. This is an impor- tant information resource for the scientific com- munity about prevention and withdrawal methods. OSH is responsible for staffing the Interagency Committee on Smoking and Health. The Commit- tee advises the Secretary of the Department of Health and Human Services on smoking issues. The Committee Is chaired by the Surgeon General; its 22 members represent various Federal and non- Federal agencies. Several other Government agencies-notably the National Cancer Institute, the National Heart, Lung, and Blood Institute, the Centers for Disease Con- trol, the National Institute of Child Health and Human Development, and the National Institute on Drug Abuse-publish material on smoking cessa- tion, fund research projects, and sponsor con- ferences on smoking prevention and cessation. In Canada, the Ministry of National Health and Welfare directs a national effort to reduce cigarette smoking, including producing educational ' TIMN 293351 21

materials, films, and TV clips; coordinating profes- sional activities; funding research programs; and conducting national surveys of smoking attitudes and habits. In 1982, in collaboration with provin- cial health departments and major voluntary health organizations, the Ministry initiated a ma- jor smoking prevention program, Zbwards a Generation of Nonsmokers, or Generation 140 Besides promoting nonsmoking among young people, the program aims to create an awareness of the consequences of smoking, encourage smok- ing cessation, and foster a nonsmoking social en- vironment. The Time to Quit program focuses on current smokers, utilizing a multimedia, community-based approach. ACS takes a prominent role in smoking preven- tion and cessation. In addition to the publication of educational materials and quit guides, ACS has produced cessation trigger films, funded cessation studies, participated in public policy programs, sponsored scientific and lay conferences on smok- ing cessation, and provided professional education on smoking control to health care personnel. ACS originated the world conferences on smoking and continues to play a major role in them. ACS spon- sored the 1978 International Conference on Smok- ing Cessation49 and the 1981 National Conference on Smoking OR Health 141 The Great American Smokeout (to be discussed in the section on Mass Media and Community Programs) was initiated by ACS as an annual cessation event and continues to receive a lot of media attention. ACS runs an active withdrawal program for adults and teenagers, which will be discussed in the section on withdrawal clinics and groups. ACS also sponsors a smoker's telephone quit-line. Recognizing the limitations of local ACS resources, ACS is placing priority attention on preparing representatives of business and industry, schools, hospitals, clubs, and other organizations to con- duct cessation programs on their own?42 ACS pro- motes independent stopping through education and health promotion and making the Quitter s Guide and I Quit Kit available. Local units are en- couraged to install recorded telephone messages and locate volunteer ex-smokers to help current smokers to quit. ACS developed a new intervention program, FreshStart, which compresses the former 16-hour program into 4 hours. Local units train representatives of community organizations to become FreshStart facilitators. In summary, ACS offers a comprehensive smoking control program. ALA, in line with its goal of cleaning up the air, discourages smoking through public policy ac- tivities, public education programs, workshops for professionals, and funding research and communi- ty activities. Local associations provide help to 22 smokers wishing to quit by offering materials, con- sultation, and cessation clinics. In 1975, in collaboration with the American Thoracic Society and the Congress of Lung Associa- tion Staff, ALA launched a project to develop smok- ing cessation programs utilizing self-help, clinic, and mass media approaches. The project took 5 years and included an evaluation of the effective- ness and cost-benefit of the programs. The result was the production of two manuals with a work- book format. The Freedom From Smoking in 20 Days is a systematic day-by-day approach leading to complete cessation on the 16th day with 4 follow- up days to cope with the initial difficulties of quitting. The second manual, A Lifetime of Freedom From Smoking, is designed to be used by the ex-smoker to maintain nonsmoking. (These manuals are discussed further in the self-care sec- tion.) The manuals are also used in a clinic format with the leader offering encouragement and con- sultation and the group providing support. ALA has adapted the manual for use at the worksite, and ALA staff help companies to develop quit programs (see chapter 4 on the worksite). The Canadian Council on Smoking and Health was formed in 1974 at the national level to foster interagency cooperation with one of the priorities being the formation of provincial and local coun- cils on smoking and health 143 The Council cooperates with the national government in pro- moting the Generation program. The Council spon- sors the annual "National Non-Smoking Week" during the last week of January. Weedless Wednes- day is the national nonsmoking day that en- courages the one-day-at-a-time approach to giving up smoking. Public and private health agencies cooperate to make Weedless Wednesday, a media event with many activities organized for that day, including smoking cessation classes. With financ- ing from the Non-Medical Use of Drugs Directorate, Health and Welfare, the Council sponsored a Na- tional Workshop on Smoking Cessation in 1977. Persons in attendance came from voluntary, com- mercial, university, and government programs. Local health departments-notably those in Regina, Tbronto, and Vancouver-have sponsored cessation programs. The 'Ibronto Department of Public Health launched a 20-year program to create an environment in which smoking is socially unac- ceptable. Included in the activities is a TV based cessation program. The Vancouver Health Depart- ment is running a controlled trial of smoking cessa- tion in physicians' offices. The Regina City Health Department operates a withdrawal clinic. The Canadian Cancer Society and the Canadian Federal Government developed the Time to Quit smoking cessation program 144 The program relies on a cognitive-behavioral approach based on the TIMN 293352

health belief model (belief in personal susceptibili- ty). The smoker examines problems connected with quitting and practices strategies for coping with these problems. The program consists of three half-hour television programs, self-help booklets, and a community guide. The program is designed for local implementation with a 2-month publicity blitz prior to the airing of the first televi- sion show. For example, the program was launched in Winnipeg by three voluntary agencies (Mani- toba units of the Cancer Society, Heart Founda- tion, and Lung Association) and the provincial Department of Education Services working through the Interagency Council on Smoking and Health. The project created an awareness of the program and distributed 60,000 self-help packages. The Canadian Heart Foundation and the Cana- dian Lung Association promote a variety of pro- grams intended to build the public's awareness of the benefits of nonsmoking. Local units have spon- sored cessation programs. For example, the On- tario Lung Association offers Countdown, a seven- session, 5-week tapering-off cessation course that consists of both a self-help and clinic program. The Operation Kick-It program is sponsored by the lung association 145 During 1980-81, approximate- ly 1,000 individuals were enrolled in the 8-week Kick It program in Manitoba 146 Educational Techniques It is sometimes difficult to classify smoking methods into a particular category. The problem is even more difficult when trying to distinguish between educational and group methods. Any method that assembles people in some type of group might result in group support. Almost all programs have educational components when they provide some facts about the harmful effects of smoking and the benefits of quitting. Cessation Programs in Schools. In addition to prevention programs, many schools sponsor cessa- tion classes for high school students and adults. Reports of followup results are generally not available. The ACS clinic format was adapted by ACS and the Iowa Department of Education for use as a high school smoking cessation program. Nine sessions emphasize decisionmaking, self-manage- ment skills, and group support activities. A similar teenage clinic is held for high school students in Boston. Followup results are available for two adult ces- sation classes. In Bergen Count}, NJ, 20 percent of 188 adults were abstinent at 1 year after a 4-week course 147 A 10-week class led by a nurse in Davis, CA, with eight students resulted in a 38-percent success rate at a 2-year followup.14a Examples of two widely different school programs follow The Northwest Arctic School District spon- sors a stop-smoking clinic consisting of five. 90-minute sessions held in Mauneluk villages. Home visits are made to native villagers unable to attend the sessions. City College of San Francisco offers an 8-week community education course de- signed to help individuals quit smoking. Materials include tapes on muscular relaxation and aversive smoking. Students receive one unit of credit and may be graded on atteridance, participation, and completing assignments. Colleges and universities also offer withdrawal methods. Merced College, CA, and Michigan State University conduct the ACS FreshStart. The Uni- versity of Iowa sponsors Smokeless, while Solano Community College, CA, offers 3 weeks of hyp- nosis and relaxation. Educational Quit Programs. Educational cessation methods generally consist of lectures by a variety of professionals, films, records of smok- ing, literature, instructions on how to quit, diet in- formation, and answers to questions. Often a smoker's self-test is used or people are paired with a "buddy." TYeatment sessions may conclude within a week but sometimes may be stretched out over 3 months. There may be some discussion, but the approach is didactic, and the conversation is between a participant and the leader. Some educa- tional programs are conducted at hospitals and have the involvement of physicians as leaders. Seriff and Finkelstein offered a stop-smoking clinic at a hospital in Queens, NY.89 The public was invited, and participants were randomly assigned to a treatment or control group of 78 people each. The treatment consisted of four weekly meetings, which included lectures by chest physicians and a pulmonary nurse, questions and answers, and a film on lung cancer. Chronic obstructive pulmonary disease was emphasized, and spiro- metric studies on normal persons and pulmonary patients were compared. The treatment group visited the pulmonary disease intensive care unit. After 1 year, 15 percent of the clinic subjects and 10 percent of the controls were abstinent. Many VA hospitals sponsor cessation clinics. Bailey evaluated a clinic at the Seattle VA Hospital as part of her doctoral dissertation 14s The clinic was led by a nurse practitioner. The followup was only 4 months with 23 percent of 48 subjects abstinent. Dawley et al. invited employees and pa- tients of the New Orleans VA Hospital to participate in an educational program consisting of 10 ses- sions.15o Six subjects who did not complete treat- ment were not followed up. Of 14 smokers, one-half were abstinent. Several hundred other hospitals offer stop smok- ing clinics. Some of them follow the format of the 23 TIMN 293353

ACS, ALA, or Five-Day Plan, but many hospitals use Smokeless or Smoke Stoppers. Eight hospitals with their own clinics are listed in table 2 to il- lustrate the diversity of programs. This material comes from the 1980 National Interagency Coun- cil survey.138 Table 2 Stop-Smokin~ Clinics Offered by 8 ospitals Phoenix Baptist Hospital, Phoenix. Cease Fire-behavior modification and group problem solving; eight cassette tapes and other materials. Cedars-Sinai Medical Center, Los Angeles. Stop-Smoking Clinic-six-session program; materials and films from ACS: films over closed-circuit TV to patients. Community Hospital of San Gabriel, CA. Stop-Smoking Clinic-two nights for 2 weeks; nutrition and exercise discussed; materials from ACS. Mercy Hospital, Miami. Quit-Smoking Program-six-session educational program with behavior change contracts; materials from ACS, ALA, and AHA. Gottlieb Memorial Hospital, Melrose Park, IL. Stop-Smoking Clinic-6 weeks of behavior modification, self-controi. and buddies. Saint John Hospital, Detroit. Want to Quit Smoking-It's Up to You-two programs: individual counseling with behavior modification and educational five-session group. Germantown Hospital, PA. One Way to Stop Smoking- lecture and acupuncture: small surgical clip is inserted in outer ear; clip removed 1 week later. Scott Memorial Hospital, Lawrenceburg, TE. Smoking Cessation-7-week class of values clarification and assertiveness training. The Regina City Health Department, with sup- port from Health and Welfare, Canada, initiated a smoking cessation clinic. Quit for Good, as the pro- gram was called, consisted of a treatment program over 5 days intended to provide insight into mechanisms underlying the smoking habit 151 The Self-7asting Kit was used, relaxation exercises ex- plained, and an attempt made to build group sup- port. As this was also a research study, an exten- sive questionnaire was administered. Out of 166 subjects, 140 were located at the 6-month followup, and 36 percent of them were abstinent. Some industry clinics are educational. An employee program at the Cummins Engine Com- pany in Columbus, IN, consisted of 11 treatment sessions and 4 followup sessions lg2 Lectures, films, and counseling were the attributes of the method. Perhaps because of the length of the program (4 months), the results were good. One-year post- treatment found 55 percent of 33 participants abstinent. Results were validated by carbon monoxide determinations. Another program was conducted over 5 days at the Bell Laboratories.153 The method consisted of lectures, discussibn, videotapes, and a "buddy" system. At 6 months, 30 percent of 81 employees were not smoking. As part of a larger study in Manitoba, Rabkin et al. ran one condition of health education that em- phasized the biological effects of smoking.154 The .24 material was presented In a didactic format with lectures by health professionals. In addition to showing films, NCI's Calling It Quits was distributed. Blood samples were drawn from sub- jects both before and 3 weeks after the program for determination of serum thiocyanate. A 6-month followup revealed that of 25 subjects answering the followup, 36 percent had stopped smoking compared to 30 percent in a hypnosis condition (N=29) and 24 percent in a behavior modification condition (N=34). Table 3 Summary of Followup Quit Rates of 19 Educational Trials Reported 1962-1984 N Range Median Percent 33% 1962-1984 At Least 6-Month Followup 7 13-50 36 71 At Least 1 Year Followup 12 15-55 25 25 1962-1977 At Least 6-Month Followup 3 13-44 33 67 At Least 1-Year Followup 11 15-38 23 18 1978-1984 At Least 6-Month Followup 4 30-50 33 75 At Least 1-Year Followup 1 55 - 100 Table 3 summarizes the quit rates of 19 educa- tional programs. The median quit rate for the 1-year trials was 25 percent with most of the evaluations reported before 1978. Five-Day Plan. In 1960, the Seventh-day Adven- tist Church initiated the Five-Day Plan. The pro- gram remained the same until 1985 when changes were made, which will be detailed below. The program has been widely copied and adapted by professionals and lay persons. Over 14 million smokers have entered this program in over 150 countries. It has been offered in a variety of settings, from prisons to commuter trains, and is available through films. The Five-Day Plan charges a small fee to defray the cost of materials. The program consists of five consecutive 90-minute or 2-hour sessions, with several weekly followup meetings. At the first ses- sion, a film showing surgery on a cancerous lung is usually shown. Cessation is immediate, and cof- fee, tea, cola, and alcohol are also temporarily pro- hibited. Physical fitness, exercise, balanced diets, whole grain breads and cereals, avoidance of saturated fats and highly-spiced foods, vitamins, forced intake of fluids, warm baths, hot and cold showers, body rubs, deep breathing, prayer, and a "buddy system" are encouraged. Sessions dis- cuss the physiological effects of smoking, and actual lung specimens are displayed. Clergymen, psychol- ogists, and physicians present spiritual, mental, or medical lectures and conduct counseling. TIMN 293354

For the first several years there were no followup sessions, but one or two maintenance sessions were added later. When maintenance sessions are held the success rate appears to improve. Very high quit rates are reported when the assessment is on the last night of the program. Schelegel and Kunetsky queried participants 3 days after the last session and found 68 percent reporting nonsmoking155 Six weeks later the quit rate had declined to 46 percent, and at 6 months it was 11 percent 1" The Atlanta Lung Association ran the Five-Day Plan for over 5 years with two differences. There were personal contacts by telephone and a sixth maintenance session on the eighth day.l5' Five clinics ranging in size from 34 to 86 smokers were evaluated in 1976-77. One year later, 34 percent of 325 original smokers were abstinent; 30 partici- pants not located were counted as failures. The Five-Day Plan has been used in occupational programs. One example is a company program in Albuquerque that included employees and spouses and added six maintenance sessions 158 One-fourth of the 118 participants were not smoking at a 1- year followup. 1able 4 Snmmary of Followup Quit Rates of 18 Five-Day Plan Trials Reported 1964-1984 N Range Median Percent 33% 1964-1984 At Least 6-Month Followup 4 11-23 15 0 At Least 1-Year Foilowup 14 16-40 26 21 1964-1975 At Least 6-Month Followup 2 16-23 - 0 At Least 1-Year Followup 9 16-40 21 22 1978-1984 At Least 6-Month Followup 2 11-14 - 0 At Least 1 Year Followup 5 19-34 27 20 There were 11 evaluations of the Five-Day Plan reported prior to 1976, which provided followups of at least 6 months (see table 4). Quit rates ranged from 16 to 40 percent for 1-year followups with the median quit rate being 21 percent. Seven reports since 1977 showed a range of from 11- to 34-per- cent success; the median for 1-year followups was 27-percent abstinence. The General Conference of Seventh-day Adven- tists Health and Temperance Department has revised the Five-Day Plan, renaming it The Breathe-Free Plan to Stop Smoking L59 Three reasons are given for the name change. (1) The old name could not be copyrighted to prevent anyone else from using it. The new name is for the exclusive use of the Adventists. (2) The new plan calls for 8 sessions, making "five-day" illogical. (3). "Breathe- free ' suggests a benefit for stopping smoking. The basic principles of the original plan are retained. Doctor-pastor teams will continue to participate, but other professionals and lay persons may con- duct the plan. New features of The Breathe-Free Plan are an emphasis on motivation and lifestyle modification strategies such as values clarification, visualiza- tion, modeling, affirmation, positive thinking, and rewards. In addition to self-rewards, the following awards are offered: The I Love Being FYee From Smoking! button for 2.4 hours of nonsmoking; a diploma on graduation called B.N.S. (Bachelor of Nonsmoking); a silver seal added to the diploma for attending every session; a gold seal for nonsmoking after the third session; an M.N.S. diploma (Master of Nonsmoking) after 6 months; and lastly, a D.N.S. diploma (Doctorate of Nonsmoking) 12 months after graduating. The eight sessions of the new plan are divided over 3 weeks: two sessions the first week held 48 hours apart, five consecutive sessions the second week, and a final graduation session the third week. Quitting will be by the third session, and en- couraging telephone calls are made 1 week and 3, 6, and 12 months after graduation. Each session includes lectures, discussion, a film, and take- home material. The plan, which is nondenomina- tional, has a strong but optional spiritual em- phasis. The General Conference of Seventh-day Adventists plans to evaluate the program follow- ing the guidelines of the Peer Review Committee on National Smoking Cessation Programs. In-Residence Zlreatment. The St. Helena Health Center has conducted a live-in Five-Day Plan for 15 years. The program is offered monthly through- out the year. Over 4,600 smokers have completed the St. Helena course. The live-in treatment goes far beyond the limited goals of the Five-Day Plan as indicated• by the staff, which consists of an exercise therapist, a dietitian, a physical therapist, a health educator, nurses, and physicians. The fee was recently increased from $995 to $1,195 and covers group sessions, lectures, films, a private room with bath, all meals for 5 days, use of the pool and sauna, a pulmonary function study, consulta- tion with a physician, and weight, tension, physical conditioning, and physical therapy ses- sions. Participants have daily calisthenics, relaxa- tion exercises, steam baths, lectures, and films. Vegetarian food is served; the usual Five-Day Plan prohibition of coffee, tea, colas, and alcohol is in effect, and liberal intake of water and fruit juice is encouraged instead. A large-scale evaluation of the St. Helena pro- gram has recently been completed. Returns from 75 percent of the 636 smokers who attended the program during 1982-1984 show that 86 percent stopped smoking for at least 1 week and 47 percent TIMN 293355 25

claim to have quit for periods of 3 to 39 months.16O The rate for those not smoking at the 1-year followup was 49 percent and at 2 years was 38 per- cent. The rate for those not smoking 1 full year was 30 percent and for those not smoking 2 full years was 22 percent. A previous evaluation of 188 par- ticipants reported in 1973 found that 60 percent were not smoking at the end of the first month; after 6 months and 1 year, the percentages still not smoking were 38 and 35 percent, respectively.l61 Motivation is high among participants because of the investment of 1 week's time plus the fee and travel expenses. It is difficult to conduct maintenance when participants return to their homes. St. Helena mails newsletters to attendees and provides a toll-free telephone number for those who wish to consult with the staff. Withdrawal Clinics and Groups Most withdrawal clinics use the group approach, but there may be vast differences between a group led by a trained leader and one led by a volunteer ex-smoker with no previous group training. There may also be differences between a therapy group that runs 5 consecutive days and one that lasts 6 or 8 weeks. It takes several weeks for group members to get to know each other, become com- fortable in admitting difficulties in quitting, and of- fer support to each other. ACS conducts smoking cessation clinics through its 58 divisions and 3,1001ocal units. The program has been widely used in the community, industry, hospitals, the military, and schools. The Helping Smokers Quit clinics are a mix of an educational and group approach. It is standardized throughout the United States. via use of selected guides, printed materials, and trigger films presented extensively by trained volunteers. Interaction of group mem- bers facilitates personal growth and later reinforces abstinence. A specific session-by-session format is stipulated, though it may be modified somewhat to take advantage of the individual leader's capabilities and the relative sophistication of the clinic participants. The clinic has three phases: first, self-appraisal and insight development; second, practicing abstinence under controlled conditions; and third, a maintenance phase that varies according to the wishes of each participant. Groups meet for eight 2-hour sessions, generally twice weekly. One trig- ger film lasting from 3 to 8 minutes is shown at each session. The films are designed to stimulate discussion and help smokers react to the quitting process. Buddies are chosen during the first phase for ongoing support, and participants are encour- aged to form an IQ (I Quit) Club to reinforce con- tinued nonsmoking. There is very little followup 26 maintenance after smokers have finished the 8-week program. A $25 contribution is requested but not mandatory. From 15 to 20 smokers are ac- commodated in each group; about 30,000 to 40,000 smokers have attended about 2,000 ACS clinics each year. An evaluation of 29 ACS clinics held in the Los Angeles area between 1970-1973 resulted in quit rates of 30 percent at 6 months and 18 percent at 18 months 162 Eighteen of the clinics met in hospitals and churches, and 11 were employee groups. A random sample of 487 of an origina1944 participants were selected for followup and about 73 percent were reached. ACS reported in 1977 that quit rates ranged from 25 to 35 percent at the end of 1 year; when maintenance procedures were in- cluded, the rates were as high as 50 percent 163 Evans and Lane reported on the results of 372 persons who attended nine clinics on Long Island, NY, following the format of ALA and ACS 1B4 Of the 590 original enrollees, 63 percent were located at followup. Half of the enrollees completed the workshops, and 56 percent of the respondents were nonsmokers at the end of treatment. Quit rates ranged from 19 to 29 percent at 1 year with a mean of 25 percent for all clinics; one clinic that ran 5 years showed a quit rate of 36 percent. Lieberman Research, Inc., under contract with ACS, tested how a shorter and more concentrated, clinic would affect quit rates.ls5 Smokers who sought help in quitting smoking were assigned to one of five types of the Quit Smoking Clinic pro- grams: (1) eight 2-hour sessions over a 4-week period (the regular program); (2) four 2-hour ses- sions over a 2-week period; (3) four 1-hour sessions over a 2-week period; (4) one "marathon" 12-hour session; and (5) one 4-hour session. The research was based on 903 smokers who participated in 94 clinics in 32 ACS units in 9 geographically dis- persed ACS divisions. There were 1,213 clinic par- ticipants, and 903 (74 percent) were reached by pro- fessional interviewers by telephone for the 6-month followup. The standard ACS clinic, and the four 2-hour ses- sion format achieved 24 percent abstinence. The four 1-hour session clinic and the marathon group scored 27-percent success, while the one 4-hour session had a 10-percent quit rate. The results in- dicate that three of the four shorter formats were as effective as the standard clinic. There were in- dications that ACS volunteers had difficulty con- ducting the marathon sessions as they were dif- ferent than the regular format and required a con- centrated commitment. Lieberman recommended that ACS explore initiating a shorter format. Acting on the results of the study, ACS developed a new quit-smoking program called FreshStart. The program consists of four 1-hour, small group TIMN 293356

sessions. Reading assignments follow each meeting to help participants keep in mind what has been discussed. The first session provides an under- standing of why people smoke and the effects of smoking. Approaches to quitting are outlined with "cold turkey" recommended. The second session deals with withdrawal symptoms; four counterac- tive behaviors are suggested: drinking a lot of water, sucking stick cinnamon, exercising daily, and deep breathing. Practicing stress management and assertiveness are other suggested activities. The third session handles obstacles such as weight gain. The fourth session includes tips to help the individual stay off cigarettes. Those persons who have not quit are encouraged to try again-on their own or by joining another FreshStart group. In addition to conducting FreshStart groups, ACS trains members of community organizations to become group facilitators. FreshStart graduates are recruited to serve as ex-smoker volunteers to help others quit. Graduates may also serve as facilitators or respondents on the Smokers' Quitline. ALA emphasizes self-help and media approaches but also sponsors a clinic program. Prior to the development of the smoking cessation and maintenance manuals, ALA provided clinic guidelines for local units, but some individual chapters formulated their own methods. The Washington Lung Association has been operating Kick the Idiotic Cigarette Habit in Seattle since 1968. In this 6-session program, participants go "cold turkey" in the first session. UNsmoke is an 8-week group class sponsored by the Lung Associa- tion of Hennepin County, MN. Some 50 visual aids are used during the classes, and nonsmoking status is validated at followup sessions by exhaled carbon monoxide and saliva thiocyanate. The 'Ihberculosis-Christmas Seal Society of British Columbia sponsored its own program called KICK IT. In 1980-1981, the Manitoba Lung Associa- tion enrolled 1,000 smokers in Operation Kick-It. The program consists of eight weekly meetings with a trained volunteer leader who is an ex- smoker. A followup of this program is now under way. Nemzer reported an evaluation of four ALA clinics conducted at three hospitals on Long Island, NY.'66 At the close of the clinic, 70 percent had quit; but 1 year later the success rate had fallen to 20 percent. In 1979, the ALA of Southeastern Michigan developed a 3-hour withdrawal clinic called Cigarette Send-Off.1B7 The approach included hyp- notherapy (suggested therapeutic reeducation), as well as cognitive and behavioral techniques. Chronic respiratory patients and physicians gave presentations, and a film was shown. Public vows to quit and throwing away cigarettes ended the ses- sion. Over 2,000 persons attended the clinics. A 1-year followup of nine clinics showed an average quit rate of 46 percent based on persons reached at followup (N not reported). With the introduction of the manuals, ALA developed a clinic program based on education and behavior modification principles. ALA clinic pro- grams, as well as other methods, were reviewed, and the most effective components were included in the Freedom From Smoking Guide for Clinic Leaders. The clinic program is based on the premise that smoking is a learned habit. Quitting is a process during which individuals must con- sciously unlearn the automatic behavior of smok- ing and substitute new healthy alternatives. Dur- ing the clinic sessions, different techniques are introduced based on principles and methods that help the individual to gain control over his or her behavior. The method offers a systematic approach to cessation aimed at reducing the stress of quitting. ALA sponsored an evaluation of the clinic format comparing three different types of clinics that varied in content and length. The association was interested in finding out whether the maintenance component could be effectively communicated in seven sessions or whether nine sessions were necessary. Quit night was the third session in all the clinics. The three clinics were (1) six sessions over 5 weeks; (2) seven sessions over 7 weeks; and (3) nine sessions over 10 weeks. The seven- and nine-session clinics covered the same topics as the six-session clinic and included a comprehensive maintenance component through the use of the ALA manual, A Lifetime of Freedom From Smoking. The evaluation was carried out in 10 cities start- ing in the spring of 1980188 A total of 547 smokers enrolled in the program and paid a $35 fee each. Enrollees were predominantly white, middle class, well educated, with an average age of 43 years. Quit rates with pipe-cigar smokers and nonresponders counted as failures were as follows: Type of Clinic Initial 6 Months 1 Year 6 Sessions (N=229) 72 16 15 7 Sessions (N=151) 81 25 30 9 Sessions (N=167) 69 21 25 With pipe and cigar smokers counted as nonsmokers and nonresponders omitted, the 1-year results were 18, 34, and 27 percent for 6, 7, and 9 sessions, respectively; thus the 7-session clinic achieved the best results. The overall success rate for the three clinics combined was 22 percent. The overall quit rate for the ALA self-help study was 16 percent at 1 year.169 In terms of cost effectiveness, 27 TIMN 293357

the dollar cost of producing a current nonsmoker was $98 for the 7-session clinic but only $23 for self-help. Based on the results of the evaluation, ALA selected the 7-session clinic for national promo- tion. A Guide for Clinic Leaders was developed to help lung association staff to conduct standardized clinics. A training program was initiated in the form of workshops that have been attended by the staff of most lung associations. In addition to train- ing in how to run a clinic, the workshops cover publicity, promotion, and how to train volunteers and paid leaders to run clinics. A major emphasis of the promotion is to interest major corporations in sponsoring programs that utilize the self-help and clinic modes. (Refer to the worksite chapter for more on company programs.) The American Lung Association is conducting an ongoing evaluation of its clinics following the Guidelines for Group Smoking Cessation Pro- grams.8O Participating lung associations forward followup reports to the national office for computer analysis. Attendance at the ALA clinics at 54 sites in 1983 totaled 1,562 smokers.17O Based on 813 participants, 49 percent stopped smoking at the end of treatment. Nonsmoking prevalence at 12 months was 22 percent based on 964 participants. Persons who did not respond were counted as failures. Rates for 1983 appeared to replicate find- ings for 1981 and 1982; the 1983 clinics, however, had higher upper bounds indicating that the lat- ter clinics did better than the earlier clinics. ALA is continuing to monitor the clinics. Bishop and Fisher used the ALA manuals in a workplace program in Eastern Missouri called Employer Assisted Smoking Elimination (EASE)17O Employees were offered a choice of par- tial help in using Freedom From Smoking in 20 Days or group clinics. Eighteen of 63 smokers chose either partial help consisting of trouble shooting (four meetings over 6 weeks) or a com- prehensive group clinic (nine meetings over 7 weeks); one-third of these smokers abstained at 1 year. Results for two other group clinics were 33-percent success (N = 48) for one group but only 7 percent (N=46) for the other. EASE has been initiated at a number of worksites with employees trained to run the clinics.l'i For many years AHF has run an active cessation program, including such methods as self-help, in- dividual counseling, self-hypnosis, and groups. The 1977 review carried a detailed report of this program.42 Three types of groups had the follow- ing quit rates: 212 subjects who chose the group method-21 percent at 1 year1?2; 173 subjects ran- domly assigned to no-fee groups-32 percent at 5 months173; and 139 subjects assigned to fee groups ($55)-29 percent at 5 months 173 These findings 28 regarding fee and no-fee groups run counter to other data that indicate that the payment of a fee enhances quit rates. For over a thousand smokers who attended AHF groups, the success rate was 26 percent at one year.l" AHF works with corporations to advise them on cessation activities and to train company person- nel to conduct programs. The Health Promotion Service was developed by AHF to focus on the leading causes of death by offering planning, education, screening, intervention, maintenance and followup. Results of one corporate program in Indianapolis are available 175 Cessation groups met weekly during working hours for 6 weeks. Behavior modification was used, but participants were encouraged to develop their own strategies for quitting. Once a smoker quit, he or she was placed in a maintenance program consisting of taped telephone messages, peer support, and telephone followup. Of 131 persons enrolling in the smoking program, 101 attended the first meeting and 33 completed the 6-week course. A 6-month followup found that 9 percent of those attending the first meeting were not smoking. Don Powell used the work he did in Michigan to develop a multicomponent cessation program for industrial groups that was offered by the AHF. The Stop Smoking System consisted of promotional ac- tivities prior to the program, an introductory meeting, four or five consecutive treatment ses- sions one week later, and a followup meeting. The treatment was highly structured and used aversive smoking techniques and workbooks. Powell left AHF and organized his own private company, which will be discussed under commercial pro- grams. AHF has cut back on cessation activities and now makes referrals to other organizations. The Kaiser Foundation Health Plan, the largest prepaid medical group in the United States, has had a continuing interest in helping their members to quit smoking. The Smoking Control Research Project was conducted among Kaiser members in Walnut Creek, CA, from 1964 to 1968176 The methods used were group and in- dividual counseling, tranquilizers, and placebos. Overall, one-third of the subjects stopped initially, but after 1 year the rate declined to 20 percent; in- dividual counseling, however, achieved 31-percent success. Kaiser-Portland participated in the large- scale Multiple Risk Factor Intervention TI; ial in which men at high risk for heart disease were helped to quit smoking and to lower their blood pressure and cholesterol levels. Several other research projects at Kaiser units have dealt with cessation. In 1970, a Stop Smoking Clinic was started at Kaiser-Oakland using the group mode. It was ex- tended to other Kaiser units in the mid-1970's. TIM.N 293358

Kaiser-Los Angeles instituted its own program utilizing behavior modification methods. Many Kaiser units in California offer quit clinics with varying programs. Kaiser-Sacramento currently offers a six-session clinic over 3 weeks followed by 4 weeks of maintenance meetings. The charge is $20 for Kaiser members and $160 for nonmem- bers. Kaiser-Oakland and Kaiser-Santa Clara both run a counseling-educational method of 13 ses- sions over 2 months; Santa Clara also offers a self- help method with three individual counseling ses- sions. Kaiser-Hayward offers a self-directed method with 2 sessions 1 month apart, as well as an 11-session group over 8 weeks. Kaiser-Redwood City sponsors 8 weekly meetings, and Kaiser- Southern California has 15 sessions over 10 weeks. Kaiser physicians prescribe nicotine chewing gum for individual patients who wish to quit. There have been several evaluations of Kaiser clinics. Ghelov reported 1-year quit rates for 1973 to 1975 at Oakland and San Francisco as varying from 41 to 51 percent 1" This was a group support method with 13 meetings over '8 weeks. Par- ticipants who did not answer the followup were counted as smokers. A comprehensive evaluation of 1,128 clients who registered for the group pro- gram in Northern California showed 47-percent abstinence at the 1-year followup.178 A 5-year followup of 426 participants drew responses from 302 persons (71 percent)179 Thirty-one percent had not smoked throughout the 5-year period. Of the 209 who did not initially quit, 25 quit later and did not smoke again; 18 other persons quit several times, but only two of these managed to remain abstinent. Over the 5-year period, 120 of the 302 participants stopped smoking (40 percent). Of 19 persons who registered for group therapy in Los Angeles-Kaiser, only 5 percent remained nonsmokers at 2 years.18O Higher rates were achieved with rapid smoking and covert condition- ing (reported in the behavioral section). Brennan describes an employee stop-smoking clinic sponsored by the Metropolitan Life In- surance Company.181 When the company founded its Center for Health Help in 1979, its first prior- ity was to reduce cardiovascular risk. A stop- smoking program was devised to be provided to employees on their own time but at no cost. Four options were offered to employees, but two-thirds of them chose the group support clinic (two times per week for 6 weeks). The other options were a 4-week "cold turkey" group (chosen by 17 per- cent); a minimal intervention program of four meetings over 3 months (selected by two percent); and a self-quit program (chosen by 13 percent). All abstainers were invited to attend 20-minute maintenance meetings and were supported by telephone calls, encouraging messages, and buddies. Over the 1979-1982 period, 179 employ- ees participated in the program. Unfortunately, all participants were combined in the evaluation. Over the 4-year period, 35 percent of the partici- pants stopped smoking for an entire year with suc- cess in individual years ranging from 29 to 40 percent. Various group and individual cessation pro- grams are offered by public agencies, medical groups, and health plans. A few examples from the 1980 survey of the National Interagency Council follow138 ACS clinics were offered by the Group Health Association of Washington, DC, and the Guam Medical Center. The Ina Healthplan of Los Angeles sponsored a group program, while the Straub Clinic, Honolulu, provided individual counseling. The Health Care Plan Medical Center, West Seneca, NY, offered individual counseling, as well as an ACS clinic. The 1985-86 survey of state and local programs provides several other examples of clinics spon- sored by health plans and medical groups.139 Northcare in Glenview, IL, sponsors a five-session ACS I Quit Clinic. The Rutgers Community Health Plan in New Jersey offers FreshStart, while the Health Maintenance Plan in South Daytona, OH, provides ALA clinics. Marshfield Clinic in Wiscon- sin sponsors both a one-session hypnosis method and a 6-week ALA clinic. The Harvard Community Health Plan offers a 7-week ALA clinic and a 3-week program for pregnant women and their partners. Prucare of Des Plains, IL, provides a gradual reduction approach with behavioral techniques. The Palo Alto Medical Foundation sponsors a 10-session program that includes smoke holding, self-hypnosis, relaxation, and group discussion; nicotine chewing gum may be prescribed. The Group Health Plan of Minneapolis sponsors a 7-week clinic that emphasizes support skills. Three clinics offer the Smokeless program: Carondelet Health Services in Tlxcson; Kootenai Medical Center in Coeur d'Alene, ID; and Group Health Service in Saginaw, MI. State health departments in Connecticut (7-week group model with behavioral techniques) and Massachusetts (two-session self-help) assist local units to establish programs. Examples of county health department programs from the 1980 survey are Pima County, AZ-6- to 8-week support group; Butte County, CA-ACS clinic; Talbot County, MD-individual or group counseling by trained volunteer ex-smokers; and Bergen County, NJ-10-session group over 5 weeks. Examples of county health department programs from the 1985-86 survey follow. Several local health departments in Colorado, Idaho, Tbxas, Minnesota, New Jersey, and Michigan sponsor ALA clinics. County health departments offering FreshStartare' TIMN 293359 29

Santa Barbara, CA; 11-i-County, CO; Dauphin, PA; and six counties in Kansas. Smoke Stoppers is sponsored by the Bartholomew county health department in Columbus, IN. The county health department in Kent, MD, offers the new Breathe Free Plan to Stop Smoking,lg9 while the county health department in Haywood, TX, uses the Five- Day Plan. The county health department in Stanislaus, CA, has its own program of eight ses- sions over 5 weeks using behavioral methods. Evaluations of five large-scale group clinics in foreign countries are available. Success rates were 26 clinics in Israel (N=322)-38 percent at 2 years182; Oscherslaben, Germany (N=742)-54 percent at 6 months183; East Berlin, East Germany (N=850)-15 percent at 1 year'$4; Vienna, Austria (N=1,356)-27 percent at 18 months'85; and France (N =1,000)-36 percent at 1 year.'s6 Four recent evaluations of group counseling by North American investigators show a wide range of success. As part of his doctoral disseration, Flow reported a quit rate of 40 percent at 4 months for 218 subjects 187 Pederson et al. conducted 2 group counseling trials, each with 16 subjects; results showed that no one quit in 1 group, while 19 percent quit in the other at a 6-month followup.188 Hackbarth et al. reported the results of smoking cessation attempts by 478 persons who attended 49 clinics sponsored by 30 institutions in collaboration with the Chicago Lung Association iss The groups were led by lay volunteers; at 1 year, 23 percent were not smoking. The final report was part of a test of self-help books. Glasgow, Schafer, and O'Neil ran 3 sets of groups (N = 14 to 16 subjects) for 8 weeks.S6 At 1 year, the group using Danaher and Lichtensteiri s book97 achieved 43-percent success versus 50 percent for Pomerleau and Pomerleau's book98 and 14 percent for the ACS quit kit. Summary of Group Methods. Evaluation reports are available for 46 group trials of which 31 had at least a 1-year followup, 12 had at least a 6-month followup, and 3 had a 5-month followup. Zbventy-one of the trials were reported in 1978 or thereafter, 20 between 1972 and 1977, and 5 between 1962 and 1967. The earliest evaluations of group therapy and counseling were reported by Lawton in Philadel- phia" and by Schwartz and Dubitzky in Walnut Creek, CA: 46 Although groups differ widely (e.g., psychotherapy, withdrawal clinic, and commercial program), they have the common features of group counseling and support from other participants. The 46 group evaluations ranged from zero- to 71- percent success at followup with a median quit rate of 27 percent, and one-third of the programs achieved at least 33-percent success. The median quit rate for programs prior to 1978, with 1-year followups, was lower than the median quit rate for 30 later programs. Almost two-thirds of the trials with 1-year followups conducted after 1977 achieved 33-percent success. lbble 5 SUMMARY OF FOLLOWUP QUIT RATES OF 46 GROUP TRLAILS Reported 1962-1984 N Range Median Percent 33% 1962-1984 At Least 5-Month Followup 15 0-54 24 20 At Least 1 Year Followup 31 5-71 28 39 1962-1977 At Least 5-Month Followup 5 12-32 21 0 At Least 1 Year Followup 20 5-71 26 25 1978-1984 At Least 6-Month Followup 10 0-54 24 30 At Least 1 Year Followup 11 7-51 36 64 Comment The leading nonprofit organizations offering ces- sation programs (ACS, ALA, and Seventh-day Adventists) signed the 1982 agreement to evaluate their programs according to the Code of Practice Group Evaluation Standards. We should insist that all programs and future research follow the stan- dards. When feasible, self-reports should be validated by biochemical measures. Those studies that use adequate methodology should be given more weight in conclusions about treatments and programs. Although most smokers who quit do it on their own or with minimal advice or support, many smokers who find it difficult to stop smoking seek out and join groups as a way of kicking the habit. Commercial Programs Review of 1elephone Yellow Pages Commercial stop-smoking programs are available in all but a few major cities in the United States. A review of the telephone yellow pages for 1984-1985 of 47 U.S. cities of 300,000 or more pop- ulation (1980 Census) revealed 3851istings under the heading "Smokers' Information and 1Yeat- ment Centers: ' lso A similar review of the same cities for 1976-1977 produced 112 listings. Some programs do not advertise in the yellow pages, so no claim is made that all programs are covered by the survey. Also, there were listings for smoking treatment under the headings "Acupuncture" and "Hypnosis," but these were not included in the study. The review, however, serves as an indication of methods that are available through commercial, professional, or voluntary groups. Only a small TIMN 293360

number of local chapters of the major voluntary associations advertise in the yellow pages, so the nonprofit clinics are underreported in the listings. It was often difficult to ascertain whether some listings were commercial or professional; eight pro- grams were not classified. Table 6 shows the distribution of methods in 11 categories for 1984-85 and 8 years earlier.191 The 47 cities are grouped by size: the 6 very large cities (1 million or greater), the 18 large cities (500,00 to 999,999), and the 23 medium cities (300,000 to 499,999). What is striking about the findings is that commercial programs, which made up about one-half of the listings in the earlier survey, now account for just one-fifth of the listings, although they increased in number from 52 to 83 listings. Hypnosis made up 17 percent of the pro- grams in the first survey but almost a third in the current survey, where it is the most frequent listing, up from 19 to 119 listings. The proportion of all listings that were medical or physician doubled when compared to the earlier study, and the advertisements were placed before nicotine chewing gum was available. A big increase was also shown by acupuncture in the current review. The nonprofit organizations also had proportion- ally more listings in the latter period. The smallest increase in the number of treat- ment centers occurred in the six very largest cities (up 139 percent compared to an increase of 280 percent in the large- and medium-sized cities). The large cities with major Increases in the number of programs offered in the yellow pages are San Fran- cisco-13 in 1976-77 to 22 in 1984-85; Phoenix-4 to 21; San Diego-6 to 16; and Dallas and Minneap- olis-1 to 14; 9 cities with 1 listing in 1976-77 now had 72 listings. In the medium-sized cities, Denver increased from 4 to 17 listings; Seattle 5 to 13; and Oklahoma City 1 to 10. Six cities with no listings in 1976-77 now listed 25 centers, with Albuquerqize now advertising 8 listings. The greatest decline in the proportion of commer- cial programs was in the large cities (decreasing from 54 to 18 percent of the total). While the num- ber of commercial listings increased by only 6 in the large cities, hypnosis went from 8 to 52 listings, psychological from 1 to 18, medical from 4 to 21, and acupuncture from 1 to 15. In the medium cities, there were corresponding increases in the same categories, and although commercial programs doubled in number, the proportion of these pro- grams declined. There were 11 listings by wellness centers and exercise programs in 1984-85. One example is the The New York Health & Racquet Club, which offers the Quitsmoke Program, a five-session group pro- gram (plus one followup session) led by a clinical psychologist. Common concerns about weight gain, withdrawal symptoms, and motivation are covered. The payment is unique, inasmuch as the cost is Table 6 COMPARISON OF YELLOW PAGE LISTIATQrS UNDER "SMOHERS' IIYFORMATION AND TREATMENT CENTERS"1"'1f1 1976-1977 and 1984-1985 Very Large City Large City Medium City Total All Cities (i million and over) (500,000-999,999) (300,OOU-499,999) 1976-1977 1984-1985 1976-1977 19s4-19ss 1976-1977 19s4-19s6 1976-1977 1984-19s6 Type of Listing No. % No. % No. % No. % No. % No. % No. % No. % TOTALS 112 100.0 385 100.0 31 100.0 74 100.0 43 100.0 166 100.0 38 100.0 145 100.0 Commercial 51 45.5 83 21.6 11 35.5 21 28.4 24 55.8 30 18.1 16 42.1 32 22.1 Counseling 3 2.7 9 2.3 3 9.7 2 2.7 0 - 2 1.2 0 - 5 3.4 Hypnosis 19 17.0 119 30.9 5 16.1 18 24.3 8 18.6 52 31.3 6 15.8 49 33.8 Psychologist! Behavioral 9 8.0 38 9.9 3 9.7 8 10.8 1 2.3 18 10.8 5 13.2 12 8.3 Physician/Medical 6 5.4 44 11.4 1 3.2 9 12.2 4 9.3 21 12.7 1 2.6 14 9.7 Acupuncture 3 2.7 29 7.5 0 - 4 5.4 1 2.3 15 9.0 2 5.3 10 6.9 Wellness Center/ Exercise Club 3 2.7 11 2.9 1 3.2 2 2.7 2 4.7 6 3.6 0 - 3 2.1 Seventh-day Adventist 4 3.6 9 2.3 2 6.5 2 2.7 1 2.3 4 2.4 1 2.6 3 2.1 Smokers Dial 4 3.6 3 0.8 1 3.2 1 1.4 0 - 1 0.6 3 7.9 1 0.7 Nonprofit Organization 4 3.6 28 7.3 1 3.2 7 9.4 1 2.3 9 5.4 2 5.3 12 8.3 Referral 0 - 4 1.0 0 - 0 - 0 - 3 1.8 0 - 1 0.7 Unable to Classify 6 5.4 8 2.1 3 9.7 0 - 1 2.3 5 3.0 2 5.3 3 2.1 Note: City populations by 1980 Census. Most telephone books were 1984. some were 1985, and a few were 1983. Charlotte, NC, (medium city with three listings in 1984) was not done in 1976-1977 and so was left out of comparisons. For New York City, Manhattan, Queens, and Brooklyn books were checked with duplicates counted once. For Los Angeles. Central. Western. Northwest, and West Los Angeles books were checked with duplicates counted once. One-half of nonprofit listings were ACS and ALA: the rest were hospitals. 31 T1MN 293361

absorbed by the club; members are required to make a $25 tax-deductible contribution to the American Cancer Society, while nonmembers contribute $95. Some yellow page advertisements carry success claims. In-Control of Honolulu states, "There's No Fee for Our Program Unless you Are Successful. We are the Nation's Most Positive & Effective Pro- gram: " The San Antonio 'IYeatment Center claims, '`85 % First ZYeatment Success: ' Fullife Stop Smoking Center of Columbus, OH, states, "99.8% Verified Success Rate (5 days): ' The Institute of Ap- plied Hypnosis, Buffalo, claims, "Most people are Free From Smoking after 1 session: ' The adver- tisement for the Nicotine Withdrawal Program, a medical clinic in Albuquerque, states, "File with your Medical Insurance." Conclusions that can be drawn from the yellow pages survey are that a variety of professionals are offering to help people quit smoking in a variety of ways and, overall, that commercial programs are less important currently than they were when the last survey was done 8 years ago. Proprietary Methods The three national commercial stop-smoking programs established between 1968 and 1971- Smoke Watchers, SmokEnders, and Schick-are still operating today but with reduced operations. Many other commercial enterprises, however, have gone out of business. Smoke Watchers, the first commercial program, ceased operations nationally in the 1970's after the corporation was the subject of legal action. Several leaders continued the Smoke Watchers method lo- cally (Los Angeles, San Francisco, and San Mateo- Santa Clara). The method is one of slow withdrawal and weekly goals. Smokers attend an open group with new members joining and graduates and drop- outs leaving the group. Wharton has run such a con- tinuous group at Seton Medical Center, Daly City, California, since 1970 and one at French Hospital, San Francisco, since 1977.192 Wharton has charged very low fees: $25 membership fee plus $5 per meeting. In 1985, the membership fee was raised to $45, and in 1986 to $90 plus $10 per meeting. Once a member becomes a nonsmoker, he or she can attend weekly meetings at no charge for main- tenance and support. Smoke Watchers in San Fran- cisco has run groups at major corporations, in- cluding Pacific Bell, Bank of America, Bechtel Corp., Crocker National Bank, and Levi Strauss. The San Mateo-Santa Clara unit began service in 1986 when two former leaders joined together to of- fer the Smoke Watchers method to the community and industry.193 The program appears to be suc- cessful for persons who complete the course, but 32 dropouts is a major problem. A recent group had 17 enrollees, but only 5 completed the program and stopped smoking; 4 of the 5 remained nonsmokers (24 percent of the original 17 enrollees) ls3 Smoke Watchers has been evaluated in four loca- tions. The first, by the company, was based on 56 persons who completed a 12-week program plus 6 maintenance sessions at the Strang Clinic, New York, in 1969.42 The company reported that 84 per- cent were not smoking up to 16 months later. If based on the 77 persons who enrolled, the success rate was 61 percent. Schwartz evaluated three Smoke Watchers sites in 1972194 The followup varied from 4 to 12 months, as some participants continued to attend the meetings for over 6 months after they had stopped smoking; when followed up, they had been out of the group less than a year. Followups were obtained on 258 of 280 participants, and those for whom no result was reported were counted as failures. The quit rates were 38 percent in Glen Rock, New Jersey, (N = 16); 25 percent in Ft. Lauderdale, Florida, (N=55); and 37 percent in Vancouver, B.C., (N=209). A commercial clinic in Canada that followed the Smoke Watchers method was evalauted in 1972 by Wake, Tyas, and Herrick.195 At the end of 12 weeks of treatment, 51 percent were successful, while at 6 months, 21 percent remained abstinent. SmokEnders was organized in New Jersey in 1969 by Jacquelyn Rogers with the assistance of her husband, a dentist. The company ran chapters directly and granted some franchises. In terms of acceptance and marketing, SmokEnders has been the most successful commercial stop-smoking pro- gram. Chapters were established in many U.S. and Canadian cities, as well as overseas (Norway, Eng- land, Sweden, Denmark, Finland, Bermuda, Austral- ia, and South Africa). SmokEnders uses a highly structured, systematic technique that emphasizes positive reinforcement and changing attitudes. The original format consisted of eight weekly meetings with "cut-off day" after the fifth meeting. The last three meetings were intended as reinforcement. All moderators were graduates of the program. SmokEnders also has an active corporate program with groups having been conducted at over 50 companies. SmokEnders was purchased by a group of inves- tors in 1979 who agreed that Jackie Rogers should continue in the management team. In 1983, the investors turned over management to the Compre- hensive Care Corporation (CCC), a health care management firm that owns 15 hospitals and man- ages some units of 130 hospitals.l96 The company concentrates on operating treatment centers for alcoholism and other dependencies. In January 1985, CCC purchased the license to operate SmokEnders in all locations excepting TIMN 293362

where franchises were in existence 196 Mrs. Rogers is no longer associated with the management of SmokEnders, and the national headquarters was shifted from the east coast to Newport Beach, California. CCC attempted to buy back existing franchises. There are still seven operating fran- chises in the United States: San Diego and Bakersfield in California, parts of New England, the States of Iowa and New Mexico, and the cities of Chicago and Pittsburgh. There are four foreign franchises, one each in England, Canada, South Africa, and Mexico. CCC operates with marketing representatives in 121ocations: San Francisco, Oakland, Los Angeles, Newport Beach (California), Houston, Dallas-Ft. Worth, Seattle, Lincoln-Omaha, Washington, DC, Philadelphia, and two in New York City. The main emphasis of SmokEnders is to conduct programs for business and industry and hospitals. Marketing representatives are available to set up programs in any location (except where there is an operating franchise). SmokEnders grants licenses to hospitals that wish to run their own programs. The SmokEnder method has been reduced from 8 to 6 weeks. Quit day is now after the fourth ses- sion so that the last two sessions are smoke-free. The general fee is $295 with the corporate fee and physician-referral fee reduced to $225196-The fee charged in hospitals is $150. An evaluation of 385 successful graduates out of 553 attendees was reported in 1976'g' Only 167 graduates responded to the followup, but it was assumed that those not found had the same suc- cess rates as respondents. The rate reported was 39 percent, but if based on all participants would have been much lower. An evaluation of 30 em- ployees and dependents of a psychiatric institute and medical center in New York City resulted in a 40-percent quit rate at 1 year.198 Hughes reported several company evaluations of SmokEnders.198 In a program at Crown-Zellerbach in Portland, Oregon, 78 percent of the 50 attendees were nonsmokers at a 3-month followup. A review of the records of SmokEnders in 1983 found that of 95,692 attendees, 81 percent graduated (quit), 10 percent dropped out before the fifth meeting, and 9 percent did not quit. A random sample of 25,000 graduates was drawn from the records and sent a followup questionnaire. Sixteen percent responded, and 84 percent reported that they were still nonsmokers. With such a low response rate, no conclusions can be drawn about the effec- tiveness of the program. For a number of years, SmokEnders was the most active commercial enterprise staffing clinics in communities and industry. Rogers attributes the success of SmokEnders to the care given in selecting leaders who have quit smoking through the program 199 Those persons chosen as leaders are articulate and are carefully monitored as to their progress. The Schick Centers for the Control of Smoking started in Seattle in 1971. Centers were opened in a number of cities, and the company invested in television advertising. Schick also invested capital in building centers, and when the public did not respond, Schick closed their Eastern U.S. units; it now serves Seattle, Portland, Dallas-Fort Worth, Houston, Minneapolis, and 19 California locations. The Schick method consists of aversive condition- ing (low-grade shocks and smoke satiation) for 5 days followed by 6 weeks of group meetings that are educational. A company evaluation reported 53-percent abstinence after 1 year based on 6,023 participants who went through the program be- tween 1970 to 1973.42 An evaluation of the Pasadena center for 1973 to 1976 found 57-percen success based on 518 persons who answered the followup out of 923 clients who attended the pro- gram?W In 1983, Powell organized a proprietary organization, the American Institute for Preventive Medicine, to conduct health promotion activities. Smokeless is the name of the cessation program, which the institute has licensed 110 hospitals to use. The institute also works with corporations to implement the -program for employees. The in- stitute charges a fee of,$600 for training the first company employee to conduct the program and $400 for each additional employee trained.zO1 For the fee, the institute conducts a 3-day training seminar and provides a set of materials to each trainee. Additional sets of materials for smokers who at- tend Smokeless cost $30 per set. Once trained, the organization is licensed to run Smokeless. The in- stitute also runs the program directly when re- quested. The charge for the program is from $75 to $150 with the participant's fee set by each com- pany. For example, General Motors paid 75 percent of the program fee for each employee. Powell estimates that about 100,000 smokers have gone through the program. The Smokeless system is designed to enable smokers to quit in 5 days. Attendees meet in a class with as many as 50 people, which is educa- tional, intensive, and highly structured. Use is made of stress management, positive rewards and reinforcements, food management, and negative smoking techniques (see below). Seven attractive pamphlets guide the smoker through the program. At an introductory meeting, participants receive instructions on what they are to do each day prior to the 4-day treatment the following week. Three maintenance sessions are held over the next 2 weeks. Dubren's self-help maintenance messages are transmitted to attendees.2°2 33 TIIVIN 293363

When the method was first developed, its success with 51 subjects who paid a $25 fee and a $30 returnable deposit was evaluated.203 Tvo aversive strategies were used: holding the cigarette awkwardly while puffing and puffing quickly without inhaling. In addition, the ashtray used was full of cigarette litter, the cigarettes were dipped in a bitter tasting solution, a tape recorder made loud noise, and a slide show presented diseased organs and cigarette advertisements. The subjects were divided into three maintenance conditions: a 4-week support group, a telephone contact system between participants, and a no-contact control. At the final session, all subjects received self-help maintenance messages developed by Dubren.202 One-year results, as reported by Powell and McCann, were very high: 65-percent success for the support group and no- contact control and 59 percent for the telephone contact subjects.zo3 Five recent evaluations of Smokeless at the Ford Motor Company showed 1-year quit rates of 64 per- cent (N=36), 50 percent (N=48), 44 percent (N=46), 51 percent (N=51), and 49 percent (N=39).204 Only persons who attended two "skill sessions" and those who answered the followup were included in the results. If noncontacts are in- cluded in the evaluation, the results decline for the first four groups to 61, 44, 43, and 45 percent. In- formation was not available on how many persons started treatment. - Another commercial enterprise that licenses hospitals to use its method is Smoke Stoppers, developed by the National Center for Health Promo- tion, Ann Arbor, Michigan. The program consists of four classes during 1 week, followed by up to three maintenance sessions. Educational and behavior change methods are used, including desensitization. Participants are taught changes in attitude, behavior substitution, stress management, nutritional awareness, and weight control. Fees average $95 to $140. Kramer reports 32- to 40-percent success at 1 year using Smoke Stoppers?O5 Boller, a respiratory therapist, directs a Smoke Stoppers program at St. Clare Hospital, Monroe, Wisconsin; he claims 60-percent success but provides no substantia- tion.206 In-Control of Honolulu provides an eight-session educational program that uses behavioral manage- ment techniques. The course covers motivation, cognitive dissonance, problem solving, and stress management. In-Control offers to implement its pro- gram in hospitals, clinics, and corporations. Comment Outside evaluations of commercial programs are rare. The programs themselves keep records, but quit rates are generally confined to graduates, de- 34 fined as persons who either quit smoking or who complete the entire method. It is instructive to note discrepancies between the claimed success rates of commercial programs and the few independent evaluations that are available. It must be recognized that proprietary programs have a strong incentive to claim high success rates. The best way for a com- mercial group to achieve recognition and acceptance by industry would be to allow its program to be tested by independent evaluators using standards of the Code of Practice, for Smoking Cessation Programs80 and objective verification of self-reports. Keeping a program going requires continual recruitment of smokers motivated to pay a fee for help in quitting. Commercial groups that have been able to penetrate the corporate market or license their program for use by hospitals are the organiza- tions that will be able to survive. The public has not yet insisted on careful objective program evaluations of organizations competing in the marketplace. Our greatest leverage for convincing commercial enter- prises to allow scientific evaluations will be economic with a competitive advantage given to more rigorously evaluated programs. MEDICATION Edmunds began experimenting with lobeline in the early 1900's,2O7•208 and Dorsey developed lobeline sulfate capsules in 1936 to minimize the craving for tobacco and help the patient stop the habit'~O`' Annoying side effects from the sulfate were minimized in 1955 by the addition of antacids to the lobeline sulfate.23O The first smoking clinics that started in Stockholm in 1955 used lobeline as well as other drugs in 10-day treatment regimens, which included lectures, pamphlets, and physician counseling. Two general categories of pharmaceutical agents have been used to help people to quit smoking: agents aimed specifically at overcoming the habit and drugs prescribed to minimize withdrawal symp- toms. Lobeline sulfate has long been the most com- mon smoking substitute. As noted in the self-help section, lobeline products (tablets and lozenges) are sold over-the-counter. Smoking clinics have injected lobeline and dispensed tablets and lozenges alone or in combination with other drugs. The 196941 and 197742 reviews raised serious doubts about the effectiveness of lobeline. In the last 8 years, few clinics have dispensed lobeline. Nicotine chewing gum, which will be examined in the next section, has received a great deal of attention. Examples of drugs prescribed to minimize withdrawal symptoms are meprobamate, intended to counter anxiety, and amphetamine, used to over- come sleepiness. Schwartz and Dubitzky found that meprobamate was ineffective in smoking control TIMN 293364

and that placebos did better in cessation than did meprobamate.211 Schuster, Lucchesi, and Emley tested the effects of d-amphetamine, meprobamate, lobeline, and placebo on the smoking behavior of six subjects who were not trying to quit smoking.212 None of the drugs decreased the amount of smoking by subjects; d-amphetamine increased smoking frequency. Another study of the effects of d-amphetamine on smoking with eight subjects also found an increase in smoking behavor.213 Low et al. studied how 17 light smokers and 6 heavy smokers reacted to d-amphetamine, ephedrine, and placebo.214 Ephedrine was more efficacious than amphetamine at suppressing smoking desires and behavior. Other drugs used in smoking control aim to pre- vent weight gain or fatigue or to promote a relax- ing effect. Drug types include anticholinerics, sedatives, tranquilizers, sympathomimetics, and anticonvulsants. Jarvik and Gritz report that placebo or drug therapy seems to be equally effec- tive in the short run in assisting smokers to quit or reduce their daily cigarette consumption.215 The results of two dozen drug trials are detailed in the comprehensive table and summarized in table 7. There were other cessation drug trials, but the short run success rates were so poor that no followups were conducted. Table 7 SUMMARY OF FOLLOWUP QUIT RATES OF 19 MEDICATION TRIALS Reported 1959-1977 Percent N Range Median 33% At Least 6-Month Followup 7 0-47 18 14 At Least 1 Year Followup 12 6-50 18.5 17 Some of the trials included counseling, lectures, and groups. Although most of the drug trials used careful followup procedures, all were conducted before 1978, and none validated self-reports by biochemical testing. Median quit rates were as follows: 7 lobeline trials-15 percent; 8 trials that combined lobeline with other drugs-22 percent; and 10 nonlobeline drug trials-17.5 percent. The range of success for the drug trials was zero to 50 percent. Four placebo trials had a median quit rate of 20.5 percent. The drug that scored 50-percent success was methylscopolamine; a replication with this drug showed 9-percent success at a 5-year followup. Henningfield claims that mecamylamine offers promise as a cessation treatment for cigarette smoking.216 This drug attenuates the effects of nicotine critical to its potential for producing abuse and is safe at doses that affect cigarette smoking. According to Henningfield, mecamylamine would work with over 5 percent of smokers. A prelimi- nary clinical trial of mecamylamine for the treat- ment of smoking, carried out by Tbnnant and. Tarver, showed reduced tobacco craving in 13 of 14 dependent cigarette smokers tested; half of the subjects stopped smoking within 2 weeks of initia- tion of treatment.217 No long-term followups are available. 'Avo antihypertensive drugs have been men- tioned as easing smokers' cravings for cigarettes. Carruthers has shown that propranolol blocks the peripheral effects of smoking on heart rate and blood pressure.218 In a double-blind clinical trial, Farebrother et al. found no evidence that pro- pranolol helped subjects stop smoking.219 At the end of 8 weeks only 6 subjects had stopped smok- ing out of 73 smokers who entered the trial. Three of the quitters were in the propranolol group, and three were in the placebo group. Clonidine, a drug used to treat high blood pres- sure, has been known to diminish withdrawal symptoms in heroin addicts. Glassman et al. sug- gested that there are similarities in alcohol, drug, and cigarette cravings and studied the effects of clonidine on smokers.22O They found that clonidine significantly reduced withdrawal symptoms and tobacco cravings among abstaining subjects. In a double-blind study, 15 heavy smokers received either clonidine, placebo, or benzodiazepine alprazolam on 3 separate occasions. When receiv- ing clonidine, subjects had less urge to smoke than when receiving placebo. Clonidine and alprazolam suppressed anxiety, tension, irritability, and -"restlessness equally, but clonidine had a greater effect on craving. They state that clonidine eased cigarette cravings by reducing activity in areas of the brain that govern automatic functions of the nervous system, such as signaling the heart to beat and regulating blood pressure. The in- vestigators do not claim that clonidine is a cure for smoking but that it could be used clinically to assist people to stop. None of the drugs tested for smoking cessation worked well. Clonidine might be helpful in quitting and deserves further study. It appears that the only drug that has demonstrated that it can improve success rates in smoking cessation is nicotine chewing gum, which is examined next. NICOTINE CHEWING GUM Because medication as an aid to breaking the smoking habit has shown only limited success (41, 42), Ferno, Lichtneckerts, and Lundgren advanced the idea that since nicotine is the chemical rein- forcer of the smoking habit, it might be possible to develop a product that could substitute for the 35 TIMN 293365

nicotine.z21 Research at Leo Laboratories in Helsing borg, Sweden, under Ferno's direction led to the development of Nicorette. The gum has been avail- able by prescription in Sweden, Great Britain, Ire- land, Austria, Canada, and eight other countries for several years. In Switzerland, Nicorette is sold with- out a prescription. Gritz and Jarvik,222 Russell,273 and Schachter224 support the notion that nicotine is the critical ingredient in smoking dependence. Ferno explains the rationale for nicotine chewing gum as follows: Since nicotine dependence as well as psycho- logical dependence are the two elements of the smoking habit, it appeared logical to provide an alternate source of nicotine to anyone wishing to stop smoking so they would only have to combat their psychological depen- dence. The only acceptable way to administer nicotine seemed to be in a chewing gum vehi- cle. If a chewing gum should be accidentally swallowed, only small and non-toxic amounts of nicotine would be released.... It was found that in order to obtain a uniform release of nicotine from the gum, nicotine could not be incorporated directly into it, so it was necessary to use a nicotine-loaded cation exchange resin instead.225 Early studies showed low success rates with nicotine chewing gum.226 After a carbonate buffer was added to the formulation, results improved. Buf- fering above pH 8.0 greatly facilitates the buccal ab- sorption of nicotine and results in nicotine blood levels resembling those produced by cigarettes.227 Cardiovascular studies showed that smoking a cigarette or chewing Nicorette caused very similar effects.2'8 The differences were a more rapid increase in heart rate and blood pressure after smoking but a more prolonged elevation of these parameters after chewing Nicorette containing 4 mg of nicotine. The 2 mg dose of Nicorette was similar to a cigarette in terms of the time course of the response. (Lando ex- pressed skepticism on this point, see his comment in the summary.) The only dosage approved by the Food and Drug Administration (in January 1984) for marketing in the United States is the 2 mg Nicorette. The majority of smokers are satisfied with 2 mg Nicorette, even though blood nicotine levels are lower than when smoking cigarettes. The reason for this is that the lower nicotine blood level is sufficient to alleviate withdrawal symptoms in the serious quit- ter.229 Side Effects and Contraindications of Nicorette The side effects reported while using Nicorette are related to the nicotine and to gum chewing.229 Nico- 36 tine effects may be local (oral irritation) or systemic; gum chewing may produce local (dental trauma), mechanical (jaw muscle ache), or gastrointestinal effects. Merrell Dow lists the following adverse reactions to Nicorette: excess salivation, insomnia, dizziness, irritability, headache, nonspecific gastro- intestinal distress, eructation, indigestion, nausea, vomiting, mouth or throat soreness, jaw muscle ache, anorexia, and hiccups. Patients are cautioned to chew the gum slowly to self-titrate the nicotine dose to minimize side effects.23° Nicorette is contraindicated in patients who have recently suffered myocardial infarction, patients with life-threatening arrhythmias, patients with severe or worsening angina pectoris, and patients with active temporomandibular joint disease. Nicorette should not be used by women who are or may become pregnant or who are nursing. Nicorette should be used with caution by patients with oral or pharyngeal inflammation or with a history of esophagitis or peptic ulcer.231 Use of Nicorette Nicorette is a prescription drug in the form of a sugar-free chewing gum containing nicotine, ob- tained from the tobacco plant, which is bound to an ion exchange resin to allow for a slow release of nicotine when chewed. The gum is buffered to facilitate absorption of the nicotine in the mouth. Nicorette is marketed in the United States through Merrell Dow Pharmaceuticals, a subsidiary of the Dow Chemical Company, and is available by prescription in 2 mg, square chewing pieces, packaged in boxes of 96 pieces. A box of Nicorette costs the pharmacist $14.21 and is sold for $20; a discount pharmacy may charge less than $20. In some other countries, Nicorette is available in the 4 mg dosage. Merrell Dow distributes a Physician's Quitting Resource Kit for Nicorette and Instructtons for Use. The patient starting on Nicorette is asked to stop smoking and to chew a piece of gum slowly when- ever he or she feels the need to smoke. It takes about 30 minutes to release most of the nicotine from the gum. The instructions state that most peo- ple find that 10 to 12 pieces per day are enough to control the urge to smoke. Not more than 30 pieces of gum should be chewed in any one day. The pa- tient is advised to reduce gradually the number of pieces of gum chewed per day as the urge to smoke fades. The instructions tell the patient not to stop using the gum until one or two pieces of the gum a day satisf)es the craving. The patient is advised not to use the gum for more than 6 months. Use of the gum for 3 months will cost the patient about $225 plus the physician's fees and any costs for a supplementary program or self-help materials. TIMN 293366

McNabb et al.2,3z and Russell'-33 compared blood levels of subjects using Nicorette and cigarettes and demonstrated that the gum produces nicotine levels sufficient to prevent withdrawal symptoms. Schneider and Jarvik studied subjects receiving nicotine gum and placebo gum and found that those using the nicotine gum suffered fewer withdrawal symptoms.z34-2,38 These findings are supported by studies of Hughes et al.237 and West et aL2-38 Hughes et al. found reductions in irritability, anxiety, rest- lessness, impatience, and difficulty concentrating for those receiving nicotine replacement compared to those receiving placebo.23' All three groups of in- vestigators (Schneider, West, and Hughes) contend that nicotine replacement reduces withdrawal symptoms and that nicotine deprivation plays a sig- nificant role in causing these effects. Ferno recommends that "The best treatment should be to increase the patient's motivation, and at the same time to decrease his resistance. Ideally, the nicotine chewing gum should be part of an inte- grated therapy program:'z39 Merrell Dow advises that Nicorette should be regarded as an aid to smok- ing cessation and not as a long-term tobacco substi- tute. Merrell Dow concludes that Nicorette is a safe and effective adjunct to advice and smoking cessa- tion programs in patients who are serious about giv- ing up smoking and in whom nicotine dependence is a major component of their smoking habit. Evaluation of Nicorette liventy-three studies produced 28 trials of Nico- rette by 20 different investigative groups. Four of the groups were from the United States, f ve from England, four from Sweden, and one each from Canada and six European countries. (One 3-month trial is not considered here.) The trials are listed in the comprehensive table and summarized in table 8. Of the 23 studies, 6 had at least 6-month follow- ups and 17 had 1-year followups. One study was re- ported in 1973, one in 1976, six between 1979- 1982, seven in 1983, and eight in 1984-1986. In 14 trials, nicotine chewing gum was the primary meth- od, while in 14 others, the gum was used in con- junction with behavioral treatment, group therapy, counseling, or cessation clinic methods. Nine trials compared nicotine chewing gum to placebo gum, and 12 compared the gum to another cessation method. This impressive amount of testing can be credited to the widespread interest in nicotine chewing gum as an aid to smoking cessation. Before turning to the studies, one troubling aspect of how the followups are reported should be discussed. (The reader can decide how serious this flaw is.) The studies show that while a patient is taking the gum, he or she can refrain from smoking. Considerable relapse is noted when the gum is stopped, and several investigators suggest that the gum may have to be used by some people for 1 year or more.24o In my opinion, as long as the patient is using the gum, he or she is still in treatment, and followups should be conducted posttreatment. It is the stan- dard in smoking cessation evaluation to conduct followups after treatment has ended. The Guide- lines for Research on the Effectiveness of Smoking Cessation Programs assumes that followups are posttreatment79 Withdrawal clinics that conduct programs for 8 to 12 weeks start their followups after the treatment period has ended. Fee and Stewart, who have run clinic programs, began the followup period for their Nicorette trial from the time the gum was no longer provided.'41 From the information reported, all other nicotine chewing gum in- vestigators began their followups at the start of treatment. If a sizable number of patients are still using the gum at 6 months, a 6-month followup rate means a 6-month followup for a few subjects, a 5-month followup for others, a 4-month followup for still others, and so forth. Jarvis et al. reported that 41 percent of their patients were using the gum at 3 months, 21 percent at 6 months, and 12 percent at 1 year.242 Lando et al. found that 21 percent of their patients reported continued gum use at 12 months.m Users.of gum averaged 6.72 pieces per day at 1 week, 6.25 pieces at 3 months, 5.25 pieces at 6 months, and 6.02 pieces at 12 months. For Hjalmarson's subjects, 18 of 31 successes used the gum for 6 months or longer and 3 percent were still using the gum after 2 years.244Raw et al. suggest that nicotine chewing'gum is safer than cigarette smoking,24g so extended use of the gum is not ques- tioned here, only how followups are measured. It should be noted that followups for a single treatment session (e.g., with acupuncture, rapid smoking, hyp- nosis, or physician counseling) are measured from the start of treatment because the start of treatment is also the end of treatment. There is a marked difference between 6-month and 1-year quit rates. The summary table shows that the median quit rate for Nicorette trials declined from 23 percent at 6 months to 11 percent at 1 year. Several examples of quit rates for nicotine chewing gum trials follow, with 6- and 1-year success rates, respectively: Hjalmarson-37 to 29 percent244; Fagerstrom-63 to 49246; Raw et al.-45 to 38245; Schneider et al.-15 to 8 and 48 to 30.24' A 6-month followup rate for Nicorette indicates the percentage who are not smoking but does not necessarily indi- cate success. As in Hjalmarson's study, if 58 percent of the successes were still using gum at 6 months, it is difficult to decide what a 6-month success rate means. A i-year followup rate is the minimum that should be considered in nicotine chewing gum trials, and an 18-month rate would actually report a more accurate 1-year result. 37 TIMN 293367

Nicorette studies were generally well done with almost three-fifths validating followup abstinence by physiological measurements. Placebo comparisons were double-blind, and subjects were randomized to treatments when possible. Nicotine gum trials are grouped in table 8 by whether nicotine chewing gum was the major treatment or was given in con- junction with some other treatment, primarily be- havioral, therapy, or cessation clinic methods. In the discussion that follows, validation will not be noted; the reader can refer to the comprehensive table for validation information. Tab1e 8 SUMMARY OF FOLLOWUP QUIT RATES OF 28 NICOTINE GUM TRIALS Reported 1973-1986 N Range Median Percent 33% Reported 1973-1976 Nicotine Chewing Gum At Least 6-Month Followup 1 24 - 0 At Least 1-Year Followup 1 23 - 0 Reported 1979-1986 Nicotine Chewing Gum At Least 6-Month Follawup 3 17-33 23 33 At Least 1 Year Followup 9 8-38 11 11 Nicotine Chewing Gum and Behavioral 'll-eatment/Therapy At Least 6-Month Followup 3 3-50 5 7 At Least 1 Year Followup 11 12-49 29 36 Placebo Gum At Least 6-Month F°Ilowup 3 5-28 8 0 At Least 1 Year Followup 6 9-21 13.5 0 When nicotine chewing gum was part of another treatment, quit rates were substantially higher. Fagerstrom achieved 63-percent success at 6- months followup and 49 percent at 1 year utilizing psychotherapy with Nicorette patients.246 The pa- tients who were not given the gum, however, also achieved high quit rates (45 and 37 percent at 6 months and 1 year, respectively). High 1-year absti- nence rates were also produced by Hall et al. with nicotine chewing gum plus behavioral treatment (44 percent) and a more modest nicotine chewing gum plus four group sessions (37 percent)248 The be- havioral treatment included aversive smoking, relapse prevention training, and relaxation; behav- ioral treatment alone achieved 28-percent abstinence. Schlegel et al. tested nicotine chewing gum ver- sus no gum with 243 Canadian military volun- teers249. They provided comprehensive treatment (17 sessions) with a therapist for some subjects, minimal treatment (four sessions) for others, and no therapist contact for still others. The subjects with no gum had the higher quit rate at 1 year: 29 per- cent versus 20 percent for nicotine chewing gum 38 subjects. Other 1-year quit rates for trials that in- cluded a supplemental method with nicotine chew- ing gum were as follows: with group therapy-47 percent (Jarvis et al.),'42 29 percent (Hjalmarson),244 and 13 percent (Fee and Stewart)241; and with a clinic-30 percent (Schneider et al.).247 Kunze et al. also used nicotine chewing gum at a cessation clinic (Vienna) and claimed one-third success at 1 year.25O However, the investigators ' reported only results based on the patients who had stopped smoking a year earlier. When the other subjects are added, the quit rate was 12 percent. The first four studies, just mentioned, utilized a placebo condition with the supplemental method; in each case, the nicotine chewing gum subjects had a higher quit rate with two of the differences being significant.242.244 One-year followup trials in which no more than advice, warnings, or booklets were given to nicotine chewing gum subjects had low success rates. The only exception was Raw et al. (38 percent, N = 69) who drew their subjects from a withdrawal clinic and provided six visits during the first month.242 Raw et al. compared their result to a rapid-smoking trial, but this was not a fair comparison as the rapid- smoking study was conducted 2 years earlier. The 1,500 men (60 percent smokers) aboard the H.M.S. Hermes were notified of a smoking cessation trial with nicotine chewing gum.251 The population was young and healthy, and there was an unlimited supply of cheap cigarettes. Of 230 pretrial question- naires, 190 were returned, and 161 men entered the trial. No psychological support was offered. At 3 months and 1 year, 11 percent were abstinent. Soul reports that many of the recidivists thought the gum was a cure and were disappointed after a few days of use. Five of the 18 quitters were chiefs who received peer support. Three 1-year nicotine chewing gum trials with general practice patients and one dispensary study had quit rates between 6 and 10 percent, indicating that without a supplemental treatment, results are low. The British Thoracic Society randomly as- signed 1,550 patients with smoking-related diseases to 4 treatments: (1) verbal advice; (2) advice with booklet; (3) advice with booklet plus nicotine chew- ing gum; and (4) advice with booklet plus placebo gum25z Quit rates for the four treatments at 1 year were 8.9, 8.5, 9.8, and 11.4 percent, respectively, in- dicating that the nicotine gum added very little to abstinence and placebo gum did slightly better. The authors comment that it was possible that the in- structions for the gum use were insufficient even though there were written explanations. Jarvis and Russell criticized this study suggesting that the negative results were due to lack of experience by the English physicians in administering the gum?53 U.S. physicians also lack experience with the gum, and if they do not take the time to instruct patients TIMN 293368

how to use the gum and offer advice and support, results with Nicorette may be disappointing. In another general practice study with a 1-year followup, Russell et al. assigned 1,938 patients to either a nonintervention control, advice plus book- let, or advice, booklet, and an offer of nicotine chewing gum.'5a•255 Some subjects did not wish to quit, and about half of those in the gum group did not try the gum. The results showed a clear advan- tage for those using nicotine chewing gum; at a 1-year followup, proportions not smoking were 4 percent for the groups not assigned to the gum and 9 percent for the gum group. A subgroup who used more than one box of gum achieved 24-percent suc- cess. The authors claim that it is feasible and effective for general practitioners to offer the gum to smokers with minimal instructions as an inter- vention procedure. Lando et al. prqvided typewritten self-help mater- ials to 156 nicotine chewing gum subjects and a factual ACS pamphlet to a contrasting nicotine chewing gum group of 148 subjects.'43 Those who received nicotine chewing gum and the pamphlet scored 22-percent success compared to 19 percent for the nicotine chewing gum plus self-help sub- jects. The authors comment that patients may have been overwhelmed with excessive written content, indicating that the materials could be streamlined and made more attractive. A French study conducted by Clavel et al. com- pared nicotine gum, acupuncture, and controls who received a cigarette case that locked at variable times.256,2s' Nicotine chewing gum was reduced after 2 months and discontinued after 4 months. Originally, 651 smokers were assigned to treat- ments, and those who did not return for followups were considered failures. At 13 months, quit rates showed 8 percent for acupuncture (N=224), 12 per- cent for nicotine chewing gum (N=206), and 3 per- cent for the controls (N=222). Schneider et al. tested dispensing nicotine chew- ing gum without support.247 Thirteen subjects got nicotine chewing gum, and 23 received placebo gum. At 6 months, only 15 percent of the nicotine chewing gum subjects had quit compared to 18 percent for placebo gum subjects. At 1 year, suc- cess rates were 8 percent for nicotine chewing gum subjects and 13 percent for placebo subjects. In the other part of this study, when subjects received support, rates were 30 percent for nicotine subjects and 20 percent for placebo subjects. In a recent study with general practice patients, Jamrozik et al. randomized 200 patients willing to try the gum, assigning them either to nicotine or placebo gum.'58 Twenty-four physicians from six practices participated in the study. All subjects had previously made an unsuccessful attempt to stop smoking, and there was a high prevalence of early disease associated with smoking. At an unan- nounced home visit after 6 months, subjects were interviewed and asked to provide a breath sample for analysis. Seven of 25 who claimed abstinence, were not validated as being nonsmokers. The quit rate for the nicotine chewing gum was 10 percent against 8 percent for the placebo gum. Raw criti- cized this study by pointing out that a sample of 200 was too small to detect a meaningful difference between nicotine chewing gum and the placebo.zse Raw agreed with Jamrozik et al. that results with nicotine chewing gum when it is offered by physi- cians are usually worse than when it is offered in specialized smokers' clinics. Physicians generally lack the knowledge of how best to present the gum as a tool to cessation. Backstrom et al. divided 145 patients into four conditions. Each group received either long-term or short-term treatment with and without nicotine gum.m The long-term treatment consisted of a telephone conversation 7 days after quitting, two visits to the physician's office at 14 and 30 days, and a letter sent after 3 months. Short-term treatment was limited to one visit to the physician's office 2 weeks after quitting. At a 1-year followup, the suc- cess rates were as follows: nicotine chewing gum plus long-term treatment (N=50)-27 percent; nicotine chewing gum plus short-term treatment (N=46)-22 percent; long-term treatment (N=22)- 15 percent; and short-term treatment (N=27)-3 percent. The authors claim that long-term treat- ment was superior to short-term treatment and use of nicotine chewing gum combined with psycho- logical counseling was superior to counseling alone. It is difficult to see how a telephone conversation, two visits to the doctor's office, and a letter can be labeled psychological counseling. Nevertheless, four contacts produced a higher quit rate than did one contact. Killen, Maccoby, and Taylor assigned.64 subjects to either nicotine gum, skills training, or a com- bination of both the gum and the training.261 All subjects received four sessions of aversive smoke holding and skills training. During a maintenance phase, subjects assigned only to the gum attend- ed a 20-minute drop-in clinic, while the other two groups attended therapist-led groups and received cognitive-behavioral skills training. Gum was available for only 7 weeks. At a 10-month followup, 23 percent of the nicotine gum subjects were not smoking compared to 30 and 50 percent for skills training and combination subjects, respectively. The authors pointed out that relapse was relatively high for gum subjects who did not receive the skills training. They contend that comprehensive train- ing may help long-term maintenance. Bourke and Callaghan provided nicotine chewing gum to 23 resistant smokers in Dublin, Ireland.262 39 TIMN 293369

At a 9-month followup, 17 percent were not smok- ing. Results of 6-month followups of nicotine chew- ing gum studies by other investigators were as follows: Malcolm et a1.-23 percent success (N = 70, London)263; Zbomes and Paul-33 percent (N=51, Germany)264; and Puska et al.-35 percent (N=84, Kuopio, Finland).285 Malcolm et al. and Puska et al. compared nicotine chewing gum to a placebo gum; in both cases, the nicotine chewing gum subjects did better. Summary and Comment The studies reviewed indicate that nicotine chew- ing gum can be an effective tool in achieving abstinence from cigarettes if some type of support, counseling, or therapy is provided. A person trying to quit smoking who continues on the gum can usually refrain from smoking. Some people, however, chew the gum and continue to smoke. Gum chewers are advised by the distributor not to smoke. Lando et al. reported that by 12 months, many remaining gum users in their study appeared to be heavily dependent smokers who chewed gum while continuing to smoke cigarettes.243 Blum266 and Feldman'6'' advise doctors to proceed with caution in prescribing nicotine gum. They point out inadequacies in nicotine chewing gum studies. Feldman warns that the gum should not be used indiscriminately, possibly in lieu of an ade- quate support system. Schneider et al. found that subjects who used the gum for very short periods relapsed simultaneous- ly with stopping the gum.247 In Fee and Stewart's trial, the gum was available for just 5 weeks, and the resulting success rate was 13 percent.241 In the Killen et al. study, where gum was used for 7 weeks and behavioral skills training was also provided to nicotine chewing gum subjects, half of them were able to continue nonsmoking for 10 months.z61 Several investigators suggest that if the gum were used for longer time periods, followup quit rates would improve.z45•288 Lando questions the statement that the time course of 2 mg Nicorette is similar to a cigarette.269 He points out that the initial absorption of nicotine from gum is much slower. This both limits the usefulness of Nicorette as a substitute for smoking and suggests the addictive potential of the gum. Pa- tients often have unrealistic expectations of the gum. Also, despite package instructions, users may not chew properly, resulting in an increase in the likelihood of undesirable side effects. Patients must realize that nicotine from gum is absorbed much more slowly and that gum will not duplicate the effects of cigarettes. Fagerstrom has devised an eight-item 7blerance Questionnaire that measures dependence on 40 nicotine.270 Those smokers with high scores have a higher degree of withdrawal symptoms when at- tempting to stop smoking.271 Fagerstrom contends that the more dependent smokers are more likely to be helped by Nicorette as the gum diminishes withdrawal symptoms. He found that the more Nicorette consumed, the less physical response to abstinence. Several other studies have also shown that nicotine chewing gum is more helpful in smok- ing cessation in subjects who register as highly dependent on nicotine.248•2'2-2'a Jarvik and Schneider found that of those with low dependence scores, 30 percent of the placebo versus none of the active gum group remained abstinent.272 Among the highly dependent smokers, only 8 percent of those receiving placebo compared with 41 percent of those receiving active gum remained abstinent. Hall et al. measured nicotine dependence by blood cotinine levels and found that those with high cotinines were more likely to be helped by nicotine gum.246 These data suggest that Nicorette use may be counterproductive for less dependent smokers. Many investigators emphasize that it is necessary to provide supplemental cessation methods along with nicotine chewing gum use,239°281,2'4and prac- titioners agree. For example, Carter275 and Pom- rehn276 state that nicotine chewing gum may be ef- fective as an aid to quitting in special settings such as smokers' clinics, but when it is used in general practice, the results are less certain. The trials that included behavioral treatment or therapy showed higher quit rates at followup than did the trials that only dispensed Nicorette. Killen et a1.261 and Hall et al.248 demonstrated that training in coping skills boosts success rates. Investigators skilled in smok- ing cessation techniques achieve higher quit rates. For example, Fagerstrom scored 49-percent success at 1 year with subjects assigned to nicotine gum plus psychotherapy; with psychotherapy alone, the rate was still high (37 percent).24B Russell and Jar- vis contend that nicotine chewing gum is suitable for use as an adjunct both to intense psychological methods of treatment and to minimal and largely self-help types of intervention.277 When Nicorette is used in general practice set- tings, the quit rate at 1 year ranges from 6 to 10 per- cent. Several researchers leveled criticism at these trials, contending that the physicians were unskilled in dispensing the gum or that their instructions were not adequate. Realistically, U.S. physicians in practice settings tend to have little or no experience with Nicorette. Yet unless physicians offer support and counseling to patients, results with Nicorette are likely to be low. On the other hand, when the gum is dispensed by experienced practitioners who pro- vide careful instructions for gum use, at smoking clinics, or in conjunction with therapy or skills train- ing, results can be expected to be good. .rIMN 293370

Grabowski and Hall state that the critical deter- minants of successful use of nicotine chewing gum are related to whether the gum is used as a'`phar- macological adjunct" in conjunction with appropri- ate behavioral intervention techniques and environ- mental influences.278 In the short term, Nicorette increases success rates by enabling more smokers to stop initially. In motivated patients, use of Nicorette decreases the urge to smoke. When compared to placebo gum, Nicorette showed no clear advantage when the com- parison was gum alone or with minimal advice and warnings. It is also the case that Nicorette proved effective relative to a placebo more often as a treat- ment adjunct than as the sole treatment. Once the gum is discontinued, many patients return to smoking. How long smokers should use the gum is yet to be determined. What is known is that longer use of nicotine chewing gum (6 months to 1 year) improves quit rates. Extended gum use raises the question of addiction to the gum, since its use does not necessarily assist in diminishing the chemical dependency. Hjalmarson reported that 3 percent of her subjects developed a long-term dependence on Nicorette and were still using gum aiter 2 years.244 In the study done by Raw et al., of 54 subjects who chewed nicotine chewing gum for at least 1 month, 6 (11 percent) were chewing the gum at 1 year and 2 (4 percent) were still chewing gum at 18 months.245 A letter to the British Medical Journal reported that a 59-year-old businessman had consumed an average of 16 pieces of nicotine chewing gum per day over a period of 2 years.279 Ef- forts to reduce his consumption had failed, and he underwent hypnotherapy in an effort to cure him of his addiction to the gum. Although the health risks, particularly pulmonary problems, are greater from cigarettes than gum, there are some disadvan- tages to chewing the gum. Hughes et al. conducted a series of studies that examined self-administration of nicotine among ex- smokers given concurrent access to nicotine and placebo gums during the first 2 weeks of abstinence.'w They found that oral nicotine can serve as a reinforcer in humans and that instruc- tions can control the ability of nicotine to serve as a reinforcer. In addition, they concluded that in- structions can control abuse liability and therapeutic efficacy of a drug. The implications of these findings are that dispensers of nicotine chew- ing gum should provide clear and carefully worded instructions for gum use. Two ways of administering nicotine, other than gum, are being explored. Russell and his colleagues reported the testing of a nasal nicotine solution that might prove useful as an aid to giving up smok- ing.za1.zsz The nasal nicotine solution provides more rapid and efficient absorption of nicotine than does nicotine chewing gum. The investigators point out that nasal nicotine solution might be particular- ly useful for smokers for whom gum is less suitable due to dentures or peptic ulcers or for those persons who experience certain side effects from the gum. Considerable variability was noted with nasal nicotine solution, indicating that more efficient ad- ministration techniques are needed before benefits from nasal nicotine solution can be obtained. Rose et al. are experimenting with transdermally applied nicotine as a smoking reduction and cessa- tion aid283•2,84They applied nicotine topically to the skin of an adult nonsmoker and detected a signifi- cant level of nicotine in his saliva for up to 2 hours.283 In a second study with 10 smokers, nicotine ad- ministered transdermally reduced cigarette craving with relatively few adverse side effects.'841ransder- mal nicotine significantly increased saliva nicotine levels within 30 minutes after application. The authors suggest that the technique may be preferable to others in preventing cigarette craving usually observed after smoking cessation. Concluding Comment For Nicorette trials to gain credibility and com- parability, it is necessary for Nicorette investigators to do further followups to ascertain if their subjects remained abstinent after discontinuing the gum. Only one trial measured followup results after gum use was discontinued. All other nicotine chewing gum trials started their followup period when treat- ment was begun. Investigators of nicotine chewing gum studies should present data indicating the number of months subjects have been free of cigarettes and the gum. Results should be shown separately for subjects free of the gum and for those still using the gum. This is the only way to assess how effective Nicorette is in helping people to stop smoking and wean themselves of its addictive chemical, nicotine, on a long-term basis. Nicorette provides the physician with a product that he or she can prescribe for patients willing to stop smoking. The availability of Nicorette should encourage more physicians to advise and counsel patients about quitting smoking. Strong physician advice about quitting could improve long-term suc- cess rates. Physicians will have to use care to in- struct patients in the proper use of Nicorette. NCI is funding five projects that are using nicotine chew- ing gum as an intervention 137 Best is studying the effectiveness of compliance-enhancement tech- niques, reactions to gum use, relapse, and variations in physician instructions and compliance. Hughes and Miller raise two unknowns about nicotine chewing gum: whether the gum will be ef- fective in general practice and to whom it should be prescribed.285 They state that since smokers seen 41 TIMN 293371

in general practice appear to be less dependent on nicotine than smokers seen in smoking clinics, the gum may be less effective in general practice. They question whether the gum should be prescribed for all smokers, just for those willing to quit, or just for persons who appear to be dependent on nicotine. In my opinion, the gum should be offered to all smokers who do not fit the contraindication exclu- sions. But the prescription should be written only for those smokers who are highly motivated to try quitting and who understand how the gum should be used. The physician has an obligation to provide counseling and support or to refer the patient to a source where such support is available. For those smokers who are addicted to nicotine, the gum will help them to alleviate withdrawal symptoms. These people still will have to contend with the psychosocial aspects of quitting. Smoking clinics, extended counseling, therapy, or behavioral treatment can help the smoker to handle these aspects of the quitting process. Additional research remains to be done to deter- mine optimal protocols for gum dose, duration, and weaning. Research also is needed on instructions that should be provided to physicians and patients. A great deal of research on using gum is now under way. We should expect to see a good deal more in- formation on nicotine chewing gum in the near future. HYPNOSIS The popularity of hypnosis as a smoking cessa- tion method is suggested by the survey of the telephone yellow pages, which found that hypnosis was the most frequently advertised method (see table 6). In 1976-77, only 19 hypnosis listings for smoking treatment appeared in telephone books for cities of 300,000 or more population. In the 1984-85 survey, there were 119 hypnosis listings for smok- ing treatment, almost a third of all listings, and 36 more than that listed for commercial programs. Reports regarding the effectiveness of hypnosis as a smoking cure are contradictory. Evaluative reviews of the hypnosis literature were provided by Schwartz and Rider in 1977,42 Schwartz in 1979?86 Holroyd in 1980,287 Simon and Salzberg in 1982,m Wadden and Anderton in 1982,289 and Agee in 1983.2,90 Johnston and Donoghue reviewed the hyp- nosis literature in 1971, but at that time, there were only a few evaluations.291 They found little evidence that the use of hypnosis as a smoking treatment was effective. Numerous accounts describe the use of hypnosis with small numbers of patients, but only a limited number of reports are based on followup data or state whether patients actually quit smoking. Some hypnotists claim good results based on estimates 42 or faulty evaluations. Schubert studied hypnosis as part of his doctoral dissertation and concluded that it was impossible to make any valid conclusions about whether hypnosis was effective as a smok- ing treatment because of methodological deficien- cies in the evaluations of hypnosis.292 Cohen minimizes the utility of hypnosis as a smoking cessation method.293 He points out that success rates claimed by therapists are biased since followups are haphazard and long-term results are lacking. He states that even hypnotists who have successfully treated other types of disorders have found the technique to be ineffective with smokers. It is not a method that can reach large numbers of smokers. Nevertheless, hypnosis can help some smokers to quit, particularly those persons who have tried other methods and need intensive in- dividual attention to succeed. Orne provides a thoughtful critique of the use of hypnosis to help people to stop smoking.294 He em- phasized that although hypnosis is not a potent means of controlling behavior, it is uniquely effec- tive in helping individuals to do what they want to do. The patient must assume responsibility for changing his own behavior and must recognize that failure can only be blamed on himself or herself, not on the therapist. Orne raised several problems with hypnosis and smoking studies, and Katz pointed out that it was difficult to evaluate the effectiveness of hypnosis as a treatment for smok- ing because of insufficient data about procedures and results.29g Orne noted that at least one result was so good "as to strain the credulity of the reader."294 Simon and Salzberg described five approaches to hypnotic procedures: giving smokers direct sug- gestions to change; hypnosis to alter the smoker's perceptions with regard to addictive behavior; hypnotherapy-use of hypnosis as an adjunct to verbal psychotherapy; hypnoaversion-use of hyp- nosis to help the patient develop aversion to addic- tive behavior substances; and self-hypnosis-used as an adjunct to supplement hypnotic treatment 288 It should be noted that most hypnosis methods in- clude behavioral adjuncts such as imagery, sugges- tions, desensitization, self-relaxation, aversive methods, positive and negative reinforcement, substitute behavior, inconvenience ploys, and counseling. Hypnosis studies will be examined in three categories as suggested by Agee: individual treat- ment with a single session; individual treatment with multiple sessions; and group treatment.2so None of the evaluations of hypnosis trials were validated by physiological measurements. All results are based on self-reports. Therefore, the reader should use caution in interpreting these results. In evaluation, more credence should be TIMN 293372

given to interventions that validate their results. In the discussion that follows, seven studies that had only 3-month followups are not reviewed, but they are listed in the comprehensive table. Single Individual Session Moses was the first to report the use of a single hypnosis treatment for smoking,296 but Spiegel's work popularized the single treatment method for smoking.297 Spiegel teaches his patients to hyp- notize themselves. He provides one session of psychotherapy reinforced by hypnosis. The patient, instructed to utilize the technique 3 to 10 times per day, then continues by himself. Spiegel maintains that hypnosis alone is not a deterrent to continued smoking, but 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 for the body and instructs the patient in self-meditation. Spiegel claims that this state of concentration or self- hypnosis increases the patient's receptivity to his or her own thoughts and helps to imprint the new point of view-a commitment to his or her own well-being-which gives the patient the power to give up smoking. Spiegel conducted a mail followup with 616 pa- tients who had the single hypnosis treatment.298 Forty-four percent returned the questionnaire, and of these 55 percent had quit; all but 10 percent had stopped smoking at some time. Spiegel counted nonrespondents as failures and reported his initial results as 20 percent successful based on all sub- jects. A later followup by Spiegel found 35 percent of the subjects had stopped smoking for 1 year.z99 Prior to 1978, there were three other evaluations of single-session self-hypnosis treatment for smok- ing 1'z.296 The quit rate varied from 12 to 18 per- cent. Three evaluations of single-session treatment with 6-month followups are available after 1977. Most hypnotists teaching self-hypnosis followed Spiegel's method, but some therapists made a few changes. Berkowitz et al. tried self-hypnosis with 40 patients, of whom 25 percent quit 3O° Their method consisted of taking a brief history, apply- ing the Hypnotic Induction Profile, inducing a hyp- notic trance, and confronting the subject with the knowledge that smoking is harmful. The patient was instructed to repeat the self-hypnotic exercise 10 times per day. Stanton included in his single-session treatment the following: the establishment of a favorable men- tal set on the part of the patient; a hypnotic induc- tion; ego enhancing suggestions; specific sugges- tions directed toward the cessation of smoking; an adaption of the "red balloon" visualization; and success visualization.3o1 Of 75 patients, 45 percent were abstinent 6 months later after a single session of treatment. Rabkin et al. followed Spiegel's method of self-hypnosis with 38 subjects154 Twenty- nine subjects answered the followup with 30 per- cent claiming abstinence; based on all subjects, the result was 24-percent success. Rabkin et al. also tested a health education method and a behavioral method; results were about the same as that recorded for hypnosis. Multiple Individual Sessions Prior to 1978, there were seven hypnosis trials of individual treatment utilizing multiple sessions. The results varied from 13 to 68 percent at followup. Miller claimed to have achieved a 68-percent quit rate after 1 year with 1,000 patients he hypno- tized.302 He did not state how he did his followup, whom he selected to follow, how many patients did not answer, or whether he followed scientific evalua- tion procedures. His technique consisted of giving strong suggestions that the patient experience a previous nauseous episode while tasting or inhal- ing cigarettes. Z3-eatment was administered weekly for 4 to 6 months depending on the patient's progress and then bimonthly and monthly. Another high 1-year result was reported by Hall and Crasilneck who provided 4 hypnotic sessions to 75 highly motivated patients who were referred by other physicians.303 Three consecutive daily ses- sions and a fourth session 1 month later included nonhypnotic techniques. They employed a direct suggestion approach telling their patients that they would be relatively free from excessive desire for tobacco. Patients were asked to call the office every day during the month between the third and fourth session. Patients who regressed were offered addi- tional sessions. The followup was based on 67 returns of whom 64 percent claimed abstinence; if based on all subjects, 57 percent were successful. The other two multiple session trials with 1-year follawups completed before 1978 reported quit rates of 13 percent (Fee)304 and 18 percent (Orr) 3O5 In Orr's treatment of 195 patients, he provided an unlimited number of 15-minute sessions that included sugges- tions that the patient would no longer enjoy smok- ing.305 There were three trials with 6-month followups prior to 1978. 'livo were by Nuland and Field with an unlimited number of sessions.306 In the first trial, 25 percent of 97 patients were successful. They hypnotized a second group of 84 smokers but in- cluded several additional procedures; this time, 60 percent quit. Their method consisted of feeding back to the patient his or her own reasons for quit- ting, maintaining contact with the patient by telephone, using meditation during hypnosis to 43 TIMN 293373

obtain individual motives, and self-hypnosis. The in- dividualized aspect of the method may account for the better results. The other trial was by Watkins with 48 college students.307 She also used an in- dividualized approach and included relaxation, con- centration, and self-hypnosis. 11reatment lasted 4 weeks, and one-half of the students quit smoking. There has only been one report after 1977 of in- dividual hypnosis with multiple sessions that had a long-term followup. Sheehan and Surman pro- vided individual hypnosis to 100 patients and found 21 percent were abstinent at a 15-month followup.308 There were three trials of individual hypnosis with multiple sessions after 1977 with 6-month followups. Results varied widely: Powell reported 17 percent with 23 subjects,3O`' MacHovec and Man reported 50 percent with 12 subjects,s'o and none of Wilmot's 40 subjects in two hypnosis trials were completely abstinent.311 (Ziwo recent studies utilizing hypnosis are described in the worksite chapter.) Powell provided two sessions but added a flooding and hypnotic desensitization technique for the recidivists.3O9 MacHovec and Man compared in- dividual and group hypnosis to acupuncture with the hypnosis treatments coming out better.31o They offered three sessions and included aversive sugges- tions and progressive relaxation. Wilmot randomly assigned 40 subjects to two hypnotic strategies.311 The first treatment utilized individualized imageries and suggestions designed to capitalize on the sub- ject's personal motivations. The second treatment sought to bring the urge to smoke under the sub- ject's control and to desensitize the smoker to the desire for tobacco with a modified version of Kline's group procedure.312 Each condition involved four 1-hour individual treatment sessions on a biweekly basis. Group Hypnosis In all, there were 12 trials of group hypnosis with six of them contributed by Pederson, Scrimgeour, and Lefcoe. In their first study in 1975, they random- ly assigned 48 volunteers to three conditions: group counseling plus one session of group hypnosis; group counseling; and waiting-list control.313 After the 6-week treatment period, groups met monthly for 6 months. Followup showed that hypnosis plus counseling achieved 50-percent success at the end of 10 months, while no one quit in the counseling alone group, and 13 percent of the controls quit. One of the investigators provided a single group hypnosis session to patients wishing to quit smoking. An evaluation after 8 to 12 months revealed that only 8 percent of 50 people had remained off smoking.s13 Group hypnosis, therefore, when combined with counseling and followup maintenance support pro- 44 duced good results, but hypnosis alone or counsel- ing alone were not successful approaches. In a second study, Pederson et al. attempted to replicate their own hypnosis plus counseling results.314 Forty-nine volunteers were assigned to three treatments lasting 6 weeks each. Group hyp- nosis was part of one session. It consisted of a presentation of reasons for quitting, benefits of con- tinuing abstinence, and techniques for coping with withdrawal. In the counseling group, these items were discussed. Results for 1 month and 6 months, respectively, were as follows: one session of group hypnosis plus counseling, 65- and 53-percent suc- cess; a similar treatment with the hypnotherapy ses- sion presented on videotape, 38 and 19 percent; and a relaxation-hypnosis session plus counseling, 19 and 13 percent. The result for the counseling group was 18 percent at 6 months. In their third study of group hypnosis, Pederson and her colleagues tested the difference between hypnosis and rapid smoking.315 There were three conditions, all of them providing group counseling. In the group with hypnosis (N = 9), 56 percent had quit at 6 months; the rapid-smoking group (N=38) had 38-percent success; and in the combined hyp- nosis plus rapid smoking, only 13 percent were abstinent. The following can be concluded from these well- done trials by Pederson and her Canadian col- leagues. The presence of the hypnotherapist is essential to the relative success of the hypnosis plus counseling condition as use of videotape instead produced a markedly lower success rate. The presence of the hypnotherapist was not sufficient to aid in treatment as the specific content of the hyp- nosis session with reference to quitting smoking is also needed. As a treatment condition, groups alone or hypnosis alone did not do well; but in combina- tion, they produced excellent results, which were replicated by the Canadian investigators. Ap- parently, one must be careful not to combine too much into one method as the addition of either rapid smoking or relaxation to the hypnosis-group combination reduced the results drastically. The group treatment appeared to be a more important aspect of the method than did the hypnosis treat- ment, but hypnosis did enhance the overall results. Groups may have been more important because the groups were held over a period of 6 weeks, whereas the hypnosis treatment occurred only once. One wonders if hypnosis might not have contributed more to the overall results if the number of hypnosis treatments were increased. Groups, however, are more cost-effective as they can be led by less expen- sive personnel and serve more clients at once. The best result for hypnosis was reported in 1970 by Kline based on a 12-hour marathon group hyp- nosis session 312 He treated 60 smokers in groups TIMN 293374

of 10 with each patient being hypnotized individual- ly for 15 minutes. The method included relaxation, imagery, and self-hypnosis. Kline claimed a success rate of 88 percent at a 1-year followup. There were two other group trials prior to 1978. Barkley et al. reported 25-percent success at a 9-month followup with eight subjects who went through seven ses- sions that included suggestions and relaxation 316 Sanders ran 4 sessions of group hypnosis, imagery, and self-hypnosis with 19 subjects.317 At a 10-month followup, 68 percent reported they were non- smokers. 'liwo reports are based on the results of the Damon Smoking Control Program of Oklahoma City. The method consisted of a single group hyp- notherapy session supported by cassette tapes made available as a reinforcement tool. It is not known if the reports overlapped in terms of sub- jects. At followups 6 to 9 months after treatment, 28 percent of 468 clients had quit318; and at 1 year, 14 percent of 783 clients remained nonsmokers.319 The authors reported that only 14 percent of those who quit used the tapes. They concluded that additional sessions might increase the quit rate.318 The final study was by MacHovec and Man who reported 50-percent success with individual hyp- nosis.31o Their group hypnosis consisted of three sessions with aversive suggestions and progressive relaxation. At 6 months, 40 percent of 10 subjects were not smoking. Aspects of Hypnotic Treatment There appears to be little standardization in the field except for those practitioners who follow Spiegel's single-treatment method. Many hypnotists utilize suggestions, imagery, relaxation, and self- hypnosis to supplement their treatment. Some hyp- notists use desensitization, meditation, nicotine fading, concentration, exercise, counseling, psychotherapy, or educational techniques. Wadden and Anderton state that ... hypnosis covers such a variety of theoretical assumptions and clinical tech- niques that it has lost its descriptive value. . .. Frequently, investigators fail to describe therapeutic techniques in sufficient detail to differentiate a hypnotic treatment from a cognitive-behavioral intervention, except in name alone.320 Several descriptions of various aspects of hypnosis treatment for smoking follow. The reader is referred to earlier descriptions of hypnosis treatment, par- ticularly Stanton's single-session method3O1 and Simon and Salzberg's outline of hypnotic pro- eedures.2as Ewin described a three-part program of hypnosis to control the smoking habit.321 Hypnosis is used to remove or restructure subconscious ideas and at- titudes that prevent success. The nicotine withdrawal effect is reduced by switching for 2 weeks to the lowest nicotine cigarette available. The smoking habit is finally ended by hypnotic sugges- tion augmented by a cassette tape to be used daily at home. A substantial part of the first session is devoted to development of a personal history in which patients usually describe their rationaliza- tions, expose their defenses, and reveal the sub- conscious attitudes that.prevent them from giving up smoking. In the third part of the program, pa- tients are reminded that they are free to choose to smoke whenever they have an urge to smoke. The cassette tape reviews their own reasons for stopping (stated during hypnosis) and emphasizes their im- portance as people and the pleasure they will have in getting well. Sanders described the use of mutual group hyp- nosis as an environment in which to carry out a problem-solving, quit-smoking program.317 He stated that hypnosis provides a relaxed milieu, heightens imagery, and intensifies concentration. Specific techniques used include brainstorming about reasons for wanting to be a nonsmoker; thinking about time progression and imagery to consider the possibility of change in the future; and spontaneous dreaming to monitor motivation and rehearse imagery associated with self-control and choice. Sanders added that mutual hypnosis is used to provide social support and feedback to group members. The use of posthypnotic suggestion for the elimination of smoking is described by Cox.szz Punishment in the form of various degrees of nausea and headache can be suggested by the therapist each time the patient purchases, lights, or smokes a cigarette. Positive reinforcement is sug- gested by the feeling of relaxation, heightened self- worth and power, and symptomatic relief of nausea and headaches when deciding not to purchase or smoke a cigarette. The model must be individual- ized and take into account specific psychosocial fac- tors influencing smoking behavior. The patient must be fully informed and involved in the therapy as much as possible because the higher the level of patient expectation, the more likely the desired result will occur. Cox provides a tape recording of a therapy session to be played between sessions as reinforcement. Wollman involves the five senses in hypnosis treatment.323 He states that the prime requisite for overcoming the smoking habit is strong motivation. 'lb achieve a greater recognition of the problem, the patient is made aware of the need to protect his or her own body. The patient's attention is directed to each sense (e.g., the odor of cigarettes is unpleasant, the taste is unpleasant, and the feel of a cigarette 45 TIMN 293375

is harsh and coarse). The patient is reminded that he or she is hearing from the therapist that all these sensations will tend to help him or her to control this noxious habit. Spiegel has added some theoretical concepts regarding who does well with hypnosis. He stated that patients with high transcapacity (high hypnotic induction profile) have high immediate quitting rates (up to 80 percent) but also have very high recidivist rates.324 Those who stay off appear to have encouraging families supporting their efforts to quit. Persons with low transcapacity have lower rates of initial quitting (about 40 percent); however, these people are more independent and more frequently can remain off smoking (lower recidivist rates) without extra support. West states that about 10 percent of subjects can achieve a deep trance when hypnotized, and 90 per- cent of these people will be able to abstain from smoking for 1 year.325 Another 10 percent cannot be hypnotized, and only 5 percent (or fewer) of these persons will be able to quit through hypnosis. For those who fall into light hypnosis (about half the subjects), about 40 percent will succeed in quitting, and of those who can be hypnotized to a moderate depth, 70 percent will become abstinent. Frankel and Orne found that 30 percent of smokers present- ing themselves for hypnosis treatment were not hyp- notizable,326 but Crasilneck and Hall claim that their success with hypnosis in smoking control is relative- ly independent of depth of trance.327 Mott contends that there is a lack of a relationship between hyp- notic susceptibility and smoking reduction.328 Orne concluded that there are at least two major components involved in the hypnotherapeutic treat- ment of smoking.'94 The first is a specific effect of hypnotic suggestion leading to an immediate, non- traumatic cessation-with a high rate of recidivism after a single session. The second component deals with nonspecific effects that involve the mystique of hypnosis but do not require the patient to be respon- sive to hypnosis. These effects, best conceptualized as a placebo response, can nonetheless be remarkably effective in bringing about long-term changes in smoking behavior. Rabkin et al. support Orne's conclusion 154 They point out that several factors may play a role in hyp- nosis treatment for smoking. While the patient is in a hypnotic trance, suggestions may change un- conscious forces that are operative in maintaining the addictive nature of the smoking. Also, the smoker's expectations are influenced by the magic of hypnosis and beliefs about the power of the hyp- notist and the hypnotist's magical skills. Summary and Comment The results of 19 individual and 12 group hyp- nosis trials are summarized in table 9. Only one- 46 third of the trials had results based on 1-year follawups. Success rates are reported here as stated by the authors, but high quit rates are suspect as most investigators did not describe their followup procedures adequately. There was a lack of bio- chemical verification with results based on self- reports. Quit rates ranged from zero to 68 percent for individual hypnosis and 8 to 88 percent for group hypnosis. Overall, success rates were slightly higher for group programs. Quit rates for earlier studies were higher than those of more recent studies, but this may be related to better followup procedures in the latter trials. Individual hypnosis with multiple sessions showed better results than those with a single session. 'ftb1e 9 SUMMARY OF FOLLOWUP QUIT RATES OF 31 HYPNOSIS TRIALS Reported 1964-1984 Percent N Range Median 33% 1964-1984 Individual Hypnosis At Least 6-Month Followup 11 0-60 25 36 At Least 1 Year Followup 8 13-68 19.5 8 Group Hypnosis At Least 6-Month Followup 10 8-68 34 50 At Least 1-Year Followup 2 14-88 - 50 1964-1977 Single Session Individual Hypnosis At Least 6-Month Followup 1 12 - 0 At Least 1-Year•Followup 3 17-35 18 33 Multiple Session Individual Hypnosis At Least 6-Month Followup 3 25-60 50 67 At Least 1 Year Followup '4 13-68 41 50 Group Hypnosis At Least 6-Month Followup 4 8-68 37.5 50 At Least 1-Year Follawup 1 88 - 100 1978-1984 Single Session Individual Hypnosis At Least 6-Month Followup 3 25115 30 33 Multiple Session Individual Hypnosis At Least 6-Month Followup 4 0-50 8.5 25 At Least 1 Year Followup 1 21 - 0 Group Hypnosis At Least 6-Month Followup 6 13-56 34 50 At Least 1-Year Followup 1 14 - 0 West concluded that combining hypnosis with other treatments (groups or individual counseling) appears to be more effective.325 He also stated that having multiple doctor-patient contacts and employing hypnotic reinforcements of initial sug- gestions of abstinence are more effective than a single session. He pointed out some of the dif- ficulties in the general employment of hypnosis in the treatment of smoking. Not all patients are will- ing to undergo the procedure, and not all of those who do participate will be sufficiently good TIMN 293376 r

subjects to produce high success rates. West said that hypnosis is expensive because it is time con- suming, although this is less so if there is only one treatment session. West also noted that hypnosis is relatively wasteful because success with hypnosis is uncertain in smoking control. Nuland also sug- gested that having more than a single session of hypnosis would improve results.329 Kline concluded that longer term group therapy in which hypnosis is used "first to intensify depriva- tion behavior and then . . . to reduce psycho- physiological manifestations of deprivation results" has produced significantly better results in smok- ing control than have been produced through in- dividual hypnotherapy.330 Kline also reported that hypnosis decreased the discomfort associated with withdrawal from smoking. Cohen found from his review of hypnosis and smoking reports that some types of individuals may be helped more than other types to stop smoking by hypnosis. However, he states that "available clinical and statistical evidence does not indicate that hypnosis achieves a rate of smoking cure dif- ferent from spontaneous cessation or other therapy techniques."331 Crasilneck and Hall, however, insist that hypnotherapy, used with proper psychothera- peutic skill in the context of a medical or psycho- logical picture, is a powerful tool in helping patients to overcome the smoking habit.332 Holroyd reviewed the variables associated with success in utilizing hypnosis in smoking treatment. She reported that whether subjects were patients or volunteers or whether self-hypnosis training was utilized did not seem critical.287 Holroyd found the most salient variable counting for outcome dif- ferences to be whether the suggestions for not smok- ing were tailored to patients' individual needs and motivations. Also, adjunctive treatment to foster overall improved mental health or continued sup- portive contact with telephone calls seemed to be associated with better outcome. Francisco found that nontreatment factors, including self-reported need to smoke, as well as motivation to quit, were the most important determinants of outcome.333 Huggan334 and Ryde335 agree that the success of hypnotherapy in smoking cessation depends on the patient's motivation. After reviewing the literature, Holroyd concluded that hypnosis treatment for smoking is most effec- tive when there are several hours of treatment, when an intense interpersonal interaction is part of treatment, when suggestions in the trance are designed to capitalize on the specific motivations of individual patients, and when there is adjunctive counseling or foll_owup telephone contact.. . . The reasons why hypnosis is effective ... are a matter of conjecture. Many hypnotherapy techniques are strikingly similar to some behavior therapy techniques. . . . Furthermore, trance in the absence of suggestions. appears to have little impact on behavior. The hypnotic state may increase suggestibility, make im- agery more vivid, decrease reality orientation, increase dissociation, facilitate focusing atten- tion, and lead to a feeling of compulsion to do what the hypnotist suggests or a feeling of deep relaxation. Any of these factors or a combina- tion of them might be• useful for a particular individual336 Concluding Comment It is difficult to assess the true effect of hypnosis as a treatment for smoking since the studies reported were weak in followup methodology. Only one-third of the trials conducted a 1-year followup, and only two of these were reported over the last 7 years. Several hypnotists claimed very high quit rates, but it is not known if they included all patients who began treatment in their results. Many hyp- notists included other methods along with hypnosis (e.g., counseling and behavioral techniques), so it is difficult to determine how much hypnosis con- tributed to the result. Wadden and Anderton con- cluded from their review that although hypnosis may be effective with addictive behavior, the therapeutic success is attributable to nonhypnotic factors.'89 From my review of over 50 reports, comments, and critiques of the use of hypnosis to control smok- ing, I conclude that hypnosis produces only modest results when used alone, but when combined with other methods, the success rates are enhanced. The skill and experience of the therapist are very impor- tant to the proper use of hypnosis. A single treat- ment of hypnosis seems most cost-effective, but multiple sessions appear to improve quit rates. Several trials of group hypnosis produced good results, but this may be due to the adjuncts associated with the group method. As with any method, counseling and followup support are needed to maintain abstinence. In view of the finding that hypnosis is the most frequently advertised smoking cessation method in the telephone yellow pages (see pages 30-32), it is essential that therapists provide us with objective evidence that hypnosis promotes abstinence. Any study completed after 1978 should be held account- able for meeting accepted methodological standards regarding followup and verification of self-reports.41• 42h s,. ss. 7s. eo Research on hypnosis should examine not only treatment outcomes but also beneficial ef- fects on motivation to quit and to remain abstinent and on withdrawal symptom severity. Future re- search should help to elucidate the appeal of 47 TIMN 293377

hypnosis treatments. What features of actual or ex- pected hypnotic procedures motivate smokers to seek such treatment, and what intrapersonal factors might mediate outcomes? The public has a right to know if hypnosis is effective in promoting cessation, and we have an obligation to present the evidence. ACUPUNCTURE Acupuncture is based on the Chinese science of connections in the body. Use is made of needles or staple-like attachments to treat the smoker. Cousin discusses two methods of treating smokers by means of acupuncture.337 The first method, nasopuncture, consists of selecting points on the surface of the nose in such a way as to decongest the respiratory tract and generate in the patient a feeling of disgust toward tobacco. The second . .._..... . method is auriculopuncture, which is said to regulate the neurovegetative system. Laterality is im- portant, since one of the ears is the so-called leading ear. This method may occasionally be painful and is popular in the Far East. Cousin claims that pro- viding one treatment of nasopuncture to 100 patients will result in a 64-percent quit rate. He also claims that half of the patients will quit with either treatment. Acupuncture at the site of the ear can be by press needle or staple puncture. Choy, Parnell, and Jaffe describe the use of press needles.338 After the ear is cleaned with alcohol, a stainless steel press needle is inserted into the tragus of each ear. Collodion is applied as sealer, and a circular adhesive bandage is applied. Choy et al. change the needles once per week for 3 weeks and remove them the fourth week. These practitioners tell the patient about the hazards of smoking and advise the patient to avoid social situations where smoking is endemic and to seek the active support of family and friends. They prescribe diazepam to patients for 10 days. In staple puncture, use is made of a surgical staple at fixed acupuncture needle points for the purpose of conducting frequent stimulation to the ear. Threads and beads are also implanted at the ap- propriate body and auricular points. Electro- acupuncture also is used in treatment for smoking. There is a difference of opinion as to which points are best for smoking cessation. Many acupunc- turists advocate the "Ear-0" and "Lung Point" of the ear, but other points are recommended. Several practitioners claim to have discovered new points that give high success rates with smokers. For ex- ample, Olms discovered a point on the wrist that he named "Tim Mee" (Cantonese for "sweet taste") 339 He used Tim Mee for his own cough and found that he no longer needed to smoke although he was a heavy smoker and had tried to quit many times 48 before. He tried Tim Mee plus the auricular ' Aggres- sion Point" of the dominant ear and claimed great consequent success in curing the smoking habit. Evaluation Acupuncture for the treatment of smoking has gained in popularity since the last review of the literature in 1977. As already noted, acupuncture listings in the yellow pages for smoking control in- creased from 3 percent of all listings in 1976-77 to 7 percent in 1984-85. There are, however, only a handful of evaluation reports with followup data. Overall, these evaluations are poorly done; informa- tion on who was followed up or how the results were calculated often was not provided. Some in- vestigators claim very high rates of success based on their estimates. Many authors base their quit rates on end of treatment results. Only one study validated abstinence. Generally, the few studies that had better designs revealed low quit rates. 'liwo evaluation reports indicate the length that the investigators went to in order to count definite failures as successes. Requena et al. claimed 56- percent success based on replies from about half their patients and did not count as a failure anyone who returned for treatment.m Olms, who discovered Tim Mee, tells patients that he will repeat treatment, at no charge, if the first treatment does not work or if they resume smoking within 1 month.339 Thus if he does not hear from a patient, he counts that pa- tient as one who has stopped smoking! In addition, Olms takes a history from failures who return for repeat treatment. If a patient says it worked but "I started again because I thought I could play with cigarettes" or "I tried one for a lark and started again;' Olms counts that patient as a success! Based on this manner of "evaluating" his quit rate, Olms reported 84-percent success. There is widespread interest in acupuncture for smoking cessation in France. Unfortunately, many of the French reports did not provide followup data. Those studies with at least 6-month followup data are reported in the comprehensive table and sum- marized in table 10. Of 13 reports, 4 were from the United States, 4 from France, 2 from Canada, and 1 each from New Zealand, Australia, and England. Ti,vo reports were based on 2-year followups, four were on 1-year followups, and the other seven were 6-month reports. The earliest evaluative report was by Sacks in 1975 based on a 6-month followup.-1`'1 The quit rate cited for 642 patients was 64 percent using auri- cular staple puncture. His treatment consisted of three visits the first week, two the second week, and one at 1 month when the staple was removed. Maintenance visits were made by patients every 2 weeks for 3 months and then once per month until TIMN 293378

6 months. Part of the reason for his high success rate could be the support provided through the ex- tended maintenance period. Table 10 SUMMARY OF FOLLOWUP QUIT RATES OF 1S ACUPUNCTURE TRIALS Reported 1978-1955 N Range lYledian Percent 33% 1975-1977 At Least 6-Month Followup 2 14-61 At Least 1 Year Followup 1 24 1978-1985 At Least 6-Month Followup 5 5-34 18 20 At Least 1 Year Followup 5 8-32 30 0 Using auricular acupuncture, Choy et al. claimed that 55 percent of 33 patients stopped smoking and 20 percent relapsed, leaving 42 percent successful at followups, which varied from 2 months to 2 years.338 Choy et al. provided a later report on 514 patients of whom 339 completed the 4-week treat- ment and 297 quit smoking.342 At 2 years, 220 ab- stainers were assessed; 31 percent had relapsed. If results are based on those completing treatment, the quit rate was 45 percent; if based on patients treated, the quit rate was 30 percent. The other 2-year followup revealed a 30-percent quit rate based on 194 patients.343 The four 1-year followup reports are from France. Pene et al. used auricular acupuncture on 200 pa- tients and found that 24 percent were abstainers at 1 year.344 Their method consisted of applying surgical agraffes to two specific points on the pavilion of the ear for 2 to 3 days and then transfix- ing the helix base with a wire and leaving the wire in place for a month. The operation was repeated 1 week later in case smoking withdrawal was not complete. The authors advise that the treatment should be supplemented by simple psychotherapy, fruit juices, respiratory exercises, and, if necessary, light sedatives. Labadie et al. compared acupuncture to use of a tranquilizer adding Nicogum, nux vomica tablets, and Tabacum to both treatments.345 There were 65 subjects in each treatment group, and the quit rates were almost the same: 32 percent for acupuncture subjects and 31 percent for those taking a tran- quilizer. The study by Clavel et al. was discussed previously in the nicotine gum section.256.2g7 These investigators compared acupuncture to Nicorette and a locked cigarette case; the quit rates at 1 year were 7 percent for acupuncture (N=224), 6 percent for the gum (N = 205), and 3 percent for the locked case (N=222). In the acupuncture group, needles were placed bilaterally for 30 minutes. Cottraux et al. compared acupuncture to behavioral therapy (stress reduction and self- control); two additional conditions were placebo pill and wait-list controls.35i Subjects in the experimen- tal treatments attended three sessions of 3 hours duration for 2 weeks. In their evaluation, 28 sub- jects not reached were assumed to be successful in the same ratio as subjects followed up. I recalcu- lated results with those not reached counted as failures. There were about 140 subjects in each con- dition. Success rates at 1._ year were acupuncture- 16 percent; behavioral therapy-7 percent; placebo pill-14 percent; and controls-6 percent. Six studies compared acupuncture at the "cor- rect" site for smoking cessation against an incor- rect or "sham" site. Only three of the studies presented 6-month followup data. The comparisons are shown in table 11. Table 11 STUDIES COMPARING "CORRECT" AND "INCORRECT" ACUPUNCTURE SITES FOR SMOKING CESSATION Correct Incorrect Site Site Percent Percent Inrestigators Fblloyrnp N Quit N Quit MacHovec et al."O 6 Months 12 25 12 0 Gillams et a1?46 6 Months 28 18 27 15 Lamontagne et al?*~ 6 Months 25 8 25 16 Gilbey et a1.98 3 Months 44 21 49 15 Parker and Mokg*® 6 Weeks 21 14 20 15 Steiner et a1.350 End of treatment 11 9 12 8 In only one study did the correct site show a clear advantage over a placebo site.31o In the study done by Lamontagne et al., the contrasting site was not entirely incorrect as it was said to be one that enhanced relaxation; in fact, it appeared to produce better results than the correct site.347 These in- vestigators also had a self-management condition that included a counter. Zi,venty percent of these subjects had quit at 6 months. Parker and Mok divided their subjects into four groups; two received acupuncture at an effective site for smoking con- trol with one group receiving electroauricular treat- ment and the other press needles.349 Both groups were compared to placebos; the quit rates at 6 weeks were similar when the two correct site con- ditions were compared to the placebo groups. Gillams et al. commented that acupuncture at any site may cause endorphin release that in turn alleviates symptoms of smoking withdrawal.346 They concluded, however, that acupuncture is not as effective in helping smokers to quit as has been claimed. Lamontagne et al. stated that although acupuncture appears to have become a popular TIMN 293379 49

treatment for cigarette smokers, its effectiveness re- mains to be proven.347 A contrasting view is expressed by Chen, who claims that he treated 184 cases and at 6 months 82 percent had succeeded in stopping smoking.3g2 Chen contends that auricular acupunctur:, is a sim- ple, safe, economical, rapid, and effective method to kick the smoking habit. In an unpublished paper, Mabry and Fosbury reported 42-percent suc- cess with 270 subjects who were reached at 6 months, out of an original group of 335 subjects.353 Based on all subjects, the quit rate was 34 percent. In addition to acupuncture, their subjects received sodium bicarbonate, procaine, B vitamins, and diet suggestions. These high rates of success are con- trasted with Martin and Waite's study of 405 sub- jects in which they found that acupuncture helped between 5 and 15 percent to stop smoking for 6 months.354 Electroacupuncture, they stated, did not enhance quit rates. They concluded that the effec- tiveness of acupuncture in the cessation of smok- ing is largely the result of a psychological component. Lagrue and Choppy-Jacolin reviewed two acu- puncture studies.355 A single-blind study revealed comparable results between real acupuncture and "placebo" acupuncture. They stated that the study points out the importance of the physician's power of conviction. The second study involved three dif- ferent treatments, but each included acupuncture and psychotherapy. One condition added lobeline, while another added placebo. The placebo group was significantly more successful in helping sub- jects to abstain from smoking. The other two groups had equivalent quit rates. The reviewers at- tributed the results to the emphasis on psycho- logical treatment in the placebo group. Schneideman356 and Poupy et al.357 disagree that acupuncture's effect is psychological. The latter in- vestigators denounced the attempt to assimilate acupuncture as a psychological aid and pointed out that acupuncture diminishes or suppresses the vis- ceral urge of an intoxicated individual. They stated that it is up to the patient to abstain from smoking and admit that a psychological aid could be effec- tively added to treatment. Fuller believes that acupuncture merely eases smoking withdrawal symptoms and if the patient's motivation is weak, relapse will occur.343 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.35a Schneideman agreed that acupuncture functions to control withdrawal symptoms after cessation but added that it does not prevent resumption of the habit.356 He urged that patients be screened thoroughly and that only those anxious to quit should be selected for acupuncture. Labadie et al. supported the conten- tion that acupuncture is effective only when the pa- tient is strongly motivated, in which case, the method plays a supportive role.345 Summary and Comment Reported quit rates for acupuncture at 1-year followups ranged from 8 to 32 percent as shown in table 10. The median quit rate was 30 percent. Not considered in the summary table were several studies that counted failures as successes. As noted earlier, some of the studies of acupuncture were poorly done. Only one study attempted to validate reported success, and that study found that only 8 percent had quit smoking at 13 months. The comments regarding the methodology and evalua- tion of hypnosis trials (see pages 47 and 48) apply as well to acupuncture. There is no evidence from this review that acu- puncture may relieve withdrawal symptoms. De- spite increasing popular interest in acupuncture as a treatment technique, it has not been demonstrated that acupuncture is able to promote smoking cessation. Acupuncture may act as a "placebo procedure" to help the smoker to handle the addictive component of smoking. If so, the psychological and social aspects of smoking must also be handled. Needed along with acupuncture are counseling and support or some type of therapy, skills training, or smoking clinic procedures. As with any method, motivation to quit is necessary for successful abstention. PHYSICIAN COUNSELING* Trends in Physician Counseling About Smoking National surveys have indicated that a high pro- portion of physicians believe that it is their responsibility to help their patients to stop smok- ing and that they should convince people to quit 3s°-3sz A local survey of physicians supports the findings of the national surveys.363 Physicians, however, are reluctant to counsel their patients to quit smoking until serious health problems are present. *For this section, I relied on J.W. Cullen's paper, Opportunities for Physicians' Intervention in Smoking Cessation,a59 and L.L. Pederson's chapter on the Role of the Physician in Smoking Cessation in the 1984 Surgeon General's report .-16O 50 i TIMN 293380

1able 12 PHYSICIAN OPINIONS REGARDING HELPING PEOPLE QUIT SMOKING Percent National Survey, Coe and Brehm, 1971783 Physician responsibility to help their patients stop smoking 92 Physicians should convince their patients to stop smoking 83 National Survey, Center for Disease Control, 1975m Physicians should convince people to stop smoking 74 Physicians should be more active in speaking to lay groups about smoking 82 Los Angeles County Medical Association, Zeitlin, Dismuke, and Miller, 1983-"6' Physicians have a professional obligation to help patients give up smoking 0 Wechsler et al: s survey of 430 primary care physi- cians in Massachusetts provides some reasons why physicians are reluctant to offer such advice.364 Physicians were asked how important certain health-related behaviors were "in promoting the health of the average person: " Eliminating cigarette smoking received the strongest response of any of the behaviors with 93 percent of the physicians responding "very important: " (Avoiding excess calories was second with 70 percent.) A survey of Maryland primary physicians found similar results regarding the importance of promoting the elimina- tion of cigarette smoking.365 Nine out of 10 physi- cians in the Wechsler et al. survey reported that they routinely gathered information on smoking habits. Physicians had little confidence in their ability to help patients to change smoking behavior. Although physicians reported that they were better prepared to offer counseling about smoking than about other behaviors, only 58 percent thought they were "very prepared" to offer smoking counseling, and just 3 percent thought they were "very successful" in helping patients to stop smoking. Most smokers state that they are aware of the health risks of smoking; they view the physician as an important person in their decision to quit smok- ing. Russell points out how doctors can influence their patients: In the eyes of their patients, doctors represent authoritative informants of high credibility, especially when advising on health matters. When attending a doctor, people are in a situa- tion where the perception of their own vulnerability to health threats is maximal, especially if the complaint is related to their smoking. Advice in this setting is, according to the tenets of communication theory, likely to be highly effective.-166 Although the physician is seen as a health com- municator,367 national surveys have indicated that only 22 to 25 percent of smokers report having been advised by a physician to quit smoking.38s,3ss A nationwide survey of teenagers by the ACS revealed that 72 percent of nonsmokers identified physicians as the one group that could persuade them not to start smoking, and 42 percent of those who smoked said their physician's advice would influence them to stop.3'O The proportion of physicians who smoke has declined dramatically so that only about 10 percent of them remain smokers,36O and there are indications that more physicians are advising and counseling their patients to stop smoking. Green and Horn reported in 1968 that 38 percent of physicians claimed that they advised "all" or "aimost all" of their patients without smoking-related disorders to quit or cut down.371 A much larger pro- portion of physicians (88 percent) presented this ad- vice to pulmonary patients. Coe and Brehm's survey found that 6 out of 10 physicians advised their patients who smoked to stop.3s1 An ACS study reported that physicians advised 6 to 7 of their last 10 patients who smoked to stop.372 A 1978 survey of a western county medical society found that 52 percent of the physi- cians reported that they counseled all smoking pa- tients to quit, 18 percent advised heart and lung disease patients to stop smoking, 16 percent coun- seled only lung disease patients to quit, and 14 per- cent did not address patients' smoking habits.373 Of those who advised patients to quit smoking, about half initiated counseling, spent more than 2 minutes for counseling, and repeated advice more than once per year. A Canadian survey of primary care physi- cians (1982) revealed that 98 percent reported that they advised their smoking patients to stop.374•3'5 Williams pointed out that the family physician has a unique opportunity to contact and establish communication with patients and their families. Seventy-three per- cent of the population of the United States con- sults a physician at least once a year, averaging five visits per person per year. The family physi- cian's patient sees him on the average of 2.5 to 4 times a year, the frequency of which depends on age, sex, etc. Most visits are episodic and curative in nature. If the prevailing attitude of the physician and his support staff is one of concern with health as well as disease, these occasions can be used to enlist his patients in a program of education on the subject of prevention ofdisease. ... Influence on other members of the family who accompany the patient on such a visit may be exerted at the time or the preventive attitude learned in this climate may be carried by the pa- tient into his home, the work place, or into the community.376 TIMN 293381 51

Russell et al. stated that 18 of the 20 million smokers in Great Britain visit a general practitioner at least once every 5 years.377 If each general practi- tioner counseled all smokers on how to stop smok- ing and achieved a 5-percent permanent quit rate, the result would be equivalent to that of 10,000 smoking withdrawal clinics achieving a high rate of success. The yield in Great Britain would exceed half a million ex-smokers a year. In the United States, approximately 38 million smokers visit a doctor each year. If U.S. doctors counseled all their patients who smoked on how to stop and were successful with just 4 out of every 100 patients, the yield would approximate 1.5 million ex- smokers. There is reason to believe that quit rates would be even higher if physicians offered followup support to their patients. The rest of this section will examine evaluations of trials in which physicians provided advice and counseling to their patients. Linda Pederson's find- ings will be summarized with regard to compliance of pregnant women and pulmonary and cardio- vascular patients with physicians' advice to quit smoking.360 Some recent studies not covered by Pederson will be included. 'I3-ials will be reviewed in which physicians merely offered advice or counsel- ing to patients, followed by a summary of studies in which physicians provided more than counseling. As with the reviews of other methods, studies with 1-year followups and reports after 1977 will be given more attention. It should be noted that there may be high rates of false reporting in physician advice studies, particularly where the patient has not volunteered to quit. Summary of Findings on Patient Compliance Pregnant Women As noted in the introduction (page 3); cigarette smoking during pregnancy has an adverse effect on the well-being of the fetus, the health of the newborn baby, and the future development of the child. Gastrin and Ramstrom378 and others379380 have de- scribed strategies to influence pregnant women to cease smoking. The 1975 Survey of Physician Ad- vice found that about three out of five physicians specializing in obstetrics and gynecology reported that they advised most to all of their pregnant pa- tients to quit smoking or cut down 3s1 Quit rates among pregnant women range from 1 to 35 percent.382 The 1980 National Natality Survey questioned 4,405 mothers 6 months after delivery on changes in smoking and drinking behavior dur- ing pregnancy.383 It was found that of those mothers who smoked or drank, 30 percent stopped drinking but only 18 percent stopped smoking. The better educated women had higher quit rates for smoking. 52 Kaetz, Samson, and Scott conducted a study of pregnant women in rural Nova Scotia.384 They found that women who live in rural areas have low rates of quitting smoking. In many rural communities of Nova Scotia, smoking is still accepted uncritically and with little attention paid to health implications. In these rural areas, there is a lack of media penetra- tion, a scarcity of nursing and health education pro- fessionals and programs, and the preponderance of serious economic problems within the local society. The investigators offered, 202 pregnant women who smoked a 6-session group cessation program. Only 59 women expressed an interest in the program, and 29 of them indicated that they would par- ticipate. 'Iiwenty pregnant women and 2 nonpreg- nant women attended the first session; of these, 16 completed the program. 4 stopped smoking, and 5 cut down. The authors indicated that many women appeared reluctant to seek help outside the family- friendship structure. Our findings that smokers would prefer to quit on their own may apply here.47 Perhaps self-help methods would be acceptable to this population. Baric et al. studied 134 pregnant British women, all of whom thought smoking could be harmful to the fetus.3851i.venty-four (18 percent) of the women quit smoking on their own, 63 were exposed to educational materials, and 47 served as controls. Fourteen percent of the intervention group stopped smoking 3 months later compared to 4 percent of the controls. Since this was only a 3-month followup, some of the women could have returned to smok- ing. Nevertheless, there is an indication that counseling does result in behavior change. Another British study surveyed 282 pregnant women, of whom half smoked when they became pregnant.3se About one-third of the smokers claimed they re- ceived no advice to quit smoking. Advice was pro- vided in a minimal fashion and rarely by physicians. Tbn percent quit smoking during pregnancy. A poster and leaflet campaign aimed at increasing cessation at an antenatal clinic had no effect. A Pittsburgh study of 179 pregnant women re- vealed that 55 percent smoked at the start of pregnancy.3B7 Of the smokers, 37 percent reduced their consumption and 19 percent quit. A validation of the self-reports on smoking by a carbon monoxide breath test found some false reporting. Most of the continuing smokers claimed they wanted help with their smoking, but only 1 woman out of 80 attended a free cessation program nearby. Changes in smok- ing were made during the first trimester so the authors emphasized that help with smoking should be offered early in pregnancy. Two studies did not test physician intervention. In one, behavior modification, muscle relaxation, and educational information were provided to 11 pregnant women over a 6-week period.388 A TIMN 293382

9-month followup found that of eight women who completed the program, three were abstinent. In the second study, health educators informed 36 preg nant women of their own levels of carbon monoxide; the women were also told about the adverse effects of smoking during pregnancy.-'119 A comparison with 43 women smokers who served as controls showed that 13 percent of the controls but only 7 percent of the experimental group had quit. The 73-i-County Health Department designed a We Quit program in the Denver area that featured rewards to pregnant women who quit smoking.39° The program included a provider message, printed materials, and a media presentation. Rewards were distributed six times during the first 8 weeks and at the third and fourth months, consisting of such items as a photo packet, food, and cosmetics. Sixty- two women enrolled in the project, but only 26 reported in the followup. All but 8 percent made some change in smoking during their pregnancy with 61 percent claiming to have quit permanently. A cessation program for pregnant women was carried out by a health maintenance organization in Southern California.391 During a 3-month period, 35 women attending a prenatal class were mailed typeset booklets for 7 weeks. A telephone answer- ing system with taped messages was also made available. A 3-month followup found 29 percent of the women abstinent. Langford et al. provided antismoking information and pamphlets to 77 women who were in their seventh month of pregnancy; some of the women had a home visit.392 Three-quarters of the women reported some smoking changes during pregnancs, but no significant differences were found between the experimental group and a control group. One year after delivery, however, the percentage of nonsmokers was significantly higher among the women who had received the educational program (23 percent) than among the control group (5 per- cent). The authors concluded that educational pro- grams should be carried out much earlier than the seventh month of pregnancy. The presence of a significant difference in smoking between the two groups at 1 year after delivery suggests the long- term value of a prenatal program on smoking. In a recent study conducted in public health maternity clinics in Birmingham, AL, Windsor et al. evaluated the effectiveness of two self-help cessa- tion manuais.393•394 Pregnant smokers (N = 309) who entered care before the seventh month and agreed to participate were randomly assigned to either controls, the ALA Freedom From Smoking Manual, or A Pregnant Woman's Seif-Help Guide to Quit Smoking.395 The guide uses a 7-day quit plan and includes such skills as smoke holding, breathing exercises, and dealing with physical reac- tions to quitting. Both experimental groups received an ALA information booklet prepared for pregnant smokers and a 10-minute counseling session in- structing them how to use the self-help materials. All three groups were exposed to the regular smok- ing cessation advice and health effects of smoking prenatal lecture presented by the medical and nursing staff. Smoking status assessed during the last month of pregnancy (validated by saliva thiocyanate) showed that 2 percent of the controls, 6 percent of those assigned to the ALA manual, and 14 percent of those who used the pregnant woman's guide had quit smoking. The authors concluded that health education methods tailored to the preg- nant smoker are more effective in changing smok- ing behavior than are standard methods. Pulmonary Patients Serious pulmonary problems result from con- tinued smoking.396 Pederson's review demonstrates that the presence of serious illness adds credence to the physician's message and is related to increased compliance.-'60 Studies that investigated quit rates among pulmonary disease patients were listed by Pederson397 and are shown in the comprehensive table and summarized in table 13. Of the trials, 6 had at least a 1-year followup, 10 had a 6-month followup, and 2 had a 3-month followup. Not all the studies were based on physician advice. TZvo studies included intervention by psychologists. Only one study validated abstinence by objective verification. Tab1e 13 SUMMARY OF FOLLOWUP QUIT RATES OF PATIENTS WITH PULMONARY OR CARDIAC DISEA3E Reported 1969-1984 N Renge Median Percent 33% Patients With Pulmonary Disease 1969-1983 At Least 6-Month Followup 10 10-51 24 20 At Least 1 Year Foilowup 6 25-76 31.5 50 1969-1977 At Least 6-Month Followup 6 13-51 25 33 At Least 1 Year Followup 2 25-76 - 50 1978-1983 At Least 6-Month Followup 4 10-26 18.5 0 At Least 1 Year Followup 4 25-63 31.5 50 Patients With Cardiac Disease 1971-1984 At Least 6-Month Followup 5 21-69 44 80 At Least lYear Followup 16 11-73 43 63 1971-1977 At Least 1 Year Followup 6 22-51 47 83 1978-1984 At Least 6-Month Followup 5 21-69 44 80 At Least 1 Year Followup 10 11-73 37 50 Quit rates for pulmonary patients ranged from 10 to 76 percent with the median for 1-year studies being 53 TIMN 293383

31.5 percent. Cessation rates did not improve over time as the more recent studies had lower quit rates. Pederson et al. found that abstinence was related to primary diagnosis with those patients having chronic obstructive lung disease more likely to quit 398 Based on experience with chronic respiratory pa- tients at the Rees-Stealy Clinic in San Diego, Peabody indicated that 25 percent of the patients will stop fairly easily after an initial suggestion by the physician and another 25 percent will stop after several attempts.3ss Cardiac Patients Table 13 summarizes the quit rates for 21 studies of patients with cardiac disease. (Risk factor trials were not included in the summary.) Sixteen of the trials had at least a 1-year followup, and four studies validated abstinence by biochemical verification. Quit rates ranged from 11 to 73 percent; the median quit rate for 1-year studies was 43 percent. A high proportion (63 percent) of 1-year trials achieved quit rates of at least 33 percent. It should be noted that several studies found a deception rate of approx- imately 25 percent.4°°A0' Pederson reasons that studies ... among cardiac patients further support the notion that presence of disease may be an important precursor of compliance. The occurrence of a myocardial infarction (MI) is a dramatic event that ... should add credence to the physician's admonishments. . . . smoking cessation decreases mortality among post-MI patients, so that attempts to increase compliance among this group could have life-or-death ramifications.4o2 Burling et al. provided a critical review of the literature pertaining to smoking following myocar- dial infarction 4O3 They pointed out methodological shortcomings of the studies, including poor defini- tion of abstinence and how followup period is measured; unverified self-reports; intervention pro- cedures are not adequately described; and factors influencing cessation are rarely controlled or systematically examined. Nevertheless, their review strongly suggested that although percentages are debatable, a sizable proportion of individuals quit smoking following a myocardial infarction. Advice varies in intensity and directly influences quit rates. When stronger advice or warnings are offered, more people cease smoking. Burt et al. provided conventional treatment and more intense advice to contrasting groups of post- myocardial infarction patients.404 Those who re- ceived more intense advice had higher cessation 54 rates than did those receiving normal care: 62 per- cent compared to 28 percent. Other attempts to in- crease quit rates by using group counseling405 or exercise with or without counseling406 did not im- prove success. Orleans and Rotberg reported high success rates (69 percent at a 6-month followup) with 16 cardiopulmonary inpatients who quit on their own when hospitalized and then were presented with physician advice to stay quit and relapse prevention counseling from a psycholo- gist.59 Quit rates were validated by reports from informants. In another inpatient study, Baile and associates followed up 61 smokers who were patients hospital- ized for myocardial infarction.407 All patients were cared for in the coronary care unit for 2 to 7 days where they could not smoke. When they were transferred to the recovery ward, they were allowed to smoke but were discouraged from doing so. It was the ward policy that patients should not smoke. An educational rehabilitation program was offered to patients and their spouses, consisting of discus- sions about the risks of smoking and the advan- tages of quitting. Advice was provided on how to quit by physicians and other staff members. The authors were disappointed that 38 percent of the patients relapsed, but looking at the results positively, 62 percent were still nonsmokers when they left the hospital. It was found that the prob- ability of smoking was inversely related to severity of the myocardial infarction but was unrelated to the patient's smoking history or beliefs. The more severely ill patients remained in intensive care longer and thus had to refrain from smoking longer. Since their illness was more severe, they were sub- ject to more pressure not to smoke again, which may have contributed to the results. ' In a recent study, the Stanford Cardiac Rehabili- tation Program randomized 126 cardiac patients to intervention or control.408 The intervention con- sisted of a firm recommendation from a physician to quit smoking and cessation instructions from a nurse. Intervention patients were followed at 3, 11, and 26 weeks, while the controls were not seen until 26 weeks. About two-thirds of the patients in both groups stopped smoking, suggesting that pa- tients in standard care probably received equivalent instructions about giving up smoking from their physicians. Fuller-Bey discussed the importance of physician counseling and support for myocardial infarction patients who are hospitalized.4O9 During forced nonsmoking confinement is an ideal time to inform patients of the risk of smoking and to provide specific coping strategies that can be used when they are again faced with situations associated with smoking. Fuller-Bey cited a study that supports the value of counseling while patients are in the TIMN 293384

hospital: 66 percent of myocardial infarction pa- tients remained abstinent at 4 months following hospital counseling about smoking. Cardiac patients who continue to smoke should be counseled about the relationship of heart disease to smoking. Patients should be encouraged to quit smoking, and assistance should be offered by the physician. The more severe the disease, the more likely patients are to heed the physician's advice and attempt to cease smoking. Physician Advice and Counseling During Routine Patient Visits The communication of information is widely regarded as the single most common form of in- teraction during routine medical visits.41o The primary care physician is estimated as devoting from 19 to 35 percent of the time during a patient visit to health education and counseling.411 Sometimes that advice or counseling is brief. The results of 11 studies yielding 15 trials of physician advice or counseling (with at least a 6-month followup) are shown in the comprehensive table and summarized in table 14. Although the visits were routine, some patients may have had smoking-related diseases. Table 14 SUMMARY OF FOLLOWUP QUIT RATES OF 28 PHYSICIAN INTERVENTION TRIALS Reported 1965-1984 Percent N Range Median 33% Physician A,dvice and Counseling Interventions 1968-1984 At Least 6-Month Followup 3 5-12 5 0 At Least 1 Year Followup 12 3-13 6 0 1968-1972 At Least 6-Month Follo%wp 2 5 - 0 At Least 1 Year Followup 1 13 - 0 1979-1984 At Least 6-Month Followup 1 12 - 0 At Least 1 Year Followup 11 3-10 5 0 Physician Interventions Including More Than Counseling 1965-1984 At Least 6-Month Followup 3 23-40 29 33 At Least 1-Year Followup 10 13-38 22.5 20 1965-1977 At Least 1 Year Folloa•up 3 19-35 23 33 1979-1984 At Least 6-Month Followup 3 23-40 29 33 At Least 1 Year Followup 7 13-38 22 14 Three trials were reported between 1968 and 1972. The first trial was conducted in Philadelphia among 157 patients who visited two doctors' offices during an 8-week period.412 One physician told all patients who smoked that they ought to do something about their smoking. The entire message took 35-40 seconds. The other physician said nothing to his patients about smoking. Six months later, 5 percent of the advised patients and none of the other patients had stopped smoking. The other two trials were conducted in England. Business executives (N=1,493) were followed up for 1 to 2 years after a physical examination during which smoking cessation advice was given 413 Thir- teen percent had quit smoking. In a study con- ducted in a small English'town, brief advice was of- fered to patients in one practice and not in another.414 Five percent of the advised and 4 per- cent of the controls were not smoking 6 months later. In a well-designed large-scale study, Russell et al. assigned all cigarette smokers who attended the of- fices of 28 general practitioners in London during 4 weeks to 1 of 4 groups.37 One group was advised to stop smoking; a second group received the ad- vice but in addition was given a leaflet and warned they would be followed up; the other two groups were controls. The investigators reported that changes in motivation and intention to stop smok- ing were evident immediately after the advice was given. Of the people who stopped smoking, most did so because of the advice. Abstinent at 1 month and 1 year were 5 percent of the subjects in the advice and warning condition compared to 3 percent of the advice-only group and 1 percent of the controls. Overall, the following proportions of subjects were abstinent at 1 year: 19 percent-advice and warn- ing; 17 percent-advice only; and 12 percent- controls. The investigators commented that with more experiences, better leaflets, self-recording booklets, and the availability of aids, the results should improve further. In another study conducted by Russell and col- leagues, 1,938 smokers who attended the offices of 34 family physicians were assigned to 1 of 3 condi- tions.zs4.as5 One group was given advice plus a leaflet, and one group served as controls. A 1-year validated followup found that 4 percent of the ad- vised group and the controls were not smoking. (The third condition included nicotine gum; see page 39 or the comprehensive table for the result.) Li et al. conducted two experiments in the Baltimore area among shipyard workers and black women attending a family planning clinic.415 Sub- jects were either advised to stop smoking or presented with a 3- to 5-minute message about their smoking. In each case, the subjects who received the message had higher rates of quitting after 1 year: 8 and 10 percent compared to 4 percent for each advice group. Li and associates also tested the im- pact of a physician message and of posters and a movie in the waiting room of a public family plan- ning clinic.416 At a 1-year followup, a questionnaire 55 TIMN 293385

group showed 3 percent were abstinent compared to 5 percent for those exposed to the posters and movie and 10 percent for the physician-message group. Verification of nonsmoking status reduced success rates considerably. Smokers who attended a family planning clinic in the Denver area were presented with a provider message about smoking plus posters in the waiting room, a self-test, and a pamphlet 417 Of 165 women surveyed 3 months later, 44 percent had made some change in their smoking with 9 percent of them quitting. Several studies of physician advice about smok- ing have been conducted in Ottawa by Stewart and Rosser.416•419 In the first study, 691 patients were assigned to 1 of 3 conditions: advice, advice plus pamphlet, or control.418 The trial found no difference between the control and intervention groups; 3 per- cent quit in each condition. A second randomized trial involved a more detailed family physician in- tervention.419 Preliminary findings of this study sug- gested that the physician intervention was not dif- ferent from the control. A behavioral modifica.tion group and a self-help group had fewer smokers. The investigators commented that only modest success by family physicians supporting people once they have decided to stop can be expected. However, the family physician should screen smokers, explain the risks, and intervene to pressure smokers to stop. Once the patient decides to stop, the physician should consider referral to outside agencies or the use of a self-help program. Ledwith and Howie conducted a study of physi- cian counseling in 10 group practices in Scotland.42° One group of subjects only got counseling, while the other had counseling, a letter from a physician, and a mailed questionnaire. Results at 1 year were 7 and 10 percent, respectively. The final two advice and counseling trials were by Wilson et al. (N = 105, 12 percent success at 4-14 months)421 and Orleans and Rotberg (N = 63, 29 per- cent quit at 6 months).59 In the latter study, physi- cian advice to quit was followed by smoking cessa- tion counseling from a psychologist. Although it is difficult to measure the strength of the counseling and advice delivered by different physicians in the studies just reviewed, they con- sisted of simple advice or counseling. It appears that even simple advice is better than the physician re- maining silent about smoking. Four of the studies compared slight additions to counseling. A pam- phlet did not enhance success.418 but a warning,377 a message,415 and a doctor letter42° did raise quit rates. The next section reviews studies in which more than simple counseling was offered. 56 Physician Interventions Including More Than Counseling The comprehensive table lists a dozen studies in which the counseling was enhanced by strong messages, warnings, record keeping, followups, a complianc-- contract, and demonstration of exhaled air. It can be noted in table 14 that when more was offered, results improved over simple counseling. The median quit rate for simple counseling (1-year followups) was 6 percent compared to 22.5 percent for trials in which the intervention included more than just counseling. The range for the latter studies was substantially higher. The following five studies had 1-year followups. When a strong antismoking message was delivered, 23 percent quit,422 and when patients were told to quit, one-fourth did 423 A warning during a physical examination encouraged 19 percent to quit.424 A risk-assessment questionnaire added to advice recorded 22-percent success.425 In a large-scale study of over 2,000 patients, Jamrozik et al. as- signed subjects to 4 conditions: verbal and written physician antismoking advice; advice and a demonstration of exhaled air; advice and help from a health visitor; and a control.426 Quit rates were 15, 17, 13, and 11 percent, respectively. In one study that was reported in the previous sec- tion, procedures were added to physician counsel- ing and produced higher quit rates. Wilson et al. added followups at 1, 3, and 6 months resulting in a doubling of the rate (from 12 to 23 percent).421 It is possible that the differences in quit rates were due to the style of the individual physicians and how brief or strong their advice to quit was perceived by the patient. It does appear that if something extra is done, higher success can result. Physician Efforts in Smoking Cessation Blum stated that there is much that physicians can do to combat the propaganda barrage in sup- port of smoking.427 For instance, physicians' offices should not have magazines containing cigarette advertising. Doctors should use different techniques with patients to encourage them to stop smoking. Physicians can also participate in health promotion and prevention efforts outside the office, such as joining DOC (Doctors Ought to Care), an organiza- tion of health professionals whose aim is to curb unhealthy lifestyles. In 1969; Fredrickson explicitly outlined the role of the physician in office management of smoking problems.428 His outline is still appropriate today. His premise was that since smoking is a learned be- havior, it is subject to change through a relearning TIMN 293386

process and that the physician's ability to facilitate the smoker's decision to quit is good because of the doctor's most favorable and receptive environment: the examining room of the office. Because the physi- cian has access to the patient's medical history and has authority and influence over the patient, the physician is in a unique position to help the patient find incentives to quit. Counseling need not be lengthy; the minimal intervention of inquiring and encouraging can reinforce the patient's efforts toward cessation. lbday, the physician has resources that can be used to assist patients, such as physician kits sup- plied by NCI and ACS and excellent self-help materials produced by ALA, ACS, the American Col- lege of Chest Physicians, and others. The physician also can offer Nicorette to smokers who are motivated to quit. But as noted in the section on nicotine chewing gum, Nicorette alone, without the support and guidance of the physician or smoking specialist, will produce few long-term ex-smokers. The National Heart, Lung, and Blood Institute (NHLBI) has published a physician's guide to help hypertensive patients to stop smoking.429 The guide outlines a step-by-step approach to smoking cessa- tion counseling designed for physicians with a busy office practice. Expanded procedures, offering more detailed approaches, also are included for physicians who have the interest to devote greater attention to the smoking habits of their hypertensive patients. The ACS evaluated how receipt of the Physicians' Help Quit Kit and the Quitter's Guide affects physi- cian interaction with smoking patients.43O The study was conducted in 6 states among 494 physicians, of whom 175 were general practitioners, 143• were internists, and 125 were obstetricians or gynecolo- gists. Some physicians were given the kit, others the guide, and a third group both the kit and the guide; a fourth group served as a control and was not given any materials. It was found that, in general, the materials distributed to physicians fostered greater interaction between physicians and smoking pa- tients in physicians' efforts to persuade them to quit. The materials increased the extent to which physi- cians felt comfortable in speaking to patients about smoking and increased the forcefulness with which physicians spoke to their patients about quitting. Receiving both the kit and the guide had greater im- pact on physicians than receiving only one material. Physicians who received materials responded bet- ter than physicians who received no materials. About 4 out of 5 physicians felt the kit should be distributed to other physicians, while an impressive 9 out of 10 thought the guide should be distributed to physicians to hand out to their smoking patients. About half of the physicians who were given the guide handed it out to an average of 24 smoking pa- tients. Interaction with smoking patients was strongest among internists, next strongest among general practitioners, and weakest among obstetri- cians and gynecologists. NCI also evaluated their Helping Smokers Quit Kit by comparing three groups of patients.a31 One group received a strong warning from their doctor plus use of the kit; a second group received only the strong warning; and the third group received usual care from their physician. NCI also wanted to find out if the kit was more effective with high- risk patients. The test was conducted in Boston and Albuquerque among general patients and among cardiac patients in Boston and uranium miners in New Mexico, both high-risk populations. A 6-month evaluation showed that in general, neither the warning alone nor the warning plus the kit significantly increased the number of quitters over that of a control group. As it turned out, not enough high-risk smokers were recruited into the study to provide answers as to the effect of the kit with these populations. There are numerous outlines of procedures that physicians can follow in counseling pa- tients.6•3ss.4z84sz-439 I have described five aspects of the counselor's role in helping people to give up cigarettes: preparing the patient to stop and inten- sifying motivation; choosing a method appropriate for the patient and problem solving; selecting the tips, aids, and substitute behaviors that the patient can use; helping the patient decide when and how to quit, considering the patient's addiction and en- vironment; and providing followup support.s.4s2 Best calls for three counseling sessions 433 The first is a planning session to obtain a commitment to the change effort, devise coping strategies, and set a quit date. In the second session, monitoring notes, coping strategies, social supports, and dif- ficult situations are discussed and support is of- fered. The last consultation reassesses the change plan and continues to analyze problem situations. Peabody groups patients who smoke into three categories (asymptomatic patients, those with chronic respiratory diseases, and patients with other than respiratory diseases) and proposes a specific approach for each one.399 A new patient is generally more responsive to suggestions regarding health promotion. Appropriate remarks concerning the harmful effects of smoking usually can be made during the examination. Campbell and Valente listed the barriers and obstacles to physician practice of health education as being time, cost, concept of role, anxiety, pa- tient's knowledge level, physician-patient relation- ship, competition from negative influences, and lack of good materials.44o The availability of physi- cian guides and kits addresses the last-mentioned barrier. The patient-physician relationship will have to be restructured so that patients' take more 57 TjMN 293387

responsibility for their health and for implementing their physician's instructions. Physicians must give up some control of the interaction to allow more of a partnership. Summary The median quit rate for patients advised to quit for 12 trials with at least a 1-year followup was 6 percent. When the physician intervention included more than counseling, the median quit rate for 10 trials with 1-year followups was 22.5 percent. For pulmonary and cardiac patients, the median quit rates for 1-year trials were 31.5 and 43 percent, respectively. As the data presented in this section show, physi- cian advice and counseling encourage many pa- tients to attempt to break their cigarette habit. The proportion of patients who succeed in quitting and remaining nonsmokers after a brief message or warning is small, but the yield is large. When the physician enhances the advice with a stronger message, gives tips on how to quit, or provides followup support, the results improve. The quit rates for patients with pulmonary or cardiac disease who are advised or counseled are substan- tial. It should be pointed out that not all patients who are counseled by physicians are willing or ready to stop smoking. This is in contrast to clients attending cessation clinics or subjects who volunteer for behavioral methods. The latter smokers are already motivated to quit. Comment Regarding Counseling by Nurses, Pharmacists, and Dentists Although the role of physicians in helping pa- tients to quit cannot be underestimated, there are several other health professionals whose daily con- tact with patients can also be significant. The role of dentists, dental hygienists, nurse practitioners, physician's assistants, nurses, inhalation therapists, paramedics, pharmacists, and others has not been adequately studied in terms of their effect on in- fluencing patients to quit smoking. Fuhs pointed out that the nurse is the ideal per- son to counsel hospitalized smokers since the nurse sees the patient most frequently and is viewed by the patient as a credible health worker.441 The nurse should attempt to involve the patient's family in the counseling process so they can provide support and encouragement. It should be noted that in the past, nurses have had high rates of smoking. Surveys in the United States, Great Britain, and Australia reveal that a higher percentage of nurses are cigarette smokers compared with the percentage of other health professionals and of women in the general 58 population 442 The National Center for Health Statistics (NCHS) estimates lower levels of smoking by registered nurses (28 percent) but very high rates for nursing aides (42 percent) and practical nurses (41 percent).443 Cessation of smoking by nurses is emphasized as necessary to enable nurses to serve as better role models of health for the public.444445 There are indications that many nurses are giving up smoking.445 NCHS estimates that between 1970 and 1980 the prevalence of smoking among nurses declined 11.4 percent; the decline for practical nurses was 3.7 percent.4`}6 NCI has produced the Helping Smokers Quit Kit for several professional groups (eg., dentists, phar- macists). A pilot test found that the kit designed for pharmacists is a viable program 447 Pharmacists • were able to participate in the cessation program with minimal interference of their schedules, and they liked the program materials. Unlike programs designed for physicians and dentists, the focus is on smoking and drug interactions. The pharmacist has a special role to play regarding the use of Nicorette. Two studies demonstrate how pharmacists can play an active role in smoking cessation. Of 400 retail outlet pharmacists invited to participate in an antismoking campaign, 150 responded and re- ceived stop-smoking materials, including window display posters, leaflets, and badges.448 Fifty-eight percent had more than 26 customer requests for smoking cessation advice and assistance. Three- fourths of the pharmacists stated that they had discussed smoking cessation with customers. Through the Manitoba Pharmaceutical Associa- tion, pharmacists were utilized as distribution centers for a self-help smoking cessation booklet 44s In Winnipeg, city pharmacies distributed 38,000 booklets. Following three televised quit-smoking programs, a phone-in quit line directed callers to a pamphlet on maintenance. Pharmacies distri- buted 30,000 of the pamphlets. It was concluded that pharmacists not only have the knowledge to discuss smoking cessation but are in a strategic position for dissemination of that knowledge. O'Shea and Corah reported that dentists lead the general population in abstaining from cigarettes.4so They described the role of the dentist in smoking cessation. Dentists in general practice can serve as nonsmoking role models, provide information about the hazards of smoking, give advice, refer pa- tients to cessation programs, recommend cessation measures, and monitor patient's efforts to quit smoking. They commented that although smoking cessation measures taken by dentists are not like- ly to convert more than 1 or 2 percent of their pa- tients per year, efforts to promote smoking cessa- tion can have an appreciable impact over time. Christen and Glover contend that the dentist is in an ideal position to give specific, authoritative TIMN 293388

information concerning clinical oral ill effects of tobacco.451 They suggest 10 steps to help patients to quit smoking. They describe the use of nicotine chewing gum, which can be prescribed and super- vised by dentists. Slater discusses the dentist's and hygienist's role in educating their patients of the health hazards of smoking, particularly on the risk of oral carcinoma.452 Gamboa states that dentists have excellent opportunities for persuasive com- munication, and even brief counseling by dentists has proved helpful in getting patients to stop using tobacco.453 A survey of 157 dentists (8 percent smokers) revealed that 71 percent reported that they advise patients to stop smoking.454 Special efforts were made with high-risk patients (pregnant women, hypertensives, and high coronary or cancer risk). In counseling, dentists most often discussed negative health effects from smoking, but a few pro- vided suggestions for stopping, referred patients to cessation programs, provided a self-help pamphlet, or scheduled followup sessions. It was suggested that a 5-minute counseling session can benefit pa- tients' efforts to stop smoking. Comment Regarding Physician Counseling Bass advocated that smoking cessation methods be conducted at physicians' and dentists' offices, hospitals, health departments, and health insurance plan offices.4-9g Bass pointed out that considering the magnitude and seriousness of the smoking problem, it is amazing that health departments at the local and state levels have been so inactive. He stated that public health departments have the responsibility and authority to educate the public and intervene to foster cessation. Pederson and her colleagues have done a number of studies of patient compliance.39s,4ss.4s7 In a study of the "health belief model,"458 they concluded that the patient's response to advice may depend on the interaction of health beliefs and other variables such as reasons for smoking.456 They suggested that the physician may have to tailor his or her message to the type of smoker who is being treated. A study of self-efficacy by Pederson et al. revealed that the factor most consistently related to changes in smoking behavior among the patients studied was their own assessment of their likelihood of quit- ting.457 None of the specific techniques used by the physicians appeared to be related to success. They stated that it does not seem likely that the kinds of treatments that the physician can readily use in a clinical setting have much promise. They recom- mended that more comprehensive and intense treat- ment programs will have to be offered as a followup to physician advice. It should be pointed out that not all physician counseling is created equal. We would not expect the same results from counseling emphasizing the health harms of smoking and exhorting patients to quit as from counseling emphasizing the health and emotional benefits of cessation with practical recom- mendations on how to quit and the offer of support in that attempt. In addition, physicians equipped with only ineffective counseling and behavior change strategies are likely to be unsuccessful. Using the most effective counseling methods, garnering support from family and friends, and recommending methods for coping with transient withdrawal symptoms are likely to improve success. Investigators are urged to provide descriptions of the content of counseling methods so that we can ascertain the distinguishing features of successful and unsuccessful interventions. The availability of nicotine chewing gum by prescription should place more pressure on physicians to become actively in- volved in smoking cessation. The reader is referred to the summary and comment of the nicotine gum section (pages 40-42). Every physician can play a leading role in help- ing patients to give up cigarettes. However, misconceptions abound in regard to the process of ending dependence on cigarettes and thus have hindered clinical and political involvement of physi- cians in attacking the cigarette pandemic.459 Physi- cians overestimate their patients' awareness of the hazards of smoking and underestimate their own ability to get patients off cigarettes. Although primary care physicians are busy peo- ple and many claim they just do not have the time to go into detail with patients about smoking, it takes very little time for a physician to offer advice on how to stop smoking. If the physician is to be ef- fective, however, more time should be devoted to counseling. As Blum pointed out, the approach to each patient should be personalized, taking into ac- count social, cultural, ethnic, and occupational fac- tors, as well as factors related to the smoking habit.46O Success in breaking the habit depends on both the participant and the method. Persons who smoke 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 and in those who have a compelling reason to stop. This is why the role of the health professional is so important in helping patients to stop smoking. RISK FACTOR PREVENTIVE TRIALS Background Use of cigarettes has long been determined to be a major health risk. Its association with other ma- jor risks-hypertension and high cholesterol-led to 59 TIMN 293389

its involvement with research trials to study the single and multiple risk factor phenomena, especial- ly as it relates to coronary heart disease (CHD). In 1980, cardiovascular disease accounted for approx- imately half of all U.S. deaths-960,000 out of 1,980,000 total deaths.`'6' Of these, slightly over 565,000 were due to CHD. Thirty percent of CHD deaths are attributed to cigarette smoking, mean- ing that 170,000 Americans will die prematurely of CHD each year.461 As indicated, the major risk factors identified in the development of CHD are cigarette smoking, hypercholesterolemia, and hypertension. It is known that cigarette smoking acts both indepen- dently and synergistically with the other two ma- jor risk factors to produce CHD morbidity and mor- tality. Each of the three major risk factors poses ap- proximately the same increase in risk of CHD for the person with the risk factor, but cigarette smok- ing is far more prevalent as a risk factor than either hypertension or elevated serum cholesterol.461 The 1983 Surgeon General's report concluded that ciga- rette smoking should be considered the most im- portant of the known modifiable risk factors for cor- onary heart disease in the United States.461 The American Heart Association's Pooling Project found that men free of the three major risk factors had fewer deaths from all causes, as well as from heart attack and coronary deaths, over a 10-year period than did comparison groups of men who had one or more of the risk factors.48z Specifically, one risk factor doubled mortality, two tripled mortality, and three raised mortality five times. A series of single factor preventive trials in heart _ disease pointed to the possibility that intervention in the major risk factors could reduce the incidence and risk of CHD. This led to the concept of multi- ple risk factor trials. A planning group met during 1966 to 1969 and prepared a detailed design and protocol for multifactor preventive trials in CHD.463 International discussions were initiated in 1968 to consider the need, priorities, and methods for clinical trials in CHD and hypertension. In 1970, the Inter-Society Commission for Heart Disease Resources recommended that the Federal Government develop coordinated plans for a na- tional strategy to accomplish changes in diet, elimination of cigarette smoking, and control of elevated blood pressure.462 Out of these activities, two studies were implemented in London and Goteborg, Sweden, in 1969, and hypertension trials were launched in France and the United States in 1971. The World Health Organization European Collaborative 1l-ial was initiated in London, Brussels-Ghent, Rome, and Warsaw.464 This section will review only U.S. studies. The reader is referred to Judy Ockene's excellent review of five European risk factor trials.465 The compre- 60 hensive table provides the highlights of these studies pertaining to smoking, and the available quit rates are summarized in table 16. The Coronary Prevention Evaluation Program of Chicago attempted to modify major CHD risk fac- tors through intervention that primarily involved skilled advice, personal counseling, and support. Although 37 percent of 519 volunteers dropped out of the 7-year program, Stamler reported that signifi- cant measurable changes occurred in eating habits, serum cholesterol levels, and cigarette smoking and that death rates were lower than for a comparison group.466 Seventy-five of the original 191 smokers dropped out of the study, leaving 119 subjects. Of these, 37 percent quit smoking for an overall quit rate of 23 percent for the trial. The primary em- phasis in this study was on diet modification. Smoking cessation was deferred until diet and weight changes were made. Cooper et al. reported that half of the smokers who quit did so after being in the program over 2 years.467 Malotte et al. ran a 24-day residential program at the University of California, Los Angeles, which attempted to intervene in several risk factors related to chronic disease.468 Upon arrival at the center, each participant underwent a baseline physical and psychological evaluation and had a lifestyle modifi- cation regimen prescribed. All participants who smoked cigarettes were encouraged, but not re- quired, to attend the smoking cessation compo- nent. The cessation program used a behavioral self- management approach, providing support and teaching skills in a group setting. The group met for six 1-hour sessions. Thirty-six of the 43 smokers attended the smoking cessation groups. Of 32 sub- jects evaluated 6 months later, 15 of 25 subjects who attended the groups and 2 of 7 who did not participate reported abstinence for an overall quit rate of 53 percent. Unfortunately, all results were based on self-reports, only a small number of sub- jects were evaluated, and the followup period was too short. MRFIT The large-scale Multiple Risk Factor Intervention 'IYial (MRFIT) was initiated in 1972 in 20 centers of 18 U.S. cities by NHLBI with intervention begin- ning in 1974. In each of the 20 project centers, about 20,000 men between the ages of 35 and 57 were screened for combinations of three risk factors-cigarette smoking, high cholesterol, and elevated blood pressure.42 Subsequent to thorough screening trials, 2 groups of about 300 men each were selected by each center and randomized into 1 of 2 groups. In 1 group, the men were instructed to return to their personal physician ("Usual Care," UC) for help with risk factors, while in the other TIMN 293390

group ("Special Intervention," SI), 300 men par- ticipated in intervention methods conducted by a team of specialists. The methods were designed to eliminate cigarette smoking, reduce cholesterol, and lower blood pressure. The project lasted 7 years, and men in both groups were examined periodically to determine changes in risk factors. The hypothesis underlying the trial was that men in the SI group who were systematically helped to reduce risk factors would show lower rates of heart attack and death from CHD than would men ran- domly assigned to the usual care group who returned to their physicians for care.42 A complete description of MRFIT appears in the July 1981 issue of Preventiue Medicine.489 The smoking intervention consisted of an inte- grated program that included a message by a physi- cian to quit smoking, annual physical examina- tions, assignment to groups, individual counseling or a self-directed approach for those who declined to participate in assigned methods, and an elaborate maintenance program conducted over several years. The men and their wives (or friends) were invited to attend groups that met for 10 weeks. Intervention was guided by the Quit Smoking Book, specially prepared for MRFIT,47O and smok- ing specialists who were trained at national seminars. A series of seven short films aimed at stimulating conversation in the group was also pro- duced. A calendar datebook and other educational materials were used by the project. An extended intervention program was directed at those men who did not quit, including case con- ferences and group meetings. Some centers used behavioral techniques such as relaxation, role play- ing, and stimulus control. In summary, the in- tervention program was extensive, many tech- niques were used, and there were many procedures that could have influenced cessation, such as sub- jects' knowing that they were at high risk of heart disease and the taking of annual physical examina- tions.42 One example of a treatment program used by the New York center was reported by Powell and Arnold.471 SI subjects who had not stopped smok- ing by the fourth year were invited to participate in a 5-day multiple-treatment program based on behavior modification and self-control techniques. Procedures included stimulus control, relaxation training, cognitive coping, contingency contract, and eating management. An aversive smoking pro- cedure was used that made it inconvenient to smoke and left a bitter taste in the mouth. Three maintenance meetings were held, and subjects were telephoned frequently by the health counselor. Validated results 1 year later (MRFIT's year 5) showed that half of the 22 participants had quit. Both the SI and UC groups returned annually to the center for physical examinations, laboratory studies, and assessment of risk factors.472 Results for UC subjects were sent to their usual source of medical care. There were 8,194 cigarette smokers out of the total group of 12,866 MRFIT partici- pants.473 Serum thiocyanate (SCN) levels were used as a check on self-reported smoking. Cessation rates reported by MRFIT included both self-report and SCN-adjusted rates.465 Individuals who failed to attend the annual assessment were included at their baseline levels of smoking. Quit rates for MRFIT reported by Ockene are shown in table 15 48e Table 15 SELF-REPORTED AND ADJUSTED QUIT RATES FOR MRFIT AT YEARS 1, 3, AND 6 Intervention Group Usual Care Self- Report SCN- Adjusted Self- Report SCN- Adjusted Year 1 40 29 13 11 Year 3 40 35 16 15 Year 6 43 42 26 24 According to Ockene, the reported cessation rate for SI smokers was relatively stable from year 1 to year 4-about 40 percent-and then increased in years 5 and 6 to 41 and 43 percent, respective- ly.465.474 Quit rates for UC smokers increased linearly from 13 percent at year 1 to 26 percent at year 6. The difference in reported and adjusted rates between SI and UC subjects decreased each year but remained significant. Twenty-six percent of all SI smokers and 6 percent of all UC smokers stopped at year 1 and continued to report cessation through year 6.465 The adjusted quit rate for year 6 was 42 percent for the SI group and 24 percent for the UC group. A recent article provides MRFIT self-reported quit rates for year 7.475 The cessation rate for SI subjects was 46 percent and for the UC group was 23 per- cent. This indicates that as time passes, interven- tion smokers continue to quit (according to self- reports). It is questionable whether or not credit should be given to MRFIT for smokers who quit at years 3 to 7. Other factors besides the original inter- vention could be responsible for their abstinence, including illness or use of other cessation methods. Summary and Comment Table 16 summarizes the quit rates for seven large risk factor trials. The trials included in the summary table are the five European studies shown in the comprehensive table, the Coronary Preven- tion Evaluation Program, and MRFIT. Quit rates ranged from 12 to 46 percent with the median quit 61 TIMN 293391

rate being 31 percent. Followup comparisons to a control group were available for six of the studies, but only MRFIT validated abstinence. Four of the trials reported significant differences between the intervention and control groups. Table 16 SUMMARY OF FOLLOWUP QUIT RATES FOR 7 RISK FACTOR TRIALS N Range Median Percent 33% At Least 2 Year Followup Intervention Group 7 12-46 31 43 Control Group 6 0-26 16 0 MRFIT recorded a validated quit rate of 29 per- cent at year 1, 35 percent at year 3, and 42 percent at year 6. Although differences in quit rates between _ SI and UC subjects in MRFIT were significant, the rate for SI subjects was, nevertheless, disappointing for the first 3 years. In the planning phase of MRFIT, it was predicted that about 25 percent of the UC smokers would stop smoking through help from their physicians, through participation in communi- ty cessation methods, or through solo methods as these people were motivated by their knowledge of being at risk for CHD.42 It was also estimated that 60 percent of the intervention subjects could quit during the initial phase of the trial, and if this suc- cess rate were achieved, substantial differences would occur in mortality between SI and UC sub- jects. As it turned out, the 7-year CHD mortality rate difference between the SI and UC men was just 7.1 percent, much lower than the 22 percent predicted by risk factors.4'B The total CHD deaths in the UC group were substantially less than expected. Part of the reason for the low mortality rate for UC men was their 23-percent quit rate. The amount of time, money, and effort devoted to the MRFIT project should have resulted in a higher quit rate for SI smokers. The reason quit rates were not higher the first year of the project may be due to the restrictions imposed on the cessation methods that could be used by smoking specialists. Originally, only group or individual counseling or a self-directed approach were permitted, and other methods, including behavioral techniques, were pro- hibited. In later years, when it became apparent that high quit rates were not being achieved, the restric- tions were cancelled, and the centers tried a varie- ty of cessation techniques. It was in the first year, however, that it was necessary to score a high quit rate. Another factor that may have hindered a higher quit rate was the multiple risks that subjects were trying to reduce. Changing one behavior is difficult, but most subjects had to tackle high cholesterol and hypertension, as well as smoking. 62 The control subjects in MRFIT were highly se- lected and received repeated, extensive assessments that were almost certainly reactive. Nevertheless, based on the showing of the controls, we could screen high-risk smokers for risk factors, provide them with a physical examination and self-help kits, and yield a 25-percent quit rate. This would be a cost-effective approach of assisting high-risk smokers to quit. MRFIT was a mammoth undertaking. It involved 20 intervention centers in 22 clinical institutions, as well as a coordinating center, 2 electrocar- diogram centers, a national laboratory a standard- ization laboratory, and a drug distribution center. A total of 361,662 men were screened to produce 12,866 high-risk subjects. Considering its size and complexity, conducting and completing the project represents a major accomplishment. In the smok- ing area, a cadre of smoking specialists were trained, and some of these people are now leaders in the field of smoking cessation. The project demonstrated that it was possible to validate smok- ing status with objective measures. MRFIT and the other risk factor trials laid the groundwork for the intervention and community studies that followed. MASS MEDIA AND COMMUNITY PROGRAMS Background Mass media-television in particular-was used by the tobacco industry to influence smokers to con- tinue their smoking and recruit new smokers to the habit. One way to reach a wide number of smokers with instructions on how to quit smoking is through radio and television. Mass media communications through electronic media have resulted in increas- ing public awareness of the serious health hazards of cigarette smoking. During the late 1960's, the Federal Communications Commission required net- works to air antismoking advertisements. These spot advertisements apparently had a considerable impact, as the per capita consumption of cigarettes decreased between 1967 and 1971 and then began to climb when the advertisements were stopped.42 Wallack, however, points out that "Pro-use advertis- ing and funds far outweigh those of the health field, and pro-health media efforts have been embarrass- ingly ineffective compared to corporate promotional efforts."477 Fielding is convinced that radio and television broadcasts can be helpful in making the public develop strong negative feelings about unhealthy behavior.478 Theories concerning the effects of the mass media are varied and often contradictory. McAlister states that media were TIMN 293392 I

considered nearly omnipotent in directly altering behavior, but it was later discovered that they are incapable of producing effects independent of other, more powerful social forces.... mass media may have effects, but ... they are small.... shifts of a few percent- age points in consumer preference may be very significant in consumer marketing, while similar reductions in chronic-disease promoting behaviors may have enormous ab- solute significance.... '9 Nostbakken states that the value of the media in smoking cessation must be considered in view of the strengths and weaknesses of each medium for the task at hand.48O 'Iblevision, he says, is im- portant for smoking cessation because of its per- vasiveness in our lives. Ninety-six percent of homes in Canada have a television set, and 94 per- cent of Canadians use the set every day. Audiences go to the television set to be entertained, so televi- sion is a poor information source.lblevision serves as an example of mass media for creating or changing perceptions. Television should be used in all aspects, not just for commercials and public service announcements but through existing pro- gramming as well. Mass Media Programs Mass media programs can be grouped into three categories: those that seek to impart information or awareness; those that aim to induce people to take particular actions (e.g., attempt to quit smok- ing or request a self-help kit); and those that pre- sent smoking cessation clinics on camera. 'Ihlevi- sion interventions can differ widely in intensity. Some consist of brief public service announce- ments or segments during the evening news. Other programs may air an entire smoking withdrawal method. Reports of television and radio cessation pro- grams are sketchy, and only a few have been evaluated. Most evaluations of media programs are based on self-selected respondents who write in or telephone, and most have relied on self-reports without biochemical verification. The optimal evaluation strategy for a mass media campaign or message would be some kind of probability survey sample. Flay and his colleagues discuss the major problems that beset the evaluation of mass media programs.481-483 They note that the diffuse nature of the target audience limits the identification of persons at risk. The format of broadcast withdrawal clinics generally consists of advance publicity asking listeners to request kits, materials, and record cards. The program includes facts about the risks of smoking and the benefits of quitting, instruc- tions on how to cure the habit, and tips to aid the listener in maintaining nonsmoking status. Sometimes local announcers quit along with the listeners, or athletes or public figures present testimonials. The 1978 review listed a number of early radio and television programs, which will be sum- marized here.42 In 1969, the National Clear- inghouse for Smoking and Health broadcasted a television series over educational stations on how to quit'smoking utilizing the Self-Testing Kit. Each of the four tests of the kit made up one program. The kit was mass distributed free through phar- macies and other sources. It was estimated that 1 million smokers viewed the series. One followup of 207 persons who watched the program and used the kit showed that 23 percent were not smoking 1 year later.484 In June 1975, WCBS-AM radio (New York City) offered a smoking clinic through its news depart- ment. Promotional spots encouraged smokers to send for a special kit prior to the start of the clinic. The kit included educational material, question- naires, and record cards. Different messages were aired five times daily for 4 weeks. The messages advised listeners how to reduce cigarette con- sumption and presented tips on how to quit. Some of the station's announcers, who were also trying to quit, revealed their progress and empathy for listeners who were giving up cigarettes. The sta- tion had requests for 13,000 baseline question- naires, of which around 5,000 were returned to the station. A 10-percent sample was selected for study; of these, 384 (76 percent) were reached.485 It was found that 16 percent were not smoking a year later, 49 percent had quit for at least 1 day, and 26 percent had quit for at least 1 month. Dubren reported the results of quitting mes- sages broadcast over WNEW-TV, New York City, in August 1975.486 A step-by-step quitting plan con- sisting of twenty 30- to 90-second segments was broadcast five evenings a week for 4 weeks over the evening news. About 5,000 smokers registered for the clinic, and 310 were followed up at the end of the clinic and 1 month later. Fifteen percent of the men and 7 percent of the women quit and were able to remain abstinent 1 month later. The overall success rate was 9 percent. One of Dubren's impor- tant findings was that about half the sample had previously never been able to quit smoking for as much as 1 full day; yet some of them were able to quit with the help of these short, daily guidance messages on television. Dubren reported that WSM-TV in Nashville broadcasted a similar clinic but, in addition, showed two smokers going through the steps of the daily plan. This clinic had an overall success rate of 15 percent.487 63 TIMN 293393

WCAU, a Philadelphia radio station, aired Smokeless Radio for the month of April 1976.488 Listeners were offered tips on quitting, expense-paid trips to smoking cessation clinics, and free stop- smoking kits. During the month, 250 antismoking announcementG and editorials were aired. In 1978, Fredrickson televised his New York City Health Department Withdrawal Clinic over WOR-TV. In five half-hour programs around noon on Sundays, viewers were presented with information on their smoking habits and instructions on how to quit 489 Fredrickson's television clinic was rebroadcast several times, but unfortunately, its success was not evaluated. Best designed a feasibility study to provide data on the effectiveness of comprehensive self- management programming for a television or print format.490 The television series was produced and broadcast by KVOSTV, a CBS affiliate in Bell- ingham, WA. The series was broadcast on 6 con- secutive Saturday evenings in April-May 1977 to an audience that averaged 20,000 adults. Viewers were invited to register by mail or telephone and in return received a self-help guide. After eliminating nonsmokers, Best's study sample consisted of 1,403 subjects, of whom 60 percent were women. Each television show was linked to a specific chapter in the self-help guide. Viewers were instructed on how to analyze their smoking behavior. The facts about smoking, how to go about quitting, and coping strategies were provided to the audience. Actors demonstrated cessation methods and how to solve problems that arise when quitting. Support strategies that could be used by friends and relatives were described. In the last two broadcasts, quitters presented their experiences and use of coping strategies. Best managed to reach 87 percent of the sample at the end of the program and 71 percent 6 months later. 'Iiwelve percent stopped originally, but over time, the self-reported quit rate increased to 18 per- cent at 6 months. The cost of the program was $8,500, including $3,000 for evaluation. The cost per reported success at 6 months was $48. Best's study was well done. He commented that controls should be used to test the effectiveness of television programming. Although the study was preliminary, the results were promising. A smoking cessation program using radio and television was offered to residents of Denver, C0.491 Two weeks of promotion, which provided a Quit Line telephone number and 1 week of daytime program- ing, were given. Respondents who called the Quit Line were sent a smoking kit, and followups were made at 2 and 3 months. Packets were requested by 3,806 persons. Of these, 544 smokers were in- terviewed; a comparison group of 326 smokers was chosen from the area. After the program, changes 64 in smoking behavior (reduction or quitting) were reported by 71 percent of the media group and by 12 percent of the comparison group. While success of the program is difficult to determine, 33 percent of the media group reported that they were very like- ly to quit smoking. 'Ibtal cost of the program was less than $2 per person. In the Los Angeles area, an innovative television cessation program was coordinated with a school smoking preventive program. The investigators utilized a school-based, family-oriented smoking prevention program to motivate smoking parents to participate in a smoking cessation program. Flay and his colleagues at the University of Southern California presented five different 5-minute preven- tion segments on consecutive days in February 1982 on KABCTV.483•492 The segments were aired during the local news. A prevention curriculum was presented in the school classroom during the same week. Written materials were made available to chil- dren and parents. All family members were en- couraged to view the television segments and work with their children on homework assignments re- garding the factors influencing their children to smoke. During a second week, five additional segments on smoking cessation were aired. The pro- gram followed four smokers as they tried to quit. A self-help quitting kit was provided with further in- structions on how to break the habit. Preliminary results of the school prevention pro- gram are available but will not be discussed here.482-494 From program ratings, it was estimated that an average of 200,000 smokers viewed each of the segments, and as many as 400,000 smokers (22 percent of the smokers in the area) viewed at least 1 of the cessation segments.492 A random sample of 1,500 people was selected from among 30,000 who had requested program materials from the television station. A mail survey questionnaire was sent to them 6 weeks and again 1 year after the program. Only 20 percent (N = 300) of the contacted sample returned the questionnaire. Of these respondents, 89 percent reported viewing one or more segments. Nineteen percent of the re- questers reported that they attempted to quit; 12 percent reported being off smoking at 2 months. Two-thirds of the original respondents replied to the 1-year followup (N = 203). Eleven percent (9 percent of the original sample) reported that they remained quitters for 1 year. An additional 14 percent had quit sometime during the year, providing a total of 17 percent who were nonsmokers at the 1-year followup. Students who received the classroom program were more likely to viewr the television segments (65 per- cent) than were control students (10 percent).492 Of smoking parents of viewing students, approximately 45 percent watched the cessation programming, 30 TIMN 293394

percent attempted to quit or reduce, and 15 percent were not smoking at both 1-month and 1-year followups. Flay et al. comment that the results demonstrate the important role that families play in motivating adults to attempt to quit smoking.492 The Canadian Cancer Society and Health and Welfare Canada joined in the development of Time to Quit, a program designed to assist individuals aged 25 to 45 to stop smoking 144 The program con- sists of three main components: three half-hour television programs; self-help booklets that provide strategies to assist in practicing, - achieving, and maintaining nonsmoking behaviors; and a com- munity guide, which introduces and explains the program to the community. The series is based on the philosophy that people watch television not for information but for entertainment.495 Time to Quit is designed to be used on a community-by- community basis. Each community prepares for 6 months in advance of a 2-month publicity blitz, followed by release of the self-help booklet and the airing of the first television show The program relies on a cognitive and behavioral approach organized on the basis of a health belief model where a smoker must believe he or she is susceptible to the negative consequences of smoking and that quitting is the preferred choice. The program is currently being evaluated. Beginning in 1982, the Saskatchewan Lung Association and the University of Saskatchewan undertook a smoking campaign that was extended to several cities and resulted in the Lloydminster Community Project. The investigators gained the assistance of CKBI radio and television in Prince Albert to determine whether the electronic media could support a community effort to stop smok- ing.496 ALP;s FYeedom FYom Smoking in 20 Days provided smokers with a day-by-day working plan. CKBI worked to develop a community spirit in half- hour programs and daily live announcements. Talk show hosts, physicians, and lung association person- nel contributed on the air. There were 1,822 P-rncakPrs uzhn_rvirrhaaPrT thP AT_A_st-1L-hPLn aitTSies quit at day 20, and at 14 months, 20 percent claimed abstinence, and another 16 percent said they had reduced their consumption. The investiga- tors commented that a combination of television and radio together is more successful than televi- sion alone.497 They concluded that the increased public awareness of smoking and health problems would be impossible to achieve in a form other than the electronic media. A variety of papers detail the Finnish stop- smoking television series broadcast in 1978, 4981501 and Danaher et a1502 and McAlister479 have provided reviews of this program. Danaher et al. have also reviewed a cessation program televised in Melbourne, Australia.-902 The reader is referred to the original reports or the reviews for the details as only a brief summary is included here. The Finnish program was broadcast for 1 month in 1978. Seven 45-minute episodes followed a group of 10 volunteers videotaped 6 months previously.5ol The program consisted of a series of televised counseling sessions and an effort to organize volunteer-led, self-help viewing groups. Written materials were made available through a communi- ty effort. A survey (90-percent return) revealed that more than half the population saw at least one show and 7 percent viewed at least four segments. Various data indicated that some 100,000 smokers (10 per- cent of all smokers in the country) followed the pro- gram closely. Over 20,000 smokers stopped with the aid of the television program, and some 10,000 (1 percent) succeeded for a period of at least 6 months.49`' The Melbourne program was broadcast during a news program on five consecutive nights with segments lasting 5 minutes.502 Oversmoking prac- tice, coping, and maintenance strategies were treated. Interviews 1 week after the program revealed that 27 percent of the smokers watched the program; 12 percent of them said the program was "very helpful," and 33 percent found it to be "helpful: " Abstinence data were not reported. Dansh.er Pt al _ rnmmPntPrl that althsuigh. the _

smoking through the television program.499 The 1980 program promoted smoking cessation and dietary change. Printed guides, workbooks, self- tests, and reference materials were widely distributed. Program evaluation of the 1980 pro- gram was conducted through a mail. survey that produced 4,711 replies (79-percent response).504 Self-reported effects were verified by telephone or letter. Six months later, 0.5 percent of all smokers had stopped smoking, yielding approximately 5,000 ex-smokers. The authors commented that dealing with more than one risk factor resulted in lower rates for smoking cessation. Televised cessation programs have been broad- cast in many countries. A British program will be described briefly. During 1982, BBC Television broadcast a series of six weekly 10-minute pro- grams designed to help smokers who wished to stop smoking.505 Approximately 8 million people viewed each program. An extensive evaluation of the effectiveness of the series and the accompany- ing free information was undertaken. Considerable research was carried out before making the series. Pilot programs were shown in 11 cities to groups of the target audience and health professionals in order to ascertain responses to styles and types of information and to establish criteria for an effective smoking cessation series. A Give Up Smoking kit was sent to all general practitioners in the event pa- tients would request additional help after watching the program.506 Evaluation showed that at 1 year the results were disappointing with no difference between viewers and nonviewers. Kunze and Wood edited a report that pointed out that the program appeared during a period in which several price rises contributed to a substantial fall in the prevalence of smoking and cigarette sales.41o Use of the Telephone Television and radio programs have been shown to help some people to give up smoking. The prob- lem with these types of clinics is that once the pro- gram ends, maintenance support is lacking. Dubren devised a way of offering followup support to per- sons who had gone through a television smoking clinic.507 He designed a program in which recent quitters were able to telephone for 20 different 3- minute taped messages aimed at reinforcement following abstention. Subjects and controls were drawn from a television quit program. A letter in- formed the subjects that they could call a number daily for the message that would help them stay off cigarettes. Sixty-six percent of the persons in the telephone self-reinforcement group (N = 29) reported that they were not smoking at the end of the month compared to 34 percent of the persons in the control 66 group (N=32). Tiwenty-three out of 29 persons in the self-reinforcement group called the number at least once. The self-reinforcement telephone calls are practical and extremely cost-effective as a maintenance method. There are a number of telephone hot lines pro- viding information about smoking and quitting. Ex- amples of three of these are reported. In 1977, ACS initiated a telephone intervention system for smokers and ex-smokers in San Diego called Quitline. Saunders described the system, which of- fers immediate access to volunteer ex-smokers who are specially trained to provide assistance to smokers who have decided to quit or ex-smokers who need support in remaining abstinent.508 The volunteers are responsible for assessing the scope of the questions and guiding callers to the ap- propriate resources. ACS developed a manual for the operation of a Quitline. During the first 6 months of the San Diego Quitline, there was a low response attributed to lack of public awareness of the project. Zb remedy this, the Quitline turned to a television station to put a series of quitting tips into its news broadcast. Within a 2-week period, the Quitline received 600 calls, and the unit office accounted for 32,000 written requests for information on how to quit smoking. Of 439 Quitline callers followed up, 18 percent had quit for 6 months, 27 percent had reduced consumption, 12 percent were attending ACS smoking clinics, 8 percent had made no change, and the remaining 35 percent could not be reached. The vast majority of calls received were from people seeking either literature or tips on quit- ting or referral to smoking clinics. Rl-Med is a library of tapes on health and medical information that is available to the general public via telephone. Te1-Med was funded by a grant from the Public Health Service in 1973 with financial support transferred to the San Diego County Medical Society in 1975.509 By 1975, 'Ibl-Med had spread to 39 cities. The library contains tapes on a variety of health subjects that are 3 to 7 minutes long. Callers select the tape or subject they wish to hear. Of 325,000 messages requested of TN-Med during its first 2 years of operation, 6 tapes on Quit- ting Smoking accounted for 10,000 of the calls. The tapes are used by physicians to assist their patients to stop smoking. The Freedom Line was provided as a taped tele- phone support service for ex-smokers in Rochester, NY, to enhance maintenance of nonsmoking.51o•g11 The service was promoted through voluntary associations, public service announcements on radio stations, newspaper coverage, and television and radio interviews. Over an 8-month period, more than 8,000 calls were received. TIMN 293396

Great American Smokeout A media event that has been quite successful is the Great American Smokeout. The first mass movement by smokers to give up cigarettes was led by Lynn Smith of the Monticello, MN, Times in 1974.512 The idea of "D-Day" was adopted in the entire State of Minnesota in 1975 and in California in 1976. The Smokeout was sponsored nationally by ACS in 1977. The idea of "taking a day off from smoking" has spread to Canada, Great Britain, Ireland, France, Australia, South Africa, Norway, and Sweden 513 There are indications that the Smokeout may become a worldwide no-smoking day. The Smokeout is held each year on the Thursday before Thanksgiving. The event is sponsored by ACS, but thousands of other organizations, schools, businesses, and hospitals join the nationwide effort. Smokers are asked to sign pledge cards indicating that they will not smoke during the Smokeout Day. An 8-day media blitz precedes the Smokeout Day, and events are sponsored locally to draw attention to the Smokeout. For the last 4 years, Larry Hagman has been the national chairman for the Smokeout. A national hotline is available to smokers seeking advice and encouragement about refraining from smoking. On the eve of the 1984 Smokeout, the Public Broadcasting System aired a national televi- sion variety show on smoking called Breathing Easy, aimed at teenagers and their families. ACS sponsors an evaluation of the Smokeout. In 1977, the first year of the national effort, Lieberman Research supervised telephone interviews with 1,538 adults in 7 states.514 Three out of every 10 cigarette smokers either stopped or cut down smok- ing during the Smokeout Day. Of those cigarette smokers questioned, 13 percent reported that they quit on Smokeout Day with another 18 percent noting that they cut down on smoking. One month after the Smokeout, there was a 4-point percentage drop in the incidence of smoking among those ques- tioned. In 1978, the Gallup organization evaluated the event.515 There were 3.5 million smokers who quit for the day, and another 10 million stopped for part of the day. After 2 weeks, 2.5 million smokers reported to be still off the habit. A 1981 survey showed that over 1 million participants in the 1980 Smokeout were still not smoking 11 months later.516 Dawley and Finkel studied the response to the 1979 Smokeout at a Veterans Administration Hospital in New Orleans.517 Pledges to refrain from smoking on the day of the Smokeout were solicited from patients, visitors, and staff. One-third of the pledgees were nonsmokers or ex-smokers, leaving 82 smokers who signed pledges to stop for 1 day. The investigators contacted the smoker pledgees 2 months later and found that 73 percent had par- ticipated. Of these, 43 percent refrained from smoking for 1 full day, and 18 percent were still not smoking 2 months later. Thirteen percent of those who signed pledges were abstinent at 2 months. According to a survey conducted by the Gallup organization in 1983, just under 36 percent of American smokers attempted to give up cigarettes on Smokeout Day.513 Over 8 percent succeeded in stopping for a full 24 hours, and 1 to 11 days later, over 4 percent reported still not smoking. A Gallup telephone survey of a representative sample of 1,291 men and women after the 1984 Smokeout found that 1 out of 3 smokers attempted to stop smoking for at least 24 hours.518 An estimated 20.4 million smokers succeeded in either avoiding cigarettes completely or cutting down. Of the participants, 5.4 million smokers-almost 10 percent of all smokers in the country-made it through the day without cigarettes. An additional 15 million tried to curtail their habit by smoking less. The survey also revealed that among those who gave up cigarettes for the day, more than half-3.1 million persons-still were not smoking 1 to 5 days after the Smokeout. More than four out of five adults surveyed reported that they had heard of the 1984 Great American Smokeout. Smoke-Free Days in Australia and Great Britain A Smoke Free Day was held in Perth, Western Australia, on November 10, 1982.519 The day was advertised heavily on television and radio, in the press, and by community promotion. Three months after the Smoke Free Day, 93 percent of subjects surveyed indicated their awareness of it. An estimated 37 percent of smokers tried to quit that day, and 23 percent succeeded; 2.3 percent quit smoking and were still nonsmokers 3 months later. Up to 1.8 million smokers (13 percent) took part in National No Smoking Day 1984 in Great Britain by quitting, attempting to quit, or reducing their consumption on that day.52O The day was sponsored by a coalition of national organizations. The day generated considerable publicity for smoking and health. An estimated 500,000 people reported smoking less 3 months later. Doctors Ought to Care In 1977, Alan Blum launched Doctors Ought to Care (DOC) as a coalition of health professionals aimed at promoting good health and curbing such lethal lifestyles as cigarette smoking.42T521 The organization has been supported by over 2,000 physicians and medical students.522 In addition to setting up a speakers bureau of local health profes- sionals, DOC conducts a counteradvertising cam- paign that employs paid radio and television commercials, posters, newspaper and bus bench 67 TIMN 293397

advertisements, and T-shirts. DOC uses humor and ridicule by creating parodies on cigarette themes.42'•szs DOC represents one of the few organized efforts by medical practitioners to use the media to counter cigarette smoking. Although DOC has directed its efforts primarily at prevention, the counteradvertis- ing campaign has likely reached smokers. Community Programs San Diego Community Laboratory A number of programs have involved all or part of a community in an antismoking campaign. The National Clearinghouse supported two early com- munity programs in San Diego and Syracuse. The San Diego Community Laboratory was funded from 1966 to 1974. The primary objective of the project was to reduce cigarette consumption over a 5-year period and to identify those programs that were most effective.524 The program aimed to develop a reinforcement model in which the mass media, school programs, health professionals, military, workforce, and community agencies were maximal- ly involved in antismoking education. Evaluation was keyed to 3 major U.S. probability surveys con- ducted by the Public Health Service in 1966, 1970. and 1975 with approximately 2,500 adults in the San Diego sample. The results indicated statistically significant reductions between 1966 and 1975 in the percentage of adult males and females smoking in San Diego compared to the national sample. Lloydminster Community Project The Freedom From Smoking in 20 Days cam- paign in Saskatchewan has been described above. The same groups (the lung association and univer- sity) undertook a community program in 1984 in Lloydminster, a market area of 15,000 people.525 The program aimed to combine the media, community, and smokers in a 20-day cessation effort using the FYeedom From Smoking in 20 Days manuals. The project secured the cooperation of the local televi- sion and radio stations, daily and weekly news- papers, professional health community, and in- dustry. Next, "high profile quitters" (HPQ) from the media were recruited, and endorsements were received from the mayor and city council. Among the HPQ's were a news reporter, the wife of the editor, several persons from the radio and television stations, and three council members. The public library offered to be the signup center and resource for selling the manuals. A great deal of publicity was generated prior to the start of the program. The proj- ect brought all HPQ's to the University Hospital for a lung function test and slide presentation by a radiologist. A full television crew filmed the event 68 and interviewed the radiologist and a cardiologist. As it turned out, the radio HPQ showed quite severe breathing problems. On day one, a town meeting was held during which a chest specialist and technicians were available to conduct breathing tests. The television and radio audiences and newspaper readers followed the HPQ's in their efforts to quit. The program ended on day 20 with a pancake breakfast. Over a thou- sand people signed up for the project at the public library. This represented almost one-fifth of all smokers in the community. A random sample of 200 participants was chosen for evaluation and fol- lowed up 30 days after day 20. It was found that 31 percent reported that they had quit, and 25 percent said they had cut down on their smoking. The cost of this community effort was only the salary and travel of the lung association staff. The media and all other activities were donated. This was not a scientific study; there was no control community, and abstinence was not validated. The program shows what can be done at the local community level at a minimal cost. Stanford Three-Community Study `Ib determine whether community health educa- tion can reduce the risk of cardiovascular disease, a field experiment was conducted in three northern California towns by the Stanford Heart Disease Pre- vention Program.52s.5so In two of these com- munities, there were extensive mass media cam- paigns over a 2-year period (1973-1974), and in one of these, face-to-face counseling was also provided to a subset of high-risk people. The third community served as a control. In each community, a random sample of approximately 500 persons aged 35 to 59 received preventive screening examinations that were repeated annually for 3 years. Subjects were compared for changes in risk factors (smoking, plasma cholesterol, blood pressure, and relative weight). Serum samples from high-risk individuals were analyzed for thiocyanate concentrations as a check on inaccurate reporting of smoking status. The measurements for smoking yielded 3-year smoking trends among survey subjects in the three communities.479 The mass media and counseling campaigns were designed to produce awareness of the probable causes of coronary disease and of the specific measures that may reduce risk. The mass media campaign consisted of about 50 television spots, 3 hours of television programming, over 100 radio spots, several hours of radio programming, news- paper columns and advertising, billboards, and mailed messages to participants.527 Smoking cessa- tion consisted of information on the harmful effects of smoking, advice on how to stop, booklets with TIMN 293398

instructions on self-control skills, and small groups that met for 10 weeks. Tiwo-thirds (N=113) of the participants in one city identified as high risk were randomly selected for counseling. Of these, 107 attended counseling ses- sions, and 77 high-risk individuals completed the 3 interviews and examinations.5?8 In the control community, the risk of cardio- vascular disease increased over the study period; but in the treatment communities, there was a substan- tial (20-30 percent) and sustained decrease in risk. In addition to the overall risk reduction, the inten- sive instruction group exhibited a 50-percent quit rate at a 3-year followup; an adjustment for attrition reduced the quit rate to 32 percent. A surprising finding was that none of the media-only smokers in one city reported cessation, while the quit rate in the other city for media subjects was 11 percent; this compared to 15 percent of the controls who reported abstinence. These results were based on those at- tending the followup (from 58 to 68 percent). The investigators concluded that the combination of media and face-to-face instruction was more suc- cessful than mass media alone in increasing awareness of risk factors and in motivating and maintaining health behavior changes.53° One wonders why none of the media subjects in one city stopped smoking. Ockene offers the opinion that there may be "a 'saturation point' with regard to the effectiveness of increased awareness, which when reached requires intervention to be at an in- tensive individual level before the next level of smokers can be affected: 's31 Leventhal, Safer, Cleary, and Gutmann critically examined the objectives, methods, results, and con- clusions of the Stanford Three-Community Study.sm They state that the Stanford study was not a "com- munity study" but a quasi-experimental study of individuals in a community setting. They found that incorrect conclusions were drawn about the effec- tiveness of mass media in reducing risk factors and changing lifestyle. They point out that the high risk subjects in the media-only condition showed virtual- ly no reduction in cardiovascular risk, although they did show increased knowledge about risk factors. Studying changes in smoking provided no evidence of media effects, as significantly fewer subjects quit smoking in the media-only group than in the con- trol community. Nevertheless, the Stanford study and the North Karelia Program were pioneering ef- forts to reduce risk factors in community settings. These two projects laid the groundwork for the next series of community programs. Recent U.S. Community Studies: Stanford, Minnesota, and Pawtucket NHLBI has funded three community projects aimed at reducing risk of cardiovascular disease: the Stanford Five City Project, the Minnesota Heart Health Program, and the Pawtucket Heart Health Project. These studies are research and demonstra- tion projects aimed at assessing the effects of educa- tion and health promotion programs and community strategies. The projects are designed to run 9 to 10 years. Investigators of the three projects meet regularly to standardize outcome criteria and ex- change technical information.593 Each project has a smoking cessation component. Unfortunately, the intervention and control communities were not chosen randomly. The projects are now in the early evaluation phase. The Stanford Five City Project (1978-79 to 1986-87) aims to test whether a significant decrease in risk for people in two intervention communities will lead to a greater decline in morbidity and mor- tality from cardiovascular disease compared to peo- ple in three control communities.534 A 6-year health education campaign aims to encourage people to make lifestyle changes in smoking, weight, blood pressure, and nutrition. Mass media, intensive in- struction, and community organization are the at- tributes of the intervention program. Survey samples will be drawn every 2 years to monitor community-wide changes independent of survey ef- fects. Tiro communities were selected for education. and three cities were chosen as controls. The five cities have a total population of 350,000. The Stan- ford project monitors the annual rates of fatal and nonfatal cardiovascular events in the five cities. The project collaborated with the County Health Department to establish smoking classes in the communities. Stanford helps with training, cur- riculum development, evaluation, and curriculum revision.534 The broadcast media is being used to provide information, support community programs, change knowledge, attitudes, and behavior, and recruit smokers into cessation programs. The Stanford project aims to reduce individual risk factors of the following magnitude: a 9-percent net change in the proportion of smokers; a 2-percent change in relative weight; a 7-percent change in systolic blood pressure; and a 4-percent change in cholesterol.534 A goal is to create a health education program that will be continued by the community after the project ends and that would have general applicability in other American communities. The Minnesota Heart Health Program (1980-81 to 1989-90) is designed to reduce risk of cardiovascular disease by providing community health education and enhancing the community climate to support healthy behaviors.535.538 Three pairs of educated and reference communities were chosen for study with staged entry so that a new community entered into treatment each year for 3 years. The three pairs of communities are located in Minnesota, North Dakota, and South Dakota. The communities were chosen to represent three different types: small towns, large free-standing cities, and large 69 TIMN 293399

metropolitan areas. The project deals with four ma- jor risk factors: hypertension, hypercholesterolemia, smoking, and physical activity. The communitywide smoking education program emphasizes increasing knowledge of the social and psychological consequences of smoking and the benefits of quitting. The aim during the first year of the program was to build community awareness of smoking cessation. In addition to planned activi- ties in the first community, the local television sta- tion aired a 5-day series of cessation tips. A telephone evaluation revealed that about one-sixth of the smokers watched at least one segment and approximately 1 percent stopped smoking.5-15 A smoking cessation short course, Quit and Win, is a packaged program designed for smokers who want to quit smoking but are not interested in for- mal cessation programs. Quit and Win is offered during one 90-minute session with followup activi- ties suggested in a self-help guide.53s During the second project year, a Quitter's Con- test was sponsored to increase public interest. Smokers were asked to quit for at least a month in order to earn prizes, which were family oriented. A total of 544 smokers (5 percent of all smokers in the community) committed themselves to quit. A wide variety of mass media coverage promoted the con- test. Chemical testing was used to verify reports of quitting. A telephone survey revealed that over 50 percent of those who signed up quit for a month and that 34 percent were still abstinent at 2 months.535 The educational program for youth and parents involves a combination of communitywide and school-based activities. The Minnesota smoking prevention programs have been adopted by all schools in the intervention community of Mankato, MN. According to the investigators, the smoking education plan is comprehensive, involving multi- ple segments of the community, and is based on educational activities that should be persistent and cumulative.538 Education is also provided to health professionals to encourage them to serve as role models. Health professionals play a key role in the practical applica- tion of preventive practices and serve as the pro- viders of health information. Approximately 190 community leaders have been involved as volunteers in Mankato. Through spring 1984, 123 newspaper articles appeared, 47 television and radio announcements were aired, and 13 educa- tional radio programs were broadcasted 53s 'Ib determine awareness of the Minnesota program in Mankato, a sample was randomly selected and surveyed by telephone.538 Forty-one percent of the sample reported awareness of the quit-smoking seminar, and 24 percent knew about the quit- smoking promotion. The investigators report that the program in Mankato has achieved its aims of generating community awareness of its health messages and of community exposure to health pro- motion activities. 70 This is a long-range study, and the investigators expect to detect true changes in smoking prevalence only after 4 to 5 years of educational effort. Surveillance is carried out in annual population- based surveys with periodic cohort studies.533 Ttends of health behavior, risk level factors, and morbidity and mortality rates are being measured in the educated and comparison communities. Specific goals for the average differences in risk factor levels between pooled educated and comparison com- munities are as follows: 1.5 percent in systolic or diastolic blood pressure; 2.0 percent in relative body weight; 3.5 percent in total serum cholesterol; 50 percent in persons engaged in vigorous activities; and 20 percent in quit smokers or amount smoked.536,537 It is my opinion that "amount smoked" is a poor evaluation measure as it is possible to show signifi- cant differences in large population samples even though these differences have little meaning. The investigators are advised to drop this criterion and base their evaluation on differences in the percen- tage of smokers who quit. The goal should not be to reduce the amount smoked but to get smokers to quit completely. The Pawtucket Heart Health Program (1980-1991) differs from the other two recent community pro- jects as it relies on volunteers recruited from within the community to deliver the change pro- gram.539.540 The Pawtucket program aims to develop and assess the effectiveness of a com- munity-based program to prevent atherosclerotic heart disease by modifying behaviors and risk fac- tors. The major risk factors targeted are cholesterol, smoking, blood pressure, weight, and physical ac- tivity. The study community of 72,000 in southeastern New England is made up predomi- nantly of blue-collar residents. A Leadership Committee, composed of approx- imately 70 community leaders provided guidance regarding both information and access to the com- munity and its organizations. The Leadership Com- mittee is expected to help organize and assist the community group that will assume governance and maintenance of the program after most Pawtucket program staff members withdraw. Professional guidance is being provided for 4 years. Thereafter, program management will be directed almost en- tirely by the community volunteer system.54° The project will assess the use and effectiveness of lay facilitators and community involvement in health promotion, behavior change, and reducing risk factors. The program's intervention was de- signed to introduce behavior change activities through social networks. Participants will be offered the skills to stop smoking individually, as well as through social groups and organizations. Par- ticipants are advised to encourage other individuals TIMN 293400

in their social networks to alter their risk factors. Newspaper articles, risk factor screenings, and self- help programs are also used to promote healthful lifestyles.541 Electronic media is not being utilized by the pro- gram as the two cities being compared share the same television and radio stations. The print media and ongoing health-related activities in each city are being monitored for health promotion efforts. The overall outcome evaluation is based in part on a cross-sectional random sample survey of 1,400 subjects in the intervention city and the comparison city.g39 The surveys are being conducted at 2-year intervals. Morbidity and mortality surveillance con- sists of a review of deaths and hospitalizations to determine cardiovascular events. Although the program is currently being evaluated, it has already been demonstrated that lay volunteers can lead small group change programs without professionals in attendance.54O The use of volunteers in the Pawtucket program has been ex- tensive with volunteers involved in all levels from program planning through implementation. In a report covering the first 26 months of the project, the investigators describe three phases: the first 11 months of approaching the community through local organizations; the next 7 months during which programs were directed at the com- munity; and 8 subsequent months of greater em- phasis on community programs along with an organizational component 541 The investigators found that the approach through organizations was slow and labor-intensive. It was therefore decided to shift toward an emphasis on community programs. The Parks and Recreation Department had an ongoing physical fitness program, which they ex- tended to cover other risk factors (smoking cessa- tion, weight loss, and cholesterol control). An Up In Smoke Lottery drew 111 smokers for a smoking cessation effort. School children were enlisted to promote the cessation program. Working within the community, as compared with an organization or small group context, re- quires a more complex intervention model. The Pawtucket program is guided by three principles: local ownership that encourages volunteers and organizations to participate in the design and im- plementation of all programs; inexpensiveness so that a resource-poor organization or community can sponsor program activities; and personal program promotion to enhance participation. The program learned that when simultaneous consideration was given to community, organizational, small group, and individual programs to strengthen program effects reciprocally at each level, a substantial acceleration in participation was realized.541 Community Programs in Australia, Switzerland, and Finland Reports of these programs are taken from McAlister's fine description of community studies.542 The Australian North Coast Program used small communities (12,000 to 27,000 popula- tions) in a project similar to the Stanford study. Each of three towns was assigned to one of three conditions: control, media only, or combined media and community programs. Random samples in each town were invited for interviews and examina- tions in 1978. Smoking behavior, attitudes, and knowledge regarding smoking were measured. The media program used television, radio, newspapers, and a variety of materials. Interpersonal support in- cluded groups, clinics, and workshops, some with physician involvement; 386 smokers took part in these activities. McAlister reports that the 3-month success rate was 16 percent for workshop partici- pants. Forty persons who received help kits from physicians achieved a 48-percent quit rate. The following percentage reductions in smoking were recorded: 6 to 15 percent in the town with the com- bined media and community program; 6 to 11 per- cent in the media-only town; and 2 to 5 percent in the control town. There were no changes in knowl- edge or attitudes. liwo pairs of German- and French-speaking com- munities (12,000 to 16,000 populations) were ran- domly assigned to intervention or regular care con- ditions in the Swiss National Research Pro- gramsaz,sas Stratified random samples of 2,000 persons aged 16 to 69 were examined in each com- munity for baseline measures in 1977-78 and reex- amined in 1980. Media and community programs promoted a variety of classes, self-help groups, and discussion meetings. Results showed that the in- tervention sample resurveyed reported 26-percent cessation compared to 18 percent in the control community.543 Independent samples indicated that 11 percent more of the people in the intervention community stopped smoking when compared to people in the regular care community. McAlister commented that "the use of independent surveys and the random assignment of communities to conditions represent significant methodological strengths as compared to the Stanford and Aus- tralian studies."544 The North Karelia Project is well known through over three dozen published articles.496'5o1,®ossoa The national television series has been discussed earlier in this section. This account will be brief; the reader is referred to the original articles or the reviews by McAlister479 or Ockene.465 The project began in 1972 and is still ongoing, comparing changes in cardiovascular d'--ease risk factors in two adjacent counties in easec:rn Finland.479 In the 71 TIMN 293401

intervention county (North Karelia), a broad pro- gram of education and training was provided through community health centers, the mass media, and community organizations. Initially, an intensive educational campaign was conducted for the reduction of cigarette smoking, and a group program was offered to smokers. The other county had no special programs, but as already indicated, people in this area could have viewed the national television programs. Independent samples of households of about 5,000 persons in each county were drawn in 1972, 1977, and 1982; the response rate was about 90 percent.545 Self-reported smoking behavior was checked for a subsample in the 1977 and 1982 surveys by serum thiocyanate value; for the 1977 sample, there was 99-percent agreement in smok- ing status.479 McAlister reported that "since 1978, when new antismoking laws were passed, the pro- portion of male smokers aged 15 to 64 has changed from 44 to 31 percent in North Karelia, and from 39 to 35 percent in the rest of the country."546 The prevalence of smoking decreased considerably at year 5 in both the study and control groups with a net reduction of 2.5 percent in the intervention county for the men and 6.1 percent for the women.545 Seventeen percent of the baseline smokers in the Intervention county reported smok- ing cessation compared to 15 percent of com- parable smokers in the control county.5's McAlister offered the following comment about the North Karelia Project: Because a large number of independent units were not randomly assigned to experimental and control conditions, the Finnish study cannot be taken as a conclusive test of the effects of community programs, but it does provide a promising illustration and evalua- tion of what can be achieved through broad and vigorous intervention to rc.duce smoking behavior.g46 Summary and Comment Table 17 summarizes the results of the mass media and community programs. The trials are not comparable to each other due to differences in methodology, followup, the way the evaluation was done, and other factors. These types of studies are difficult to evaluate as the response rate is usually low when random samples are chosen and the peo- ple selected are asked to cooperate. For results of the Stanford Three-Community Study and the North Karelia Project, the reader should consult several references for a more comprehensive picture. A variety of mass media approaches to smoking cessation have been reviewed in this section. Many people are reached by television and radio quit pro- grams, and it is clear that many smokers are en- couraged to try quitting and some succeed. Pro- grams, such as the Great American Smokeout, receive wide publicity and trigger quit attempts by smokers. DOC aims most of its efforts at prevention, but its counteradvertising parodies may affect smokers. Use of the telephone to provide mainte- nance support is noteworthy. The results of these programs are very difficult to evaluate. Table 17 SUMMARY OF THE RESULTS OF MEDIA AND COMMUNITY STUDIES Year Number ia Quit Program and Methods Reporter Sample Rate Pbllownp National Clearinghouse for Smoking and Health 1969 National television series using SeiJ-lbsting Kit Green484 207 23 1 Year AM-Radio Smoking Clinic, New York City 1975 Different messages 5 times daily for 4 weeks Dubren 384 16 1 Year Out of 5,000 questionnaires. 10% sample chosen for study; 76% reached Television Quit Plan, New York City et al.485 1975 Quitting messages 5 evenings per week for 4 weeks Dubren488 310 9 1 Month 20 segments 30- to 90-seconds Out of 5,000 persons registered. 310 followed up Iblevision Quit Plan, Nashville 1976 nr 15 1 Month Similar to New York program plus 2 smokers shown going through program TV Quit Program, Bellingham, Washington Dubren*M 1977 Self-management, coping, and support strategies Best*9O 1,403 18 6 Months 6 consecutive evenings 71% of sample reached 72 TIMN 293402

Table 17 (continued) Program and Methods Tear Reporter Number in Quit Sample Rate Followup Freedom From Smoking TV Series, Saskatoon and 1983 Regina, Saskatchewan Freedom From Smoking tn 20 Days followed Korchin496 585 20 14 Months Finnish National 'Iblevision Series 1978 7-45 minute segments following 10 volunteers Puska et al.*99 - 1 6 Months 'Iblevision counseling sessions 10% of smokers in country followed series Program repeated in 1979-4% of smokers quit Finnish National 'Iblevfsion Series 980 Smoking and dietary changes Puska et. a).gO4 4,711 0.5 6 Months Mail survey-79% response Taped Messages by 'Iblephone for Maintenance 1975 Subjects watched television quit program Telephone reinforcement group Dubren507 29 66 1 Month No telephone reinforcement 32 34 guitline. San Diego 1977 Volunteers offered advice to smokers Saunders508 439 18 6 Months Great American Smokeout, American Cancer Society 1977 Sample 1,538-4% drop in smoking at 1 month 3 out of 10 smokers stopped or cut down Great American Smokeout: 2.5 million still off Liebermana'* 1978 smoking at 2 weeks Great American Smokeout: 1 million still off Gailups1a 1980 smoking at 11 months Great American Smokeout: 4% still not smoking Gallup516 1983 at 1-11 days Great American Smokeout: sample of 1,291-50% Gallup513 1984 not smoking at 1-5 days Great American Smokeout: pledges taken at VA Gallups1H 1979 hospital, New Orleans Cessation-13% of those who participated, Dawley and Finke1517 82 18 2 Months 9% of those who signed pledges Lloydminster Community Program, Saskatchewan 1984 Mass media campaign, community support KorchIn525 200 31 1 Month 'Ielevision quit program followed Freedom From Smoking in 20 Days Australian North Coast Program, New South Wales 1978 Mass media and community program (groups) plus workshop McAlister479 150 16 3 Months plus kits from physicians 40 48 % reductions in smoking (samples 600-1,200): Media and community program, 6 to 15 Media only, 6 to 11 Control. 2 to 5 Swiss National Research Program, 978 4 towns: French- and German-speaking pairs Media and community program McAlIster49 Gutzwiller - 26 2 Years Regular care control et al 3Sg - 18 Independent samples: 11 % more cessation for intervention sample than control North Karelia Project. Finland 1973 Mass media, community health centers. Puska et al sss - 17 5 Years community organizations Intensive education campaign Control McAlister'7g - 15 Independent household samples studied 25% reduction in smoking at year 10 for intervention sample, 10% controls Stanford Three-Community Study. California 973 Mass Media plus intensive instruction. face-to-face counseling (high-risk subjects) Stanfordsz7sso.a7s 77 32 3 Years Mass media only 56 0 Mass media only 136 11 Control 136 15 (Samples studied in each community) 73 TIMN 293403

The Lloydminster Community Program demon- BEHAVIORAL METHODS strates that community projects can be accom- plished at the local level with the lead of a volun- tary or public health agency. These projects should be carefully analyzed with appropriate controls and followup proccdures. Without outside funding, ex- tensive evaluation may not be possible; but evalua- tion is. nevertheless, necessary to determine the ef- fectiveness of the community effort. Community studies have mixed results when in- tervention and control communities are compared. Outside factors, such as a national antismoking campaign, activities of voluntary and commercial Thoreson and Mahoney call "behavioral cessation programs, new antismoking laws, price humanism: '542 It involves three factors: the increases in cigarettes, death of a well-knotivn per- specification of a behavior; the identification of the son from a smoking-related illness, or the release antecedents, cues, and environmental conse- of a new report on smoking and health, can influ- quences; and the alteration of some of the ence quitting in both the intervention and control antecedents or consequences. Essentially, behavior communities. Dealing with more than one risk fac- modification entails two divergent approaches to tor showed lower rates for smoking cessation. The behavior change. One approach is through punish- studies appear to suggest that a combination of ment, which employs aversive procedures, and the mass media and intensive instruction is more sue- other uses positive reinforcement, which includes cessful than media alone. As with any method, self-management procedures. motivation is needed and the mass media can in- For this review, behavior modification research crease motivation, but the quitter must still cope will be presented in two major categories: aversive with addiction and personal, environmental, and procedures and self-management procedures. The social problems. Support and skills training are aversive procedures are divided further into rapid necessary, and intensive instruction can provide smoking, other smoke aversion procedures, covert these attributes. McAlister concluded from his sensitization, and shock therapy. Self-management review of community programs that although there procedures are subdivided into self-monitoring, are methodological limitations to these studies, the nicotine fading. stimulus control, contingency results yield fairly consistent positive results in management. systematic desensitization and relax- reducing smoking. ation, sensory deprivation, and self-control The three new community studies (Stanford, packages. The emphasis will be on studies reported Minnesota, and Pawtucket) are long-range efforts over the last 8 years and on those studies that con- designed to reduce risk factors in whole com- ducted followups of at least 6 months. Several munities. They were developed out of the ex- studies will be discussed more than once under dif- perience of the multiple risk factor trials and com- ferent categories. The reader is referred to my munity studies that preceded them. The idea for reviews for early studies4',42,4s•546 and to behavioral community studies is not a recent one. The San reviews by Pechacek,549 Best and Bloch,55° Diego Community Laboratory was initiated in Pechacek and McAlister,551 Lando,552 Lichtenstein 1966. My review of recent community studies in- and Brown,553 Glasgow,99 and Hall and Hall,554 dicates that the lessons learned from the San Diego Orleans and Shipley have provided a topical study have been ignored. Investigators should ex- bibliography covering approaches to smoking amine the programs and results of the San Diego cessation for the years 1969-1979,555,556 The Community Laboratory so that successful pro- references were comprehensively coded for each of grams can be adapted and errors avoided. 28 topical areas. Nostbakken stated that the mass media is The reader is advised to use caution in inter- valuable in creating or changing one's percep- preting quit rates as the results of many reports are tions.4aO Community meetings serve to motivate based just on the subjects who answer followups people. Individualized, face-to-face techniques are or on those who completed treatment. Also, only often the most effective in providing personal sup- a limited number of studies validated abstinence port in the decision to act. Nostbakken noted that through physiological measures; the majority of television plays an important initial role in the pro- studies based their results on self-reports. cess of changing a smoker to a nonsmoker. Televi- sion, however, has been shown to be an ineffective means of presenting explicit, instructional informa- tion. This is why mass media should be combined with group or individual instruction. 74 Early behavioral studies of smoking cessation were undertaken primarily by social and behavioral scientists and graduate students. In recent years, behavioral methods have also been sponsored by commercial and voluntary groups, risk factor trials, community programs, and medically sponsored clinics. Behavioral procedures have been combined with individual and group counseling, as well as other interventions such as hypnosis, acupuncture, medication, and educational techniques. Aversive Procedures Aversive agents or techniques include electric shock, breath holding, smoke, unpleasant taste, TIMN 293404 Inherent in behavior modification is what

noise, or smell, and imagined stimuli. Bernstein and McAlister report that the principles of extinc- tion, negative practice, and aversive conditioning employ stimuli from cigarettes themselves as the aversive component, e.g., rapid smoking and satia- tion smoking.557 These procedures are based on two assumptions: first, that the reinforcing aspects of almost any stimulus are reduced and may ac- tually become aversive if that stimulus is presented at sufficiently elevated frequency or intensity; and second, that aversion based upon stimuli intrinsic to the target response (smoking) is more salient and generalized than that stemming from artificial sources. Past reviews of smoking modification research in- dicate that aversive techniques largely have failed to help people to quit smoking. Lichtenstein stated that methodological problems have confounded in- terpretation of many of the investigations.55S Initial results with aversion techniques were good, but replication failed. Investigators persisted in their ef- forts to utilize aversive procedures, and in the last decade, some studies have shown improved results. The most promising techniques use some form of smoke aversion. Rapid Smoking Blowing warm, stale smoke in subjects' faces while they smoked was introduced in 1964559 but showed only limited success.42 Lublin and Joslyn combined hot, smoky air with rapid smoking and reported a 19-percent quit rate at 1 year.560 Their study was criticized for invalid methodology but set off a series of experiments by Lichtenstein and his colleagues at the University of Oregon, which subsequently produced impressive results for rapid smoking. This procedure requires the subject to in- hale from a cigarette once every 6 seconds for the duration of the cigarette or until nauseated. Tvo of these rapid-smoking studies showed at least 57-percent success at a 6-month followup561.5sz, followups 5 to 6 years later located almost two- thirds of the subjects, of whom 37 percent were abstinent.563 Tvo-year followups of two other studies revealed that 33 percent were non- smokers.563 (Most subjects who reported abstaining at long-term followup intervals also reported having smoked at some point after treatment.) In the early trials, Lichtenstein's group used warm, smoky air along with rapid smoking but dropped this procedure when they found it did not contribute to effectiveness. Dawley and Sardenga also used warm, smoky air along with rapid smok- ing and handling cigarette litter as aversive pro- cedures in attempting to cure the smoking habit.564 Out of 12 smokers who completed treatment, only 2 (17 percent) were abstinent at 9 months. Lando conducted a series of experiments utiliz- ing smoke aversion. One study found rapid smok- ing and satiation produced equivalent results (about 20 percent at 1 year).565 In two other studies, rapid smoking had similar results to self-paced smoking566 and to slow smoking.587 In another study, rapid smoking outscored self-paced smok- ing.568 In Glasgow's study, regular paced aversive smoking showed a higher quit rate than did rapid smoking (23 percent to 7 percent at 6 months), but when self-control and counseling were added to rapid smoking, the result improved to 25 percent.86 Danaher provided a comprehensive review of rapid-smoking studies reported by mid-1977.569 His review covered 12 studies with 6-month followups and 9 studies with at least 3-month followups. In most of the studies in which rapid smoking was compared to a placebo control or another treat- ment, rapid smoking had higher quit rates, but only a few of these reached statistical significance. Danaher described the standard rapid-smoking procedure used in the early successful studies as involving successive episodes of accelerated stnok- ing interrupted by periods of rest and cognitive rehearsal. The number of cigarettes consumed per trial and the number of treatment sessions were in- dividualized according to each smoker's level of tolerance and ability to resist further smoking. Danaher pointed out that changes in the method of treatment by later investigators might have af- fected outcome. Danaher suggested that significant limitations of exposure to rapid smoking serve to attenuate the therapeutic value of the procedure. He also emphasized the need for a warm, personal client-therapist relationship as was offered by the Lichtenstein group. Danaher concluded that rapid smoking usually proved to be superior to other treatments and that it produced relatively effective results. Rapid smoking has continued to be, a popular treatment for smoking. The comprehensive table reports 45 rapid-smoking studies of which 10 have at least 1-year followups, 22 have at least 6-month followups, and 13 have 3-month followups. A few investigators have conducted 2- to 6-year followups, and there were several other studies in which rapid smoking was a minor part of the procedures used. More than one-third of all smoke aversion reports were based on work done by graduate students. Studies with at least 6-month followups yielded 49 rapid-smoking trials and the 3-month studies another 23 trials. The 3-month trials will not be discussed further as the followup period was too brief. Quit rates for the 3-month studies ranged from zero to 81 percent with eight trials showing rates below 22 percent, four with rates between 22-32 percent, seven with rates between 33-50 per- cent, and four trials with rates over 50 percent. TIMN 293405 75

The quit rates of studies after 1977 will be sum- marized below. Rapid smoking is often combined with other pro- cedures, making it difficult to assess the effec- tiveness of rapid smoking alone. Only four trials of rapid smoking are available after 1977 without substantial other procedures included. The follow- ing breakdown shows how rapid smoking has been combined with other techniques: Nnmber of TYials With at Lesst 6-Month Followmps 49 Rapid smoking alone without substantial add-ons .... 18 Rapid smoking with hot, smoky air or satiation ...._. 5 Rapid smoking with self-control .................. 4 Rapid smoking with self-control and smoky air or satiation ..................... . . . 2 Rapid smoking with covert conditioning .. . . . . . . . . . . 4 Rapid smoking with contingent contract ........... 2 Rapid smoking with relaxation and coping or relapse training . . . ................... 3 Rapid smoking with other procedures (counseling, hypnosis, discussion groups, complete physical exams, etc.) ................................ 11 Best et al. compared rapid smoking with satia- tion in combination with self-control;g7O they also ran a treatment with both rapid smoking and satia- tion. The results in each of the three conditions (N = 20) were good with rapid smoking alone show- ing the highest quit rate: 55 percent at 6 months, 45 percent for rapid smoking plus satiation, and 40 percent for satiation. A French study that com- bined rapid smoking with excessive smoking and individual therapy (N=200) had a quit rate of 33 percent at 1 year.s71 Barbarin compared rapid smoking to covert sen- sitization with 15 subjects in each condition.572 Rapid smoking was successful (40 percent at 1 year), but covert sensitization and a combined rapid smoking plus covert sensitization showed only 7 percent abstinence. Pederson et al. compared rapid smoking to hyp- nosis, each in combination with counseling?m Hyp- nosis (N=9) did best with 56 percent at 6 months compared to 38 percent for rapid smoking (N =21); but a combined rapid smoking plus hypnosis treat- ment (N=23) scored only 13 percent. Barkley et al. also compared hypnosis and rapid smoking, but in their study, rapid smoking scored a higher quit rate at 9 months than did hypnosis (42 to 25 percent, N=12 in each condition) 316 Hall et al. conducted two studies in which sub- jects received an extensive physical examination along with rapid-smoking treatment. About half the subjects in each study were abstinent at follow- up (N = 27, 6-month followup; N=18, 2-year followup).g7g574 Poole et al. tested rapid smoking in four ways: alone, with relaxation, with contingency con- tracting, and with both relaxation and contingency 76 contracting.1575 Rapid smoking with contingency contracting showed just 14-percent success at 1 year (N=17), while the other three conditions had 22 to 25 percent success (N=18 to 21). Raw and Russell added support to rapid smok- ing but came away with a poor result.576 Only 6 per- cent had quit at 1 year compared to 18 percent for those in support without rapid smoking (N=16). Parker and Younggren ran a 4-week clinic in a military setting, providing educational seminars along with rapid smoking.577 The result for 173 subjects was 28 percent at 6 months. Danaher et al. provided subjects with a relaxa- tion audiotape and meetings with a consultant.578 One group was assigned to rapid smoking (N =16) and the other to regular paced aversive smoking (N= 14). The rapid-smoking group showed slightly better results at 8 months (38 to 29 percent). Corty and McFall compared rapid smoking to a response prevention treatment that focused on eight situations in which smokers commonly smoke and attempted to diminish the power of these situations in eliciting smoking.579 The authors concluded that response prevention was neither more nor less effective than rapid smoking. Six-month followup results based on only 27 of the original 39 subjects were 9 percent for response prevention and 23 percent for rapid smoking. Hall et al. added relapse prevention and skills and relaxation training to rapid smoking and regular paced aversive smoking conditions.58O At 1 year, 52 percent of the rapid-smoking group (N = 29) had stopped smoking, while only 39 percent of the regular-paced group (N=28) were abstinent. 'livo other groups without the extra training had lower results: rapid smoking (N=32) 34 percent and regular paced aversive smoking (N = 34) 26 percent. In a second study of the rapid smoking plus the relapse prevention and skills and relaxation train- ing condition, Hall et al. failed to replicate their good results.248 Only 28 percent were abstinent at 1 year (N=36). In the same study, Nicorette and the special training yielded a quit rate of 36 percent, and a com- bined rapid-smoking, Nicorette, and special training condition scored 46-percent success. The range of quit rates for trials in which rapid smoking was used ran from 6 to 67 percent (table 18). The median quit rate for all 1-year studies was 25 percent. 'Irials in which rapid smoking was the main treatment had a median quit rate of 25 per- cent. The highest rates were achieved in the early studies by Lichtensteirfs group, some of which in- cluded warm, smoky air. Other quit rates above 50 percent combined rapid smoking with other pro- cedures (e.g., self-control, covert sensitization, physical exams, and training in relapse prevention and relaxation). (The reader is reminded that most of the results were based on self-reports, and many r[A11V 293406

of the quit rates were based only on subjects who completed treatment or responded to followups.) Table 18 SUMMARY OF FOLLOWUP QUIT RATES OF 49 RAPID SMOKING TRIALS Reported 1968-1988 Percent N Range liw<edian 33% 1968-1977 At Least 6-Month Followup 23 7-67 30 43 At Least 1 Year Followup 4 19-38 20 25 1978-1985 At Least 6-Month Followup 10 13-60 38 60 At Least 1 Year Followup 12 6-52 26.5 50 Rapid Smoking Alone At Least 6-Month Followup 12 7-62 25.5 33 At Least 1 Year Followup 6 6-40 21 17 Rapid Smoking With Other Procedures At Least 6-Month Followup 21 8-67 38 57 At Least 1 Year Followup 10 7-52 30.5 50 Relative to investigations of the rapid-smoking technique is a genuine concern about the effects of the technique on the cardiopulmonary system. Hauser noted that increased amounts of nicotine could induce cardiac arrhythmias in people with coronary artery disease.581 These risks, were underscored by Dawley and Dillenkoffer who found that rapid smoking produced clinically significant hypoxemia (insufficient oxygenation of the blood) in some individuals.582 Horan et al. found not only increases in heart rate, blood pressure, and car- boxyhemoglobin levels but also electrocardio- graphic abnormalities.583 Numerous other investi- gators have reported on the effects of rapid smok- ing on the cardiovascular system. The early reports were summarized by Lichtenstein and Glasgow along with recommendations for screening and selection.584 They pointed out that up to 1977, 35,000 subjects had used rapid smoking with no known serious consequences. They concluded that rapid smoking is safe for healthy young adults. Hall and associates have carefully studied the ef- fects of rapid smoking.573.g74~ 585 They compared 24 healthy young male smokers abstaining for 12 hours, smoking normally, and smoking rapidly. They found that statistically significant increases occurred after rapid smoking in heart and respiratory rates, systolic blood pressure, carboxy- hemoglobin, and pH.585 Rapid smoking produced alveolar hyperventilation in all subjects. They found no electrocardiographic abnormalities. Despite the changes produced, there were no arrhythmias. Hall et al. also studied the effects of rapid smoking on cardiopulmonary patients.574 None of the 21 patients studied developed evidence of myocardial ischemia or significant cardiac arrhythmia during rapid smoking. After the early study, the investigators concluded that rapid smoking was safe for healthy subjects but should not be used for higher risk pa- tients. After the later study, they stated that rapid smoking was safe to use for patients with mild to moderate cardiopulmonary disease and for those who have had previous, uncomplicated heart at- tacks.574 They advised cautious nonphysician clini- cians not to carry out rapid smoking on patients with cardiopulmonary disease unless they are in a medical setting. According to Hall and Hall, it Is safe to conduct rapid smoking with patients who have recovered from myocardial infarction. They advise nonphysicians to exclude from rapid smok- irig patients whose heart attack has been com- plicated by congestive heart failure or the need to take digoxin or diuretics following an infarction.554 Glasgow et al. explored subjective reactions to rapid smoking and normal paced aversive smoking through the use of a negative sensations check- lisL586 Both groups reported a high frequency of irritations of the mouth and throat. Rapid smok- ing produced more frequent feelings of gastro- intestinal distress and irritation of the eyes and more frequent checking of cardiovascular symp- toms than did normal paced smoking. The in-, vestigators found minimal relationships between measurements of negative sensations or aver- siveness and treatment outcome, thus raising ques- tions about the efficacious mechanism in rapid smoking. They postulated that aversive smoking may work by facilitating recall and revivification of unpleasant experiences rather than by nonmedi- ated conditioning effects. Rapid smoking appears to produce high quit rates at end of treatment: nearly 100 percent in trials by Lichtenstein and colleagues, although trials by other investigators averaged only 50 to 70 percent. Overall, when rapid smoking was the primary treatment, long-term quit rates were not improved. In only 5 out of 18 trials in which rapid smoking was the main treatment were quit rates above 30 percent, and the results of 8 trials were below 22 percent. However, when other procedures are part of the treatment (e.g., self-control, physical examinations, and relapse training), results are much improved. Danaher569 and Hall and Hall5g4 outlined the in- gredients needed for rapid smoking to succeed in producing long-term success. A warm, supportive therapist is required to supervise therapy. The therapist should heighten the subject's awareness of the aversion and admonish the subject not to smoke between sessions. The process of revivifica- tion should be used to enhance the aversion be- tween rapid-smoking sessions. Z]-eatment should continue until the subject experiences no more urges to smoke. According to Hall and Hall, about seven or eight treatment scssions are needed to end urges to smoke. 77 TIMN 293407

In view of the acute effects that rapid smoking has on the cardiopulmonary system, care should be taken to screen subjects and monitor them closely during treatment. Persons with cardiac disease should be treated with rapid smoking only if medical backup is available. Other Smoke Aversion Procedures In addition to rapid smoking, other smoke aver- sion methods are the use of smoky air, smoke satia- tion, chain smoking, regular paced aversive smok- ing, and smoke holding. Blowing warm, stale smoke in the subject's face was noted in the previous section. This procedure requires the use of a cumbersome apparatus. There were only eight reports of the use of warm, smoky air with at least a 6-month followup, and in five of these, rapid smoking was also used. No studies reported the use of warm, smoky air after 1977. Satiation subjects are required to increase the number of cigarettes smoked not the rate at which they are smoked. The amount of smoking and dura- tion varies according to the experiment. Usually the subject is asked to double or triple the baseline amount smoked. Satiation is generally done at home, which creates monitoring and compliance problems. Lando, however, had subjects satiate themselves in the laboratory.565 Satiation requires no apparatus but does require health screening of subjects because satiation produces high doses of nicotine that could adversely affect the car- diopulmonary system. Early reports by Resnick claimed good results for satiation,587•58S but other investigators failed to replicate Resnick's success.ss9.591 Satiation has generally been combined with other procedures. There were only five reports in which satiation was the major treatment; quit rates ranged from 15 to 35 percent. The combinations have included smoky air, rapid smoking, self-control, desensitiza- tion, contractual management, group support, and special maintenance procedures. The quit rates for satiation trials are shown in table 19. Caution should be observed in drawing conclusions from these data as the results may have been influenc- ed more by the other procedures used along wi"th satiation. Eleven trials with 6-month followups in which satiation was used showed a median quit rate of 38 percent; 12 trials with 1-year followups had a median quit rate of 34.5 percent. More than one-half of the trials in which satiation was used were performed by Lando's group. Good success rates have been achieved by groups led by Lando-992 and Bestg7O when satiation was combined with other procedures. 78 Table 19 SUMMARY OF FOLLOWUP QUIT RATES OF 23 SATIATION SMOKING TRIALS AND 16 REGULAR PACED AVERSIVE SMOKING TRIALS Reported 1968-1985 N Range Median Percent 33% Satiation Smoking At Least 6-Month Followup 11 14-76 38 64 At Least i Year Followup 12 18-63 34.5 58 Regular-Paced Aversive Smoking At Least 6-Month Followup 13 0-56 29 31 At Least 1-Year Followup 3 20-39 26 33 Best, Owen, and 'ftentadue theorized that too many studies concentrate on the instrumental value of smoking for tension relief or on self- management as a means of achieving both cessa- tion and maintenance.570 Best and colleagues designed a study combining aversive procedures with techniques aimed at developing both the in- dividualized functional alternatives and the self- management skills hypothesized to facilitate main- tenance of change. Rapid smoking, satiation, and a combination of the two were compared with regard to their impact on treatment process, out- come, and followup. Sixty subjects were distributed equally among each of the three treatments. The subjects were offered much moral support and in- dividualized instruction. At 6 months, the satiation group had a 40-percent success rate, rapid smok- ing had 55 percent, and the combined condition group had 47 percent. Lando,noted that "the majority of evidence sug- gests that interventions limited to aversive condi- tioning alone are not immune from the pervasive relapse so characteristic of smoking research: '583 He designed a broad-spectrum treatment that in- cluded satiation, contractual management, group contact, and support; a control group was treated with satiation only.592 The satiation was provided in small groups with six sessions over a 1-week period. Part of the contract called for booster rapid- smoking sessions for those subjects who relapsed, but only 3 of 17 subjects underwent the booster sessions. At a 6-month followup, the results were outstanding: 76 percent of the experimental sub- jects were abstinent, and of those who received satiation only, 35 percent were successful. Lando and McCullough replicated this result in a second study with 71 percent being successful.sQ4 Satiation has been shown to be less effective than rapid smoking. Although the techniques are similar, Lichtenstein and Danaher suggested that the difference could be due to greater treatment time in rapid smoking and to the minimal interper- sonal persuasiveness used in satiation studies.52 TIMN 293408

In addition, there is a lesser relative emphasis on cognitive focusing and revivification in satiation procedures. In rapid smoking, subjects are in- structed to focus on negative experiences during the trials and immediately thereafter. Satiation in the natural environment appears not to involve such explicit instructions to use cognitions and thus may not facilitate generalizations or maintenance. Satiation, however, is useful in multicomponent programs in combination with other procedures. Another form of oversmoking has been tried in two early studies. Marrone et al. divided 32 smokers into 3 conditions: chain smoking for 20 hours, chain smoking for 10 hours, and a control.595 Un- fortunately, the followup period for this study was only 4 months. Six of ten subjects who were in the 20-hour treatment stopped smoking compared to two in the 10-hour group and one in the control group. In a doctoral dissertation study, Young had subjects chain smoke eight cigarettes at each of six sessions.596 Subjects in the comparison group, who were not required to oversmoke, did better than those in the chain-smoking group. Regular paced aversive smoking was used as a control in early studies by Lichtenstein's group5sz and has been used as a control by Lando.565 Regular-paced smoking was called focused smok- ing by Hackett and Horan.597 Regular-paced smoking is used to avoid the risks posed by rapid smoking and satiation. It is delivered in a variety of ways. Generally, subjects smoke at their usual rate while focusing on the negative features of cigarettes, such as the irritation in the mouth and throat, coughing, and the accumulation of smoke. Some investigators ask subjects to puff every 30 seconds.sse.ssa Miller required her subjects to view a list of antismoking statements while they under- went the regular-paced smoking procedure.598 In a study with chronically ill patients, the therapist repeatedly pointed out the aversive aspects of cigarettes while the subjects puffed every 30 seconds.599 In two studies with 6-month followups, Hackett and Horan achieved 56 (N=9) and 40 percent (N = 30) with focused smoking that was combined with a treatment program.597•eO0 In the latter study, results were verified by measuring carbon- monoxide in the breath. Hall et al. provided a com- prehensive program of relapse prevention and skills and relaxation training along with either rapid or regular paced smoking.58O Rapid smoking (N = 29) had 52-percent success at 1 year compared to 39 percent for regular paced smoking (N = 28). Sub- jects who underwent regular paced smoking but did not have the relapse program had 26-percent success (N=34). In another study by Hall and associates, 16 patients with chronic illness who had regular paced smoking plus relaxation training showed 6-percent success after 6 months.599 In both studies, results were verified by physiological measures. Zumoff assigned 48 subjects to 4 conditions: car- bon monoxide feedback, focused smoking, focused smoking with the feedback, and a control.6O1 Fo- cused smoking alone did not have any successful subjects at 1 year, while the subjects on feedback had 20-percent success. The combined focused smoking and feedback • group had 50-percent success. Walker and Franzini divided 64 subjects into 8 combinations involving focused smoking, taste satiation, physiological measures, and booster ses- sions.6O2 Overall, focused smoking had a quit rate of 19 percent, but when combined with physiologi- cal measures, the quit rate increased to 63 percent. Booster sessions tended to have a negative impact on abstinence. Other investigators have run regular-paced smok- ing trials with success rates in the 20- to 30-percent runge.ss. sss. sss Shipley divided 44 subjects into 2 groups who received regular paced smoking and a relaxation tape.603 One group that was mailed 20 supportive letters over a 3-month period came away with the lower quit rate at 6 months (20 percent against 30 percent for the no-letter group). Danaher et al. randomized 47 subjects to either a rapid- smoking group, regular-paced aversive group, or control group.g78 The program included relaxation by audiotape and meetings with a consultant. At 8 months, the rapid-smoking group showed 38- percent success, while the regular-paced group had 29-percent success. As shown in table 19, median quit rates for studies in which regular paced aversive smoking was used were 26 percent for 3 trials with 1-year followups and 29 percent for 13 trials with 6-month followups. When regular paced smoking is the only treatment, the procedure yields low success rates. When used along with a treatment program, the quit rates are much improved. The procedure is generally done at home, creating compliance and monitoring problems. Regular paced smoking has the advantage of requiring no extra health screening. Taste satiation or smoke holding was tried by 'Ibri with 25 smokers.604 He instructed subjects to draw smoke directly into their mouths and hold it there for 30 seconds while breathing normally through the nose and concentrating on the unpleasant sen- sations evoked by the smoke. When inhalation oc- curred, subjects were instructed to hold the smoke in their mouth while they breathed through the nose and to concentrate their attention on their lungs. After 20 seconds, they were allowed to inhale burning vapors and then to exhale the smoke 79 TIMN 293409

through their nose. Subjects were given a 5-minute rest before the next cigarette. Smoke holding con- tinued until feelings of discomfort and nausea caused loss of desire for cigarettes. Iteatment lasted for 5 consecutive days. Unfortunately,lbri also pro- vided five weekly sessions of hypnotherapy, so it was not possible to assess the independent effect of smoke holding. At a 6-month followup, 68 per- cent of the smoke-holding subjects were abstinent. Tori also treated 10 smokers with rapid smoking = and hypnotherapy; the claimed result was 60 percent. Three other investigators have reported results for smoke-holding studies. Kopel et al. achieved a 33-percent quit rate at a 6-month followup.6m Lando and McGovern also combined smoke hold- ing with nicotine fading.606 Their result at 1 year was 44 percent; nicotine fading alone had a 19-percent quit rate. In the last study, Walker and Franzini achieved 50 percent with smoke holding alone at 6 months.6O2 When combined with several other treatment procedures, the result dropped to 28 percent. As part of a self-help package for employees at a worksite, Nepps describes modules that teach users smoke-holding and nicotine-fading procedures.607 Smoke holding appears to be a safe procedure and has the advantage of not requiring special screen- ing procedures. Unfortunately, not enough data are available to permit assessment of the efficacy of smoke holding per se as a cessation treatment. Behavioral investigators should do more work with smoke holding. Covert Sensitization The objective of covert sensitization is to produce avoidance behavior through use of the subject's imagination. Both the behavior to be modified and the noxious stimulus are imagined. Cautela in- dicated that it is analogous to a punishment paradigm since the smoker is asked to imagine that he or she is receiving noxious stimulation while associating cigarettes with aversive thoughts." The subject can also imagine positive consequences when thinking of not smoking. Cautela concluded that investigations that utilized covert sensitization in conjunction with other treatment procedures have been more effective than have those that used it as treatment. An example of the use of covert sensitization is provided by Zbngas.609 In his study, there were six punishment scenes, six escape scenes, and three positive reinforcement scenes. These were provided at five treatment sessions. In addition, subjects were given home assignments and were instructed to do them five times daily. The assignment consisted of five scenes each of punishment, escape, and positive reinforcement. 80 Early studies showed poor results for covert sen- sitization.42 Many of the studies had only 3-month followups, but even at that point, results were weak. Weiss found that when covert sensitization was com- bined with relaxation, results improved as there is the need to deal with tension.610 He attributed failure of covert sensitization to low frequency of punish- ment or use of weak aversive scenes. Sipich et al. claimed that covert sensitization was effective in reducing but not eliminating smoking behavior and that it was not significantly more effective than attention-placebo or self-control conditions.61 'Ibngas et al. based their study on multiple tech- niques and emphasized maintenance.612 Subjects (N = 72) were assigned to covert sensitization, rapid smoking, group therapy, or a combined treatment. Subjects received 19 treatment and maintenance sessions. As noted above, covert sensitization was provided at five sessions, and there were home assignments. Based on all subjects, the covert sen- sitization and rapid-smoking treatments each achieved 19-percent success at 2 years, while the combined group had 38-percent success. 7i,vo other studies combined rapid smoking with covert treatment. Severson, O'Neal, and Hynd claimed 50-percent success at 9 months with the combined treatment compared to 11 percent for covert sensitization alone and 30 percent for rapid smoking (N=9 or 10 in each treatment) 813 Barbarin reported a much lower rate for the combined treat- ment (7 percent); covert sensitization alone also scored 7 percent (N=15 in each treatment).572 Elliott and Denney treated 20 subjects with a combination of covert sensitization, systematic desensitization, relaxation, and behavioral rehear- sals14 The quit rate was 45 percent at 6 months, but one cannot assess the contribution of covert sen- sitization to success. Lowe et al. tested the effects of covert sensitiza- tion by treating two self-control groups, one with and the other without covert sensitization 81g Clinic meetings were held three times per week for 3 weeks. Covert sensitization subjects imagined smok- ing along with coughing, choking or nausea, and uncontrollable vomiting. Subjects also practiced situations and aversive consequences of their own choosing and were urged to use covert sensitization outside of the treatment sessions as a way of con- trolling urges to smoke. 'Ibn maintenance sessions were held over a 90-day period. Of 33 subjects who started treatment, 30 attended one-half the sessions before the quit dates. Evaluation was coniined to the 30 subjects (N = 15 in each treatment). At a 6-month followup, the validity of self-reports was checked by measuring the thiocyanate concentration in saliva. Results indicated that covert sensitization did not increase the quit rate as there was no significant dif- ference between the two treatments. As a trend, the TIMN 293410

treatment without covert sensitization did better (33 to 13 percent). Of 10 trials with at least a 6-month followup in which covert sensitization was used, the median quit rate was 25.5 percent. It should be noted that the quit rates were low when covert sensitization was used alone, and when covert sensitization was combined with other procedures, it added little to effectiveness. Shock Therapy The use of electric shock as a punishing stimulus to eliminate smoking behavior has been used with limited success. The 1977 review evaluated the early studies, and there have been no reports of smoking cessation trials using electric shock since 1977.42 Quit rates for the early shock studies ranged from zero to 63 percent. The commercial Schick method uses a mild shock as part of their treatment. Berecz has claimed that shocking triggering cognitions (urges to smoke) is more effective than shocking actual behaviors.616 He supported this contention with a small study.617 Clients vividly imagined cognitions associated with smoking and administered aversive shock to themselves. One group of five subjects imagined smoking, while the other group of five subjects imagined urges to smoke. Three subjects who imagined urges to smoke were abstinent at a 2-year followup, while none of the other subjects had quit. Berecz conducted a later study in which 42 per- sons who had attended a clinic of the Five-Day Plan participated in maintenance procedures.618 One group was instructed to focus vividly on the trig- gering thoughts that lead to smoking each time the urge to smoke occurred. Subjects then were to self- administer a painful snap immediately using the rubberband they were wearing around their wrist and to engage in alternate behaviors such as chew- ing gum. A second group wore the rubberband as a reminder, and a third group did not wear the rub- berband. At a 1-year followup, it was found that the aversion group had 57-percent success compared to 7 percent for the rubberband reminder group and 21 percent for the nonusers. Since most of the abstainers were men, these procedures appear to be less effective with women. Berecz commented that the wristband technique is highly efficient in terms of time and cost. Although the procedure is painful, it does not seem to arouse as much anxi- ety as electric shock. Summary of Aversive Procedures Previous reviews found that aversion therapy tech- niques generally showed poor results.4i.42-s1sszo A review of the comprehensive table indicates that aversive techniques show a wide range of success. The results are sometimes difficult to interpret because many of the studies base their quit rates solely on subjects who either complete the program or are located at followup. There is also the problem of basing results on self-reports. It should be noted that some of the research groups are validating their results by physiological measures. Many of the pro- gram reports are based on doctoral dissertation work that has limited followups and often bases the results on reduction in smoking rather than abstinence. Generally, results produced by electric shock treatment are mediocre, although the Schick pro- gram, which uses a mild shock, claims good results. Berecz conducted an interesting study using wristband aversion, but it has not been replicated.618 Covert sensitization has failed to pro- duce good long-term success, but it may be useful as a maintenance technique. The various forms of smoke aversion have shown mixed results. Rapid smoking has drawn a great deal of attention and appears to be effective in the short term. For good long-term results, a warm sup- portive therapist and individualized treatments are necessary. When rapid smoking is the primary treatment, success rates are low, but when com- bined with other procedures, results improve. Con- cern over the physiological effects caused by rapid smoking limits its use without proper screening procedures, monitoring, and medical backup. Satiation has not produced consistent results. As with rapid smoking, when satiation is used alone, long-term success is poor; but when combined with other procedures, some dramatic quit rates have resulted. Lando has obtained impressive results us- ing satiation as part of a combined package.592 A few investigators have achieved good results with normal-paced focused smoking and smoke holding, procedures that are safe and do not require medical screening. More work needs to be done with these techniques, particularly in combination with other procedures. Aversive methods like rapid smoking can elimi- nate smoking, but also needed are maintenance and reinforcement procedures to continue the behavior change. Some of these procedures will be discussed in the next section. Self-Management Techniques Strategies for quitting smoking through self- management encompass a variety of techniques, some of which are employed with aversive methods. Self-control programs are not self-initiated, but they include both self-administered programs and those involving a leader or therapist. The reader is 81 TIMN 293411

reminded of the difference between self-care and self-management or self-control outlined on page 15. The latter are behavioral techniques, generally initiated and directed by leaders or therapists, that usually include supervision. Self-care methods are reviewed on pages 15-21. The use of self-control evolves from three factors: first, attention to one's own smoking actions and recording their occurrences; second, the awareness of and willingness to change one's environment so that either the cues preceding the smoking response or the immediate consequences of it are changed; and third, recognition of and ability to break longstanding, cue-elicited smoking patterns. The usual self-control program involves the subject more actively in treatment than do aversive methods. Predominant self-management methods are those based on concepts of self-monitoring, nicotine fading, stimulus control, contingency management, systematic desensitization and relaxation, restricted environmental stimulation therapy, and self-control packages. Self-Monitoring Keeping records of the number of cigarettes smoked has been required by almost all smoking cessation programs in order to assess baseline smoking, progress in treatment, and outcome. Pro- gram requirements regarding self-monitoring have differed from counting cigarettes smoked for just 1 day to elaborately recording for 1 week the time, place, activity, and mood when smoking each cigarette and the need for it. McFall carefully studied the effects of self- monitoring on normal smoking behavior and demonstrated that when an individual begins pay= ing unusually close attention to one aspect of his or her behavior, it is likely to change even though no change may be intended or desired.621 The study specifically showed that focusing on positive in- stances of smoking (rewards) increases the fre- quency of smoking while decreasing the time spent per cigarette and that focusing on negative conse- quences of smoking decreases smoking frequency while also decreasing time per cigarette. The author also demonstrated that smoking frequency and duration were significantly affected by self- monitoring, which indicates that it is a reactive data- gathering procedure (producing its own behavior changes). Best and Flay indicated that self= monitoring is in effect both an evaluation and a behavior change technique because it is reactive.622 They stated that the more reactive the self-monitor- ing the more useful it is therapeutically but the more problematic its use as an evaluation strategy. McFall and Hammen compared 11 major stop- smoking studies and discovered similar data among 82 different procedures.623 The mean quit rate of the 11 studies was 26 percent at end of treatment and 13 percent at followup. Common to all of these studies were structure and self-monitoring. McFall and Hammen then designed a treatment program that encouraged motivated volunteers to employ self-control and required them to monitor their smoking and report progress at regular intervals. Success rates were 28 percent at the end of treat- rrient and 5 percent 6 months later. Since outcome of their nontreatment program was so comparable to the 11 studies reviewed, the authors suggested that the nonspecific factors they studied may ac- count for the temporary behavior change found in most smoking treatments. In a study a decade later, Abrams and Wilson in- vestigated the reactive effects of self-monitoring as a function of varying the target behavior and the perceived negative consequences.624 They assigned 40 subjects to 1 of 4 conditions. livo groups self- monitored nicotine, and two groups self-monitored cigarettes; one of each type of group was provided with health hazard information. Subjects self- monitored during a 4-week pretreatment phase and during treatment. The two nicotine self-monitoring groups showed greater reactivity. The authors speculated that nicotine content appears to be a discriminative stimulus that is moie salient and hence more powerful in controlling behavior than is the number of cigarettes smoked. According to this explanation, self-monitoring nicotine content makes it harder for the subject to avoid a negative self-appraisal of continued smoking. In two studies, Foxx and colleagues assigned sub- jects to a treatment of self-monitoring their daily in- take of tar and nicotine.62s. szs In the first study, none of the subjects had quit at 18 months (N=10),62g and the result for the second study was 29-percent success at 1 year (1V=7).626 When self- monitoring was combined with brand fading- switching to lower nicotine brands-the quit rates were higher. These studies will be discussed further in the section on nicotine fading. Reliability of measurements and controlling ef- fects of three procedures for self-monitoring smok- ing were examined by Frederiksen, Epstein, and Kosevsky.627 The procedures were continuous re- cording of each smoking event, daily recording of the number of cigarettes smoked, and weekly re- cording. Results showed continuous recording to be the most reliable procedure; it tended to be the most accurate and exerted the most positive control over smoking behavior. Continuous recording, however, led to higher dropout rates than did daily or weekly recording. The reactive effects of three self-monitoring pro- cedures were evaluated with respect to session attendance by Moss et a1.628 Fifty subjects were TIMN 293412

divided among three self-monitoring and two no- monitoring conditions. Dropout rates for the two no-monitoring groups were equal at the second ses- sion and significantly lower than the self- monitoring groups. This significant difference was still present at the sixth session. The authors cau- tion smoking researchers regarding the use of self- monitoring procedures in cessation treatment. Glasgow provides the opinion that self-monitoring can be useful provided that self-monitoring assignments are not overly complex, are varied or are not continuously required throughout a lengthy program, and are not focused solely on "negative" targets such as withdrawal symptoms.6z9 The reader is reminded of the problems con- nected with self-reports discussed on page 8 and the need to validate self-reports by physiological measurements discussed on page 9. Nicotine Fading Cutting down the number of cigarettes smoked based on weekly goals has been used as a cessa- tion method for many years.433 Generally called gradual withdrawal or tapering, this method was advocated for "habit" smokers in contrast to cold turkey, which was advocated for "negative affect" smokers. Smoke Watchers bases its program on gradual withdrawal and weekly goals assigned by the group leader; clients are praised by the group when they meet their goals. The rationale for nicotine fading differs from that of gradual reduc- tion in numbers of cigarettes. Although Smoke Watchers has had some success with tapering, the evidence for gradual reduction in numbers is not very positive. As cigarettes are reduced, each re- maining cigarette can become more reinforcing. With nicotine fading, however, individuals can con- tinue to smoke the same number of cigarettes. By recording nicotine content over several brand changes, participants can perceive considerable progress in nicotine reduction (even if much of this apparent decrease is illusory). Three commercial filters have been on the market (Venturi Tar Gard. Water Pik's One Step at a Time, and Nu-Life) with the aim of gradually reducing the tar and nicotine content of a ciga- rette in order to help smokers break their habit (see page 18). Nicotine or brand fading by changing one's brand of cigarettes is a relatively new treatment method that was introduced by Brown in an unpublished paper in 1978630 and reported by Foxx and Brown a year later.82g Brands are switched in the direction of gradually lowering the nicotine intake to wean the smoker from his or her nicotine dependence. The nicotine content of cigarettes is derived from figures published by the Federal Made Commission (FTC). Foxx and Brown advocated a change of brands to lower nicotine content from the baseline brand 30 percent, 60 percent, and 90 percent over a 3-week period. Most investigators follow this nicotine reduction schedule, but in one study, Lando and McGovern had subjects switch brands on a 25-, 50-, 75-, and 90-percent weekly reduction schedule.606 Prue et al. instructed smokers 'to change brands systematically to lower nicotine 0.2 mg every 2 weeks.631 Brand changes continued un- til smokers were consuming cigarettes with nico- tine levels of 0.2 mg or less per cigarette. Attesting to the interest in brand fading, there have been 13 cessation studies yielding 23 trials reported over the last 7 years, 9 of these during the last 3 years. In the original study by Foxx and Brown, 38 subjects were assigned to 4 conditions: nicotine fading, self-monitoring of daily tar and nicotine intake, a combination of the two, or a modified ACS program.625 At an 18-month follow- up, none of the self-monitored subjects had quit, and results for nicotine fading and the ACS clinic were 10 percent. In the condition in which nicotine fading and self-monitoring were combined, 40 per- cent were successful. In a second study, Foxx and Axelroth reported 40-percent success at 1 year for nicotine fading compared to 29 percent for self- monitoring (N =12).szs Lichtenstein's group conducted three studies that involved nicotine fading. In the first study, Beaver et al. compared nicotine fading to a treatment that combined nicotine fading and anxiety manage- ment training.632 The anxiety training consisted of teaching subjects to use relaxation techniques in- stead of smoking as a response to stress. The nicotine fading procedure (N=11) outscored the combined condition (N=17) 27 percent to 6 per- cent. The authors suggested that the poor show- ing of the anxiety training might have been due to overly complex, inappropriate, or poorly executed methods. In the other two studies (Brown et al.), nicotine fading was combined with relapse train- ing for a good result in one study (46-percent suc- cess at 6 months, N=24)B33 and a poor result in the other (19 percent at 1 year, N=16).634 A nicotine fading plus group support condition had 7-percent success, while a group support condition and a relapse prevention condition showed no success. Prue was involved with three studies of brand fading at the Jackson, MS, VA Hospital. In the initial study based on Prue's doctoral dissertation, nine VA outpatients and staff members were pro- vided with brand fading and feedback of carbon monoxide and thiocyanate.635 Ziwo of the subjects were abstinent 6 months later. In the second study, 23 percent of 21 outpatients who were offered 83 TIMN 293413

brand fading and abstinence training were not smoking at 1 year.63l Ten control subjects were pro- vided with brand fading after a 6-month wait; three subjects were abstinent 6 months later. The third study by Scott, Denier, and Prue was conducted with nurses at the worksite.e`16 The treatment, which was provided at the nurses' duty stations, consisted of brand fading, abstinence training, and daily feedback and public posting of carbon monox- ide levels. The daily contact and carbon monoxide monitoring were carried out for 3 months posttreat- ment. Of 18 nurses who attempted abstinence, one- third were able to remain nonsmokers 9 months later. Lando and colleagues were involved in three nico- tine fading studies with 1-year followups. Results in the first study, in which 130 subjects were assigned to 4 conditions, were as follows: nicotine fading plus smoke holding, 44 percent; oversmok- ing, 46 percent; nicotine fading with maintenance, 19 percent; and nicotine fading without maintenance, 26 percent.606 In the second study, the subject chose between nicotine fading and oversmoking; both groups were provided with 17 sessions over 9 weeks in which coping strategies were offered 637 Three-fourths of the subjects chose nicotine fading. Results were good in both groups: 42 percent for nicotine fading (N =123) and 38 per- cent for oversmoking (N=42). In the third study, Etringer et al. were testing group cohesion; they used nicotine fading and satiation as treatment methods.638They provided 3 weeks of treatment and 6 weeks of maintenance. Results for nicotine fading were 45 percent (enriched cohesion) and 40 percent (standard cohesion). Satiation scored 32 and 6 percent with enriched and standard cohesion, respectively. Orleans and Rotberg, working with 55 physician- referred chronically ill patients, utilized nicotine fading as part of a multicomponent treatment pro- gram.59aeatment included a physician's advice to quit, abstinence counseling, self-help materials, and a compliance contract. One group was assigned to a monitored nicotine fading program. At the end of 6 months, the group with abstinence training alone did better than the abstinence training and nicotine fading group (40 percent to 23 percent). In the final study, Nicki et al. divided 49 subjects into 4 nicotine fading plus self-monitoring condi- tions.839 7iwo groups with high self-eflicacy scored 25- and 46-percent success at 1 year. The groups without self-efficacy had 8- and 9-percent abstinence. As the foregoing review indicates, nicotine fading produced variable results. Quit rates ranged from 7 to 46 percent with a median of 25 percent for 1-year trials (table 20). For those smokers who wish to reduce their dependence on nicotine gradually, 84 nicotine fading offers that opportunity, but It will be necessary to provide maintenance support, in- cluding coping strategies and relapse prevention. Behavioral investigators should do more work with nicotine fading. MLb1e 20 SUMMARY OF FOLLOWUP QUIT RATES OF 23 NICOTINE FADING TRIALS AND 13 CONTINGENCY CONTRACTING TRIALS Reported.1967-19Sffi N Range Median Percent 33% 1979-1985 Nicotine Fading At Least 6-Month Followup 7 26-46 27 29 At l.east 1 Year Followup 16 7-46 25 44 1967-1981 Contingency Contracting At Least 6-Month Followup 9 25-76 46 89 At Least 1 Year Followup 4 14-38 27 25 Stimulus Control As a clinical procedure, stimulus control seeks to eliminate undesirable behaviors by altering the prevailing stimulus situations in which the maladaptive response occurs. Smoking generally is associated with a variety of specific environmental and internal events. These associations trigger the smoking response (e.g., finishing a meal and drink- ing coffee or alcohol). Certain associations reinforce that response. Lichtenstein and Danaher state that the prevailing stimulus-response conditions are generally altered via a two-step stimulus control program: (a) smoking is initially restricted to novel situa- tions in order to extinguish the power of prior cues, and (b) the novel stimuli are subsequent- ly faded thereby encouraging a corresponding reduction/elimination of smoking.e4° Lando has worked with stimulus control procedures as part of preparation in which smoking is divorced from normal cues (cued by time interval) but with- out reducing smoking levels. Stimulus control treat- ments emphasize gradual reduction instead of im- mediate cessation. Stimulus control, however, can take a variety of forms. Various investigators list three strategies for achieving stimulus control of smoking.52•99•gbO The first, increasing the stimulus interval, allows con- tinued smoking but limits smoking to particular times that are signaled by some cuing device, e.g., a pocket timer. Once well established, the new smoking cue is gradually faded out simply by in- creasing the time interval. The second strategy is hierarchical reduction. Subjects are asked to moni- tor their smoking activity carefully and to identify situations in which smoking would have a high or TIMN 293414

low probability of occurring. A hierarchy is devel- oped based either on the presumed difficulty of reducing smoking in a situation or on the enjoy- ment derived from smoking in the situation. The subject then reduces or eliminates smoking in cumulative and progressive fashion from the easiest to the hardest situation in the hierarchy. The third strategy is deprived response perform- ance. This method progressively narrows the discriminative stimuli for smoking by limiting the circumstances in which smoking is allowed. The procedure requires that all smoking occur in a deprived setting, one devoid of all possible distrac- tions and accompanying reinforcers. There are a limited number of studies in which stimulus control is the primary treatment as this procedure is generally combined with several other treatments. Another problem interfering with evaluation of stimulus control is that the few studies that are reported have only brief followups (2- or 3-month) or none at all. It is thus necessary to depart from the standard of not discussing studies with less than 6-month followup in order to report the few studies that are available in this area. The predominant technique under the first clas- sification is using a signal or timer device that in- terferes terferes with the normal smoking responses. Shapiro et al. described their investigation as a method of smoking reduction aimed at breaking the connection between environmental cues and the smoking response by having the subject smoke on a new cue presented at random times by a port- able signaling device.641 The substitute cue is in- itially set at the smoker's normal rate and then gradually phased out. Although the study was primarily designed to test the feasibility of the method, it also indicated that people who followed the program reduced their smoking more than did those who dropped out. In a similar study, Upper and Meredith demon- strated a short-term decrease in smoking using pocket timers. Unfortunately, no followup data or quit rates were reported.642 The study was repli- cated by Bernard and Efran who used three groups: timer elimination, timer reduction, and control 643 They compared the success of those who set out to quit versus those who were just trying to reduce smoking. Their method was based on the theory that if smoking can be brought under the control of a single stimulus (the pocket timer) rather than the usual, multiple elicitors, then it can be more easily modified. Although reduction was found in both the timer elimination and timer reduction group, a 2-month followup revealed that none of the subjects trying to quit had succeeded, while 4 of 10 subjects trying to reduce their smoking had quit. Levinson et al. compared 2 methods of gradual reduction using signaling devices with 38 sub- jects.644 The first method required subjects to smoke at preset random times using the signaling device; the second allowed subjects to smoke at times of their choice using a mechanical counter to self-regulate their daily smoking quota. Each method was tested with and without group meetings. More subjects in the mechanical counter conditions finished the program, but a 3-month followup found complete failure by all subjects in this group. Of those using the signaling device, 17 percent were still not smoking at a 3-month follow- up. The authors found that most subjects were unable to reduce their smoking below 12 cigarettes per day. They speculated that 12 cigarettes per day might be a level below which one must deal with withdrawal symptoms. They proposed that a gradual reduction procedure might serve as a useful first step toward complete cessation if com- bined with abstinence strategy. Kaplan rationalized that if smoking behavior could be brought under control of a single stimulus rather than a great number of stimuli, it could be more easily modified or eliminated.645 Fifty-one subjects were each given a mechanical parking- meter timer that emitted a buzzing alarm to regulate and measure intervals between cigarettes. Only three subjects (6 percent) were abstinent at a 3-month followup. The second classification of stimulus control is hierarchical reduction. Flaxman evaluated self- control programs with and without aversive con- ditioning (hot, smoky air and rapid smoking) under conditions of abrupt quitting immediately upon entering treatment or 2 weeks later or gradual quit- ting.e46-647 Sixty-four volunteers were involved in a two-phase self-control treatment program. Each subject was randomly assigned to either gradual procedures, target quitting date, or immediate cessation and to either aversive smoking or support encouragement after quitting. Having a target quit- ting date was significantly more effective than gradual quitting. Delaying the quit date was more effective than quitting immediately for women but less so for men. Rabkin et al. tried a stimulus control procedure with 34 subjects as part of a group behavioral treat- ment program 154 Strategies for changing smoking behavior were used based on the premise that smoking was a learned behavior in response to in- ternal (thoughts and emotions) and external signals or cues. Subjects were asked to keep detailed rec- ords of each cigarette smoked (time, feelings, and need). Specific strategies were discussed for avoid- ing, changing, or eliminating the signals leading to smoking, and subjects were advised to eliminate the cigarettes of least need. Rewards, target dates, 85 TIMN 293415

1 io and training in deep breathing and relaxation were also part of the method. There were five sessions over 3 weeks with quit day being the ninth day. A 6-month followup showed that 24 percent of the subjects had stopped smoking. In the study by Lowe et al., 40 subjects were assigned to 1 of 3 conditions: cue extinction; self- control, or a combination of the two.61g Cue extinc- tion is a procedure designed to extinguish associa- tions between desires for cigarettes and cues paired with previous smoking. Cue extinction did not ap- pear to be effective as the quit rate for this pro- cedure at 6 months was 8 percent, while self- control alone had a quit rate of 29 percent; the combined group showed 27-percent success. The third classification of stimulus control is deprived response performance. The technique was effectively used by Morrow et al. as a means of ac- tualizing the subjects' responsibility in assuming a direct role in the quitting process.B4$ For exam- ple, 55 subjects were asked to select 1 chair in their home for smoking purposes. This allowed the sub- ject to practice smoking in the environment most identified with smoking. Several other procedures were used, including individual counseling, so it Is difficult to determine the contribution of stimulus control to the 46-percent quit rate at 6 months. Several other investigators have utilized stimulus control procedures along with other self-control techniques. Colletti et al. reported 23-percent suc- 0 L and provide followup information. Except In a few programs, no formal contract is presented or agreed upon. Many programs collect a small deposit that is returned if the client attends treatment sessions or submits followup data. A number of employers have offered monetary incentives to employees who either refrain from smoking at work or quit altogether. These instances are not considered to be contracting. The purpose of contingency contracting is to ob- viate the goals of the smoker while enhancing moti- vation through commitment. Ziuo forms of these contracts are monetary deposit systems and social contracts with peers. The concept of social con- tracts has not been tested with sufficient scientific rigor. The practice of making public statements to peers or colleagues regarding one's intention to quit smoking, however, is not uncommon to most smokers. It tends to be an accessible form of motivation on which to base hopes of cessation. Return of a money deposit is generally contingent on abstinence but sometimes is tied to reduction in the number of cigarettes smoked. Thus the money deposit acts to reinforce cessation behavior. Early studies by Elliott and Tighe652 and by Winette53 demonstrated that refunding portions of deposits to subjects for continued abstinence in- fluenced long-term cessation. In Winett's study, a contingent contract group (repayment tied to absti- nence) achieved a success rate at 6 months double -- -4r-. nnnfrarf drntln (.rin nP.r(:ent_ i

remained reduced after the contingency was with- drawn. Lando signed formal contracts with subjects con- sisting of several elements. They pledged to forfeit from 25 cents to $3 for every cigarette smoked. These contracts were renewable at 1-month inter- vals. Subjects also completed behavioral self- contracts calling for specific rewards for abstinence and punishments for smoking. In addition, subjects contracted to undergo booster aversive treatment following any smoking. This study, which was reported earlier, included satiation and had a remarkable 76-percent quit rate at 6 months.592 In a different study by Lando in which the contract consisted of returning a deposit to abstinent sub- jects, the result was 25 percent at 6 months.g67 Paxton conducted two contracting studies in Scotland in which subjects were provided with a behavioral program. In the first study, a contingen- cy contract group (N=33) was compared to a no- contract group (N=27).657 Forty English pounds were deposited and returned at the rate of 5 pounds per week to subjects who were abstinent. Although results were good (42 percent abstinent at 6 months), there was no difference between the con- tract and no-contract groups. In the second study, Paxton varied the rate and the time period at which the deposit was returned to three groups but found no difference in abstinence rates at followup.658 Paxton validated these results by analysis of urine. From the studies reviewed, it appears that con- tracting leads to some measure of success during treatment or until the deposit is returned. Once the contract has ended, many subjects regress because maintenance is not provided. Use of contracting as one aspect of a multicomponent program may con- tribute to success, but as the primary treatment, contingent contracting has limited application (see table 20 for median quit rates). Systematic Desensitization and Relaxation Desensitization was designed to strengthen responses that are incompatible with smoking. The investigators hypothesized that smoking behavior is frequently cued to anxiety and that if the prior and proximal stimuli leading to smoking were desensitized, then smoking would diminish. Other investigators suggested that subjects could be con- ditioned to relax as an alternative to smoking. Still others believed that reducing the stress generated by quitting would help to create positive results. The early use of desensitization techniques in smoking control was summarized in the 1969 review41 and the 1977 review 42 Most of the early studies did not conduct 6-month followups, but the results they reported were disappointing. Two studies that conducted 6-month followups reported 10-percent6-',9 and 19-percent suceess.66° Elliott and Denney used systematic desensitiza- tion along with seven other component proce- dures.614 This combination achieved a good result, but it would not be possible to assess the contribu- tion of desensitization. In a hypnosis treatment pro- gram, Powell used desensitization as a mainte- nance technique; the results at 6 to 9 months were 17-percent success.309 Relaxation training has been offered by a variety of programs, including voluntary and commercial clinics and hypnotherapists.2s2•s07.s12.s14 A number of behavioral investigators have used relaxation along with other treatment procedures. The combi- nations in which relaxation was used include the following: rapid smoking5'5•578•W4•661•662; rapid smok- ing and self-control86; normal paced aversive smok- ingw3; smoke holdingw4; covert sensitization598; con- tingency contracting575; self-control615; stimulus control154; self-monitoring and smoke aversiongg6; and multicomponent programs.204,248.580,650.664 Results varied, and one cannot judge the efficacy of relaxation from these studies. In one small trial in which relaxation was the only treatment, Severson et al. reported that none of the eight subjects quit smoking.613 Hall and Hall have used relaxation train- ing as one of the three components of their relapse prevention program. They noted that although they have no empirical evidence, they suspect that relaxa- tion training adds little, and they are omitting it in their current program.554 Controlled studies do not support desensitization as a treatment for smoking. Although relaxation seems to make sense as a helpful procedure, insofar as nicotine has primarily stimulating effects, the smoker seeking stimulation may not find relaxation satisfying enough to replace smoking. Restricted Environmental Stimulation Therapy (REST) This procedure derives its rationale from evidence that a period of sensory deprivation leads to general- ly increased persuadability and responsiveness to external cues.619-665 The procedure facilitates open- ness to new information and reduced defensiveness. REST is an attitude change technique in which a subject remains in a dark, soundproof chamber in a bed for a long period, usually 24 hours. A monitor is on duty during the entire treatment session and has audio contact with the participant. In some con- ditions, subjects periodically hear messages con- cerning the dangers of cigarette smoking and methods of controlling the urge for a cigarette. Less than 24 hours of confinement is considered partial REST. Restricted environmental stimulation therapy is also called sensory deprivation. TIMN 293417 87

Suedfeld and Ikard conducted several studies that were described in the 1977 review.42 In one study with 20 subjects who underwent 24 hours of sen- sory deprivation and heard messages at 90-minute intervals, 30 percent were abstinent at 1 year.92 Another group that had sensory deprivation but no messages scored 24-percent success. There has been little interest in sensory depriva- tion as a smoking cessation treatment as evidenced by only three studies reported after 1977 and only a few before 1977. All studies except one involved Suedfeld as an investigator. Best and Suedfeld assigned 45 subjects to 3 conditions: REST, behav- ioral self-management, or a combination of both methods.666 REST and self-management had simi- lar results at 1 year (21 and 27 percent), but when combined, the quit rate increased to 53 percent. Christensen and DiGlusto contrasted Suedfeld's 24-hour sensory deprivation treatment with 6-hour and 12-hour treatments and a placebo condition of 24 hours of social isolation in which subjects could read and listen to music.66' It turned out that the social isolation treatment had the highest quit rate at 9 months (N=16, 31 percent), while the 24-hour sensory deprivation treatment had no quitters out of 15 subjects. The 6-hour and 12-hour treatments scored 20- and 24-percent success. This study does not support Suedfeld's claims regarding the effec- tiveness of REST.665• 668 Suedfeld and Baker-Brown have reported a recent REST study in which 74 subjects were divided into 4 conditions that used satiation and REST as treatments.669 REST was compared to a placebo condition consisting of 24 hours of recuperation dur- ing which subjects were isolated and were able to relax after satiation smoking treatment. REST was combined with satiation and tried alone with a demonstration of satiation. The placebo condition came out the best at 1 year (28-percent success). 'Iivo active REST treatments scored 5 and 6 percent; satiation with covert conditioning had a 5-percent quit rate. This study does not support the value of REST in smoking cessation. Best and Suedfeld maintain that REST is cost- effective because it calls for little expense and minimal therapist contact'366; Suedfeld adds that the procedure is safe and nonaversive.6155 REST, however, requires a special chamber (room) and standby staff for a full 24 hours. It appears to be impractical as a procedure that will reach and cure many smokers. Self-Control Packages The 1969 review concluded that too much should not be expected from any one approach, no matter how ingenious, since no single method can be counted on to produce 88 high rates of long term success. Most methods achieve their maximal success at the end of the treatment program but recidivism occurs sharply during the next few months. Thus, even if highly successful cessation methods were devised, these techniques themselves cannot be expected to maintain the burden of keeping people off cigarettes once abstinence is achieved.670 Early practitioners left the task of keeping people off cigarettes to societal and environmental in- fluences as little effort was devoted to maintenance support. In recent years, investigators have paid at- tention to maintenance by devising techniques aimed at helping quitters to remain nonsmokers. As we have seen throughout this review, many in- vestigators combine several procedures in their methods. Often there is no theoretical or even logical reason for the combination. Sometimes, however, the combinations aim at increasing motivation, breaking the habit, and helping the client to refrain from smoking. Some investigators have taken a "cafeteria" approach by offering a multitude of pro- cedures and leaving it to the clients to select the techniques that suit them. Their thinking is that since no single method can be counted on to help all smokers quit, the combined approach ought to produce better results. Lichtenstein and Danaher have noted that different components are packaged together not because they demonstrate individual effectiveness but in the hope that combining pro- cedures may yield a unique and more powerful pro- duct 52 These combined methods have been labeled "multicomponent" programs. Almost all multiple programs include self-control procedures. Although they differ widely, three types can be distinguished. Each type can be further subdivided into programs that include aversive smoking procedures and those that do not. Simple programs are those that com- bine a single procedure with self-control. Coping strategy programs include as a major component coping strategies, relapse prevention, abstinence training, or anxiety management. Multiple pro- grams combine three or more techniques. Some programs could fall in two categories if they provided coping strategies. Perhaps a miscellaneous category should be added for the few programs that will not fit into any of the three types. Many multicomponent programs include smoke aversion (rapid smoking or satiation) as a way of breaking the habit and self-control to maintain non- smoking. This combination appears to improve quit rates over smoke aversion alone, but there have been some exceptions.67 Best, Owen, and Trentadue provided self-management training along with either rapid smoking or satiation or both aversive TIMN 293418

procedures.S7O The self-management program was flexible and individualized. For each difficult smok- ing situation, a coping strategy was planned. Among the techniques suggested were relaxation, deep breathing, behavioral rehearsal, covert con- trol, contingency contracting, stimulus control, and social support. The procedures were not proposed as a cafeteria approach but were designed to fit problem situations. The overall result with 60 sub- jects was 47-percent success at 6 months. Foxx and Brown combined nicotine fading with self-management for an improved result,625 but Beaver et al. got a poor result from nicotine fading and anxiety management .632 The emphasis on ab- stinence training has usually produced favorable quit rates. Scott et a1.,638 Lando et al.,606 and McGovern et al.637 got good results with brand fading and abstinence training although Prue et al. did not.631 Brown et al. had a good result with a pilot program of nicotine fading and relapse preven- tion, but they failed to replicate this result.634 Some of the very best results have been achieved with multiple treatment programs headed by Hall, Lando, and Powell. Hall and her colleagues have developed a relapse prevention program that em- phasizes the interacting role of coping strategies and commitment in maintaining change in_addic- tive disorders.672 It is worthwhile to examine their model that includes both behavioral and cognitive components. It suggests that (a) both knowledge and perform- ance of relapse prevention skills are needed to maintain change; (b) continued commitment is needed to motivate performance of coping skills; and (c) commitment is a function of perceived costs and benefits of the problem behavior and change attempts s'3 The skills training treatment of Hall et al. had three components: cue-produced relaxation training; commitment enhancement by reviews of the costs of smoking and the benefits of nonsmoking; and relapse prevention skill training in which subjects identified relapse situations and either role played or rethought these situations.5BO Six of 14 treatment sessions are devoted to relapse training. Hall et al. combined aversive smoking with their relapse prevention program for a result of 52 percent at 1 year.5eO A later replication scored only 28-percent success.24$ Hall and Hall maintain that relapse training is an effective technique that requires con- siderable skill to implement effectively.554 Powell devised a program to include lectures, stress management, negative smoking, relaxation, snapping a rubberband, positive rewards, and self- control.204 Results with Ford Motor Company em- ployees for five groups ranged from 43- to 61- percent success at 1 year (see pages 33 and 34). Lando has made several contributions to the development of self-control packages. He used satiation, contractual management, and group sup- port for his multiple program.592 The features of his complex contract with subjects are detailed earlier. There were six treatment and seven maintenance sessions. Lando s multiple treatment resulted in a quit rate of 76 percent at 6 months. Lando and McCullough replicated this treatment package for a 71-percent success rate.s94 Lando conducted two additional studies in at- tempts to test the effects of satiation, fear appeals, stimulus control, minimal and intensive contacts, and maintenance procedures. He utilized the same type of contract as described previously. Lando labeled his treatments two-stage (aversion and maintenance) and three-stage (preparation, aver- sion, and maintenance). In the first study, two-stage treatment came out better than three-stage treat- ment.674 Subjects in the two-stage program bene- fited from intensive contact. Stimulus control and fear appeals did not add to effectiveness. The con- dition with aversion, contracting, intensive contact, and maintenance produced 46-percent success at 1 year. When stimulus control and fear appeals were substituted for aversion, the quit rate was 19 percent. Lando and McGovern conducted a 3-year followup of subjects and found that the 46-percent success rate held up, although if continuous absti- nence throughout the 3 years is considered, the quit rate would be 33 percent.67-9 In the second study, Lando dismantled the treat- ment stages into seven different combinations.gsl Preparation, consisting of stimulus control and fear appeals, was conducted in two sessions; satiation consisted of six sessions; and maintenance was provided in seven sessions. Those assigned to maintenance participated in contracts. Although the combined preparation, aversion, and main- tenance condition came out best, there were no significant differences between any of the combinations. Two other multiple treatment packages are noteworthy. Elliott and Denney combined eight pro- cedures: smoke aversion, covert sensitization, systematic desensitization, relaxation, self-reward and punishment, role playing, cognitive restructur- ing, and behavioral rehearsa1.e14 The quit rate at 6 months (N = 20) was 45 percent compared to 17 per- cent for 18 subjects who had either satiation or rapid smoking alone. After systematic research, Pomerleau et al. developed a package that did not include smoke aversion.85O They provided a multi- ple treatment to 100 subjects consisting of stimulus control, covert conditioning, contingency manage- ment, relaxation, and use of pocket timers. One- third of the subjects were abstinent at• 1 year. TIMN 293419 89

As shown in table 21, the median quit rate for 17 multiple program trials with 1-year followups was 40 percent. liwo-thirds of these multiple program trials had medians that reached 33 percent. Table 21 SUMMARY OF FOLLOWUP QUIT RATES OF 30 MULTIPLE PROGRAM TRIALS Reported 1973-1985 Percent N Range Median 33% At Least 6-Month Followup 13 18-52 32 38 At Least 1 Year Followup 17 6-76 40 65 Perri et al. interviewed 48 college students who were either successful or unsuccessful in reducing smoking on their own 13o The results indicated that successful reducers used more techniques for longer periods of time and used self-reinforcement and problem-solving procedures more frequently than did unsuccessful reducers. The investigators concluded that self-control smoking reduction pro- grams should be comprehensive, mulifaceted, and long-term and should include self-reinforcement and problem-solving procedures. Some multicomponent programs prepare manu- als that guide the subjects in their quitting program and provide instructions in how to apply the self- management procedures. In a review by Glasgow and Rosen of behavioral treatment manuals, they noted that studies on therapist-administered self- control strategies suggest the potential superiority of multicomponent behavioral approaches.676 Although some multiple programs have pro- duced good results, Lichtenstein and Brown553 and Glasgow99 caution that more is not always better. 1bo many procedures confuse subjects and make it difficult to provide an integrated treatment. The law of diminishing returns applies here as a point is reached where additional treatment procedures reduce compliance and in turn reduce effec- tiveness. Lichtenstein and Brown defend their use because, they say, "Multicomponent programs re- main attractive because they can deal with the multiple factors maintaining smoking as well as with the considerable individual differences among smokers."677 Comment on Self-Management Zechniques The combination of aversive and self- management procedures has been suggested as providing an optimal model for smoking cessation. Smoke aversion procedures have been shown effec- tive in producing short-term smoking withdrawal. All aversive procedures, however, share an inherent limitation that when applied to behavioral excesses, 90 if alternate responses are not available, the quitting effort is likely to be temporary. Accordingly, self- management techniques can be used to provide the repertoire of nonsmoking responses necessary for long-term maintenance of smoking cessation. It should be noted that aversive procedures often re- quire medical screening and that they may suffer from low subject acceptance. When used as the primary treatment, the self- control techniques reviewed did not produce favorable long-term results. For example, con- tingency contracting appeared to result in short- term success during the contract period, but when the contract ended, many subjects returned to smoking. Nicotine fading, a relatively new (and safe) pro- cedure, can be used to wean smokers from the nico- tine addiction as long as it is backed up by relapse prevention and maintenance support. It should be noted that nicotine fading may be less effective when used with smokers who consume low nico- tine cigarettes. Very little work has been done to ex- amine the mechanisms underlying the success of nicotine fading. This procedure, when combined with record keeping of nicotine intake, may involve a large placebo component. The issue of compen- satory increases in nicotine intake should be kept in mind. FTC tar and nicotine values may be a poor guideline to actual intake experienced by the smoker. Future research should document actual reductions in nicotine intake (serum or saliva nicotine and cotinine levels) and explore factors possibly associated with greater quit rates at followup than immediately after treatment. (Could there be discontent with lower nicotine brands?) Some interesting work has been done with re- lapse prevention and coping strategies. These tech- niques help the new nonsmoker to handle difficult smoking situations. More studies are needed to re- fine relapse prevention procedures. A number of multicomponent programs have generated good results, but some programs have combined too many techniques in one package. The most successful programs have been those with more treatment sessions, strong maintenance components, and manuals that guide and instruct the subject how to use the self-control procedures. One more general issue that should be raised in evaluating behavioral methods is the number of treatment sessions or the sheer intensity of treat- ment and how this impacts success. Do more ses- sions generate better results? For example, Lando's program tends to be among the most successful of behavioral approaches, and it is also one of the more intensive treatment programs, requiring about 14 sessions. Number of sessions is also a rough indicator of cost in terms of time and money for both client and counselor. TIMN 293420

Smoking is a complex habit causally related to a variety of pharmacological, environmental, cognitive, and affective factors. Psychological fac- tors involved in the smoking habit are central to the problems of smoking modification. The key factor in assisting smokers to break the habit rests with the maintenance phase rather than in the initial treatment. Self-management of the smoking prob- lem is valid because the smoker relies less on the leader or therapist and more on himself or herself, leading to a more lasting change because success in quitting is self-attributed rather than credit be- ing given to other sources. 91 TIMN 293421

4. WORKSITE SMOKING POLICIES AND CONTROL PROGRAMS BACKGROUND One of the positive developments in health pro- motion over the last 8 years is the increase in smok- ing control at the workplace. The.worksite offers an excellent opportunity for implementation of strategies that lead to cessation of smoking. In 1983, a measure to restrict smoking at the workplace was placed on the ballot in San Fran- cisco. The ordinance gave nonsmokers power to veto smoking in an office. Tbbacco interests set a record for local campaign spending by contributing more than $1.2 million to the unsuccessful effort to defeat the ballot measure.878 The winning side on the smoking initiative spent a total of $134,000. Prior to the ballot measure, several large San Francisco employers (e.g., Pacific Telephone and Bank of America) had already developed policies aimed at restricting smoking. Their plans were sup- ported by a Pacific Telephone employee survey (N=2,942) that found that 83 percent of the nonsmokers and 53 percent of the smokers thought that the company should be concerned about workplace smoking.679 Sixty-five percent of the smokers thought the company should offer a smok- ing cessation program; 44 percent of the smokers said they would attend such a program, and an ad- ditional 30 percent were "not sure: " A recent nationwide survey of 662 employers showed that 36 percent of them have established policies on employee smoking, and 2 percent said they plan to introduce such restrictions within a year.eBO An additional 21 percent of the private com- panies and organizations surveyed said they have smoking policies under consideration. The survey was conducted by the Bureau of National Affairs and the American Society for Personnel Adminis- tration. The report concluded that workplace smok- ing policies have continued to grow. Of the 239 companies with smoking policies, 85 percent said they had been introduced within the past 5 years, and 60 percent said their policies were less than 2 years old. Among the scores of major corpora- tions with smoking policies that participated in the survey were General Motors, Ford, Tbxas Instru- ments, Aetna Life Insurance, Campbell Soup, Levi Strauss, Boeing, Bank of America, Merck, Hewlett- Packard, IBM, and Proctor & Gamble. Local and state ordinances requiring workplace smoking policies were the most common reason cited by personnel administrators for implementing restrictions. Seventeen jurisdictions have legislation governing smoking in offices and other workplaces. Zbvelve states have laws regulating smoking at private workplaces. At least 73 California cities and counties have ordinances that regulate smoking. New smoking control laws passed locally are tough and generally outlaw smoking in public places. An example is the smoking control law enacted by Nassau County, NY, which bans smoking at work- places except in special areas. The reader is referred to papers by Swingle.681 Fries,s82 Roemer,683 and Eriksen684 for reviews of the legislative and legal aspects of workplace smoking. Employers have taken an interest in smoking control because smoking employees generate extra expenses due to their higher health care costs, absenteeism, reduced performance, greater num- ber of accidents, and excess premature deaths and disability. Smoking increases ventilation and maintenance costs. Smoking also disturbs the en- vironment of nonsmokers as secondhand smoke is irritating and may have adverse health effects. Some employers are interested in health promotion as it improves morale, reduces turnover, and results in better employee-management relations. The negative impacts of smoking and the extra costs to employers will be outlined briefly. For a more detailed overview of this material refer to the sources cited. Health Risks Chapter 1 of this monograph discussed the greater risk and excess mortality faced by smokers compared to nonsmokers. The 1985 Surgeon General's report presented a comprehensive review of the interaction of cigarette smoking with occupa- tional exposure in the production of cancer and chronic lung disease.28 The report concluded that for many workers, cigarette smoking is a greater health risk than is any other factor in the workplace. 93 TIMN 293422

Smoking and occupational exposure can interact synergistically to create more disease than the sum of the separate exposures. Blue-collar workers are more likely to be exposed to workplace agents, which in combination with their higher smoking rates, may place these workers at considerable risk of cancer and chronic lung disease. The National Institute for Occupational Safety and Health recommended that the use or carrying of tobacco products into the workplace be curtailed in situations where employees may be exposed to physical or chemical substances that can interact with tobacco products.685 Additionally, curtailment of the use of tobacco products in the workplace should be combined by simultaneous control of worker exposure to physical and chemical agents. These recommendations were based on evidence that indicated that smoking can act in combina- tion with hazardous agents to produce or increase the severity of a wide range of adverse health effects. Evidence is accumulating that secondhand smoke impacts the health of nonsmokers.611B$92 The 1986 Surgeon General's Report on the Health Consequences of Involuntary Smoking (not available when this chapter was written) documents that nonsmokers are placed at in- creased risk for developing disease as the result of exposure to environmental tobacco smoke. The 1986 report concludes that the separation of smokers and nonsmokers within the same air space may reduce, but does not eliminate, the ex- posure of nonsmokers to environmental tobacco smoke. Eighty percent of the nonsmokers and 16 percent of the smokers in the Pacific Telephone employee survey reported being either always, frequently, or occasionally bothered by smoking at work.679 Col- lishaw et al. point out that tobacco smoke contains over 50 known carcinogens and many toxic agents and constitutes a health hazard for nonsmokers regularly exposed at work.689 A significant conse- quence of long-term exposure is decreased lung function.B88•689 Weber, investigating the acute ir- ritating and annoying effects of environmental tobacco smoke, reported that in the workplace, 30 to 70 percent of the indoor carbon monoxide, nitrogen oxide, and particulate concentrations were due to tobacco smoke; 25 to 40 percent of the employees were disturbed or annoyed by smoke; and 25 percent suffered from eye irritation at work. In the Pacific Telephone survey, Eriksen reported that 66 percent of nonsmokers who were bothered by secondhand smoke reported eye irritation.684 Costs of Smoking Luce and Schweitzer estimated that the eco- nomic consequences of cigarette smoking in the 94 United States reached $27.5 billion in 1976.693 Their estimate considered three items: lost pro- duction-$19.1 billion; direct health care costs- $8.2 billion; and fire losses-$0.2 billion. The per capita cost of illness related to smoking was cal- culated to be $459. Using 1980 dollars, Kristein estimated that the annual cost of cigarette smok- ing is $47.5 billion.694 Eleven billion dollars is at- tributed to excess medical expenses incurred by smokers and $36.5 billion to early death, pre- mature retirement, and losses due to absenteeism. (The cost of illness to exposed nonsmokers is not considered.) Kristein estimated the annual costs of smoking to the average employer as ranging from $336 to $624 in 1980 dollars per average smoking employee.894-696 Kristein broke down the $624 cost to employers as follows: excess insurance costs- $274; absenteeism- $80; reduced productivity- $166; and involuntary smoker impact- $104. He indicated that smokers average 33 to 45 percent more absenteeism than do nonsmokers. The 1979 Surgeon General's report stated that smoking employees use 50 percent more sick leave than do nonsmokers,4 while an analysis of sick leave in a state health department showed that smokers used 23 percent more sick leave than did nonsmokers.697 Weis estimated that the total cost of allowing smoking at the workplace and employing smokers is much higher, $4,611 per smoker per year.898 Us- ing 1981 dollars, he cited eight cost sources: absenteeism- $220; medical care-$230; morbid- ity and early mortality-$765; insurance-$90; on- the job time lost-$1,820;• property damage and depreciation-$500; maintenance-$500; and in- voluntary smoking-$486. It should be noted that Weis' estimates are higher than those of the other economists. Regardless of which cost figures are used, it is clear that allowing smoking at the workplace is ex- pensive to employers. Weis states that the business reasons for adopting restrictive smoking policies are compelling since health care expenses, which are borne substantially by the employer, have soared over the last few years.699 Also, labor and pro- duction costs have increased, further exacerbating the excess absenteeism, on-the job down time, and maintenance burdens associated with workplace smoking. The employed smoker also imposes a much greater maintenance burden on the em- ployer for cleaning, repairing, repainting, and replacing furnishings and equipment.7O° Weis has outlined the savings that could be effected by a workplace smoking ban or a policy that restricts hiring to nonsmokers.'ol TIMN 293423

WORKPLACE ANTISMOKING POLICIES Results of Surveys on Policies and Programs In addition to the economic and health costs of workplace smoking and its impact on productivity and morale, "employers have a responsibility and, in many cases, a legal duty to provide a safe work- ing environment: '7O2 We get an indication of the extent of company smoking policies and cessation programs from 12 surveys that were conducted be- tween 1977 and 1986. Seven of the surveys were conducted prior to 1982, and five were done in 1982 or later. Selection criteria and response rates varied among surveys. Several of the surveys were targeted at the largest U.S. companies, while others included medium-sized or small companies or public agen- cies; one survey was confined to manufacturing plants. Four were state surveys, and one was con- fined to the insurance industry. Some of the surveys inquired about smoking policies or restrictions, while some asked about cessation programs. The recent Bureau of National Affairs survey of 662 employers was noted earlier.680 In that survey, 36 percent of the companies reported that they had smoking policies. A brief review of the highlights of the other surveys follows. In 1979, the National Interagency Council on Smoking and Health surveyed 3,000 small, medium, and large corporations regarding their policies and programs on workplace smoking.703 A 30-percent response rate revealed that half the com- panies had a policy restricting or prohibiting workplace smoking. Fifteen percent indica.ted that they had a health education or health promotion program on smoking, and one-third were interested in implementing such a program. Of the 124 com- panies with smoking programs, 28 offered one-time lectures, 40 used physician counseling, 41 used other counseling, 70 provided how-to-quit materials, and 13 had other types of programs. The Washington Business Group on Health studied the health promotion activities of its 160 member companies in 1978.704 Thirty-seven per- cent of the companies responded with 56 percent reporting that they had a smoking cessation program. The Dartnell Institute of Business Research con- ducted surveys of company smoking policies in 1977 and 1980.705•7O6 Dartnell found that 23 per- cent of the 325 companies in the 1980 survey had a policy covering smoking in the office. This was a 7-percent decline from the 1977 survey. Com- panies with antismoking campaigns also declined from 11 percent in 1977 to 9 percent in 1980, while those offering incentives to quit remained at 3 percent. Eighteen percent of the companies restricted office smoking to certain designated areas; 8 percent instituted special seating arrange- ments for smokers and nonsmokers; and 5 percent scheduled separate breaks for smokers and nonsmokers. A survey was sent to the Administrative Manage- ment Society's Committee of 500 survey group on the issue of smoking in the office.707 Responses were received from 302 companies. Sixteen percent of the firms had formulated an official policy re- garding the rights of smokers and nonsmokers. Most of the policies forbid smoking by employees in certain designated office areas (most often the public contact or reception area). Bennett and Levy surveyed the smoking policies and programs of 128 large companies in Massachu- setts in 1978.'08 Eighty-four (66 percent) re- sponded, and in one-third, medical personnel actively discouraged smoking. Sixty-four percent of the respondents had designated jobs or work areas in which smoking was prohibited. Eight per- cent of the employers provided counseling, and 12 percent provided smoking cessation programs for those employees who desired to quit smoking. Of the 10 companies with programs, 2 were one-time lectures, 3 were run by the Seventh-day Adventists, and 5 by SmokEnders; 8 programs were provided after work, and employers partly paid for 3 programs. Fielding and Breslow conducted a telephone in- terview survey in 1981 of 511 California employers with more than 100 employees to determine the ex- tent of health promotion activities.7Og Eighty-three percent of the employers were interviewed, and half of these were small companies (fewer than 200 employees). Eleven percent of the employers had smoking cessation programs, and another 10 per- cent were planning such programs. Of the 35 cessa- tion programs, 27 were conducted on'site, 21 were run by company personnel, and 17 were offered on a continual basis. An occupational health services survey was con- ducted in 1982 among South Carolina manufactur- ing plants with 50 or more employees.71O Of 1,206 plants, 717 or 60 percent responded. The survey asked about five health promotion and disease prevention programs: alcohol and drug abuse, smoking cessation, diet, stress, and physical fitness. It was found that even in the larger industries, these programs have little acceptance. Alcohol control programs were the most widely available (21 plants); smoking was second in 7 plants, covering 12 percent of manufacturing employees. The authors concluded that the national vogue for health promotion and physical fitness was simply not reflected in interest in services provided to employees in South Carolina. Perhaps the lack of 95 TIMN 293424

medical and nursing services in these plants is partly responsible for the scarcity of preventive pro- grams since of the 717 plants, 108 had no arrange- ments for medical or nursing services. Fourteen plants had a full-time physician, 449 had a part- time physician, and 32 had a physician on call; a nurse was onsite in 24 other plants. The Colorado Department of Health surveyed a sample of Colorado employers in 1983 to determine the extent of worksite health promotion and disease prevention activities.711 The sample assessed both public agencies and private businesses with 50 or more employees. Only companies that expressed an interest in health promotion were included in the final sample (N=358); therefore, we cannot estimate the extent of such programs among all employers in the state. Interviews were completed with 84 percent of the eligible companies. Smok- ing information programs (e.g., speakers, materials, and exhibits) were sponsored by 75 percent of the companies, and 63 percent provided cessation ser- vices (e.g., group instruction, individual counseling, or referral to community resources). Policies to control or eliminate smoking at the worksite were reported more frequently by Col- orado companies that had health promotion and disease prevention programs than by companies that did not have such programs. A higher percent- age of private businesses than of public agencies had policies to control or eliminate smoking. The Center for Corporate Public Involvement of the American health and life insurance industry surveyed its members regarding smoking cessation activities.7O2 Half of the insurance companies in the center poll reported having conducted smoking cessation programs for employees using a variety of approaches: self-help literature; educational pro- grams or clinics conducted by either outside ven- dors or specially trained company personnel; and in-house medical counseling. Over two-thirds of the companies that had conducted quit-smoking pro- grams had used one or more of the following promotion strategies: 63 percent ran articles in company publications; 44 percent used posters; 36 percent used bulletins; 31 percent distributed brochures; 19 percent held meetings; 16 percent showed films; 7 percent used payroll stuffers; and 19 percent used other promotions. Over half of the companies that had conducted cessation programs offered employees incentives to participate: 18 per- cent partially subsidized costs; 10 percent totally subsidized costs; 16 percent allowed time off for at- tendance; and 13 percent offered financial incen- tives for sustained nonsmoking. The Human Resources Policy Corporation sent its survey to large companies and fastest growing companies. It showed that less than one-third have a formal policy on smoking.712 Prevalence of smoking policies varied widely by industry: 57 per- cent of pharmaceutical companies have smoking policies compared with only 11 percent of mining, petroleum, and refining industries. Most policies were instituted as safety measures around hazar- dous materials. The majority of companies (70 per- cent) encouraged employees to work out disagree- ments among themselves. Most companies were willing to provide ventilation or rearrange work areas but would not segregate workers or build par- titions to separate smokers from nonsmokers. Examples of Company Smoking Policies Some companies have adopted restrictive smok- ing policies in response to state or local regulations. Prodded by the San Francisco ordinance, Wells Fargo Bank and Pacific Bell established policies restricting smoking in their offices throughout California. Every Wells Fargo employee received a memorandum prohibiting smoking near sensitive equipment and in corridors, elevators, and con- ference and training rooms. In common work areas, managers were charged with working out arrange- ments with the preference going to nonsmokers. The Pacific Bell policy created some no-smoking areas and banned smoking in other areas when a local manager decided that an insoluble problem existed. Fielding reports that most commercial insurers and Blue Cross-Blue Shield plans have severely restricted smoking, especially in common areas and meeting rooms.713 'Ibtal smoking bans have been implemented by Northwestern National Life of Minneapolis and Union Mutual of Portland, ME. Some companies have adopted antismoking policies in response to their own needs. For exam- ple, in 1977, the Johns-Manville Corporation banned smoking in its 14 plants in the United States and Canada and announced it would no longer hire smokers for its 8,000-person work force in asbestos operations.714 The smoking ban was in- stituted at two plants in 1976, at three more in 1977, and at the other nine plants in 1978. The company took the following measures: individuals who smoked could no longer be hired in asbestos- using operations; literature explaining the smok- ing, asbestos, and lung cancer relationship was distributed to all supervisors and employees; meetings to discuss the program were held between representatives from the corporate headquarters, local management, and the relevant union; a presentation to provide the rationale for the pro- gram was given to all employees by a physician from the corporate health program; and smokers were encouraged to participate in stop-smoking seminars provided by a professional smoking 96 ' TIMN 293425

cessation organization. Following the stop-smoking seminars, smoking was eliminated in all operations, including cafeterias, locker rooms, offices, and the work place. A spot check of 15 employment agencies around the country in 1982 indicated that hostility toward smokers is building in executive offices.'i-9 Increas- ingly, managers are requesting that agencies send them nonsmokers. The job application for the Seattle-based Radar Electric Inc. headlines a "Do you smoke?" question.716 Those who answer "yes" are told not to complete the application. Radar president McPherson started the policy for his 100 employees in 1977 after a family tragedy related to smoking.717 A small company (75 employees) in Sioux Falls, SD, banned smoking when it began in the early 1960's.718 The Austad Company has a total ban on smoking on the premises, and employees know they will be fired if they violate this rule. Recently, USG Acoustical Products told its 1,300 employees in seven states to stop smoking or quit their jobs. The company said the restriction is not a ban on smoking but a ban on smokers. Another example of a total ban on smoking is the policy of the Alexandria, VA, fire department, which stopped hiring firefighters who smoke.'ig The policy was adopted because of the occupational risk posed by smoke exposure. Not all restrictive smoking policies are related to health, economics, or legislation. Pro- 1bc Inc., a west coast marketer of protective athletic equipment, decided to ban smoking and refuse to hire smokers after the president found the flower beds full of cigarette butts.7i5 Recently, the U.S. General Services Administra- tion (GSA) instituted an almost total ban on smok- ing in the 6,800 buildings it owns or leases. The proposal affects about half of the Government's 2.8 million civilian workers. The plan, which took ef- fect in February 1987, banned smoking in general office space, lobbies, hallways, restrooms, elevators, libraries, and classrooms. Smoking is allowed in private offices, but agency heads can ban smoking in individual offices. The only smoking areas pro- vided in the regulations are special areas of cafeterias and around vending machines or canteen areas. Although the ban does not include the Depart- ment of Defense and the Postal Service, it covers employees who work in GSA buildings such as the Pentagon. Unions representing Federal workers have generally praised the regulations. The Depart- ment of Defense also is engaged in a vigorous cam- paign to discourage smoking, segregate smokers, and limit smoking to specific areas. 'ib back up its goal of making "nonsmoking the norm; ' the Army prohibits smoking in all poorly ventilated spaces on posts across the country, including auditoriums, offices, and hospital areas, and in helicopters, airplanes, and trucks. Supervisors may designate smoking areas only where they have determined that the secondhand smoke from tobacco products can be sufficiently isolated to protect nonsmokers from its effects. This restriction went into effect on July 7, 1986, covering 781,000 Army personnel plus 450,000 civilian employees. The U.S. Navy issued a directive on July 25, 1986, limiting tobacco use among sailors. The rules also apply to the Marines and civilian employees. The directive prohibits smoking in closed areas ashore but leaves it to commanders aboard ships and aircraft to designate no-smoking areas. Unlike the tougher Army policy, the Navy does not prohibit smoking in all military vehicles, warships, and planes. Many Federal agencies have taken steps to curb smoking in all work areas, and several have banned smoking (e.g., Centers for Disease Control, Environ- mental Protection Agency, Merit Systems Protec- tion Board, and sections of the National Institutes of Health). Congress and the Supreme Court have their own smoking prohibitions. The Group Health Cooperative of Puget Sound, a group healthrplan, adopted a policy banning smoking in its 35 facilities.720 The policy was in- itiated by the cooperative membership, which passed a resolution to reduce the proportion of smokers among its 6,000 employees and 325,00 enrollees. The ban was phased in during three stages over the period of 1 year. At the start, an ad- visory group held open meetings at each facility. Information about smoking and the policy was pro- vided in the second stage along with promotion of self-help materials and classes on smoking cessa- tion, stress management, and weight control. The prohibition took effect in April 1984 in all but one facility. Inpatients may smoke only with a doctor's prescription. Rosenstock et al. assessed the effect of the pro- hibition through a random sample of 687 employ- ees 4 months after its implementation.7zO 'Iiwo- thirds 'of the employees responded to the survey, and 85 percent indicated that they approved of the ban. Thirty-six percent of the smokers approved of the ban, and two-thirds of them said that they wished to quit smoking. Although 77 percent of the 67 smokers said that they knew about the cessa- tion classes, only 2 of them attended a class. Three ex-smokers reported that they quit smoking in response to the ban. The authors concluded that the smoking ban was implemented with little disruption. They state that results of the survey suggest that employer groups can introduce very restrictive smoking policies without risking employee unrest provided that the new policies are introduced gradually, opportunity is provided for 97 TIMN 293426

dissidents to express their feelings, and the limita- tions of employee influence are clearly communi- cated. Weis reports that although employers are general- ly reluctant to discuss publicly their policies against hiring smokers, many are deliberately selecting nonsmokers when hiring, especially for professional positions.721 A survey of managers in the Seattle area showed that 53 percent were already giving preference to nonsmoking appli- cants. Weis points out that since the U.S. Supreme Court has verified smoking as a legal criterion for hiring, discrimination against smoking does not violate equal opportunity statutes. Four grievances were filed in different states against the Johns-Manville policy of banning smok- ing.722 Three were decided in favor of the company, and in the fourth, the judge ruled that the company must go through the collective bargaining process to implement the ban. However, it was decided that the company can unilaterally implement smoking restrictions. This decision was upheld in an appeal to the Federal court. Therefore, in the Texas plant where the court decision occurred, Johns-Manville adopted a smoking restriction rather than a ban. A number of guides are available that offer pro- cedures for implementing smoking policies and programs. At the ACS National Conference on Smoking OR Health, Keiihaber and Goldbeck dis- cussed the barriers that interfere with the establish- ment of company smoking policies and offered recommendations for overcoming these barriers.722 The conference Work Group on Smoking Control in the Workplace identified 34 barriers in 5 major categories:723 (1) Employers' lack of knowledge of the health and economic impact of smoking and oppor- tunities for smoking control. (2) Perceived conflicts in labor-management relations. (3) Program costs and lack of cost-effectiveness information. (4) Lack of evidence of smoking control pro- gram effectiveness. (5) Inadequate resources. The work group adopted recommendations for eliminating these barriers. As a result of the con- ference, the ACS developed a Model Policy for Smoking in the Workplace.724 The National Interagency Council on Smoking and Health published a guide to start a company smoking control program."5 The guide includes examples of company smoking policies. ALA offers two manuals to management and employees to help them develop effective policies on smoking, 7hking Executive Action and Creating Your Com- pany Pblicy.728 Three Canadian guides were made 98 available by the Ontario Provincial Government,727 the Manitoba Lung Association,728 and the 'Ibronto Non-Smokers' Rights Association.729 Environmen- tal Improvement Associates in New Jersey pro- duced two separate guides to smoke-free work areas for employees73O and management.'31 The most comprehensive guide to initiate a worksite cessation program was produced by Orleans and Pinney for the Center for Corporate Public Involvement.702 Although directed at the in- surance industry, the authors adopted the manual for use by businesses and public agencies.732 The guide contains the elements of an effective pro- gram, implementation advice, evaluation pro- cedures, and a model policy. Three recent (1985) handbooks for implementing worksite policies and programs have been offered by the New Jersey Group Against Smoking Pollu- tion,733 by the U.S. Office of Disease Prevention and Health Promotion and the Office on Smoking and Health,734 and by Weis and Miller.735 The New Jersey group presents an outline for establishing a smoking policy and includes a model policy. The Federal Government guide explains the steps re- quired to reduce worksite smoking. These steps de- pend on many factors, including measures already taken, special occupational hazards, employee at- titudes, union contracts, and group willingness to start a program. Successful smoking policies of several large companies are described, and ex- amples of businesses with successful smoking cessation programs are provided. Weis and Miller describe Weis' economic considerations regarding workplace smoking and Miller's guidelines for employers and employees who want to establish tobacco-free air. The elements of a comprehensive company smoking policy include the following: rules and restrictions about smoking (e.g., prohibited areas, work areas, and common areas); an educational program on smoking and health for employees and their families; incentives for employees to quit smoking; sponsorship of smoking cessation pro- grams; and participation in community efforts to control smoking. This last element of the proposed policy is optional but indicates to employees that the company is committed to smoking control. The smoking policy should be formulated by manage- ment and employees and should favor a smoke-free environment. The recommendations concerning a comprehen- sive company smoking policy are offered without considering the cost-effectiveness of such a com- bined program versus its component parts. Each of the five recommendations individually makes sense, but we do not know enough presently to make con- clusions about the optimal combination of strate- gies. This would be a useful area for research. TIMN 293427

It is difficult to summarize the surveys on smok- ing policies as they differ so widely in sampling pro- cedures, response rates, and findings. About one- third of the companies appear to have policies on smoking, but there were wide differences by in- dustry. About 10 to 15 percent of the companies reported that they had some type of cessation pro- gram with the larger companies more likely to have such a program. It should be kept in mind that companies with smoking programs were more apt to reply to the survey. It also should be noted that because the Federal Government is the Nation's largest employer, the action of the GSA could set off similar bans in private firms. Indications are that nonsmoking is being con- sidered in hiring. Goerth states that the momen- tum created by the courts, legislatures, public opin- ion, and awareness of the economic impacts of smoking contributes to the prediction that nonsmoking eventually will become a requirement of hiring, promotion, and continued employ- ment.736 He points out that the courts have general- ly accepted discriminatory practices if they have a rational basis, and the basis for prohibiting smok- ing is building. In view of the ordinances restric- ting smoking in public places and the threat of lawsuits from nonsmoking employees, legal liability is becoming an increasing concern of employers. Walsh reviewed corporate smoking policies and found that some employers are adopting strategies to change smoking behavior due to the growing concern over company-borne health care costs and to anticipate demands of nonsmokers.73' Fielding notes that a good investment return may be at- tained with well-organized and well-delivered smoking cessation programs.738 In a recent edito- rial, Fielding indicates that increasing reports of worksite prohibitions on smoking suggest that a national consensus is rapidly forming.713It should be noted that there have been very few negative reactions from smokers in the worksites in which stringent smoking restrictions have been instituted. We turn now to a review of programs intended to change worksite smoking behavior. WORKSITE SMOKING INTERVENTION STRATEGIES The workplace has been a neglected arena in terms of both research into and practice of smok- ing cessation.739 The training of occupational physi- cians has in the past focused mainly on assuring adequate standards of safety and the adoption of appropriate procedures to prevent industrial disease. It is hoped that the new generation of oc- cupational physicians will turn their attention to the reduction of major risk factors, including smoking. Another reason for the scarcity of worksite prevention programs is that only 12 percent of all companies with 500 or more workers employ 1 or more physicians; 18 percent employ a physician part-time.74O Company physicians devote less than 20 percent of their staff time to health education, and company nurses spend less than 25 percent of their time on health education. Only 58 percent of the companies with 5,000 or more employees of- fer any kind of health education. Among smaller companies, the percentage offering health educa- tion is even lower: 45 percent for companies with 1,000 to 2,499 employees and 15 percent for com- panies with fewer than 1,000 employees. At the National Conference on Health Promotion Programs in Occupational Settings, seven health promotion programs were recommended, includ- ing smoking cessation.'41 Several authors discuss the advantages and disadvantages of worksite smoking cessation programs.741•'42 The workplace is an ideal setting in which to provide a variety of approaches tailored to the needs of individual smokers.739 Large numbers of smokers are avail- able, ongoing programs are possible, and long-term evaluation is feasible. For employees, the primary potential advantages appear to be convenience, reduced expenditure, and the opportunity to par- ticipate with friends and coworkers. The potential advantages to employers were discussed earlier (e.g., cost savings from reduced health care costs, absenteeism, and maintenance, increased produc- tivity, and improved employee morale). Glasgow and Klesges point out that potential benefits do not occur automatically, and they may be offset by potential disadvantages.742 Programs may interfere with work, scheduled meetings may not be convenient, smokers may feel coerced into participating, unions may object to programs, and employers may be burdened by program costs and the time lost at work. It should be noted that only a limited number of worksite intervention programs have been evalu- ated. Procedures for evaluation as outlined in chapters 1 and 2 apply as well to worksite programs (e.g., description of recruitment, study population, and methodology, use of controls if possible, results based on all subjects, assessment based on absti- nence at 1 year, proper followup procedures, and biochemical verification). Fielding lists three characteristics of program reports interfering with evaluation:743 • Goals and objectives are not explicit. • Information is not available on which to assess whether goals and objectives have been met. • An adequate evaluation scheme makes it dif- ficult to assess whether changes observed can be reasonably attributed to the health promo- tion program. 99 TIMN 293428

Feldman suggests three types of questions to be answered in an evaluation of health promotion pro- grams.'44First, are employees participating? Sec- ond, do employees like the program and think it is useful, and does it meet their expectations? Third, is the program effective compared to a control group (e.g., waiting list and other nonintervention sites). In addition, worksite programs can be assessed in other ways (e.g., morale, productivity, and cost). Glasgow and Klesges discuss the criteria for evaluating worksite programs under three general headings: changes in smoking behavior, effects on smoking and health-related variables for all employees in the organization, and secondary ef- fects of a program on nonhealth variables of con- cern to employers.742 They state that most pro- grams assess only one or two of these areas. Danaher,75 Orleans and Shipley,746 Kiesges and Glasgow,74' Glasgow and Klesges,'42 and Hallett'48 have provided reviews of worksite smoking inter- vention programs. In the review of intervention strategies that follows, three categories will be used: educational campaigns, incentives for quitting, and cessation programs. Employer policy restrictions and prohibitions of smoking also may be con- sidered an intervention strategy as they may lead to changes in attitudes and behavior toward smok- ing. These policies were discussed in the previous section. Educational Campaigns Many employers sponsor antismoking educa- tional programs using a variety of methods such as publishing articles in company newspapers and bulletins; distributing pamphlets and other materials obtained from voluntary and public health agencies; displaying posters; and holding meetings where films are shown and talks are pro- vided by a company doctor, nurse, or health educator or an outside consultant. A few companies offer antismoking education during routine health screening examinations. Voluntary health organiza- tions have developed special promotional materials for use at the worksite. ACS and ALA provide con- sultants who assist in designing worksite promo- tions and help organize orientation meetings. A few of the large companies that have sponsored educational programs on smoking are IBM, Ford, Johnson and Johnson, AT8t1; General Foods, Campbell Soup, DuPont, Eastman Kodak, and Boeing. State Farm Insurance Company performs spirometry testing on employees; during this ex- amination, smokers are advised to quit and offered educational material. Fielding mentions several smaller firms and in- surance companies with educational programs on 100 smoking: Kimberly Clark (Neenah, WI), Blue Cross/Blue Shield, Metropolitan Life Insurance, The Travellers, and Massachusetts Mutual Life Assurance.738 Safeco provides employees with a self-assessment questionnaire and encourages smoking cessation in its monthly newsletter. Tvo Los Angeles firms-Mattel and 'Ibsco Corporation- have special health enhancement programs in col- laboration with the UCLA School of Public Health. As described in a previous section, the Johns- Manville Corporation ran an extensive smoking education campaign prior to instituting a ban on smoking.714 An educational campaign was con- ducted among Tyler, TX, asbestos workers con- sisting of information on the additional risks faced by asbestos workers who smoke.714 The campaign was presented during preemployment interviews, in onsite programs, through posters, pamphlets, and union and industrial publications, and in the mass media. The Texas Division of the Dow Chemical Company prefaced an incentive program with an intensive educational campaign that reached 97 percent of 7,200 affected employees and many of their family members.746 A cancer education and screening program was conducted among 19,000 Cannon Mills workers in North Carolina?49 Lectures were presented on com- pany time for all employees within each of the three 8-hour shifts. In addition to information on cancer, the effects of smoking and various hints for stop- ping smoking were provided. The Cummins Engine Company joined with six other firms in Columbus, OH, to offer an occupa- tional health and disease prevention program to employees.424 The service included a complete physical examination annually and an antismoking discussion aimed at encouraging smokers to quit. Of 543 smokers, 22 percent were persuaded to stop for 1 year. Further followup indicated that 13 per- cent returned to smoking, however, reducing the long-term quit rate to 19 percent. This appears to be a good result for a smoking program limited to one persuasive discussion and a physical examination. Companies that sponsor cessation clinics gener- ally employ educational campaigns to motivate employees to participate in the clinics. One exam- ple is the program of Blue Cross/Blue Shield of Indiana developed by the Health Promotion Service of the American Health Foundation 17g The Health Promotion Service focuses on smoking cessation and reduction of weight, blood pressure, and cholesterol levels. The first of four phases consists of planning and education. Employees are moti- vated to participate through an active campaign of educational and promotional materials. Health education is also carried out during the second phase of screening. The last two phases consist of intervention groups and maintenance. TIMN 293429

There is a general lack of evaluation of the im- pact of worksite smoking education campaigns. Future research should determine whether educa- tional campaigns translate into behavior change. Incentives for Quitting A number of small and a few large companies have offered monetary incentives to employees for giving up smoking. The incentives have varied from direct cash payments to bonuses, chances for a raf- fle, wagers, competitions, and the return of the fee for a cessation clinic. Articles in the Wall Street Journal,715•'18a19 Business Week,'5O and local California news- papers751•'52 and a report in the 1977 review42 pro- vide a dozen examples of incentive programs ini- tiated prior to 1978 by small companies. As early as 1967, the City Federal Savings & Loan Association of Birmingham, AL, started paying monthly dividends to nonsmokers. In 1977, the company paid about $40,000 in $20 monthly pay- ments to 166 of its 185 full-time employees. Speedcall Corporation in Hayward, CA, a small company with 36 employees, rewarded nonsmokers $7 per week in extra pay. Employees were not penalized if they chose to smoke. The program started in 1976, was voluntary, and, operated on the honor system. If employees who quit smoking returned to smoking,they were eligible for the bonus when they quit again. In 1977, Speedcall paid out $10,000 in rewards. The company reduced the number of smokers from 25 to 4 over a 2-year period. Almost all employees approved of the pro- gram. Absenteeism and illness were reduced, pro- ductivity increased, and the company was offered a 5-percent reduction in its employee health care coverage as a result of the program. A followup of the Speedcall program after 4 years showed that only one-fifth of the employees reported smoking in the worksite compared to two-thirds at the start of the incentives.'42 Cyberteck Computer Products Inc. in Los Angeles estimated that smoking cost the company $675 per year per smoker in lost time. Its 140 U.S. employees were offered $500 each to quit smoking for a year. In 1978, 32 workers had collected.715 The bonus at the Austad Company in Siuox Falls, SD, was $100. Neon Electric Corp. in Houston banned smoking and offered a raise of 50 cents per hour to any employee who quit smoking for 6 months. Norweco in Spokane, WA, paid nonsmokers $10 per month, while Leslie Manufacturing and Supply Company in Minneapolis paid ex-smokers $7 per week. Merle Norman Cosmetics (Los Angeles) paid each of its 825 employees-smokers and nonsmokers alike-a $40 annual cash bonus not to smoke at their desk or on the production line.'gl Also forbid- den was sneaking a smoke in the restroom. The firm claimed that the $33,000 cost was made up in company savings from reduced housekeeping costs, lower absenteeism, and increased produc- tivity. The Flexcon Company, a specialty paper concern in central Massachusetts, offered Its employees $30 a month to give up their cigarettes.'g2 During 1984-1985, the company put $30 gift certificates into the paychecks of 49 employees who quit smok- ing and 175 nonsmokers. It also gave $15 gift cer- tificates to 59 employees who reduced their smok- ing. It is estimated that the workers collected about $96,000 during the 1-year program. The company chairman started the program after he learned that smoking was more hazardous to his workers' health than were the chemicals they handle to make laminated paper. Westminster Business Systems Inc. in Lake Bluff, IL, stopped hiring smokers in 1973 and offered a $50 savings bond to smokers who quit for 1 year. Aluminair Standard Glass Co. in Gallup, NM, paid employees who quit smoking the amount they would have spent on cigarettes. Pioneer Hi-Bred International in Iowa paid $150 to employees who stopped smoking for 1 year and $75 for remaining off a second year. Analysis & Computer Systems paid increasing monthly bonuses of $50 to $300 to smokers who quit.753 Some companies did not pay straight bonuses. Bonnie Bell Cosmetics Co. in Lakewood, OH, paid heavy smokers on its executive team up to $200 to quit, but participants were required to donate two times the bonus received to charity if they backslid. In 1976, Intermatic Inc. in Spring Grove, IL, opened a betting window to wager up to $100 with its 800 employees that they could quit smoking. Employees who refrained from smoking for 1 year could double their money. At year's end, 25 win- ners were paid $2,815, while 45 losers paid $1,105 to ACS. The Texas Operating Division of the Dow Chemical Company launched a 1-year lottery aimed at smokers.745 Employees who quit received one chance in a raffle of a boat and motor (worth $2,400) for each month of nonsmoking. A second lottery of a boat and motor was held for employees who encouraged smokers to quit. For each month of nonsmoking by the recruited ex-smokers, the recruiter received one chance in the raffle. Absti- nent employees also were offered bonuses of $1 per week and a chance to win a $50 quarterly prize. Almost one-fourth of the smokers (N=400) were recruited, and three-fourths of them quit. Followup data were not obtained, so we do not know the long- term result of this effort. TIMN 293430 101

An incentive program that provided a group penalty was reported by Rosen and Lichtenstein.754 The Eugene-Springfield Ambulance Service in Eugene, OR, with 31 employees, offered a $5 monthly bonus to any employee who did not smoke during working hours. As an added incentive, the accumulated bonuses for the year were matched at Christmas time. Employees had the choice of agreeing to participate in the program or not. Group pressure was utilized to secure conformance among the 12 participating smokers since all bonuses during the month were voided if any of the participating employees failed to abide by nonsmoking rules. Four of the employees declined to participate; they were allowed to smoke during the workday but only in the company's garage. Seven of the 12 smokers who participated in the program were not smoking at work 2 months after the program was initiated. The other five smokers reduced their smoking significantly. Even the four nonparticipating employees reduced their smoking during the workday. One year later, four of the employees who had previously smoked were still abstinent. It was found that five other employees who claimed that they were not smoking at work actually were. There was hostility among employ- ees who knew these workers were smoking and did not wish to inform on them yet resented the viola- tions. Still, the program was generally successful and acceptable to employees due to its elements of voluntary participation and positive reinforcement for nonsmoking. Some companies that sponsor smoking clinics reinforce abstinence by paying bonuses to smokers who quit and remain nonsmokers. For example, Riviera Motors in Portland, OR, conducted a pro- gram in 1978-1979 to help its employees quit smok- ing.755 Employees attended a 5-day plan clinic at a local hospital, and those who quit for 1 year received a $200 reward and a chance in a lottery for vacation trips. In addition to the clinics, the com- pany provided low-calorie food, exercise classes, and other amenities (detailed in the next section). Of 55 participating employees, 17 went without smoking for a year and collected the $200 bonus. A monetary incentive is provided by the quit pro- gram of the University of Alabama in Birm- ingham.75B After 6 weeks of abstinence, the ex- smoker receives $25 and at 6 months an additional $25. Abstinence is verified by saliva thiocyanate. Stachnik and Stoffelmayr described an elaborate incentive program to support cessation groups at three small companies in Michigan.757 The incen- tives consisted of team competitions for not smok- ing that produced around $100 for each team member, a $50 bonus, and a chance to win $20 at each group meeting. The investigators reported very high quit rates, which will be detailed in the next section. 102 Klesges, Vasey, and Glasgow described a smok- ing control competition among four banks in North Dakota.74'•'58 The four bank presidents challenged ,each other to a smoking reduction contest with prizes going to both smokers and nonsmokers. Each bank contributed $150 plus $10 per partici- pant, and prizes were awarded to each bank with the highest participation rate, the largest reduc- tions in carbon monoxide levels at posttest, and the best quit rate at the 6-month followup. Smokers received time off to take part in a gradually paced cessation and reduction smoking method.'g9 They were encouraged to participate through buttons, social support, and weekly feedback on how each bank was doing posted in the bank lobby or lounge. The participation rate at the four competing banks was 88 percent; the participation rate at a savings and loan association that received the gradually paced program without competition was 53 per- cent. At a 6-month followup, there were no dif- ferences in cessation between the competing banks (18 percent) and the savings and loan (14 per- cent).742 Several worksite programs have tied the offer of money to reduced carbon monoxide levels. Stitzer and Bigelow offered 23 hospital employees (who were regular smokers) money for reduced afternoon breath CO levels.sss.7so Payment varied up to $12 per day and was inversely related to absolute CO reading obtained. Contingent reinforcement pro- moted CO and daytime cigarette reduction. The amount of behavior change was related to the amount of payment available. The average duration of abstinence prior to the afternoon contact in- creased from 62 to 319 minutes.'sl In another hospital study, 18 employees were of- fered $12 per day for 2 weeks if they totally refrained from smoking.742 CO readings showed that 11 of the 18 employees were abstinent throughout the 2-week period and 5 continued abstinence over a 3-week followup. In still another study (N=60), reduction in CO levels was in- fluenced by the amount of money rewarded.742 Another form of incentives involves payment of all or part of the fee for participating in a cessation program. Orleans and Pinney cite three exam- ples.7O2 An insurance company pays half of the $100 fee upon enrollment and the other half if the employee is not smoking 6 months later. Another company sells its employees the ALA self-help manuals and returns the cost to those who suc- ceed. Adolf Coors in Golden, CO, offers a cessation program for $60; employees who quit are reim- bursed $15 at the end of the course, $15 at 6 months, and $15 1 year later. Several large companies have paid part of the fee for cessation programs conducted by outside or- ganizations, while some companies pay the entire TIMN 293431

cost of in-house programs. The commercial Smokeless Program was offered to employees of General Motors at a corporate rate of $95. General Motors absorbed 75 percent of the fee, making the charge to the employee $23.75. Johns-Manville paid part of the fee for the SmokEnder program. If the worker remained abstinent from cigarettes for 6 months, the entire fee was reimbursed. The Campbell Soup Company split the $50 fee paid to the Center for Behavioral Medicine of the Univer- sity of Pennsylvania to conduct cessation classes. The Abraham Lincaln Memorial Hospital in Lincoln, IL, offers employees the Smoke Stoppers 5-day program at a cost of $140. Employees are reimbursed half of the cost after 6 months of abstinence and the other half at 1 year of con- tinuous nonsmoking. USG Acoustical Products, with 10 plants in 7 states, gives employees the choice of a company-sponsored clinic held on com- pany time or reimbursement for programs recom- mended by their physicians. Shepard and Pearlman calculated the 1-year quit rates for 15 incentive programs and found that the quit rate for participants in ongoing incentive pro- grams was 63 percent compared to 44 percent for one-time incentive programs.753 They also reported that two programs that involved the spouse had higher quit rates than did programs that did not involve the spouse. Glasgow and Klesges point out that the major ad- vantage of incentive programs is that they do not require large amounts of therapist and participant time.742 They state that the results of incentive programs are very promising. If success rates for incentive programs can be validated, they might prove to be a cost-effective approach to smoking control at the worksite. Glasgow and Klesges note that almost all incentive programs have been con- ducted in small worksites and suggest that system- atic replications of findings in controlled investiga- tions in larger companies are needed. The apparent superiority of ongoing versus one- time incentive programs should be emphasized. Another attractive feature of incentive programs is that they are inherently cost-effective (or at least cost-contained) as they only cost employers money if participants are successful in quitting. On the cautionary side, it is important to stress the need for biochemical validation of reports on smoking. If the word gets out that an employee who is still smoking "beat the system," the credibility of the entire incentive program can be severely damaged. The best payoff in terms of getting employees to stop smoking would be to adopt a strict smoking policy and offer cessation methods combined with incentives to encourage employees to participate in the methods and succeed in quitting. Cessation Programs Many private companies and public agencies of- fer direct service health promotion programs to employees. The most common areas covered are fitness, alcoholism, accident prevention, weight control, stress, hypertension, nutrition, and smok- ing. Parkinson et al. provide examples of health pro- motion programs in 17 corporations, some of which are direct service programs.782 They offer guidelines for initiating these services. A guide for smoking programs is in the manual of the Center for Cor- porate Public Involvement.73z The surveys cited indicate that many large com- panies have had cessation programs for employees, but evaluations are not available. Some of these companies are IBM, Pratt and Whitney, Xerox, General Foods, Eastman Kodak, Quaker Oats, Con- tinental Illinois, Kimberly Clark, Western Electric, and TWA. Prepaid health plans have offered quit programs to subscribers and employees. The pro- gram of the Group Health Cooperative of Puget Sound already has been cited.720 Another example is the Kaiser-Permanente employee program in the Oregon Region.763 Five smoking intervention pro- grams were offered: the ALA self-help manuals, two group approaches, a weekend marathon, and hyp- nosis. The program goal was to reach one-half of the smokers (about 780 smokers out of 3,000 employees). Johnson and Johnson Corporation's Live for Life is a comprehensive lifestyle change program in- itiated in 1978.764 Core elements are a health screen and lifestyle profile; a 3-hour lifestyle seminar; ac- tion groups on smoking cessation, weight control, exercise, stress management, yoga, personal power, nutrition, and alcohol and drug abuse; and crea- tion of a healthy environment (e.g., no-smoking signs and nonsmoking areas). A random sample of company employees who attended action groups revealed that 80 to 90 percent found them helpful. Evaluations of the program are being conducted. The STAYWELL program was initiated by Con- trol Data Corporation in 1979 for its 22,000 employees and their spouses in 14 U.S. cities.765 Emphasis is on long-term change in health behavior facilitated by providing people with awareness, skills, and a workplace environment conducive to the initiation and maintenance of positive lifestyle behaviors. Provided on company time are orientation sessions for employees and management and behavioral health screening and health hazard appraisal. Offered on employee time are behavior-oriented courses and support groups. Programs focus on smoking cessation, weight con- trol, fitness, stress management, and nutrition. The program utilizes employee volunteers to modify as- pects of the work environment. Employees at sites where a smoking program was offered reported 103 TIMN 293432

that 58 percent had made "some changes" in their smoking and 35 percent had made "substantial changes." At control sites, 15 percent of the employees had made "some changes" and 8 per- cent "substantial changes." A long-term evaluation of the program is in process. Some multiple risk factor projects use workers as subjects, but they are not really "worksite pro- grams: " Rather, they are long-term clinical research trials funded by public moneys. These projects were selective in who they included in their study (e.g., some limited services to men or persons who were at high risk of heart disase or respiratory illness). The results for some of these projects are shown in the comprehensive table (under Risk Factor Intervention 'Ii ials) and will not be examined here. 7iwo dozen worksite cessation programs already have been described in this volume according to the method used; their followup quit rates are shown in the comprehensive table. They also will be noted here to bring together worksite programs in this chapter. In this volume, cessation methods were reviewed under 10 categories. Methods used by worksite programs that were evaluated included all but three categories (medication, acupuncture, and mass media and community programs). Several programs that offered treatment options provided one result for all participants. The methods will be reviewed under six categories with the number of trials noted in parentheses: self-care (4); educa- tional methods, clinics, and groups (19); nicotine chewing gum (2); hypnosis (2); physician counsel- ing (4); and behavioral methods (26). Nine of the behavioral trials used cessation and reduction pro- grams. There was one miscellaneous program with five trials. Studies with more than one method were classified in just one category. The discussion will emphasize the programs with followup quit rates of at least 6 months, but programs with shorter followups also will be cited. In all, there were 35 worksite programs with followup results provided by 30 different investi- gator teams. Tiwo teams did two studies each, and one team did four studies. These 35 programs generated 62 trials. Six of the studies were reported between 1970 and 1977, 11 were reported between 1978 and 1982, and 18 were reported in 1983 or later. Four programs were conducted in several cities, and nine included more than one company. Five programs were carried out among the Armed Forces, and four were conducted at VA hospitals. Eleven of the 35 programs had at least 1-year followups, 2 had 9-month followups, 14 had 6-month followups, and 8 had less than 6-month followups. In terms of trials, 21 had at least a 1-year followup, and 26 had at least a 6-month followup. Four programs that used cessation and reduction methods validated their results by either CO or SCN testing. Only seven other programs validated their results by physiological measurements. Table 22 provides the quit rates for the 62 trials generated by the 35 programs, along with the methods used, number of subjects, length of follow- up, investigators, locations, and identity of the worksite (where this information was available). The programs that validated self-reports by physio- logical measures are indicated. The results reported for several studies were confusing and incomplete; I had to calculate their results or rely on secondary sources. In interpreting these followup results, the same cautions apply, as noted previously, regarding self-reports and followup procedures. Self-reported abstinence rates may be inflated although non- smoking during working hours might be diflicult for a worker who has claimed to quit. Still, the worker could smoke at home and refrain in the office. Table 22 FOLLOWUP QUIT RATES OF WORKSITE CESSATION PROGRAMS Reported 1974-1986 Nnmbez Quit of Rate Follownp Investigators Intervention Method Subjects (%) Period Location Year of Report Notes Lectums, discussion, buddies, 81 30 6 Months Bauer 1978159 Bell Laboratories. and videotapes (5 days) Murray Hill, NJ Lectures, films, and counsel- 33 55 1 Year ing (11 sessions and 4 followup sessions Educational groups and 15 47 6 Months lectures Self-help modules (nine), 36 14 smoke holding, nicotine fading, and self-control Miller 1981152 Cummins Engine Company. Columbus, Ohio CO validation. 1984150 VA Hospital. T1vo patients included Dawley, Fleischer, in group. Six subjects who did not and Dawley complete treatment were not New Orleans, LA followed up. 6 Months Nepps New Brunswick. NJ 1982116 CO validation. Quit rate for 19 subjects starting second module was 26 percent. Johnson & Johnson Corporation. 104 TIlVIN 293433

Tabie 22 (continued) lrnmber Quit of Rate FbIIowap I(nvestigators Year of Intervention Method Subjects (%) Period Location Report Notes Five-Day Plan and six 118 27 1 Year Mossman maintenance sessions Albuquerque. NM Five-Day Plan 35 23 3 Months Seventh-day Adventist Church. Seattle, WA SmokEnders 30 40 1 Year Kanzler, Jaffe, and Zeidenberg New York, NY Groups, peer support, and 101 taped telephone messages (6 weeks) Group counseling Self-help Control Group meetings and self-help manual 9 6 Months Grove, Reed, and Miller, Indianapolis, IN 218' 40 4 Months Flow 18 Corvallis, OR 5 54 15 3 Months Perrin, Tanant. Moreton, and East England Four options of group sup- 179 35 1 Year Brennan port: minimal intervention, New York. NY self-quit telephone calls. messages, or buddies ALA-FFS manual and trouble 18 33 1 Year Bishop and Fisher shooting for some and four Eastern Missouri meetings for some ALA-FFS manual and group 48 33 meetings ALA-FFS manual and group 46 -7 meetings Group meetings, iottery, no- smoking contest, contracts, and 20 meetings over 7 months Health risk appraisal, health education modules, and meetings Nicotine chewing gum, clinic, and workbook Clinic-3 treatments: Full-19 sessions Minimal contact-4 sessions Self-help Nicotine chewing gum nr 91 6 Months Stachnik and 80 Stoffelmayr 85 Michigan nr 53 5 Months Spilman, Goetz, Schultz. Bellingham, and Johnson Bedminster. NJ, and Kansas City, MO 243 20 1 Year Schlegel. Manske, and Shannon 29 28 Canadian 25-38 military bases 17-29 7-10 161 11 1 Year Soul At sea 1978158 Employee spouses in^luded. Sandra Labs. 1980746 Boeing Aircraft. Result based on 27 subjects followed up was 30 percent. 19761118 New York Psychiatric Institute, Columbia Presbyterian Medical Center. and family members. Tiventy subjects graduated. 1979175 American Health Foundation pro- gram for Blue Cross/Blue Shield. CO validation. 1980187 Doctoral dissertation. 1982768 Program conducted at two sites. Laboratory of scientists and engineers. Office of engineers and clerks. 1983181 Metropolitan Life Insurance Com- pany. All participants over 4-year period combined in evaluation. Success ranged from 29 to 40 percent. 1984170 EASE (Employer Assisted Smoking Elimination). 1983757 Program conducted at three sites: hospital service organization, manufacturing company, and bank. 1986767 AT&i' Communications. Par- ticipants came from 690 randomly selected employees from two sites. 1983249 Six-month program. Results based on those choosing abstinence as goal. 'li.venty-nine percent represents result for three treatments combined. 198425' British naval seamen serving on H.MS. Hermes. 105 TIMN 293434

Thb1e 22 (continned) Intervention Method Hypnosis and group sessions Wait-list control Hypnosis Group Antismoking message during physical examination Physician advice Individual counseling Behavioral modification Physician examination, advice, and warning to quit Physician warning during examination Behavioral counseling Rapid smoking, warm smoky air, and handling cigarette litter Rapid smoking and educa- tional seminars (4 weeks) Regular-paced aversive smoking and self-control Electric shock, rapid smoking. and education (4 weeks) Classes-behavioral method Nicotine fading (8 sessions) and Health education Stress management Social support Brand fading, abstinence training, feedbaek, and public posting of carbon monoxide levels Wait-list controls 106 Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report 35 31 3 Months Jeffrey. Jeffrey, 1985771 30 0 Greuling. and 48 19 6 Months Gentry El Paso, TX Frank, Umlauf, 1986770 15 20 Wonderlich, and 1,493 13 1-2 Years Ashkanazi Columbia, MO Pincherle and 1970"3 14 15 3 Months Wright London. England Meyer and 1974772 10 10 Henderson 12 9 Palo Alta CA 543 19 2 Years Richmond 1976424 361 4 11 Months Columbus, OH Li. Coates, Kim, 1983415 215 8 and Ewart Baltimore, MD 12 17 9 Months Dawley and 1977564 172 28 6 Months Sardenga New Orleans. LA Parker and 198157 26 20 6 Months Younggren Tacoma. WA Danaher 1980745 31 39 6 Months Dearbom. MI Younggren and 197777' 36 25 6 Months Parker Tacoma. WA Pomerleau and 1980745 3 Months Pomerleau Camden. NJ Abrams. Pinto, 1985742 18 33 Monti. Jacobus, 18 27 Brown, and Elder 18 6 Providence, RI 18 33 9 Months Scott. Denier, and 1983636 10 0 Prue Jackson. MS Notes William Beaumont Army Medical Center. Military personnel and dependents. Group had four sessions. University of Missouri-Columbia. Business executives. Thirty-six screened as high risk of heart disease. Varian Corporation. Cummins Engine Company. Shipyard workers. CO validation. VA hospital employees. Clinic in military setting. Ft. Lewis. Danaher and Lichtenstein self- help book used. Ford Motor Company. Subjects were soldiers at Ft. Lewis. Campbell Soup Company. Pro- gram by Center for Behavioral Medicine. University of Pennsylvania. CO validation. Program con- ducted at two sites: medical manufacturing company and insurance carrier. VA hospital nurses. Twenty-six subjects but not all subjects car- ried out treatment. CO validation. Three-month treatment. TIMN 293435

Zhble 22 (continued) Intervention Method Number of Subjects Quit Rate (%) FoIIowup Period Investigators Location 28 14 3 Months Sutton and Eiser London, England 33 0 33 3 12-15 Months Sutton and Hallett nr 0 nr 11 nr 11 nr 8 3-5 Months nr 4 nr 3 nr 6 36 61 1 Year Powell 48 44 (Smokeless 46 43 Program) 51 45 Dearborn, MI 39 49 16 14 6 Months Kiesges, Vasey, 91 18 and Glasgow Fargo. ND 12 25 6 Months Malott. Glasgow; O'Neill, and Klesges 12 17 6 Months Fargo. ND Glasgow. Klesges, - Godding. Vasey. 12 33 and O'Neill 13 0 Farga ND 11 0 13 25 6 Months Glasgow Klesges, 16 23 and O'Nelll Fargo. ND Year of Report Notes Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Lectures, stress management, negative smoking. relaxation, snap rubberband. mainte- nance meetings, positive rewards, and self-control Cessation/reduction program Cessation/reduction program. competition, and posted feedback charts Cessation/reduction (brand fading and reduce number of cigarettes per day) Cessation/reduction and partner support Cessation/reduction (7 meetings): - Gradual reduction Abrupt reduction Gradual reduction and feedback Cessation/reduction program Cessation/reduction program and social support Self-Care The preference for self-care methods was discussed earlier.47 'Ib accommodate this pref- erence, companies have offered self-help guides, particularly materials produced by ALA, ACS, and NCL The ALA manuals and video program can be adapted to the workplace. The American Heart 1984'80 Hard-hitting film from British TV- Dying for a fag? Control videotape was on alcohol, seat belts, or political and commercial aspects of smoking. Programs conducted at five firms. 1984778 N,for last 4 firms for fear videotape was 183; control videotape was 224. All results were validated by expired air CO. 1985204 Ford Motor Company. Results based on subjects attending at least two treatment sessions and subjects who answered followups. 1986742- Savings and loan. Four banks. CO 758 and SCN validation. 1984775 'Iblephone company and medical clinic. Subjects chose buddies. CO validation. 1984774 Choice of abstinence or controlled smoking. CO validation. '181ephone company. 1985776 CO and SCN validation. Zi.vo meetings. VA hospital, health care service company, and savings and loan bank. Association (AHA) offers a multiple risk factor inter- vention program designed for the workplace that includes a module on smoking cessation. The NCI self-help smoking cessation kit (Calling It Quits) is contained in the AHA module. In 1983, 57 percent of American insurance companies with smoking cessation programs made self-help literature 107 TIMN 293436

available.702 Unfortunately, only a few worksite self- help programs have been evaluated. As part of a doctoral dissertation, Nepps evaluated the Johnson and Johnson cessation pro- gram consisting of nine self-help modules.l'e Thirty-six white-collar workers were recruited for the voluntary cost-free program. After an orienta- tion, participants were given a manual of nine modules that combined behavioral techniques (e.g., smoke holding, nicotine fading, and self-control). The techniques were dispensed sequentially to par- ticipants contingent upon completion of progress reports. Only 19 of the 36 subjects returned for module 2, and only 6 participants completed a119 modules. Based on all 36 participants, the quit rate was 14 percent; for the 19 subjects who returned for module 2, the quit rate was 26 percent. Par- ticipants were given weekly carbon monoxide assessments to corroborate self-reports and provide feedback on progress. Flow also did doctoral dissertation research on a worksite self-help program comparing it to a group method 187 Subjects (N=218) were random- ized to the two treatments and a control. At a 4-month followup, group subjects showed 40- percent success compared to 18-percent success for self-help subjects. Several worksite programs provide increasing levels of support consisting of self-help, minimal contact, and groups. Bishop and Fisher offer employees at companies in Eastern Missouri three procedures: self-help, self-help plus trouble shooting, and a comprehensive group clinic"° The ALA manuals are provided, and in the trouble shooting condition, subjects are expected to attend four meetings over a 6-week period. The com- prehensive group format (nine meetings over 7 weeks) is based on the ALA clinic but modified for the workplace. Unfortunately, the evaluations available do not provide separate results for the three procedures. At 1 company with 190 employ- ees, 18 of 63 smokers entered the program; one- third were abstinent at a 12-month followup. Two trials of the comprehensive groups resulted in 33- percent and 7-percent quit rates at 1 year. Bishop and Fisher call their program EASE (Employer Assisted Smoking Elimination). They train employees to run the clinics. One feature of the program is the formation of a steering commit- tee at each site to promote the program. EASE was begun at nine worksites during 1983-1984. A number of other evaluations of this program are under way. Orleans and Pinney recommend three self-help programs for the worksite provided by ALA, Con- trol Data Corporation, and Orlean's self-help book.702 The ALA self-help home video program (In Control) and the manuals were described in the 108 self-care section. ALA assists in designing worksite programs, including training, promotions, followups, and evaluations. The STAYWELL course of the Control Data Cor- poration consists of two self-administered pro- grams. The How to Quit Smoking Self-Study Course provides a 6- to 8-week plan for quitting smoking halfway through the course and then covers skills helpful for maintenance. Three telephone contacts with a STAYWELL consultant are scheduled for each participant. The cost of the course is $30. The second course, PLATO, is computer-based. It also is 6 to 8 weeks of self- instruction and includes aversive smoking instruc- tions. The computer course, updated continually based on a national analysis, costs $170. Control Data Corporation offers consultation to companies implementing smoking policies, promotions, or programs. Orleans and Pinney reported that an evaluation of the self-study course among 40 par- ticipants returning a questionnaire indicated that 35 percent had quit smoking at the end of the pro- gram. A long-term followup is under way.702 Orleans produced a self-help book through her consulting firm.766 The workbook presents an 8-week quitting program that includes 4 weeks of nicotine fading through brand switching. Users complete a series of exercises and are helped to develop skills needed for maintenance. Guidelines are provided for family members on how to be sup- portive. The price of the workbook varies from $15 to $25 depending on the volume of purchases and whether telephone calls are included. Consultation and training are offered to companies that intend to implement programs or policies. An evaluation of the guide is now under way. Orleans and Pinney caution that self-help materials should equip employees with quitting skills and knowledge of the characteristics that distinguish successful quitters.702 These attributes include positive quitting motivations, effective quit- ting skills, and meaningful social supports for quit- ting and remaining off cigarettes. Educational Methods, Clinics, and Groups As already noted, many companies offer educa- tional or group programs on smoking, but only a few have followup evaluation results. Three worksite cessation programs with followup results were made up of lectures, discussions, and answering questions. At Bell Laboratories, the program lasted 5 days and included videotapes and pairing par- ticipants as buddies lg3 The quit rate after 6 months for 81 employees was 30 percent. The Cummins Engine Company course ran 11 sessions with 4 followup sessions; films and counseling were TIMN 293437

offered 152 A followup at 1 year (validated by CO measurements) showed a quit rate of 55 percent for 33 participants. Fifteen employees of a VA hospital in New Orleans attended a 10-session program; the quit rate was 47 percent at 6 months.i5O AT&T Communications initiated a comprehen- sive health promotion program in 1982.767 Manage- ment actively promoted risk factor assessment ef- forts and health education modules on fitness, reduction of backache, weight control, stress management, smoking cessation, cholesterol re- duction, cancer screening, nutrition, and personal communication. Modules varied in length from 4 to 12 weeks. Full-time professional staff were selected and trained to conduct the intervention modules. These modules were offered three times in 1983-84 and were subject to evaluation pro- cedures. The study group was given a health risk assess- ment and offered the health education module. One control group was given the health risk assessment, while a second control group received nothing. The study group consisted of employees from Kansas City, MO, where they were randomly selected, and Bedminster, NJ, where one entire work group was selected. The group that received the health risk assessment was randomly selected from five loca- tions (Morris Plains, NJ; Atlanta,, GA; San Fran- cisco, CA; White Plains, NY; and Oakton, VA). The control group that received no intervention was ran- domly selected from employees in Chicago and New York City. Quit rates for participants in the smoking cessa- tion module were 90 percent at the end of the pro- gram and 53 percent after 5 months compared with a rate of 24 percent among the study group participants as a whole. Further evaluation will, be performed, including a cost-benefit analysis com- paring program costs (including the costs of employee participation on company time) with sav- ings in medical care expenditures and in payments to employees who are absent because of disabilities. Overall, the health promotion program was found to lower health risks and improve health-related and job-related attitudes among the study group. Tiwo worksites used the Five-Day Plan. At Sandra Labs in Albuquerque, 118 employees and spouses participated in the Five-Day Plan with 6 maintenance sessions added 158 At I year, 27 per- cent were abstinent. The Seventh-day Adventist Church conducted a Five-Day Plan at the Boeing Aircraft Company for 35 employees. Only a 3-month followup was reported; 23 percent were nonsmokers.745 AHF provided consultation and training to Blue Cross/Blue Shield of Indiana to assist them in establishing a group cessation program 175 Groups met for 6 weeks during working hours. Features of the program were peer support, development of in- dividual strategies for quitting, and taped telephone messages for maintenance. Of 101 employees who attended the first meeting, only 33 completed the course. Nine percent of those persons attending the first meeting were abstinent at 6 months. The Metropolitan Life Insurance Company spon- sored a stop-smoking clinic that offered four options to employees at no cost but on their own time le' Two-thirds of the employees chose the 6-week (12 sessions) group support clinic; 17 percent chose the 4-week "cold turkey" group; a minimal interven- tion program of 4 meetings over 3 months was selected by 2 percent; and 13 percent chose the self- quit program. Abstainers attended 20-minute maintenance meetings and were offered support through telephone calls, encouraging messages, and buddies. Over a 4-year period (1979-1982), 179 employees entered the program. An overall evalua- tion found that 35 percent had quit for 1 year. Stachnik and Stoffelmeyer implemented a group program with monetary incentives at three worksites in Michigan-a bank, a hospital service firm, and a manufacturing plant.757 Smokers recruited through a promotional effort attended an orientation meeting at which the incentives were explained. Employees attended meetings for 7 months with quit day being at the end of the first month. The incentives (which were noted earlier) consisted of a no-smoking contest in which the employee deposited $25 and the employer $75; team members shared prizes and bonuses and lost money for members who smoked. In addition, a lot- tery of $20 was held at each meeting for abstinent attendees. Participants signed contracts, mailed to family members and friends, in which they pledged not to smoke and agreed that staff could contact anyone to check on their smoking status. All meetings were held at the worksite and in- volved some work time. Films, speakers, discussion, and social support were features of the program. Very high quit rates (80 to 91 percent) were reported at 6 months. Although abstinence was not vali- dated by biochemical testing, smoking status away from work was checked regularly with friends and relatives. At an English worksite, Perrin et al. conducted an employee program consisting of group meetings with the use of a self-help manual.768 At 3 months, 15 percent of 54 subjects were abstinent. A(ong- term followup was not reported. Three commercial firms that train company per- sonnel to operate their programs are Control Data Corporation, the American Institute for Preventive Medicine (Smokeless), and Smoke Stoppers. SmokEnders has conducted cessation programs at many private companies and public agencies. One early worksite evaluation involved 9 staff members 109 TIMN 293438

of the New York State Psychiatric Institute and 21 employees of Columbia-Presbyterian Medical Center or family members 198 Ziwo-thirds of the par- ticipants "graduated," and 40 percent were absti- nent at 1 year. ACS and ALA offer group programs at the work- place based on their national methods. They either operate the program at the worksite or train com- pany personnel to direct the program. Two examples follow. The Seattle King County Depart- ment of Public Health offers smoking cessation classes for city and county employees.139 Classes of 10 sessions over 90 days are led by a public health educator and occupational health nurse and are based on the ACS FreshStart Program. The Dallas city health department also offers a FreshStart pro- gram for city employees four times a year.13s Hansen and Harrup point out that group cessa- tion programs, like those of ACS or SmokEnders, have certain common deficiencies that should be avoided at the worksite.769 These deficiencies are that behavioral methods are oversimplified; formats focus mainly on initial withdrawal rather than on maintenance; the needs and problems of the in- dividual are ignored; groups have too many members; and a lecture format is used almost ex- clusively, allowing minimal audience participation. Nicotine Chewing Gum Two Armed Forces clinics that used nicotine chewing gum were evaluated. At 28 Canadian mili- tary bases, 243 soldiers received either nicotine gum or no gum plus 1 of 3 treatments: full (17 ses- sions), minimal (4 sessions), or self-help.249 Of those who received the gum, 20 percent succeeded in quitting for a year; 29 percent of those who did not receive gum stopped smoking. The 6-month pro- gram included a 160-page workbook that provided exercises and discussed coping strategies, self- monitoring, problem solving, relaxation training, and other techniques. Schlegel et al. reported that 40 percent of the participants read the workbook and completed the exercises. Combining subjects who received nicotine chewing gum and subjects who did not, the three treatments had long-term quit rates as follows: full-25 to 38 percent; minimal-17 to 29 percent; and self-help-7 to 10 percent.742 The most intriguing finding of the Schlegel et al. study of nicotine gum crossed with the level of therapeutic contact was the "cross-over interaction" effects observed for nicotine gum under different amounts of therapist contact. Soul provided nicotine chewing gum to sailors aboard the H.M.S. Hermes. Out of 900 smokers, 161 entered the trial.251 Only 18 (11 percent) remained abstinent for 1 year. The author, commenting on the low quit rate, remarks that the population was 110 unselected, young, and healthy, had an unlimited supply of cheap cigarettes, was subject to long periods of boredom and rough weather at sea, and received no psychological support. Hypnosis Hypnosis was used with employees at two worksites. At the University of Missouri-Columbia, 63 employees were randomly assigned to either hypnosis treatment or 4 group sessions.70 One- third of the hypnosis subjects received two sessions of hypnosis; one-third received four sessions of hyp- nosis plus a booster 3 weeks later; and one-third received two sessions of hypnosis plus self- management training. Of the 48 hypnosis subjects, 18 percent were abstinent at 6 months. Of the 15 group subjects, 20 percent quit at 6 months. At the William Beaumont Army Medical Center, 35 military personnel and dependents were treated with hypnosis and attended 4 group sessions.71 The subjects were ordered to quit 48 hours after entering the program. Fifteen minutes of hypnosis was provided. The participants discussed problems and received advice related to behavioral cessation and maintenance strategies. At 3 months, 31 per- cent had stopped smoking. Physician Advice and Counseling Four worksite studies have evaluated physician counseling, but three of them are older studies. An intervention program at the Varian Corporation assigned employees screened as high risk of heart disease to either physician advice or two other treatments.72 Only a 3-month followup was con- ducted, but the study indicated that physician ad- vice did as well as individual counseling or behavioral treatment. Two studies of physician advice and warnings about smoking during an employee physical ex- amination showed that with minimal effort from 13 to 19 percent quit smoking and remained abstinent for 2 years. One study was conducted in London among 1,493 business executives,413 and the other was conducted among 543 employees of the Cum- mins Engine Company and 6 other firms in Columbus, OH.424 Naval shipyard workers undergoing a screening were randomly assigned to receive either a simple warning about smoking or 3 to 5 minutes of be- havioral counseling.415 Eight percent of the 215 smokers who received the counseling were absti- nent at 11 months compared to 4 percent (N=361) who received just the warning. These results were validated by CO testing. TIMN 293439

Behavioral Methods Rapid smoking was used in three worksite studies. Twelve VA hospital employees underwent rapid smoking along with breathing warm smoky air and handling cigarette litter.564 At 9 months, 17 percent were abstinent. The other two uses of rapid smoking were 4-week clinics' in a military setting. Electric shock was employed in the first clinic (N=31), and 39 percent reported abstinence at 6 months.73 Rapid smoking with an educational seminar administered to 172 soldiers showed a quit rate of 28 percent at 6 months.5" Danaher reported the use of regularly paced aversive smoking at the Ford Motor Company.745 Danaher and Lichten- stein's self-help book97 was used to teach self- control skills to 26 employees. Six months later, 20 percent had stopped smoking. VA nurses were offered a program of brand fading to reduce the tar and nicotine content of cigarettes smoked, abstinence training, feedback, and public posting of carbon monoxide levels.e3s Ziwenty-six nurses entered the study, but only 18 carried out the treatment; one-third were nonsmokers at 9 months. Nicotine fading plus three different ad- juncts were carried out at a medical manufactur- ing company and an insurance carrier, but only a 3-month followup was reported.742 The results varied from 6 to 33 percent for 54 subjects. The Center for Behavioral Medicine of the Univer- sity of Pennsylvania contracted to conduct classes at the Campbell Soup Company.745 Pomerleau and Pomerleau's self-help book98 was used to teach behavioral skills. One-fourth of the 36 participants were abstinent at 6 months. The Smokeless System offered by a number of companies and hospitals was described earlier.2o1 The 5-day multiple treatment program includes numerous elements that are detailed in table 22. The program attempts to teach the skills necessary for eliminating cigarette urges. Five evaluations at the Ford Motor Company showed average results of 48 percent at 6 months.zO4 Four studies of cessation/reduction have been evaluated by the Glasgow and Klesges group at worksites in Fargo, ND. All studies had 6-month followups and validated their results by biochemi- cal measurements. It should be noted that par- ticipants in cessation/reduction interventions have the choice of either quitting or reducing their smok- ing. In cessation/reduction treatment, subjects sequentially attempt to reduce the tar and nicotine content of cigarettes smoked, the number of ciga- rettes smoked, and the percentage of each cigarette smoked. Generally, the format followed is five to seven treatment sessions in which subjects meet in small groups of two to six smokers over a period of 6 to 8 weeks. Just after the midway point, subjects are asked to decide if they wish to stop smoking or to make further reductions. In the first cessation/reduction study, 4 of 12 telephone company employees who were assigned to gradual reduction stopped smoking compared to no quitters for those assigned to abrupt reduc- tion or to gradual reduction plus feedback of nicotine intake.774 There were reductions in smok- ing in all three conditions. 'livo studies that compared cessation/reductipn to cessation/reduction plus support showed no dif- ference in followup results. Partner support was tested with choice of buddies among employees of a telephone company and a medical clinic.775 Significant other social support was added to cessa- tion/reduction for employees of a VA hospital, health care service company, and savings and loan.776 The results varied from 17 to 25 percent. Support did not enhance treatment outcome. In the partner support condition, subjects received a 30-page Partner's Controlled Smoking Manual and were encouraged to keep in touch with their buddies on a daily basis. A partner support manual was also included in the significant other social support treatment. The support persons attended two group meetings, and an attempt was made to individualize support procedures. The fourth cessation/reduction study was con- ducted among employees of four banks758 and in- cluded competition (a smoking contest) and posted feedback charts that indicated how each bank was doing. Some of the details of the competition were described in the incentives section. All participants received the gradually paced cessation/reduction program. Emphasis was on quitting smoking rather than cutting down, and two of the prizes in the competition were based on abstinence. Prizes were awarded to both smokers and nonsmokers. The employee participation rate was very high with 88 percent of the smokers entering the competition. As a comparison condition, the gradual cessa- tion/reduction program without the competition was offered to employees of a savings and loan; their participation rate was 53 percent. There were no differences in quit rates between the competi- tion and no-competition treatments. Bank employ- ees (N=91) achieved 18-percent success compared to 14 percent for the 16 savings and loan employees. The higher participation rate for the competition program resulted in a higher long-term cessation rate for the banks compared to the savings and loan.742 Hessol has criticized the competition study on the grounds that the 6- month followup coincided with the monetary incentives and therefore was not a valid followup end point.777 She called for further followups after the incentives ceased. Klesges and Glasgow replied that they tied the largest group TIMN 293440 111

prize to the 6-month followup, maintaining that a wealth of data have indicated that group relapse curves for smoking cessation are virtually complete by a 3- to 6-month followup; they agree, however, that a longer term followup is desirable.78 I believe it is valid to tie incentive payments to followup points as the nature of the incentive is to reward continued abstinence. I agree with Hessol, however, that further followups are necessary to test the long-term value of the incentives. Numerous studies reviewed in this volume show that relapse does continue after 6 months and even after 1 year. For example, in the Cummins Engine Company study, 22 percent were abstinent at 1 year. A fur- ther followup found that 13 percent of the quitters relapsed, reducing the quit rate to 19 percent.424 Therefore, a 1-year followup is essential. In the final study reviewed, Sutton et al. con- ducted smoking programs at five firms in the United Kingdom using motivational videotapes as the main element in the intervention.79'8O The program took place during worktime. Smokers who agreed to participate watched either a fear videotape or a control videotape in small groups with random allocation of sessions to videotapes. At the end of the 50-minute session, employees were given a booklet about stopping smoking. The fear videotape was a British television program called Dying for a fag? It consists of an extended interview with a heavy smoker who has lung cancer. The controls viewed films about either alcohol, seat belts, or the political and commercial aspects of smoking. The investigators have conducted studies in five firms; results for varying followup periods are shown in table 22. The number of employees who participated in the latter 4 firms were 183 in the fear videotape group and 224 in the controls. All results have been validated by expired air carbon monoxide measurement. Long-term results are available for two trials. In one firm, 3 percent quit in the fear videotape group compared to none of the controls; in another firm, 11 percent of each group quit. The authors report that more people who viewed the fear videotape tried to stop smoking than did those who viewed the control videos, but they were unable to carry through to success."g The authors assessed smokers who did not par- ticipate and found significantly higher quit rates among video viewers. This may be a general effect from participating in the program but more likely reflects a stronger motivation to quit on the part of participants. The investigators are exploring the possibility of supplementing the videotapes with a brief course of treatment or the use of nicotine chewing gum administered by the occupational health staff. 112 A variability in results was observed in the Sutton et al. study using the same intervention in different worksites. Other investigators who have conducted multiple studies or evaluated similar programs in different companies (e.g., Bishop and Fisher and Glasgow and Klesges) have reported fairly substan- tial differences in success rates in different settings. This suggests the potential importance of organiza- tional characteristics. This review of the 35 cessation programs con- ducted at worksites indicates that a great variety of methods have been used. Only a few programs validated self-reports or used comparison condi- tions. Many more programs have been offered, but evaluation reports are not available. Orleans and Shipley comment that findings offer little guide to the industry wishing to in- vest in an employee smoking cessation pro- gram. Evaluations of worksite quitting services have lacked experimental methods, clear defi- nitions of independent variables and adequate measurement of dependent variables.... Most cessation treatments occurred after educa- " tional campaigns and/or corporate pressures or incentives had been introduced. Thus, it's im- possible to judge effectiveness of the treatment outside of this context781 Keeping in mind the above points, a few remarks about worksite cessation results can be offered. Several interventions had excellent quit rates, and overall, it appears that worksite programs achieved better results than did programs in the general community. The programs with higher followup success were more intensive: more sessions, ex- tended treatment period, more procedures, and problem solving. Minimal contact programs had lower success rates. Even in minimal programs, such as physician warnings, when slightly more was added (e.g., brief counseling), results improved. When both incentives and a cessation program were offered, greater participation and higher quit rates were achieved. SUMMARY AND COMMENT Surveys reveal that about one-third of U.S. com- panies have established policies on employee smok- ing. More companies are considering the adoption of smoking policies. Of those companies with policies, 85 percent have initiated their policies in the last 5 years. Fielding points out that virtually all policies to restrict smoking established before 1980 were adopted to avoid possible danger to pro- ducts and equipment.713 He states that smoking policies to protect the health of workers is a phenomenon of the 1980's. TIMN 293441

The U.S. Surgeon General has declared that ciga- rette smoking represents a greater health threat to most American workers than do workplace haz- ards.26 In addition, cigarette smoking greatly in- creases the threat to life already faced by workers in hazardous industries. The 1985 Report on the Health Consequences of Smoking also pointed out that blue-collar workers are more at risk than are white-collar workers because they smoke more and are exposed to more disease-causing workplace agents. The report stated that employers should be obligated to provide a work environment that does not promote smoking or interfere with cessation. This chapter discussed the costs to the employer of employee smoking in terms of lost productivity, higher absenteeism, disability, and health care costs, and other factors. Also influencing com- panies to adopt restrictions on smoking are legisla- tion, the threat of lawsuits, and other increasing demands by nonsmokers for a smoke-free workplace. In a paper presented at the 5th World Conference on Smoking and Health, Shimp told how she be- came the plaintiff in a landmark case that helped to establish tobacco smoke as an occupational health hazard782 Shimp v. New Jersey Bell showed the value of individual employee action and. helped to form the basis for the growing numbers of civil rulings, ordinances, and administrative law deci- sions favoring the nonsmoker.783 Shimp points out that there is a change of attitude among the general public, which is reflected in the workplace and in the courtroom. Shimp is the executive director of Environmental Improvement Associates, of which Luther 'Ibrry was a founding member. This organization assists employees and management to achieve a smoke-free environment. Their guides were cited earlier.73o•'31 In the first suit of its kind, a nonsmoking woman in Fremont, CA, who left her job because of a chronic smoke-related disease, sued the tobacco in- dustry over her health problems.784 The lawsuit charges that the tobacco companies exposed the 51-year-old Irene Parodi to "harmful and toxic substances" that caused hyperactive airways disease. About 50 wrongful deaths and personal in- jury suits have been filed nationwide by smokers against tobacco companies, but this is believed to be the first suit pursued by a nonsmoker. Parodi was working as a clerk with the U.S. Department of Defense when she began suffering severe lung and breathing problems. Parodi left her job on the advice of her physician and received a $50,000 set- tlement from the Department of Justice. The Department of Labor granted her $1,000-a-month claim for worker's compensation upon agreeing that her disease was caused by smoke. The lawsuit charges that five tobacco companies were negligent and breached their warranties by selling products that were "harmful and poisonous: ' Examples of smoking policies were enumerated. Generally, smoking is restricted in common areas, and the nonsmoker is favored in work areas. The smoking bans of the Johns-Manville Corporation and the Group Health Cooperative of Puget Sound are noteworthy. Both organizations phased in their policies by allowing a period of time to explain them to all employees, holding meetings between management and labor, and sponsoring cessation programs for employees. Actions of GSA and the Department of Defense to restrict smoking affect over 3 million persons. As shown by a Gallup Poll, employees are overwhelm- ingly in favor of restrictions on smoking.785 Eighty- five percent of nonsmokers and 62 percent of smokers thought that smokers should not smoke in the presence of nonsmokers. Further support for smoking restrictions can be ascertained from the San Francisco experience where regulations required employers to adopt a smoking policy that gave preference to non- smokers. During the first 12 months of the regula- tions, 124 complaints were processed, and only 1 citation was issued that was handled by a meeting that lasted only several minutes.786 There were no legal actions as a result of the ordinance. One city inspector handled complaints and enforcement; during the last 4 months of the first year, only one- fifth of his time was spent on the program. The ease with which the San Francisco ordinance regulating smoking in the workplace was implemented and maintained indicates its high acceptance by employers and employees. Implementation and ac- ceptance of workplace restrictions in other jurisdic- tions present a fertile area for future research. Some companies are refusing to hire smokers, and many employers are giving preference to hire nonsmokers. Fielding states that "prohibiting worksite smoking sends an unambiguous signal to current workers and to teenagers preparing to enter the workforce that a smoking habit may limit employment opportunities, affect job flexibility and limit their ability to achieve personal economic ob- jectives."787 Elements of a comprehensive employer smoking policy were outlined on page 98. It should favor a smoke-free environment and offer cessation pro- grams to employees. At least two dozen guides to establish worksite smoking policies are available from Government, nonprofit, and voluntary agen- cies. Several organizations have developed separate guides for management and employees. Many companies have provided educational an- tismoking information by distributing literature and through posters and articles in company bulletins. Incentive programs are less frequent. 113 TjMN 293442

Although a few large companies have operated lot- teries as rewards for nonsmoking, the most com- mon incentives have been time off for attending a cessation program or reimbursement of fees paid for such programs. I have provided numerous ex- amples of monetary incentives, but these were of- fered primarily by small companies. Incentives ap- peared to encourage the participation of employees in quit attempts. Incentives are cost-effective as they do not require extensive professional time. They also do not provide the counseling, training, and maintenance support needed by many quitters to remain abstinent. About 10 to 15 percent of companies have offered smoking cessation programs. The most common approaches have been educational, distribution of self-help kits, physician advice during physical ex- aminations, and group programs. Some companies have devised their own format, but most model their program after those sponsored by voluntary health organizations. Many companies use outside consultants or have their programs operated by out- side agencies such as the cancer and lung associa- tions, health departments, the Seventh-day Adven- tist Church, SmokEnders, and Smokeless. Perhaps a reason why so few in-house programs have been offered is the lack of company medical, nursing, psychology, and health education departments. Most occupational physicians and nurses have had little training in behavioral intervention strategies. Many cessation programs have been aimed at executives and white-collar workers. For example, a high proportion of insurance and pharmaceutical companies have had quit programs, while there have been few programs in manufacturing plants. Only a small number of worksite cessation pro- grams have been evaluated. The results of 35 such programs were presented in this chapter. Available followup quit rates for programs at the workplace appear to be higher than the rates for community clinics. It appears that posttreatment quit rates for worksite programs are not that impressive. If this is the case, what factors may contribute to the generally superior maintenance of worksite pro- grams? As described elsewhere in this volume, there is a need to evaluate worksite programs systematically through a description of participants and methods, careful followups that include all par- ticipants, and biochemical verification of self- reported smoking status. When possible, controls and comparison groups should be Included in the study design. The minimum followup period for worksite programs should be 1 year. Programs with three levels of contact should be offered to workers. At the first level are self-help manuals, physician or nurse advice and warnings, or brief educational contacts. Examples of second level programs are problem solving, educational 114 classes, counseling, or nicotine chewing gum with modest support. At the final level are group sup- port or multicomponent interventions. Advice about weight control, coping with withdrawal symptoms, and maintenance support are useful ad- juncts to any method. The review indicates that often when cessation programs were offered, participation was low. When incentives were offered along with interventions, participation improved. Research is needed on recruitment to find out -how to boost participation rates. Research also is needed on methods directed at blue-collar and minority workers and high-risk smokers. Issues regarding the social norms con- cerning smoking among all employees, what types of employees participate in occupational smoking control programs, and how to increase participation deserve greater attention. 'IZvo studies showed that the failure of coworkers and significant others to support the smoker's at- tempts to quit probably reduced quit rates. Sorensen et al. interviewed 447 smokers random- ly selected from 10 Minnesota worksites about co- worker support788; the findings suggest the impor- tance of coworkers' explicit lack of support or discouragement of quitting in cessation failures. Coworker discouragement of success differed by worksite and was related to the subject's dimin- ished confidence in the ability to quit. Their find- ings suggest that cessation programs need to ad- dress ways for quitters to cope with coworker dis- couragement of success and with social pressures to smoke. More research is needed on coworker support. Research also should be considered on company, management, and union support for cessation. Nonsmokers should be enlisted in efforts to support their coworkers' attempts to quit. Involvement of dependents (and housemates) in worksite programs makes good sense. Spouses who smoke increase health care costs to employers and discourage quit attempts on the part of the worker. Nonsmoking spouses also have a role to play in a quit program. The industrial setting provides access to more than half the adult population.789 Locating cessa- tion programs in an industrial setting maximizes efficiency in terms of convenience, time, accessibil- ity, surveillance, and followup. Greater emphasis should be placed upon organizational characteristics as they impact smok- ing (and cessation) in the workplace. In particular, research should explore the fit between such fac- tors (e.g., size, type of employees and industry, management styles, union-administration relation- ships, and economic health of the company) and the types of intervention attempted. The potential interaction between company smoking policies and cessation also should be examined. TIMN 293443

We have learned that changing smoking behavior is complex. Sorensen et al: s study of 10 worksites found variations among worksites in norms and at- titudes about smoking cessation788 This indicates that each worksite may have to be approached in- dividually in terms of recruitment, information and materials provided, incentives, and cessation methods. The workplace offers a great potential for reaching the bulk of the current smokers. If we are to achieve significant reductions in the proportion of the American people who smoke, a concerted ef- fort should be made at the worksite. This requires not only company policies on restricting smoking and the promotion of intervention programs but also the support of all the actors in the workplace- employers, all levels of management, union representatives, and the workers themselves. The impetus can come from employers or employees, but only the concerted effort of all parties will result in nonsmoking dividends at the workplace. TIMN 293444 115

5. LONG-TERM MAINTENANCE As I have repeated throughout this volume, the key to a successful cessation program is mainte- nance support. The concluding comment in the 1977 review stated: Once the smoker abstains, a myriad of forces act upon the individual influencing him to return to smoking. These forces include en- vironmental, social, and internal forces, such as mass media, smoking of peers, and stress. ... When the smoker breaks his habit he still has to contend with the effects of his former addiction. This is why maintenance is so im- portant.7so Almost any kind of treatment, including a con- trol condition, generates some quitters. Initial suc- cess rates as high as 80 to 100 percent have been reported. However, during the f"irst 4 months, a high number of successes become recidivists; and during the next 8 months, other ex-smokers return to smoking. As long-term followups have shown, some people return to smoking even after 1 year. We have learned that a 33-percent followup quit rate in smoking cessation is good. Very few early studies provided maintenance.41 In the mid-1970's, more and more investigators began paying atten- tion to maintenance, and some of them reported improved success rates. Before turning to mainte- nance strategies, a profile of continuing successes and recidivists will be presented. PROFILE OF CONTINUING SUCCESSES AND RECIDIVISTS With a few exceptions, early studies indicated that success in giving up smoking was inversely related,to the average daily amount smoked791,7s4 and directly related to age of starting smok- ing.'g'.795 Success in smoking cessation was also related to the spouse's smoking habits.792.'94,'96 Some studies related smoking friends to difficulty of quitting,794 while other studies found no such relationship.796 There is extensive literature on the prediction of cessation and long-term maintenance. A few representative studies are reviewed in this chapter. The reader is referred to Kozlowski's in- sightful review of psychosocial influences on cessa- tion of smoking797 and to Smith's early review of personality and smoking.798 Schwartz and Dubitzky analyzed profiles of suc- cesses and recidivists who participated in the Smoking Control Research Project (SCRP)"s '94 Of the 252 male treatment subjects, 33 percent ini- tially stopped smoking, with the quit rate declin- ing to 20 percent by the 4-month and 1-year follow- ups. A cluster analysis reduced 101 variables to 10 meaningful and relatively independent "clusters:" The 252 subjects were scored on the 5 most salient clusters resulting in 12 profile types. The first cluster selected was "personal adjust- ment," or contentment, in such areas as work, achievement, sex, and social situations. This was the individual's expressed confidence, security, or satisfaction with various aspects of his life- important components of his psychological well- being. The personal adjustment items were taken from Andie Knutson's Personal Security Inven- tory.'99 The second cluster combined chronic ill- ness and anxiety, recent respiratory ailments, and use of psychiatric care. Perceptions of smoking made up the third cluster. Low scores on this dimension signified belief in the health danger of cigarettes. The fourth cluster related to the degree to which smoking was internalized and included the habitual and addictive dimensions suggested by lbmkins.8O° "Smoking affect," the fifth cluster, included Tomkins' concepts of negative and posi- tive affect. The 12 types were created without regard to out- come in smoking cessation. Each type was then ex- amined for success and recidivism. Four profile types contained 60 percent of the continuing suc- cesses but only 20 percent of the recidivists. These types all had good adjustment, low illness and anx- iety, and low chronic, habitual, and addictive smok- ing scores. The type that contained a good success rate throughout the study possessed all the characteristics normally associated with high prob- ability of success; besides having the motivation and proper cognitive frame of mind, they were not hindered by personal problems or an overwhelming 117 . TIMN 293445

need to smoke. The next three types, which con- tained fewer successes, were characterized by average adjustment, high chronic illness and anx- iety, and high chronic, habitual, and addictive smoking. Although there were few similarities among types high in recidivism, two kinds of recidivists could be distinguished. The first showed poor per- sonal adjustment, which may have accounted for their return to smoking. The second kind of recidivist showed good adjustment but scored high in two of the three smoking factors. Thus some were high in habitual and addictive smoking and affect smoking but not perception of smoking dangers; others were high in habitual and addic- tive smoking and perception but not affect; and some were high on affect and perception but not habitual and addictive smoking. When the remaining five clusters not used in the typology were examined, "smoking environment" (the smoking habits of the spouse and patterns of smoking with friends) appeared to differentiate con- tinuing successes and recidivists. Successes tended to have smoking environment scores more con- ducive to quitting. Moreover, once the subject had stopped, the probability of continued abstinence was greatly increased if there was less smoking on the part of his friends and wife. Successes as a group scored higher in personal adjustment and lower in habitual and addictive smoking and smoking affect. They also had a somewhat lower incidence of chronic illness and anxiety. In addition, successes had a more negative perception of smoking than did recidivists. Similar findings were reported by Pomerleau et al. who found that smokers high in negative affect were more likely to relapse.sso Powell and McCann's study of abstainers and recidivists supported the findings of the SCRP with respect to high craving scores among recidivists.8O1 Pertinent here is the work of Shiffman on the tobacco withdrawal syndrome which is characterized by changes in the EEG and cardiovascular function, by decrements in psychomotor performance, and by weight gain. Subjective symptoms of irritability, anx- iety, inability to concentrate, and disturbances of arousal are characteristic of tobacco users in withdrawal, and intense craving for tobac- co is universally reported.802 Shiffman states that withdrawal symptoms vary in intensity and duration. He advises that interven- tions that directly attack withdrawal symptoms need to be developed and evaluated. Manipulation of patients' expectations or attributions of withdrawal symptoms, he suggests, might be one way to reduce their severity and affect relapse.802 118 SCRP developed three other items to measure previous experience with stopping smoking, ease and success in stopping, and expectation of success in giving up smoking. Perhaps related to their favorable orientation toward cessation, continuing successes had more often found it "easy" to quit in previous attempts, compared to recidivists. In regard to differences in expectation of future smok- ing, relatively more successes than recidivists thought that they would not be smoking in 1 year. There seems to be a subgroup of persons who do not consider quitting very difficult, who are confi- dent that they can stop smoking, and who are, in turn, most likely to succeed in an organized withdrawal program-perhaps because they are already on the verge of quitting. The Multiple Risk Factor Intervention 'I]-ial (MRFIT), using the same measures developed by Schwartz and Dubitzky for SCRP, replicated the findings of the earlier study with regard to personal security,8O3.804 previous experience with stopping smoking, ease and success in stopping, and expec- tation of success in giving up smoking.803 Suc- cesses (abstinent 2 years) achieved significantly higher mean personal security scores than recidi- vists. Stopping smoking prior to MFRIT significant- ly related to outcome, with a higher proportion of successes and recidivists than no changers having stopped before. Forty percent of the recidivists found their last cessation experience very difficult compared to 17 percent of the successes.803 (In SCRP, the percentages for this item were 44 for recidivists and 26 for successes.) With successes and recidivists combined in MRFIT, expectation of success significantly separated those smokers who stopped smoking by the end of treatment from those who did not.803 Ockene et al. reported that successes at 2 years experienced significantly less stress as measured by environmental changes than did recidivists.803 Four-year data indicated that high stress combined with low self-reliance significantly discriminated between successes and failures.BO5 Mermelstein et al. found in their study of stress and social support that high perceived stress posttreatment was asso- ciated with relapse but that pretreatment stress had no predictive value.806 They also reported that partner support during treatment enhanced maintenance. As with SCRP, social support and number of cigarettes smoked at baseline significantly discriminated between successes and recidivists in MRFIT. Ockene et al. state that the results suggest that it is possible to predict which participants in a smoking control program will have problems with cessation and maintenance of cessation and that programs can target intervention toward specific in- dividual needs.803 TININ 293446

Using 4-year MRFIT data, Benfari and Eaker found that lighter smokers had a much higher quit rate, accounting for 50 percent of the variance be- tween groups.804 Their analysis showed that suc- cesses emphasized personal responsibility, cited gaining insight into how to change, developed ac- tive coping skills, and were able to translate the wish to quit into a decision to quit. Continuing smokers, however, showed a profile reflective of passive resignation and a tendency to focus on the barriers to quitting. Relapse Situations In a study of relapse, Marlatt and Gordon found that the majority of relapse situations involved social pressure to smoke, with 43 percent of the smokers relapsing in interpersonal situations 8O7 They indicated that causes for relapse fell into three categories: social pressures, coping with negative emotional states, and coping with interpersonal conflict. The primary setting for smoking relapse was the home (44 percent), followed by the work environment (19 percent), restaurants and bars (13 percent), and parties (6 percent). The evening was most often cited as the time of relapse. A single slip often resulted in total recidivism. They concluded that effective maintenance requires that the smoker be taught cognitive recognition and behavior analysis as well as coping responses to relapse stimuli. Lichtenstein and Mermelstein state that Marlatt's model has not yet received empirical validation in the smoking field.8O8 Several studies have failed to support Marlatt's conclusions.533.534sos Other investigators have reported smokers relaps- ing frequently in social situations. Lichtenstein et al. conducted interviews with relapsers with results similar to those of Marlatt and Gordon. In 83 per- cent of the relapse situations, other people were present, and 62 percent of the time other people were smoking.81O In 57 percent of the instances, other people were the source of cigarettes; 11 per- cent of cigarettes were requested, and 46 percent were offered. Shiffman interviewed 183 ex-smokers who called a relapse-counseling telephone hotline for help with actual or near lapses in abstinence.811 Most relapse crises were associated with negative affects (anxi- ety, anger, and depression). One-third of the crises, however, were linked to positive feeling states and frequently were precipitated by other smokers, eating, and alcohol. Other people were present in 61 percent of the cases, and someone else was smoking in 32 percent of the crises. Ex-smokers who used coping responses more often were able to refrain from smoking. Persons who had been drinking alcohol were less likely to utilize behavioral coping responses, and depression diminished their effectiveness.812 Shiffman con- cluded that cognitive coping responses, which are less affected by these variables, may be critical com- ponents of ex-smokers' coping repertoires. In a later study, Shiffman analyzed the coping responses of 75 new callers to the hotline.813 The number of coping responses had no effect, but combining cognitive and behavioral responses enhanced effectiveness. Shiffman et al. presented an analytic classifica- tion of relapse episodes based on a cluster analysis.812-814 There were four main clusters: social situations characterized by social drinking and exposure to smoking; relaxation situations at home, usually after a meal; work situations when the ex-smoker is anxious; and upset situations oc- curring when the ex-smoker is feeling anxious or depressed while home alone. Shiffman concludes that relapse is inevitable among people who fail to cope in social situations.814 He states that relapse is more likely in social and upset situations. Shapiro interviewed 75 ex-smokers who called the hotline in Rochester, NY, regarding situations surrounding actual or near lapses in abstinence.510 At the time of the interview, 56 percent were tempted to smoke and the remaining 44 percent had slipped at some time. It was found that inter- personal conflict and negative emotional states ac- counted for more than two-thirds of all relapse crises. Negative physical states and positive emo- tional states played a minor role in precipitating relapse. Negative affects (particularly anxiety, anger, frustration, and depression) frequently were found to be present in situations that preceded relapse crises. Slips were more likely to occur when subjects were away from home in a social situation. 'Ibmpted subjects were more likely to report cop- ing than were subjects who slipped. Schwartz and Dubitzky conducted personal in- terviews with 12 continuing successful quitters, 12 recidivists, and 12 no-change subjects of SCRP to gain insights into the quitting process.794•815 Good self-image, optimism, and a good feeling of self- satisfaction characterized successes. These people were socially outgoing, had good relationships within the family, and responded positively to con- cern about their smoking. They expressed con- fidence in their self-control and rational behavior. Since they accepted themselves realistically and trusted others, they were not overly afraid of failure. More willing to commit themselves to a goal, they were more able to achieve the goal. Typically, in the home situation of the recidivist, the wife smoked and did not give her husband much support in his quitting. Recidivists did not emphasize the importance of smoking as a tension reducer but spoke more often of the physical TIMN 293447 119

gratification derived. It is important to note that these men were able to stop smoking, if only tem- porarily. Clearly, however, these subjects were unable to maintain abstinence without continued pressure-whether in the form of an organized pro- giam, an environment that emphasized the health dangers of cigarettes, or aid from their wives or close associates. Without such outside supports, the typical recidivist-who lacks the inner resources to cope with the loss of cigarettes-has virtually nothing to prevent him from resuming the habit'94 Ashenberg surveyed 94 clients of a smoking cessation clinic after quitting to determine the rela- tionship between daily stressors, coping strategies, and recidivism.816 The results showed that recidi- vists engaged in more coping strategies than did abstainers during stressful episodes in which they successfully resisted strong urges to smoke, sug- gesting that recidivists did not evidence a general coping skills deficit. Recidivists who relapsed under stressful circumstances, however, reported engag- ing in fewer coping strategies during relapse episodes than in stressful situations not resulting in relapse. Based on her experience with SmokEnders, Rogers pinpointed the following as causes of recidivism: complacency, completion of the pleasurable cycle, spite, weight gain, personal trauma, loneliness, sleep disturbance, and use of alcohol 817 She adds that when the new ex-smoker's motivation is inadequate and his or her attitude is negative, smoking is resumed. When the partici- pant views not smoking as a new-found freedom and an expression of self-mastery, he or she withstands any discomforts and deals directly with the problem without a cigarette. MAINTENANCE STRATEGIES Pechacek and Danaher view maintenance as a gradual transition away from cessation. They state: As withdrawal fears and problems are diminished by the successful accomplishment of the cessation strategies, the focus should be shifted toward skill training to enhance the participants' ability to cope with special prob- lems identified during the preparation stage or in using cessation strategies.818 Lichtenstein identified three maintenance strategies: social support, coping skills, and cognitive restructuring.819 It is worthwhile to sum- marize Lichtenstein and Browri s excellent discus- sion of these strategies.553 Social support is based on a notion that a group or close companions can provide enough support or influence to help the in- dividual sustain the motivation to continue nonsmoking. Coping skills are required to help the 120 new nonsmoker deal "with the discomfort involved in depriving oneself of cigarettes, in developing substitute responses that would replace smoking, in learning to recognize and modify the cues" to smoke, and "in altering the consequences of smok- ing:'8210 Cognitive restructuring involves changing attitudes and self-perceptions related to smoking behavior. Social Support Support for nonsmoking can come from the larger environment in the form of community at- titudes toward smoking or from the immediate en- vironment of the new nonsmoker. Williams and Shor believe that to understand and control smok- ing behavior it is important to focus primary atten- tion on the social support system of smoking.s21 They state that the difficulty that smokers experi- ence in quitting is, in part, due to a social system that reinforces smoking behavior and thus works against long-term abstinence. This system has been challenged by the nonsmokers' rights move- ment, which has resulted in "clean indoor" legisla- tion, employer support for nonsmoking, and a change in attitudes toward smoking. The recent in- terest by employers in worksite policies and pro- grams on smoking illustrates that a change has taken place. The immediate environment plays the crucial role in supporting the ex-smoker. The support can come from the family, friends, coworkers, and health care professionals (e.g., physician, dental hygienist, and dentist). Support also can come from persons related to the cessation program (e.g., leader, group members, and buddies) or from other ex-smokers. Self-help groups, such as Smokers An- nonymous in the United States and Clubs for Ex- Smokers in the United Kingdom,S22 have had limited success in providing maintenance support. Support From Family, Friends, and Coworkers Colletti and Brownell reviewed the influence of social support on quitting smoking and concluded that quitting smoking and remaining abstinent are related to family and peer pressures.823 The relative impact of the behavior of the spouse, family, and friends on ex-smokers' efforts to remain abstinent were analyzed by Morgan in 80 subjects in a 16-week quit-smoking program 824 Abstainers reported higher frequency of friends' helping than did recidivists, who noted a sharp increase in others smoking in their presence or offering them cigarettes. Mermelstein et al. studied partner support for par- ticipants of a smoking cessation program and found TIMN 293448

that successful abstainers lived with more suppor- tive spouses or partners than did subjects who relapsed.825 Analysis of the data revealed two types of helpful partners (cooperative and reinforcing partners) and two unhelpful types (policing and nagging or shunning partners). MermelsteiD et al. replicated their finding that partner support aided abstainers.w6 They suggest that smoking treatment programs attempt to improve and strengthen not only available social supports but also the in- dividual's ability to use these supports. McIntyre found that the smoking status of the spouse was strongly related to continued abstinence among 64 subjects who were randomly assigned to spouse-involved or spouse-not-involved treatments.828 Subjects in the spouse-involved treat- ment attended sessions with their spouses, who received instruction in supportive behavior. Although differences were in the predicted direc- tion, there were no significant differences due to spouse training or quitting status. Posttreatment helpfulness from partners was significantly related to smoking status through a 6-month followup. Coppotelli and Orleans provided further evidence for the value of partner support in smoking cessa- tion maintenance.827 In a prospective study of 125 newly abstinent married women, partner support emerged as the primary predictor of continued abstinence. Successful quitters significantly more often than nonabstainers had partners who were ex-smokers or partners who successfully quit with them. Schwartz and Dubitzky interviewed the wives of _ successful quitters and of recidivists in SCRP and found that subjects married to nonsmokers were more likely to be successful in the treatment pro- gram than were those married to smokers.794 The wife's attitudes toward smoking, however, did not predict success in treatment. West et al. conducted a 5-year followup of participants of the Roswell Park Smoking Clinic and they reported that more in- dividuals with wives who smoked were abstinent than were those with nonsmoking wives.'96 Ex- smokers were more likely than smokers to have a milieu that was supportive of their stopping. In the MRFIT project, those subjects with greater social support were more likely to be abstinent than were those with weaker social support 8°3 Buddies Pairing of two or more clients as buddies to telephone each other as a way of providing mutual support has been used by many programs (e.g., Five-Day Plan). Janis and Hoffman assessed the ef- fect of buddies on success.828 Subjects who were assigned to a high-contact group (daily telephone calls between partners) were more successful in reducing their smoking than were those assigned to a low-contact group. Rodrigues and Lichtenstein failed in an attempt to replicate the high-contact result 829 Karol and Richards assigned some of their subjects to buddies and found that they did better than did those without buddies, but the differences were not significant.s3o In a worksite program, Malott et al. added coworker support (buddies) to a controlled smoking-nicotine fading treatment program but found no increment over the condition without coworker support."5 Subjects chose their own bud- dies and were encouraged to discuss their progress daily. The last treatment session for both groups focused on maintenance issues, such as relapse situations. All subjects received self-monitoring booklets and participated in a booster session 2 months after treatment ended. It should be noted that buddy systems can repre- sent something of a two-edged sword. If the buddy resumes smoking, prospects for the other person's success are adversely affected. Also, it may be dif- ficult to continue a buddy system throughout the crucial 4-month period after quitting when buddies must maintain contact by telephone. In the work- place, it might be possible to continue a buddy system over an extended period of time. Contact can be face-to-face if buddies are chosen who work in the same department. Followup Support Another support tactic is continued contact be- tween the program and the client via the telephone. Generally the contact person is the leader, but sometimes a clerical assistant or receptionist does the calling. Commercial programs have used the support tactic of continued contact with clients. Lichtenstein and Brown cited five studies that showed negative results in tests of continued telephone contact with clients.553 Agne studied the effect of weekly, bimonthly, and monthly maintenance telephone calls to 22 per- sons who attended the ACS's quit clinic.s31 There were no continuing successes in the monthly group, two in the bimonthly group, and three in the weekly group, but these differences were not signifi- cant. Recidivism was associated with other smokers in the home. Agne noted that telephone followup appeared to add a humanizing element to the program as 84 percent of the clients indicated appreciation and benefits from the contact. Shipley tested the effect of followup letters on per- sons who participated in a cessation program.603 En- couraging letters were sent to half of 44 subjects at the rate of3 a week for 2 weeks, 2 for the next 4 weeks, and 1 letter each for the following 6 weeks. The let- ters had no major effect in promoting maintenance. 121 TIMN 293449

Colletti and Kopel studied three maintenance procedures: modeling (attending sessions for new treatment subjects), observing a new treatment group, and self-monitoring and therapist telephone contact.832 The therapist contact group had the best quit rates at 2 years. Colletti and Supnich replicated the therapist telephone calls as a maintenance strategy with a good result at 6 months.8s3 Dubren's taped messages offering followup sup- port to persons who had participated in a televised cessation clinic,2O2 the ACS Quitline,508 and the Rochester, NY, Freedom Line5ll (discussed on page 66), are novel approaches deserving greater use. Maintenance support also can come from the program, therapist, physician, or leader in the form of followup meetings after treatment has ended. Many withdrawal clinics and commercial programs schedule regular followup sessions. Unfortunately, attendance is not good at followup meetings. Clients who are still smoking do not want to face the leader, and clients who are not smoking think that they do not need to attend more sessions. Some clients may attend one or two maintenance sessions but find them boring. Group programs should schedule followup ses- sions that are brief, interesting, and innovative so that clients will want to attend. It is best if the ses- sions are unstructured to allow for questions and discussion. Followup meetings can be potluck af- fairs or may be scheduled at a restaurant. The im- portant aspect of the followup is contact between the client and the leader so that problems can be addressed and clients can know that someone is there to support their continued abstinence. In a group setting, some clients may be reluctant to discuss problems that they are facing; but someone else may raise that issue, and the discussion will help both clients. Physicians who advise patients to quit should find out if the patient is willing to try to stop smok- ing. If the answer is affirmative, followup meetings are essential to support that effort and provide answers to problems. Physicians who prescribe Nicorette likewise should schedule followup meetings. Part of the reason that some intervention meth- ods do not have better results is that followup sup- port is not provided. Any number of methods can help people to stop smoking-self-help manuals, rapid smoking, and individual or group therapy, to name a few-but to keep them from returning to smoking, support and attention to problems are critical. Booster sessions for rapid smoking have been tried as a maintenance procedure, but Lichtenstein and Brown report negative results.sss 122 Other Support Measures Results for programs with group support varied widely with quit rates better than 33 percent re- ported for two-thirds of the group trials with 1-year followups. Direct tests of the influence of group sup- port on the maintenance of nonsmoking based on three doctoral dissertations yielded negative re- sults.553 Etringer et al. tested the effect of group cohesiveness on success in cessation.638 Enriched cohesiveness was more successful than was stan- dard cohesiveness over the short term. Substantial relapse, however, occurred in both treatments, in- dicating that the influence of cohesion on the maintenance of nonsmoking has yet to be demon- strated. Hamilton and Bornstein found that adding social support (buddies) and paraprofessional train- ing to a multicomponent program enhanced suc- cess rates.s64 As a reinforcement method, contingency con- tracting appears to maintain nonsmoking over the short run. Perhaps if the contract were extended in- to the posttreatment period and involved close fam- ily members or friends, it could be used as a maintenance technique. Bonuses at the workplace have shown some success in maintaining non- smoking. Lando has used self-rewards as a maintenance technique.674 Feeding back improved lung function also has been used as a reinforce- ment tool. Coping Skills Lichtenstein and Brown reviewed the literature concerning coping skills up to 1980 553 They cite a number of studies that yielded good results using coping skills or self-management training. My review found differences between some programs offering self-management procedures and those of- fering coping skills, relapse management training, or abstinence training. For example, Hall et al. used rapid smoking along with a relapse prevention pro- gram that included both behavioral and cognitive components.58O They suggest that both knowledge and performance of relapse prevention skills are needed to maintain change. Their coping skills ad- dress both withdrawal symptoms and situational factors related to relapse (skills training for high- risk situations). They attempted to individualize techniques. To facilitate continued commitment, the program included physiological feedback to in- crease the perceived costs of smoking and the benefits of change. Two trials of these procedures resulted in quit rates at 1 year of 52 percent in the first trialsaO and 28 percent in the second.248 Another example is the relapse prevention pro- gram devised by Brown and LichtensteinB33 based TIMN 293450

on strategies suggested by Marlatt and Gordon 8O7 It consisted of five components: identification of high-risk situations, coping rehearsal, avoidance of the abstinence violation effect, lifestyle balance, and self-rewards. They reported two trials of this program in combination with nicotine fading: 46-percent success at 6 months in the first trial, but just 19-percent abstinence at 1 year in the second.634 Lando has experimented with various combina- tions of preparation, aversion, and maintenance with mixed results.eg1-g'4 He reports a trend favor- ing a two-stage program of aversion and main- tenance over a more elaborate three-stage program incorporating preparation as well 552 Cognitive Approaches Effective treatment procedures, Marlatt and Gordon state, include cognitive recognition and behavioral training in coping with abstinence viola- tion and self-efficacy factors.807 Abstinence viola- tion refers to a slip by a quitter that then results in "full blown" backsliding. They caution that ef- fective maintenance calls for minimizing the im- pact of slips as a way of coping with abstinence violation. Attribution theory is discussed by Lichtenstein and Brown.553 They cite several studies that sup- port the theory that behavior change that is self- attributed is more durable than is change at- tributed to external factors. In their study of maintenance strategies, Colletti and Kopel found a strong relationship between self-attribution and long-term success in smoking control.832 Bandura has postulated that the individual's ex- pectation of success in behavior change can deter- mine whether that success will be achieved.834 Ex- pectations influence whether coping behavior will be initiated, as well as the strength and duration of that effort. As noted earlier, expectation of suc- cess was related to maintenance of abstinence by subjects of SCRP794 and MRFIT.803 Self-efficacy was shown to have good internal consistency in a study of smoking cessation maintenance by DiClemente.835 Sixty-three sub- jects who underwent one of three treatments were assessed at a 5-month followup. Maintainers did not differ from recidivists on any demographic or smok- ing history variables. Maintainers, however, did show significantly higher self-efficacy scores than did recidivists. Owen and colleagues in Adelaide, Australia, studied recidivism among 46 subjects who achieved abstinence.836 At an 8-week followup, low levels of self-efficacy were related to relapse and high levels to abstinence. The only other vari- able related to outcome was previous smoking rate, with the higher the rate the greater likelihood of relapse. Condiotte and Lichtenstein tested self-efficacy among 78 persons who participated in smoking treatment.837 They reported that analysis of mood and efficacy data during followup indicated that relapsing subjects demonstrated aspects of a cog- nitive dissonance reaction and a personal attribu- tion effect that was consistent with Marlatt's description of the abstinence violation effect. They found a correlation of 0.59 between self-efficacy at the end of treatment and smoking status at a 3- month followup. Perceived self-efficacy was en- hanced coincident with intervention. The subjects who relapsed completely had the lowest post- treatment efficacy scores. In an attempt to replicate the above findings, McIntyre et al. studied 74 smokers who went through treatment.838 Subjects' self-efficacy levels at the end of treatment correlated significantly at 3 months and 6 months but not at 1 year. Pederson assessed self-efficacy in a group of 121 patients who were advised by a physician to quit smoking.457 Abstainers were those who reported quitting for at least 3 months, while recidivists were defined as those who had attempted to quit but were smoking at followup. Being more sure of quit- ting increased the likelihood of quitting or trying to quit. The authors concluded that changes in smoking are affected by self-efficacy. They advise that patients be assisted in reducing their self-iden- tification as smokers before attempting to quit. DiClemente et al. studied the construct of self- efficacy in the self-change of smoking behavior among 957 volunteers in various stages of self- change 135 Subjects were assessed initially and at a 3- to 5-month followup. The authors claim that the self-efficacy scale proved to be extremely reliable. Efficacy expectations demonstrated small but significant relationships with smoking history variables and the pros and cons of smoking but not with demographic, life stress, or persistence measures. Subjects' efficacy evaluations at the in- itial assessment were related to changes in status for recent quitters and contemplators at the followup. The above studies lend support to self-efficacy and self-attribution of change. It should be noted, however, that one variable that consistently cor- relates with continuing success is a lower level of pretreatment smoking. Perhaps lighter smokers have greater expectations of success, whereas heavy smokers believe (rightfully so) the opposite. In addition to expectations of success, light and heavy smokers may differ in pharmacological de- pendence. A proper test of self-efficacy as a predic- tor requires that it be compared to smoking status or level at the time of the efficacy measurement. If TIMN 293451 123

smoking status (or performance) is a better predic- tor, the value of the efficacy construct diminishes. Researchers should keep this in mind in future studies of self-efficacy. COMMENT Leading causes of relapse are anxiety, stress, anger, frustration, social pressures, weight gain, and lack of inner resources (e.g., low personal satis- faction or adjustment). Positive states of feeling, fre- quently precipitated by being with other smokers, eating, and drinking coffee or alcohol, also con- tribute to relapse. As I stated earlier, when the smoker breaks the habit, he or she still has to contend with the long- term effects of the former addiction. Jarvik points out that the two major components of tobacco ad- diction are tolerance and dependence.839 He presents evidence concerning increasing tolerance of tobacco, while Shiffman deals with the depen- dence in his description of the withdrawal syn- drome 8O2 Gritz and Jarvik222 and Russe11223.84° support the thesis that smoking is addictive. Schacter postulates that smokers regulate their amount of smoking to maintain a certain level of nicotine in the body,224.8'1 but this has not been proven. Shiffman states that craving for cigarettes is a major cause of relapse. "The urge to smoke, when it becomes stronger than the exsmoker's deter- mination to quit, leads to relapse," he says.842 Hansen and Harrup provide an insightful state- ment regarding craving: Intense emotions of any kind tend to be ex- perienced as craving for the drug, creating a powerful and conscious motive to resume use even after long periods of abstinence. . . Abstinence depends in part on the exsmoker's ability to resolve life problems, and attain gratification by means other than addictive smoking.843 They recommend a pretreatment consultation dur- ing which the client should be informed that "the goal of the program is to maintain abstinence, that the underlying principle of treatment is that ciga- rette smoking is an addictive behavior, and that the client's intention to quit smoking represents a ma- jor life decision: '844 Gotestam and Gotestam classified the controll- ing factors for smoking as individual factors, en- vironmental factors, and drug factors.845 They pointed out that the motives to stop smoking dif- fer from the motives to maintain the nonsmoking condition. It is therefore important to design smoking cessation and maintenance strategies differently. Support appears to be one way of countering the urge to return to smoking. It is best if support 124 comes from close companions, but support from a program (or its leader) appears to bolster the deter- mination to remain a nonsmoker. Leaders who keep in touch with clients through followup ses- sions or by telephone can permit them to raise problems they are facing and to seek solutions. The leader also can answer questions and encourage proper eating to help clients avoid the common problem of weight gain. Another way of avoiding relapse is to provide clients with coping strategies so they will know how to handle problem situations themselves. Coping strategies need to be individualized, however, so that they will fit each client's situation. Both high- risk situations and withdrawal symptoms need to be addressed. Clients should be alerted regarding avoidance of the abstinence violation effect. A"slip" does not mean they cannot quit in their second or third attempt. Maintenance of abstinence at the worksite is complex, but a variety of actions can be taken to support nonsmoking. Company policies regarding prohibitions and restrictions against smoking and support for a smoke-free environment will en- courage nonsmoking. Provision of company educa- tional and cessation programs will offer a way for workers to quit. Coping strategies, incentives, and support are essential for a successful result. Incen- tives to remain free of smoking in the form of cash bonuses, prizes, extra vacation days, and praise from management and coworkers are potential maintenance strategies. Bets, competitions, and employer recognition are other worthwhile measures. Support for the ex-smoker can come from coworkers, family members, union leaders, management, and the occupational health staff. Perhaps the most important ingredient is a suppor- tive, smoke-free environment. As self-efficacy relates to success in smoking cessation, during a preparation phase, clients also should be instilled with the confidence that they can quit smoking. In addition, clients should be provided with the skills to maintain nonsmoking once they have achieved initial success. Clients should also be involved in treatment so that they will attribute their success in stopping smoking to themselves. Substitutes for smoking should be suggested by the leader. Two appropriate substitutes are exercise and deep breathing. Exercise appears to reduce ten- sion, while deep breathing enhances relaxation. For those who do not wish to do exercises, alternatives include playing tennis, riding a bike, swimming, or participating in some other sport. Overeating or overdrinking coffee or alcohol should be avoided as substitutes. Any number of methods can help a smoker to break the habit, but to assure long-term success in smoking cessation, maintenance sup- port is necessary. TIMN 293452

6. SUMMARY AND CONCLUDING COMMENTS 'Iwo decades after the Surgeon General's warn- ing prompted substantial numbers of American men to stop smoking, the national incidence of lung cancer in white men decreased significantly for the first time in at least half a century. The lung cancer rate for white men declined 4 percent, from 82.7 new cases of lung cancer per 100,000 men in 1982 to 79.3 in 1983 846 The Director of NCI, Vincent DeVita Jr., attributed the decreased cancer rate to a reduction in the numbers of men smok- ing because they either quit smoking or did not take up the habit. The lung cancer rates for women and black men, however, were far less encouraging. NCI noted that lung cancer deaths and new cases of the disease in women showed no signs of leveling off due to women's smoking habits. Women have not shown the rapid declines in smoking of white men; therefore, a decrease in lung cancer among women is not expected for 15 to 20 years. This year, lung cancer is expected to top breast cancer as the leading cause of cancer deaths among women. Although the lung cancer rate for black men ap- pears to be leveling off, their annual rate is still significantly higher than that of white men. Life expectancy at any given age is significantly shortened by cigarette smoking. A two-pack-a-day smoker between the ages of 30 and 35 years has a life expectancy that is 8 to 9 years shorter than that of a nonsmoker of the same age.7 Specific mor- tality ratios are directly proportional to the amount smoked and to the number of years of cigarette smoking. Coronary heart disease is the chief con- tributor to the excess mortality among cigarette smokers, followed by lung cancer and chronic _ obstructive lung disease. Zbbacco use increases the hazards associated with certain types of occupational exposure and the use of oral contraceptives. It has an adverse effect on the fetus. Smokers who give up cigarettes can improve their health. This is why it is important to encourage smokers to quit smoking. Most smokers want to quit. Many smokers quit on their own. There are, however, those who need help in quit- ting or the stimulus to quit. Smoking cessation methods were developed out of this need. This report reviews and evaluates smoking cessation methods with emphasis on methods used over the last 8 years. In this review, smoking cessation methods are classified in 10 major categories with some of the categories including several different methods. The review is intended as an update of two evaluations of smoking methods in 1969 and 1977.41.42 Although the review is limited to methods reported in 1978 or later and to programs conducted in the United States and Canada, some earlier programs are included for historical or background informa- tion, and programs from other countries are in- cluded to present a more complete evaluation of several methods. For example, all available nicotine chewing gum and worksite cessation programs with followup data were included. The evaluation is limited to cessation of cigarette smoking and to reports that include results based on abstinence. Although some studies with followups of less than 6 months are included in the review, the emphasis is on studies with at least 6-month followups. Summary tables are provided for various meth- ods showing the number of trials, range of results, median quit rates, and percent of trials that achieved at least 33-percent abstinence. Only pro- grams with at least a 6-month followup are in- cluded in the summary tables. Results are pre- sented separately for trials with 6-month and 1-year followups. A comprehensive table covering both early and more recent cessation methods is presented in the appendix to provide the reader with an overview of cessation methods and their reported results. The reader is advised to keep in mind the cautionary statement that precedes the table. Also provided in the appendix is a listing of doctoral dissertations on smoking cessation that were completed in 1977-1984. HIGHLIGHTS OF THE FINDINGS 1. Although most people who quit do so without going through an organized method, such as a quit clinic, commercial program, or behavioral pro- cedure, many people act on the advice or warning 125 TIMN 293453

of a health professional. Some are aided by a quit kit from a nonprofit or public agency. Still others receive help from radio or television programs, publicity campaigns such as the Great American Smokeout, magazine or newspaper articles, books, manuals, records, tapes, Qr over-the-counter preparations. 2. Although there have been improvements, smoking cessation evaluations continue to be defi- tion of smoking cessation methods has progressed to the point that validation of self-reports of abstinence is advisable to ensure believable results. Ta.king saliva or breath samples is not particular- ly intrusive and can easily be done by any program or therapist. Measurement also increases the ac- curacy of self-reports. It is clear that abstinence should be validated in cessation studies and treat- ment programs and that methods are available to cient in design and methodology. Seven problem serve this purpose. Given some costs and incon- areas are highlighted with improvements noted in three of these areas over the last 8 years. The four problem areas with limited improvements are poor description of methods, procedures, subjects, and followups: lack of control or comparison groups and poor designs; difficulty in evaluating methods that combine several procedures in treatment; and dif- ficulty of making comparisons between methods due to vast differences in execution, subjects, defini- tions, followup period, and other factors. The three areas with improvements are the evaluation of the outcome of cessation programs based on reduction in smoking rather than abstinence; followup procedures; and validity of self-reports of smoking behavior. Some investi- gators, mainly psychologists, continue to evaluate their results in terms of reduced numbers of cigarettes smoked rather than cessation. All cessa- tion programs should use abstinence for evaluation purposes. Progress has been made over the last 8 years in the length of the followup with many programs now doing at least a 1-year followup and some in- vestigators following up subjects after several years. Still, some investigators conduct followups of less than 6 months. The bare minimum for a mean- ingful followup is 6 months, but at least 1 year is necessary to ascertain long-term results. Outcome evaluations sometimes are based simply on sub- jects completing treatment or on those replying to followups. Ideally, evaluation of results should be based on all subjects, and investigators should pro- vide a full description of followup procedures. 3. With the availability of physiological tests to validate abstinence, more and more programs are using the tests to corroborate claims of nonsmok- ing. These tests are based on analyses of carbon monoxide levels in the blood or expired air samples; plasma, urinary, or sputum thiocyanate; and blood, urinary, or sputum nicotine or its derivative, cotinine. Studies show that up to one-fourth of the people claiming abstinence may not be telling the truth. In certain contexts, such as a close relationship with a counselor or where there is a payoff for not telling the truth, the lie rates may be high. In most studies, especially where subjects seek help or pro- grams, they seem to be relatively lov% The evalua- 126 venience that still remairi with various tests, it may not be realistic to expect all nonresearch programs to include validation. 4. 'Ib satisfy the preference of most smokers to stop smoking on their own,47 a variety of self-help books and quit kits are available to guide them in their efforts. Unfortunately, there are only a few evaluations of these materials. Among the best kits available are those produced by ACS, ALA, and NCI. The general finding to emerge from the various types of self-quitting studies is that people who self- select to quit "on their own" appear to succeed 16 to 20 percent of the time in being abstinent at 1 year. This finding is supported by statistics from national samples, which indicate that of those who try to quit, 20 percent report they succeed. 5. Numerous products are available to help smokers break their habit. Their effectiveness is questionable, but some products may lead their users to quit smoking. Lobeline and graduated filters are the most common over-the-counter preparations sold to combat the smoking habit. 6. Over the last decade, there has been a notable increase in smoking control programs offered by public and private agencies and employers. Pro- grams are sponsored by a variety of organizations, including churches, schools, universities, health departments, hospitals, medical centers, research foundations, medical societies, interagency coun- cils, military units, rural, community, and service agencies, labor unions, exercise clubs, and private businesses at offices and factories. 7. The General Conference of Seventh-day Adventists has revised its Five-Day Plan, renaming it The Breathe Free Plan to Stop Smoking. The plan emphasizes motivation and lifestyle modification strategies and consists of eight sessions over 3 weeks. 8. Commercial stop-smoking programs are avail- able in all but a few major cities in the United States. My review of the telephone yellow pages revealed many more treatment center listings in 1984-85 than in 1976-77. Commercial programs, half the listings in the earlier survey, now account for just one-fifth of them. Hypnosis increased in listings to become the most frequent listing. The proportion of all medical listings doubled compared TIMN 293454

to the earlier survey. A big increase also was shown by acupuncture in the current review. Conclusions that can be drawn from the yellow pages survey are that a variety of professionals are offering to help people quit smoking in a number of ways and that, overall, commercial programs are currently less important. 9. The three national commercial stop-smoking programs established between 1968 and 1971 are still operating today but with reduced operations. Many commercial enterprises have gone out of business with new companies entering the scene. Outside evaluations of commercial programs are rare. Commercial entities have put more emphasis on franchising their method to hospitals and work- ing with industry. Proprietary groups that are able to penetrate the corporate market are the ones that will be able to survive. 10. Medication for smoking cessation does not show good results even in the short run. During the period reviewed, there were no reports of any medication trials with at least a 6-month followup. 11. Nicotine chewing gum (Nicorette) can be an effective tool in achieving abstinence from ciga- rettes in motivated patients. Once the gum is dis- continued, however, many people return to smok- ing. How long smokers should use the gum is yet to be determined. Longer use of Nicorette (6 months to 1 year) appears to improve quit rates. Cautions have been raised about long-term gum use and about prescribing the gum indiscriminate- ly, possibly in lieu of an adequate support system. Supplemental cessation methods are needed along with nicotine gum use. The trials with behavioral treatment or therapy had higher quit rates than those that only dispensed nicotine gum. Nicorette trials were generally well done with all but a few validating abstinence by physiological measurements. Unfortunately, followup periods were counted from the start of treatment when the gum was dispensed, not after giving up gum. At followup, some subjects were still on the gum (and thus still in treatment), and many subjects were only off the gum a few months. For Nicorette trials to gain credibility and comparability, it is necessary to increase followup times to ascertain if subjects remain abstinent after discontinuing Nicorette. In- vestigators should show results separately for sub- jects free of the gum and for those still using the gum. Nicorette provides the physician with a product that he or she can prescribe for patients willing to stop smoking. The availability of Nicorette should encourage physicians to advise patients about quit- ting, but physicians who prescribe Nicorette also should provide counseling and support. Ways of administering nicotine, other than gum, are being explored. Tlvo such products are a nasal nicotine solution and transdermal application. 12. Hypnosis is a popular smoking cessation treatment, but reports of its effectiveness are con- tradictory. Most hypnosis reports deal with small numbers of patients, often with limited followup data or unclear success. In general, hypnosis pro- duces only modest results when used alone but better rates when combined with other methods or used in multiple sessions. As with any method, counseling and followup support are needed. In view of the widespread use of hypnosis for sniok- ing control, it is essential that therapists provide ob- jective evidence that hypnosis promotes abstinence. 13. Acupuncture for the treatment of smoking has become more popular, but the few evaluation reports with followup data are poorly done. High rates of success are claimed based on estimates, and those with better designs had lower quit rates. Acupuncture possibly may act as a placebo to enable the quitter to handle withdrawal symptoms, but the social and psychological aspects of smok- ing also must be dealt with. 14. National surveys indicate that many physi- cians believe they should help their patients to quit smoking, though some are reluctant to intercede until serious health problems are present. With the availability of quit kits, self-help manuals, and nicotine chewing gum, physicians can build pa- tients' confidence that their efforts will succeed. 15. Physician advice and counseling do en- courage many patients to attempt to break their cigarette habit. The number who succeed in quit- ting after a brief warning is small, but the yield is large. When physicians give a stronger message, give tips on how to quit, or provide support, results improve. Quit rates for patients with pulmonary or cardiac disease who are told to stop smoking are substantial. Approximately 38 million smokers in the United States visit a doctor each year. If all doc- tors counseled all of their patients who smoked on how to stop and were successful with just 4 per- cent, the yield would approximate 1.5 million ex-smokers. 16. Other health professionals also can be signifi- cant in helping patients to quit smoking. Dentists, dental hygienists, nurse practitioners, physician's assistants, nurses, inhalation therapists, para- medics, pharmacists, and others have not been ade- quately studied in terms of their effect on influenc- ing patients to quit smoking. 17. In the last decade, a number of risk factor trials have been conducted that had smoking cessa- tion as one of their goals. The large-scale MRFIT recorded a validated quit rate of 42 percent for in- tervention subjects at a 6-year followup. Control subjects, who were screened as high risk for cor- onary heart disease and told to return to their own doctors, had a quit rate of 24 percent. Considering 127 ,rIMN 293455

the time, money, and effort devoted to MRFIT, the quit rate for intervention subjects was disappoint- ing. MRFIT made contributions to the smoking area by training a cadre of smoking specialists and by demonstrating that it was possible for a large- scale study to validate smoking status with objec- tive measures. 18. Radio and television reach a wide number of smokers with instructions on how to quit smoking. Media programs encourage many smokers to try quitting and some succeed, though quit rates are low. Mass media programs could be more effective if combined with group or individual instruction. Programs such as the Great American Smokeout receive wide publicity and trigger quit attempts by smokers. Use of the telephone to provide mainte- nance support is noteworthy. 19. Community studies have mixed results, but there is a fairly consistent trend in reducing smok- ing. Outside factors can influence quitting in both the intervention and control communities. Dealing with more than one risk factor showed lower rates for smoking cessation. The studies suggest that a combination of mass media and intensive instruc- tion is more successful than media alone. Three new community studies are long-range ef- forts designed to reduce risk factors in whole com- munities. They were developed out of the multiple risk factor trials and community studies that preceded them. Results should be available over the next few years. 20. Behavioral techniques show a wide range of success. Results are difficult to interpret because many of the studies base their quit rates solely on subjects who either complete the program or answer followups. Overall, behavioral studies have stronger methodologies than do other methods (e.g., hypnosis and acupuncture). Some of the research groups conduct carefully designed studies and are validating their results by biochemical measures. 21. Past reviews have found that aversive therapy showed poor results. Covert sensitization has failed to produce good long-term success but may be use- ful when combined with other procedures or used as a maintenance technique. Rapid smoking has drawn a great deal of attention and appears to be effective in the short term. When rapid smoking is the primary treatment, success rates are low, but when combined with other procedures, results im- prove. Concern over the physiological effects caused by rapid smoking limits its use without proper screening procedures, monitoring, and medical backup. Not all subjects are willing to accept aver- sive smoking treatments. When satiation has been combined with other procedures, some dramatic quit rates have resulted, but when used alone, long- term results have been poor. More work needs to 128 be done with smoke holding and normal-paced aversive smoking, procedures that are safe and have achieved good results in limited trials. 22. Used as the primary treatment, self-control techniques (e.g., self-monitoring, stimulus control, systematic desensitization, and sensory depriva- tion) do not produce favorable long-term results. Contingency contracting showed short-term suc- cess during the contract period, but when the con- tract ended, many subjects returned to smoking. Nicotine fading can be used to wean smokers from the nicotine addiction. The combination of smoke aversion and self-management procedures has been suggested as providing an optimal model for smoking cessation. A number of multicomponent programs have generated good results, but some programs have combined too many procedures in one package. The most successful programs have included more treatment sessions, relapse prevention-coping strategies, and strong maintenance components. 23. The worksite offers an excellent opportunity for implementing strategies that lead to cessation of smoking. Surveys reveal that about one-third of U.S. companies have established policies on employee smoking. Most companies with policies have initiated them in the last 5 years. Employers have been influenced to adopt restrictions on smok- ing due to the costs of employee smoking in terms of lost productivity, higher absenteeism, disability, and health care costs. Other influences are legisla- tion, the threat of lawsuits, and increasing demands by nonsmokers for a smoke-free workplace. 24. Recent actions of GSA and the Department of Defense to restrict smoking affect over 3 million persons. Polls have shown that employees are over- whelmingly in favor of restrictions on smoking. 25. Some companies are refusing to hire smokers, and many employers are giving prefer- ence to nonsmokers. 26. In addition to restrictions on smoking, inter- vention methods at the workplace include educa- tional information, incentives, and cessation pro- grams. The most common incentives have been time off for attending a cessation program or reim- bursement of fees paid for such programs. There are numerous examples of monetary incentives, but these were offered primarily by small companies. 27. About 10 to 15 percent of companies have of- fered smoking cessation programs. The most com- mon programs have been educational, distribution of self-help, kits, physician advice during physical examinations, and groups. Companies either devise their own format, copy voluntary agency programs, use outside consultants, or have their programs run by outside agencies. TIMN 293456

Only a small number of worksite cessation pro- grams have been evaluated. The results of 35 such programs (62 trials) are presented in this review. Available followup quit rates for workplace pro- grams appear to be higher than rates for local clinics. The review indicates that often when cessa- tion programs were offered, participation was low. When incentives were offered along with interven- tions, participation, as well as quit rates, improved. 28. Maintenance support is the critical ingredient in the long-term success in smoking cessation. Support helps counter the urge to smoke. Support from close companions or coworkers or from a pro- gram leader bolsters the determination to remain a nonsmoker. Coping strategies also help clients to handle problem situations. 29. The Multiple Risk Factor Intervention ZYial replicated the findings of the Smoking Control Research Project with regard to differences between successes and recidivists. Successes scored higher than did recidivists in the following factors: per- sonal security, ease of quitting on last attempt, ex- pectation of success in giving up smoking, and social support. Successes also had lower levels of anxiety and smoked less cigarettes per day than did recidivists. 30. Leading causes of relapse are anxiety, stress, anger, frustration, social pressures, weight gain, and lack of inner resources. Being around other smokers, eating, and drinking coffee or alcohol also contribute to relapse. Craving for cigarettes plays a lesser role in relapse. 31. Clients should be advised that a single "slip" does not mean they cannot quit on their next at- tempt. As self-efficacy relates to success in smok- ing cessation, clients should be instilled with con- fidence that they can quit smoking and be provided with the skills to maintain nonsmoking once it is achieved. COMPARISON OF QUIT RATES BETWEEN METHODS Table 23 summarizes the quit rates for the various methods. Of the trials shown, 185 had at least a 6-month followup, and 231 had at least a 1-year followup. A cautionary note appears in the table to alert the reader that the rates were largely based on self-reports and were supplied by investi- gators whose followup procedures and definitions may have differed. Some high rates reported that were suspect due to poor followup procedures were not included in the table. With the foregoing cau- tions in mind, some trends in the data are noted. The highest median quit rates for trials with 1-year followups were scored by physician interven- tion with cardiac patients and multiple programs. There were 17 multiple program trials that had 1-year followups, and two-thirds achieved at least 33-percent success. The cardiac quit rates were based on 16 trials, most with a substantial number of patients. Cardiac patients are highly motivated due to their life-threatening illness. Other methods whose median quit rates reached 30 percent at 1-year followups were physician intervention with pulmonary patients, risk factor studies, and rapid smoking and satiation when each were combined with other procedures. Methods that had median quit rates just below 30 percent were groups and nicotine chewing gum when combined with behavioral treatment or therapy. Seven methods showed good short-term results: educational techniques, nicotine chewing gum when combined with behavioral treatment or therapy, group hypnosis, physician intervention with cardiac patients, rapid smoking, satiation, and contingency contracting. The nicotine chewing gum result is based on just three trials; as a con- trast, the rapid-smoking median is based on 21 trials. Although there were a few exceptions, 6-month median quit rates were higher than 1-year rates. One-year median quit rates were notably lower than 6-month rates for nicotine chewing gum and contingency contracting. For nicotine chewing gum, the difference may be due to more patients still chewing the gum at 6 months. As already noted, results for contracting are good in the short run during the contract period. One-third of the trials of 12 different intervention methods scored at least 33-percent success (table 23). Nevertheless, one cannot select any single method as the "best: " Self-help, with no profes- sional supervision, showed a respectable 18-percent median quit rate at 1 year for seven trials. More evaluations of self-help materials are needed. When physicians provided more than advice or counsel- ing to patients, the median quit rates rose from 6 percent to 22.5 percent at 1 year. Nicotine chew- ing gum had an 11-percent median quit rate at 1 year, but the rate increased to 29 percent when combined with other treatments. As already noted, longer followups are needed for nicotine gum trials to allow for a period of time when patients have stopped using the gum. Of the behavioral procedures, rapid smoking and satiation are risky but showed good results when combined with other treatments. Smoke holding and nicotine fading, which pose no risks, deserve more exploration. Contingency contracting could be useful if the contracts were made with close companions and extended into the maintenance period. Hypnosis and acupuncture, popular quitting methods, require careful evaluation in long-term followups with abstinence validated by physiological 129 TIMN 293457

Table 23 SUMMARY OF FOLLOWUP QUIT RATES OF 416 SMOKING CESSATION TRIALS BY METHOD Reported 1959-1985 At Least 6-Month Follorrnp Percent At Least 1-Year FolloNrap Percent Intervention Method Number Range Median 33% Number Range Median 33% Self-Help 11 0-33 17 18 7 12-33 18 14 Educational 7 13-50 36 71 12 15-55 25 25 Five-Day Plan 4 11-23 15 0 14 16-40 26 21 Group* 15 0-54 24 20 31 5-71 28 39 Medication 7 0-47 18 14 12. 6-50 18.5 17 Nicotine Chewing Gum 3 17-33_ 23 33 9 8-38 11 11 Nicotine Chewing Gum and Behavioral Treatment or Therapy 3 23-50 35 67 11 12 49 29 36 Hypnosis-Individual 11 0-60 25 36 8 13-68 19.5 38 50 Hypnosis-Group 10 8-68 34 50 2 14-88 - 0 Acupuncture 7 5-61 18 29 6 8-32 27 Physician Advice or Counseling 3 5-12 5 0 12 3-13 6 0 Physician Intervention More Than Counseling 3 23-40 29 33 10 13-38 22.5 20 Physician Intervention -Pulmonary Patients 10 10-51 24 20 6 25-76 31.5 50 -Cardiac Patients 5 21-69 44 80 16 11-73 43 63 Risk Factor - - - - 7 12-46 31 43 Rapid Smoking 12 7-62 25.5 33 6 6-40 21 17 Rapid Smoking and Other Procedures 21 8-67 38 57 10 7-52 30.5 50 Satiation Smokingt 11 14-76 38 64 12 18-63 34.5 58 Regular-Paced Aversive Smoking+ 13 0-56 29 31 3 20-39 26 33 Nicotine Fading+ 7 26-46 27 29 16 7-46 25 44 Contingency Contractingt 9 25-76 46 89 4 14-38 27 25 Multiple Programst 13 18-52 32 38 17 6-76 40 65 •Three group trials had 5-month followups. {Other procedures may have been used, and some trials may be included in more than one method. Note: Percent 33% is percent of trials with quit rates of at least 33 percent. Median not calculated for less than three trials. Caution: Quit rates provided suggest overall trends. Most quit rates were based on sel[ reports. Some quit rates were recalculated to include all subjects, but most quit rates were based on reports by investigators. Some quit rates omitted subjects who did not complete treatment or persons who did not reply to followups. Definitions of followup may vary between trials. measures. The same is true for commercial pro- grams. Mass media methods, which can reach large numbers of people, likewise need to be evaluated. NCI has funded a sizable number of smoking cessation projects ls'•847 Promising approaches being studied are self-help strategies, physician and dentist interventions, mass media programs, and school-based interventions. The following high-risk groups have been targeted for priority intervention research: heavy smokers, ethnic minorities (blacks and Hispanics), women, youth, and smokeless tobacco users. Cullen et al. expect that smoking- related intervention research over the next 5 years will provide input to NCI on interventions that will reduce smoking incidence and prevalence.847 Re- sults are expected to yield sufficient data by 1990 on interventions that have proven to be effective. The NCI program expects to disseminate the infor- mation learned so that mass distribution of smok- ing intervention strategies will have widespread public health benefits by the year 2000. TRENDS IN SMOKING CESSATION Over the last 8 years, there have been a number of positive developments related to smoking cessa- tion. Some of these developments relate to the overall environment, and some relate specifically to smoking cessation methods. These trends will be enumerated briefly. 1. Smoking continues to decline in the percent of people who smoke and in per capita cigarette consumption. On the negative side are the high number of young women who smoke and that there are more heavy smokers among those who continue to smoke. Also disturbing is the continued high rate of current cigarette use among blue-collar workers compared to their white-collar counterparts. 2. The most significant trend is the increased negative attitude toward cigarette smoking as ex- emplified by the numerous ordinances and regula- tions that separate smokers and nonsmokers in restaurants, airplanes, schools, worksites, and other 130 TTMN 2 9345g

public places. Nonsmokers have become outspoken in their demand for clean indoor air. Although teenagers continue to take up the smoking habit, there are indications that many young people no longer consider smoking to be at- tractive. A recent national poll of teenagers by the Opinion Research Corporation found that 78 per- cent of the boys and 69 percent of the girls preferred to date nonsmokers.848 Even among teenage smokers, 10 percent said they would prefer a nonsmoker, while only 3 percent wanted a partner who smoked. 3. Iglehart indicates that the campaign against smoking has gained momentum as it has suddenly attracted a host of new allies who have formulated a range of strategies to limit the use of tobacco. ... The major goals are to protect the nonsmoker from the conse- quences of passive smoking, to increase cigarette excise taxes and ban all forms of tobacco advertising, to challenge legally whether cigarette manufacturers are liable for the medical consequences that stem from the use of their product, and to promote the idea that smoking is socially unacceptable behavior.849 One indication of the stepped-up campaign against smoking is the joining of AMA with the cancer, lung, and heart associations in the call for a ban on all forms of cigarette advertising. 4. Another positive trend is the increased focus on smoking cessation in the workplace by private and public employers and the military. As detailed in the worksite chapter, more employers have ini- tiated policies that restrict and prohibit smoking. Some employers are giving preference to non- smokers in hiring. More employers are providing educational and cessation programs and offering incentives to those who quit smoking. 5. Catering to the preferences of smokers to quit on their own, a number of self-help manuals and quit kits have been made available. ALA developed cessation and maintenance manuals, and ACS and NCI improved their self-help quit kits. ACS and ALA also have developed improved packages for smokers who prefer to participate in group treatment. The General Conference of Seventh-day Adventists also has introduced their new plan, The Breathe Free Plan to Stop Smoking, a needed revision of the Five-Day Plan. All of these treatments have improved maintenance features. 6. Physicians have become more involved in ad- vising and counseling their patients to stop smok- ing. Physician guides to help their patients to quit smoking have been produced by ACS, NCI, and NHLBI. NCI also has produced quit guides for den- tists and pharmacists. With a modest effort, physicians have been successful in helping chronically ill patients to break their cigarette habit. Those physicians who have put extra effort into smoking intervention have achieved greater success with regular patients than have physicians who merely advise their patients to stop smoking. The introduction of nicotine chewing gum has pro- vided physicians with a product that can be prescribed to patients who wish to quit. For pa- tients to quit with nicotine gum, however, they will need support and coping strategies. 7. Behavioral investigators have tested various treatments. Some multiple program packages show good results. Nicotine fading and smoke holding ap- pear to offer promise and should be tested further with appropriate controls and random assignments. 8. A most promising development is the avail- ability and use of methods to validate abstinence by physiological means. Although some test meth- ods are easy to administer, within a few years, new tools will become available that will be even more accurate, sensitive, and inexpensive, as well as easier to administer. 9. There has been an increase in research into smoking intervention. The community programs funded by NHLBI and the cessation projects funded by NCI should provide information on the most ef- fective intervention methods and on methods that will assist high-risk groups to cease smoking. 10. Research has identified differences between successes and recidivists in smoking cessation. Re- search also has provided insights into the reasons for relapse and the development of maintenance strategies that may bolster success in cessation. 11. Of utmost importance is the application of findings regarding the prevention of smoking among children and adolescents. As a result of research and demonstration projects conducted over the last decade, new curriculums and ap- proaches have been developed that offer hope in reducing smoking levels among children. CONCLUDING COMMENT Very little is known about persons who quit smoking on their own. Several investigators study- ing self-changers are discovering interesting facts. For example, one team found that recent quitters emphasized social support, whereas long-term quitters emphasized coping strategies 134 More work is needed in this area. The study of relapse is another recent area of investigation needing con- centration. How factors such as dependence on nicotine, withdrawal symptoms, stress, use of cop- ing strategies, and social support influence maintenance are valid areas of study. Cessation methods should be further developed and tested with high-risk population groups, such TIMN 293459 131

as young women, blue-collar workers, heavy smokers, minorities, and cardiopulmonary pa- tients. Although physician involvement in smoking cessation has increased, more needs to be done to encourage even greater participation by doctors. Other health professionals also should be involved to a greater extent in smoking cessation. Occupa- tional settings offer opportunities to reach high-risk smokers. Several ingredients are necessary for successful treatment: an acceptable method,47 dedicated leaders,aso.sa1 and well-planned maintenance strategies. There is general agreement among prac- titioners that smoking cessation treatment consists of three phases: preparation, intervention, and maintenance. Preparation consists of increasing the smoker's motivation to quit by pointing out the risks of con- tinued smoking and the benefits of quitting and by building confidence that he or she can be suc- cessful. Increasing motivation and confidence will enhance self-efficacy and expectancy of success. It is during preparation that the client should be in- formed that the key to success is the maintenance of nonsmoking. Any number of methods (or a combination of them) can help smokers to achieve abstinence. Whatever method is used, however, should involve the client actively in treatment to enhance self- attribution. Those programs with a good maintenance com- ponent will show the best long-term success. Social support, training in coping strategies, and the use of substitutes like exercise may bolster mainte- nance. The search for additional maintenance strategies should be a top priority. Cessation methods should head in the direction of developing more effective self-help and mass media programs with maintenance components. Innovative interventions using new technologies such as computers and videotapes need to be developed and tested. Actions in the overall environment, such as a ban on the advertising of cigarette smoking, the elimination of tobacco price supports, increased action by employers to restrict smoking at the workplace, and a further escalation of attitudes that make smoking socially unacceptable, will hasten a decline in smoking. Cigarette smoking remains a dffficult habit to break. Most smokers, however, wish to quit. Those smokers who cannot quit on their own need help. Cessation methods offer that opportunity. 132 TIMN 293460

REFERENCES 1. The Dragnet Magazine, Vol. 12, No. 2. Clues, Inc., New York, April 10, 1929. 2. US. Department of Health, Education, and Welfare, Public Health Service, National Clearinghouse for Smoking and Health: Department of Agriculture Statistics on US. Cigarette Consumption, November 11, 1969. 3. U.S. Department of Health, Education, and Welfare, Public Health Service, National Clearinghouse for Smoking and Health: Department of Agriculture Statistics on U.S. Cigarette Consumption, April 28, 1970. 4. US. Department of Health, Education, and Welfare: Smoking and Health: A Report of the Surgeon General. Department of Health, Education, and Welfare, Public Health Service, Office on Smoking and Health, DHEW Publ. No. (PHS) 79-50066, January 1979, p. A-7. 5. Associated Press and United Press Report: First Drop in Cigaret Sales Since 1969. San Francisco Chroni- cle, June 19, 1985, p. 6. 6. Schwartz, J.L.: Cigarette Smoking. In, R.S. Chang (Ed.), Preventive Health Care. G. K. Hall Medical Publishers, Boston, 1981, pp. 225-228. 7. 1979 Report of the Surgeon General, op. cit. ref. 4, p. i. 8. Ibid., pp. 2-9 to 2-47. 9. Ibid., p. 1-11. 10. Ibid., pp. 3-5 to 3-22. 11. U S. Department of Health and Human Senvices: The Health Consequences of Smoking: Cancer. A Report of the Surgeon General. Department of Health and Human Services, Public Health Service, Office on Smoking and Health, DDHS Publ. No. (PHS) 82-50179, 1982, pp. 21-63. 12. American Cancer Society: 1982 Cancer Facts and Figures. American Cancer Society, New York, 1981, 31 pp. 13. 1982 Report of the Surgeon General, op. cit. ref. 11, pp. 63-149. 14. 1979 Report of the Surgeon General, op. cit. ref. 4, pp. 32-53. 15. Ibid., pp. 4-7 to 4-66. 16. US. Department of Health and Human Services: The Health Consequences of Smoking: Cardiovascular Disease. A Report of the Surgeon General. Depart- ment of Health and Human Services, Public Health Service, Office on Smoking and Health, DDHS Publ. No. (PHS) 84-50204, 1983, pp. 13-201. 17. Ibid., pp. 7, 101-104, and 121. 18. 1979 Report of the Surgeon General, op. cit. ref. 4, pp. 1-4 and 4-35. 19. Ory, H.W.: Association Between Oral Contraceptives and Myocardial Infarction. A Review. JAMA 237:2619-2622, 1977. 20. Miller, G.H: The 'Less Hazardous' Cigarette: A Deadly Delusion. N.Y. State J. Med. 85:313-317, 1985. 21. Lenfant, C.: Are 'Low Yield Cigarettes Really Safer? New Engl. J. Med. 309:181-182, 1983. 22. 1983 Report of the Surgeon General, op. cit. ref. 16, pp. 8 and 297. 23. Miller, G.H., Pearson, L.J., and Schumaker, J.A.: Some Fallacies of the Gori Report on Less Hazardous Ciga- rettes. J. Ind. State Med. Assoc. 75:264-267, 1982. 24. Ledwith, F. and Rimpela, M.: Can We Have Safer Cigarettes? (Letter). Brit. Med. J. 290:157-158, 1985. 25. WHO Expert Committee on Smoking Control: Con- trolling the Smoking Epidemic. 'Ibch. Rep. Series 636, World Health Org., Geneva, 1979. 26. 1979 Report of the Surgeon General, op. cit. ref. 4, p. 9-10. 27. Ibid., pp. 8-9 to 8-91. 28. U S. Department of Health and Human Services: The Health Consequences of Smoking: Cancer and Chronic Lung Disease in the Workplace. A Report of the Surgeon General. Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1985. 29. Schwartz, Cigarette Smoking, op. cit. ref. 6, p. 229. 30. National Center for Health Statistics: Health and Prevention Prqfile, United States, 1983. Data from the National Health Interview Survey, DHHS Publ. (PHS) 84-1232. 31. Gallup, G.: Cigaret Smoking Drops-Lowest in 42 Years. San FYancisco Chronicle, June 26, 1986, p. 26. 32. US. Department of Health and Human Services: The Health Consequences of Smoking for Women: A Report of the Surgeon General. Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1980, p. 36. 33. 1983 Report of the Surgeon General, op. cit. ref. 16, p. 364. 34. Report of a Workshop on Smoking Prevention and Cessation in the Black Population. In, National Cancer Institute, Division of Resources, Centers, and Com- munity Activities: Smoking, 7bbacco, and Cancer Programs-Program Overview. Presented to the Na- tional Cancer Advisory Board, October 3, 1983, B-57-58. 35. 1983 Report of the Surgeon General, op. cit. ref. 16, p. 366. 36. Ibid., p. 369. 37. Grise, V.N.: 'Ibbacco Consumption in the United States. _ Paper presented before the Interagency Forum on Smoking and Health, Washington, D.C., March 5, 1985. 38. Schwartz, Cigarette Smoking, op. cit. ref. 6, p. 231. 39. Moss, A.J.: Changes in Cigarette Smoking and Cur- rent Smoking Practices Among Adults: United States, 1978. U.S. Department of Health, Education, and 133 TIMN 293461

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Benfari, R.C. and Eaker, E.: Cigarette Smoking Out- comes at Four Years of Follow-Up, Psychosocial Fac- tors, and Reactions to Group Intevention. J. Clin. Psychol. 40:1089-1097, 1984. 805. Benfari, R.C., Eaker, E.D., Ockene, J., and McIntyre, K.M.: Hyperstress and Outcomes in a Long-Term Smoking Intervention Program. Psychosom. Med. 44:227-235, 1982. 806. Mermelstein, R., Cohen, S., and Lichtenstein, E.: Psychosocial Stress. Social Support, and Smoking Cessation and Maintenance. Unpublished paper, University of Oregon. Eugene, 1985. 807. Marlatt, G.A. and Gordon, J.R.: Determinants of Relapse: Implications for the Maintenance of Behavior Change. In, Davidson and Davidson, Behavioral Medicine, op. cit. ref. 490, pp. 410-452. 808. Lichtenstein, E. and Mermelstein, R.J.: Review of Ap- proaches to Smoking 'Il-eatment: Behavior Modifica- tion Strategies. In, Matarazzo, Behavioral Health, op. cit. ref. 534, pp. 695-712. 809. Shiffman, S.: Cognitive Antecedents and Sequelae of Smoking Relapse Crises. J Appl. Soc. PsychoL 14:296-309, 1984. 810. Lichtenstein, E., Antonuccio, D.O., and Rainwater, G.: Unkicking the Habit: The Resumption of Cigarette Smoking. Paper presented at the Annual Meeting of the Western Psychological Association, Seattle, 1977. 811. Shiffman, S.: Relapse Following Smoking Cessation: A Situational Analysis. J. Consult. Clin. Psychol. 50:71-86, 1982. 812. Shiffman, S., Read, L., and Jarvik, M.E.: Smoking Relapse Situations: A Preliminary Typology. Intl. J. Addict. 20:311-318, 1985. 813. Shiffman, S.: Coping With Temptations to Smoke. J. Consult. C1in. Psychol. 52:261-267, 1984. 814. Shiffman, S.: A Cluster Analytic Classification of Relapse Episodes. Addict. Behav. 11:295-317, 1986. 815. Schwartz, J.L.: Successes and Failures in Smoking Cessation: Insights from Personal Interviews. World Smoking & Health 3:11-18, 1978. 816. Ashenberg, Z.S.: Smoking Recidivism: The Role of Stress and Coping. Doctoral Dissertation, Washington University, St. Louis, MO, University Microfilms Intl. 84-02189, 1983, 167 pp. 817. Rogers, J.: A Review of Causes of Recidivism and Related Considerations. In, Proceedings of the Fifth World Conference on Smoking and Health, op. cit. ref. 167, pp. 255-260. 818. Pechacek, T.F. and Danaher, BG.: How and Why Peo- 154 ple Quit Smoking: A Cognitive-Behavioral Analysis. In, P.C. Kendall and S.D. Hollon (Eds.), Cognitive- Behavioral Interventions: Theory. Research. and Procedures. Academic Press, New York, 1979, p. 414. 819. Lichtenstein, E.: Social Learning, Smoking, and Substance Abuse. In, N.A. Krasnegor (Ed.). Behavioral Analysis and Treatment of Substance Abuse. NIDA Research Monograph 25, DHEW Publ. No. (ADM)79-839, 1979, pp. 114-127. 820. Lichtenstein and Brown, Current'IYends, op. cit. ref. 553, p. 595. 821. Williams, D.C. and Shor, R.E.: The Social Support System of Smoking. Paper presented at the 87th An- nual Convention of the American Psychological Association, New York, 1979. 822. Baric, L.: Preventing Relapses After Smoking Cessa- tion. In, Ramstrom, Fourth World Conference on Smoking and Health, op. cit. ref. 143, pp. 223-227. 823. Colletti, G. and Brownell, K.D.: The Physical and Emotional Benefits of Social Support: Application to Obesity, Smoking and Alcoholism. In, Progress in Behavior Modification, Vol. 13, op. cit. ref. 288, pp. 109-178. 824. Morgan. G.D.: Abstinence From Smoking and the Social Environmer~t. Doctoral Dissertation, Washington University, St. Louis, MO,. University Microfilms Intl. 83-20567, 1983, 225 pp. 825. Mermelstein R., Lichtenstein, E., and McIntyre, K.: Partner Support and Relapse in Smoking-Cessation Programs. J. Consult. Clin. Psychol. 51:465-466, 1983. 826. McIntyre, K.O.: Spouse Involvement in a Multicom- ponent Treatment Program for Smokers. Doctoral Dissertation, University of Oregon, Eugene, Univ. Microfilms Intl. 84-08183, December 1983, 91 pp. 827. Coppotelli, H.C. and Orleans, C.T.: Partner Support and Other Determinants of Smoking Cessation Maintenance Among Women. J. Consult. Clin. PsychoL 53:455-460, 1985. 828. Janis, I.L. and Hoffman. D.: Facilitating Effects of Daily Contact Between Partners Who Make A Deci- sion to Cut Down on Smoking. J. FLrson. Soc. Psychol. 17:25-35. 1970. 829. Rodrigues, M-R.P. and Lichtenstein, E.: Dyadic In- teraction for the Control of Smoking. Unpublished manuscript, University of Oregon. Eugene, OR, 1977. 830. Karol, R.L. and Richards, C.S.: Cognitive Maintenance Strategies for Smoking Reduction. JSAS Catalog of Selected Documents in Psychology 11:15, 1981. 831. Agne. C.: The Effects of Follow-Up Procedures on the Maintenance of Non-Smoking Behavior of the Par- ticipants in a Smoking Cessation Program. Doctoral Dissertation, 'Ibxas Women's University, Denton, University Microfilms Intl. GAX82-08752, 1981, 98 Pp- 832. Colletti. G. and Kopel, S.A.: Maintaining Behavior Change: An Investigation of Three Maintenance Strategies and the Relationship of Self-Attribution to the Long-'Ibrm Reduction of Cigarette Smoking. J. Consult. Clin. Psychol. 47:614-617, 1979. 833. Colletti, G. and Supnick. J.A.: Continued Therapist Contact as a Maintenance Strategy for Smoking Reduction. J. Consult. Clin. PsychoL 48:665-667, 1980. 834. Bandura, A.: Self-Efficacy: 'Rnvard a Unifying Theory of Behavioral Change. Psychol. Rev. 84:191-215, 1977. TIMN 293482

835. DiClemente, C.C.: Self-Efficacy and Smoking Cessa- tion Maintenance. Cognitive Ther. Research 5:175-187, 1981. 836. Owen, N. and Ewins, A.: Adherence, Relapse and Health Related Behaviours. In, J.L. Sheppard (Ed.). Advances in Behavioural Medicine, Vol. 2. Cumberland College, Sydney, At.stralia, 1982. 837. Condiotte, M.M. and Lichtenstein, E.: Self-Efficacy and Relapse in Smoking Cessation. J. Consult. Clin. Psychol. 49:648-658. 1981. 838. McIntyre, K.O., Lichtenstein, E., and Mermelstein, R.J.: Self-Efficacy and Relapse in Smoking Cessation: A Replication and Extension. J. Consult. Clin. Psychol. 51:632-633, 1983. 839. Jarvik, M.E.: 'Iblerance to the Effects of 'Ibbacco. In, NIDA Research Monograph 23, op. cit. ref. 212, pp.. 150-157. 840. Russel), M.A.H.: 'Ibbacco Dependence: Is Nicotine Rewarding or Aversive? In, NIDA Research Monograph 23, op. cit. ref. 212, pp. 100-122. 841. Schachter, S.: Regulation, Withdrawal, and Nicotine Addiction. In, NIDA Research Monograph 23, op. cit. ref. 212, pp. 123-133. 842. Shiffman, 'Ibbacco Withdrawal Syndrome, op.p cit. ref. 802. p. 160. 843. Hansen, B.A. and Harrup. T.D.: Relapse Among Ex- Smokers With Smoking-Related Disease. Unpublish- ed paper. Dependency Interventions, Berke)ey, CA, 1985. 844. Hansen and Harrup, 'Ibbacco Dependency, op. cit. ref. 769, p. 477. 845. Gotestam, B. and Gotestam, K.G.: Controlling Fac- tors for Smoking. In, Proceedings of the 5th World Conference on Smoking and Health, Vol. 1, op. cit. ref. 119, pp. 187-192. 846. News article, Lung Cancer Decrease for White Males, San Francisco Chronicle, December 3, 1985, p. 1. 847. Cullen, J.W., McKenna, J.W., and Massey, M.M.: In- ternational Control of Smoking and the US Ex- perience. Chest 89(Suppl):206S-218S, 1986. 848. United Press International: Most Popular Then Date-A Nonsmoker. San Francisco Chronicle, Oc- tober 3. 1986, p. 8. 849. Iglehart. J.K.: The Campaign Against Smoking Gains Momentum. New Engl. J. Med. 314: 1059-1064, 1986. 850. Weir, J.M. Dubitzky, M., and Schwartz, J.L.: Counselor Style and Group Effectiveness in a Smok- ing Withdrawal Study. J. Psychother. 23:106-108, 1969. 851. Jenks. R., Schwartz, J.L., and Dubitzky, M.: Effect of the Counselor's Approach to Changing Smoking Behavior. J. Couns. Psychol. 16:215-221, 1969. 852. Welsch, G. (Ed.): Wirksamkeitskontrolle von Raucherentwohnungskursen in Volkshochschulen und anderen Einrichtungen der Erwachsenen- bildung. Zusammenfassung der Ergebnisse. [Con- trol of Effectiveness of Smoking Cessation Courses in Adult Education Centers and Other Vehicles of Adult Education. Synopsis of Results.] Federal Center for Health Education, Cologne, November 1978, 136 pp., German. 853. Goshtautas, A.A. and Rugyavichyus, M.Z.: Izucheniye Rezul'tatov Tselenapravlennykh Meropriyatiy po Bor'be s Kureniyem u Muzhchin Srednego Vozrasta. [Results of Purposeful Anti- Smoking Measures in Middle-Aged Men.] 7brapev- ticheskiy Arkhtv 53:118-121, 1981, Russian. 854. Pomerleau, O.R: Strategies for Maintenance: The Problem of Sustaining Abstinence from Cigarettes. In. Schwartz, Progress in Smoking Cessation, op. cit. ref. 49, pp. 355-364. 855. Riches, R.: Two Year Follow-Up of 5-Day Plan Smok- ing Cessation Programmes. British lbmperance Society, Annual Report Supplement, Watford, Hert- fordshire, 1978, 11 pp. 856. Kornitzer, M., Gheyssens, H., Lannoy, M., and Kittel, F.: Follow-Up of 903 Participants in the Five-Day Plan to Stop Smoking. Paper presented at the 5th World Conference on Smoking and Health, Winnipeg, Canada, 1983. 857. Hinunen, L.; Smoking Cessation by the Five-Day Plan in Finland. Acta Universitatis Ouluensis, Series D, Medica No. 123, Medica Publica No. 4. University of Oulu, Finland, 1984, 180 pp. 858. Wilhelmsen, L.: One Year's Experience in an Anti- Smoking Clinic. Scandinavian J. Resp. Dis. 49:251-259, 1968. 859. Wetterqvist, H.: Points in the Matter of Giving Up Smoking. Smoking Withdrawal in Lund. Complete English translation of Social-Medicinsk Tldskrift 2(Special No.):111-112, February 1971. 860. Arvidsson, T.: Views on Smoking Withdrawal. Ex- perience With Smoking Withdrawal in Stockholm. In, Social-Medicinsk Tidskrift, Ibid., pp. 113-116. 861. Grosz, H.J.: Nicotine Addiction: ZYeatment With Medical Hypnosis. Part I. J. Ind. State Med. Assoc. 71:1074-1075. 1978. 862. Grosz, H.J.: Nicotine Addiction: 1Yeatment With Medical Hypnosis. Part II. J. Ind. State Med. Assoc. 71:1136-1137, 1978. 863. Perry, C., Gelfand, R., and Marcovitch, P.: The Relevance of Hypnotic Susceptibility in the Clinical Context. J. Abnormal Psychol. 88:592-603, 1979. 864. Javel, A.F.: One-Session Hypnotherapy for Smoking: A Controlled Study. Psychol. Reports 46(Part 1):895-899, 1980. 865. Smith. D.K.: Hypnosis for Smoking Control: A Com- parLson of Aversive and Fbsitive/Motivational Imagery and Suggestions in Group and Individual Settings. Doctoral Dissertation, Fuller Theological Seminary, Pasadena, CA, Univ. Microfilms Intl. 82-16116, 1982, 118 pp. 866. Monday, L.M.: An Investigation of Pretreatment Ef- ficacy Expectations and Smoking Motives With a Population of Hypnotically Treated Cigarette Smokers. Doctoral Dissertation, University of Mississippi, Univ. Microfilms Intl. 84-04276, 1983, 76 pp. 867. Ryde, D.: Hypnotherapy and Cigarette Smoking. Practitioner 229:29-31, 1985. 868. Marston, A.R. and McFall, R.M.: Comparison of Behavior Modification Approaches to Smoking Reduction. J. Consult. Clin. Psychol. 36:153-162, 1971. 869. Hendrix, E.M.: A Comparison of 'Iwo Group Behavioral Approaches to the 'Il-eatment of Chronic Heavy Cigarette Smoking. Doctoral Dissertation, University of Louisville, Kentucky, Univ. Microfilms. Intl. 77-13,766, 1977, 298 pp. 870. Sobota, P.M.: Comparison of Self-Control Maintenance Procedures as an Adjunct to Laboratory Rapid-Smoking Satiation in the ZYeat- ment of Smoking Behavior. Doctoral Dissertation, Washington University, St. Louis, Missouri, Univ. Microfilms Intl. 82-23818, 1982, 241 pp. 871. Delahunt, J. and Curran, J.P.: The Effectiveness of Negative Practice and Self-Control'Ibchniques in the TIMN 293483 155

Reduction of Smoking Behavior. J Consult. Clin. Psychol. 44:1002-1007, 1976. 872. McGrath, M.J. and Hall, S.M.: Self-Management ?I-eatment of Smoking Behavior. Addict. Behav. 1:287-292, 1976. 873. Katz, RC., Heiman, M., and Gordon, S.: Effects of TAo Self-Management Approaches on Cigarette Smok- ing. Addict. Behav. 2:113-119, 1977. 874. Murray, R.G. and Hobbs, S.A.: Effects of Self- Rein- forcement and Self-Punishment in Smoking Reduc- tion: Implications for Broad-Spectrum Behavioral Approaches. Addict. Behav. 6:63-67, 1981. 875. Colletti, G., Supnick, J.A., and Rizzo, A.A.: Long=lerm Follow-Up (3-4 Years) of 'Ireatment for Smoking Reduction. Addict. Behau 7:429-433, 1982. 876. Blittner, M., Goldberg, J., and Merbaum, M.: Cognitive Self-Control Factors in the Reduction of Smoking Behavior. Behav. Ther. 9:553-561, 1978. 877. Coelho, R.J.: Self-Efficacy and Cessation of Smok- ing. Psychol. Reports 54:309-310, 1984. 878. Mann, L. and Janis, I.L.: A Follow-Up Study on the Long-Tbrm Effects of Emotional Role Playing. J. Fhr- son. Soc. PsychoL 8:339-342, 1968. 879. Griflith, E.E. and Crossman, E.: Biofeedback: A Possi- ble Substitute for Smoking, Experiment I. Addict. Behav. 8:277-285, 1983. 880. Paxton, R. and Scott, S.: Nonsmoking Reinforced by Improvements in Lung Function. Addict. Behau 6:313-315, 1981. 881. Strecher, V.J.. Becker, M.H., Kirscht, JP., Eraker, S.A., and Graham=lbmasi, R.P.: Evaluation of a Minimal Contact Smoking Cessation Program in a Health Care Setting. Unpublished manuscript, Veterans Ad- ministration Medical Center, Ann Arbor, MI. 882. Wielgosz, A. and Durham, C.: Smoking Habits Before and After Coronary Angiography: A Preliminary Survey. Paper presented at the 5th World Conference on Smoking and Health, Winnipeg, Canada, 1983. 883. Sirota, A.D., Curran, J.P., and Habif, V.: Smoking Cessation in Chronically IIl Medical Patients. J. Ctln. PsychoI. 41:575-579, 1985. 156 TIMN 293484

APPENDIX A COMPREHENSIVE TABLE OF SMOKING INTERVENTION METHODS AND FOLLOWUP QUIT RATES EXPLANATION AND CAUTIONARY NOTE The following comprehensive table provides a listing of smoking intervention studies, programs, projects, and trials that reported followup abstinence results of at least 3 months. Intervention methods are listed under 17 ca.tegories. The listing shows the methods used, the number of subjects, quit rates, followup period, investigators, location, year of report, reference, and explanatory notes. Those projects that validated self-reports are noted. Generally, the listing is in date order for each category and subcategory. The earliest report was published in 1959. For about 50 early listings in the table not mentioned in the text, the reference given is to my previous reviews where the original reference can be found. The reader is cautioned to use care in reviewing or interpreting quit rates. Smoking cessation studies are often deficient in design and procedures. Defi- ciencies have been described in this report. Defini- tions may differ between studies. Some in- vestigators counted the followup period from the start of treatment, but most used the appropriate approach of counting the followup period from the end of treatment. Some investigators provided quit rates for subjects who were abstinent for the entire followup period. The majority of studies, however, based their quit rates on those persons abstinent at followup. Good design calls for accounting for all subjects and considering nonrespondents as smokers. Some studies limited their followup to persons who com- pleted treatment or based their quit rates on those people who answered the followup. Other studies were methodologically sound: they included all per- sons who started treatment in their quit rates; they reached most subjects at followup and counted those not reached as smokers; and they validated self-reports of smoking status. Many reports provided few details regarding their recruitment, intervention, and followup procedures. It was difficult to determine who was included in their rates or how their rates were calculated. For some studies that did provide details, I recalculated their quit rates to include all subjects. The com- prehensive table covers more than 300 reports of studies or programs over a period of almost three decades. It- was not possible to review this many reports to distinguish "good" and "poor" studies. The comprehensive table serves as an inventory of srrioking cessation reports. It should be kept in mind that there were many other cessation studies and programs that did not report their results in published or unpublished documents, did not do followups because their end of treatment results were so poor, or did not base their results on abstinen`ce. Before drawing any conclusions or using any information that appears in the com- prehensive table, the reader is advised to refer to the original report. Evaluations of future smoking cessation efforts should be conducted according to scientific pro- cedures as outlined in this volume. All community programs may not be able to validate self:reports by physiological measures, but those programs that can should validate at least a sample of subjects. All practitioners and researchers of smoking cessa- tion interventions should be held accountable to conduct and report followups using appropriate procedures. Tr4N 293485 157

COMPREHENSIVE TABLE OF SMOKING INTERVENTION METHODS AND FOLLOWUP QUIT RATES Intervention Method Number of Subjects Quit Rate (%) Follownp Period Investigators Location Year of Report • SELF-CARE Graduated filters 67 10 4-12 Months Miller 1'980120 (purchased on own) Danaher and Lichtenstein 13. 15 6 Months Erie County, PA Glasgow, Schafer, 198196 self-help book Danaher and Lichtenstein 14 43 and O'Neil Fargo, ND book and 8 group meetings Pomerleau and Pomerleau 13 • 0 self-help book Pomerleau and Pomerleau 16 50 book and 8 group meetings ACS I Quit Kit 15 27 I Quit Kit and 8 group 14 14 meetings Pomerleau and Pomerleau 15 33 6 Months Pederson. Baldwin, 1981105 book and Lefcoe Danaher and Lichtenstein 13 23 London, Ontario book Wait list control 9 0 Quit on your own (130) 33 1 Year Hymowitz, Lasser, 1982121 Graduated filters ("One and Sapirstein Day At A Time") ( ) 22 New Jersey Placebo filters ( ) 12 Self-help modules (nine) 36 14 6 Months Nepps 198211s smoke holding, nicotine _ New Brunswick, NJ fading, self-control Freedom From Smoking 68 32 nr O'Neal 1983'03 manuals Quit Kit (Stanford 5-City) 70 14 6 Months Arkansas Sallis, Hill, Killen, 1983100 Quit Kit and audiotape 72 11 Telch. Flora, Girard, Wait list control 65 3 and Taylor Advice to quit and self- 30 17 6 Months Palo Alto, CA Pederson, Wood, 1983106 help manual (Pomerleau and Pomerleau) Advice to quit control 39 26 and Lefcoe London. Ontario, Canada Freedom From Smoking 308 15 1 Year Davis, Faust, 1984102 In 20 Days Cessation manual Cessation manual and 309 18 and Ordentlick San Diego, Salinas, CA, Minneapolis- maintenance manual ALA leaflets 308 12 St. Paul, MN, Baltimore, MD, Leaflets and 312 18 New York, NY maintenance manual Notes Worksite program. Quit rate for 19 subjects starting •second module was 26 percent. CO validation. Subjects were respira- tory patients. Nonresponders and pipe/cigar smokers counted as failures. $20 deposit. 158 TIMN 293486

Intervention Method Number of Subjects Quit Rate (%) Follo.rnp Period Investigators Location Year of Re;aort Freedom From Smoking manuals EDUCATIONAL 300 33 2-15 Months Pearlstadt and McCoy Michigan 1984104 Educative group 12 17 15 Months Lawton 196241.44 Nondirective, superficial 11 20 Philadelphia, PA Lectures, group discussion (8 sessions), lobeline 110 19-47 2 Months- 1 Year Bachman Allentown, PA 19644' Educational instruction (5 weeks) 329 9 3 Months Horn Washington, DC 196441 Lectures, discussion groups, pamphlets, medication 994 20 1 Year Bjartveit Oslo, Norway 19654' Lectures, films, specimens, 109 27 1 Year Ball 196741 group discussion (7 weeks) London, England Group discussion (150) 23 18 Months Allen and Fackler 196741 Controls ( ) 18 Philadelphia, PA Lectures, instructions, group support (10-12 weeks) 200 44 6 Months Fredrickson New York, NY 196741 Lectures, physical exams, discussion (5 sessions) 472 29 1 Year Delarue and Moss Toronto. Canada 196942 Lectures, films, discussion, 107 13 10 Months Hepper. Carr, 197042 buddies (8 sessions) Anderson, Fontana, Rosenow, and Hanson Rochester, MN Lectures, group discussion nr 20 1 Year Nemzer Long Island, NY 1973166 Adult school class (5 weeks) 159 20 1 Year Milligan and Suttake Bergen County, NJ 1975147 Adult school class led by 8 38 2 Years Schwartz 19751e nurse (10 weeks) Davis. CA Notes 1,500 questionnaires mailed. Quit rates based on subjects completing treatment. 80% of subjects had chronic illnesses. Results varied. Followup based on subjects completing treatment. Government employees. Results based on all subjects starting treatment. Withdrawal clinic. Results based on all subjects. 75 % subjects chronically ill. 33% quit rate for subjects completing treatment. Results based on all subjects. N not specified between exp.- control subjects. Subjects met 2 times per month for 6 months; considered part of followup. Withdrawal clinic. Measurement of COHb levels. 2 followup sessions. Mayo Clinic. ALA groups. Use of ACS stop smoking guide. Several maintenance meetings. 159 TIMN 293487

Intervention Method Number of Subjects Quit Rate Foliowrnp (%) Period Investigators Location Year of Report Health education, advisory 293 32(M) 2 Years Novak 1975548 service, medication 26(F) Prague, Czechoslovakia Health education program (6 weekly sessions) 51 33 8-9 Months Isacsson and Janzon Malmo, Sweden 1976548 Lectures, films, questions answered (4 weekly meetings) 78 15 1 Year Seriff and Finkelstein New York, NY 197789 Controls 78 10 Lectures, discussion, bud- dies, videotapes (5 days) 81 30 6 Months Bauer Murray Hill, NJ 1978153 Adult education class (10 sessions) nr 33 4 Months Welsch Cologne, Germany 1979852 Insight to smoking habit, group support, relaxation techniques 139 36 6 Months Greaves and Barnes Regina, Saskatchewan 1979151 Lectures, films, counseling 33 55 1 Year Miller 1981152 (11 sessions and 4 followup sessions) Columbus, IN Educational approach 57 30 3 Months Goshtautas and Rugyavichyus Kaunas. Lithuania, USSR 1981853 Educational groups, lec- 15 47 6 Months Dawley, Fleischer, 1984150 tures (10 sessions) and Dawley New Orleans, LA Health education 25 36 6 Months Rabkin, Boyko, Shane, and Kaufert Manitoba, Canada 1984 154 Smoking cessation clinic (Seattle VA Medical Center) 48 23 4 Months Bailey Seattle, WA 1984149 Health risk appraisal and health education modules, meetings nr 53 5 Months Spilman, Goetz, Schultz, Bellingham, and Johnson Bedminster, NJ, and Kansas City, MO 1986767 Notes COHb check at 6 weeks. Conducted at a hospital. Bell Laboratories. 65 classes. Regina Smoking Cessa- tion Clinic. Of 166 sub- jects, 27 not reached at followup. Cummins Engine Co. employee program. Carbon monoxide validity. Subjects were hospital employees and patients. 6 subjects who did not complete treatment were not followed up. Results based on those answering followup. ReporteQt in doLitoral dissertation. Cessation program led by nurse practitioner. Worksite program- AT&T. f 160 TyMN 29348

Intervention Method Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report FIVE-DAY PLAN Five-Day Plan ive-Day Plan Five-Day Plan Five-Day Plan Five-Day Plan Controls (signed decision cards) Five-Day Plan 144 2 73 124 173 175 201 34 3 16 28 16 16 16 3 Months Months 1 Year 1 Year 1 Year 10 Months McFarland, Gimbel, Donald, and Folkenberg Calgary, Alberta, Canada Switzer and Looney Berkeley, CA Campbell and Spalding Paisley, England Mills Hartford, CT Guilford Los Angeles, CA Thompson and Wilson Pittsburgh, PA 196441 96441 196541 196641 196691 196641 Five-Day Plan 35 27 15 Months Lawton Philadelphia, PA 196741 Five-Day Plan 1,100 19 1 Year Dale, Graves, Beck, and Lau Hinsdale, IL 196741 Five-Day Plan 80 32 3 Months Evans Brisbane, Australia 196741 Five-Day Plan 45 23 6 Months Lichtenstein and Keutzer Eugene, OR 196841 Five-Day Plan 378 33 1 Year Berglund and Green Philadelphia, PA 196942 Five-Day Plan 195 16 1 Year Berglund Norway 1969548 Five-Day Plan 990 40 9 Months- 5 Years Porter Memorial Hospital Denver, CO 197142 Five-Day Plan 24 21 2 Years Wake, Tyas, and Herrick Ottawa, Canada 1972195 Notes Followup based on subjects completing treatment. 55 percent completed treatment. Result based on all subjects. Followup based on 81 percent of subjects. Quit rate for all sub- jects was 12 percent. Unknown whether result based on all subjects. Result based on subjects completing treatment. Success rates based on a sample of subjects completing treatment. Results based on sub- jects completing treat- ment: rate on all sub- jects = 19 percent. Not all clinics were followed up. Followup of 66 percent of subjects. Results based on all subjects 16 percent quit. Results based on all subjects. Results based on all subjects. Results not based on all subjects. Results based on all subjects. 161 TIMN 293489

Number Intervention of Method Subjects Quit Rate (%) Followup Period Investigators Location Year of Report Five-Day Plan nr 43 4 Years Hammer 1975548 Bad Neuheim, Germany Five-Day Plan with 6 118 27 1 Year Mossman 1978158 followup sessions Five-Day Plan nr 14 6 Months Albuquerque, NM Pomerleau 1978854 Five-Day Plan 158 27 2 Years Philadelphia, PA Riches 1978855 Five-Day Plan and 1 325 34 1 Year United Kingdom Cruise, Fisher, and 1979 157 maintenance session and followup contacts Five-Day Plan 35 23 3 Months Cruise Atlanta, GA Seventh-day 1980745 Five-Day Plan 741 29 1 Year Adventist Church Seattle, WA Kornitzer 19831156 Five-Day Plan 19 11 6 Months Brussels, Belgium Schlegel, Manske, 1984156 No treatment 25 4 Page, and ive-Day Plan ,800 9 Year d'Avernas Waterloo, Ontario, Canada Hirvonen 984857 In-residence Five-Day Plan 188 34 1 Year Oulu, Finland Rice 1973161 (comprehensive program with exercise and counseling) In-residence Five-Day Plan 36 8 Years Deer Park, CA Lee, Jacoba, and 986160 St. Helena Health Center Charoensaengsanga Deer Park, CA GROUPS AND WITHDRAWAL CLINICS Group therapy (5 19 11 15 Months Lawton 1962 consecutive days) Philadelphia, PA Group meetings (9 ses- 19 18 28 Months 196741. 44 sions/6 weeks) 162 Notes Evaluation by "estimate" based on subjects completing treatment. Company program for employees and spouses. Based on those completing 5 days treatment. Based on all subjects; 30 subjects not contacted counted as failures. Worksite program. Result of 27 subjects answering followup = 30 percent. 1977-1981 results of withdrawal clinic. 2 years results 903 subjects: 19 percent. Quit rate drops to 7 percent if based on all subjects. Results based on 18 courses held in 13 cities in 1973-1980. St. Helena Health Center, Deer Park, CA. $595 fee includes room and board. Results for 1982-1984. Rate for subjects not smoking 1 full year = 30 percent. TIMN 293490

Intervention Method Number Quit of Rate Followup Inveatigators Year of Subjects (%) Period Location Report Notes Group psychotherapy (1G nr 44 3 Months Hammett, Graff, 196441 weeks) Bash, Fackler, roup counseling and 6 8 Year Goldman, and Yanovski Philadelphia, PA Schwartz and 96746•1e placebo Group counseling and 36 19 Dubitzky Walnut Creek, CA meprobamate Group counseling without 36 17 pill (all groups met 8 weeks) Group psychotherapy (10 14 71 1 Year Bozetti 197242 weeks) Commercial group method nr 21 6 Months San Diego, CA Wake, Tyas, and 197219s Smoke Watchers (commer- 16 38 4-12 Months Herrick Ottawa, Canada Schwartz 1973194 cial) group method Smoke Watchers 55 25 Glen Rock, NJ Ft. Lauderdale, FL Smoke Watchers 209 37 Vancouver, BC Group counseling, insight 354 28(M) 18_ Months Pyszka, Ruggels, and 1973162 development (ACS 20(F) Janowicz clinics) Group method of Smok- 167 27 4 Years Los Angeles, CA Kanzler, Jaffe, and 1976197 Enders (commercial program) SmokEnders 30 40 1 Year Zeidenberg New York, NY Kanzler. Zeidenberg, 1976198 Group discussion 60 32 3 Months and Jaffee New York, NY Flow and Tullius 197542 (8 sessions) Group therapy 850 15 1 Year Sutter-Yuba Co., CA Paun 1976184 Group therapy 230 East Berlin, and Tabex (cytisine) Groups met for 2 years 44 39 10-24 East Germany Fisk, Bortz, and 197742 after self-control and lectures Group counseling program 136 48 Months 1 Year Hammond Palo Alto, CA Ghelov (now Harrup) 1977177 155 41 Oakland, CA 61 51 San Francisco, CA 120 45 Group program (Kaiser 1,128 47 1 Year Harrup, Hansen, and 1979178 Foundation Health Plan-5 centers) Soghikian Northern California Based on all subjects result was estim,ated to be 31 percent. Part of Smoking Control Research Project. Dropouts, nonresponders counted as failures. End of treatment quit rate was 57 percent M, 43 percent F: quit rate increased to 85 percent M, 57 percent F. Nonresponders counted as failures. 18 percent quit if based on all subjects. Report claimed 39 per- cent based on returns from 167 "graduates." Worksite program. Counseling service at Berlin-Frei driehshain City Hospital. Palo Alto Education Center. 13 meetings over 8 weeks. Kaiser Founda- tion Health Plan. 163 TIMN 293491

Intervention ~ Method Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report Group counseling (Ameri- 104 21 1 Year Shewchuck, Dubren, 197717z• can Health Foundation) Burton, Forman, 174 Group (participant choice) 212 19 1 Year Clark, and Jaffin New York, NY Group counseling 173 32 5 Months Shewchuk, Burton, 197742° (random assignment) and Dubren 173 Group (participant assigned) 446 12 New York, NY Group (fee charged) 139 24 American Health Foun- dation summary 1,034 26 1 Year Shewchuk 1976174 Withdrawal clinic 322 38 2 Years Lehrer 26 clinics in Israel 1978 1112 Group therapy (done at Kaiser Health Plan, Los Angeles) 19 5 2 Years Tongas, Goodkind, and Patterson Los Angeles, CA 197742 Group therapy (1964-1965) (342) 12 6 Months Fee and Benson 1977304 (1967-1970) 28 1 Year Tayside, Scotland Group counseling 16 0 10 Months Pederson, Scrimgeour, 1979188 Group counseling 16 19 6 Months and Lefcoe London, Ontario, Canada Groups (6 weeks), peer support and taped telephone messages 101 9 6 Months Grove, Reed, and Miller Indianapolis, IN 1979175 Psychotherapy and medical consultation 1,000 36 1 Year Leophonte, Lafue, Sperte, Albarede, and Delaude Toulouse, France 1979186 Group counseling 218 40 4 Months Flow 1980187 Self-help 18 Corvallis, OR Control 5 Clinics following ACS-ALA format (6 meetings over 3 weeks), speakers, discussion, buddies 372 25 1-5 Months Evans and Lane Long Island, NY 1980164 ACS Group-8/2-hour sessions (903) 24 6 Months Lieberman 32 ACS units in 9 1981165 ACS Group-4/2-hour sessions ( ) 24 ACS Divisions ACS test clinic-4/1-hour sessions ( ) 27 ACS test-1/12-hour marathon ( ) 27 ACS test- 1/4-hour session ( ) 10 Notes Scottish Anti-Smoking Clinic. Company program designed by American Health Foundation. CO validation. Acupuncture and drugs optional. Doctoral dissertation. Results based on 63 percent response. Quit rates increased to 36 percent at 5 years. Of 1,213 subjects. 74 percent reached at followup. 94 clinics in evaluation 164 TIMN 293492

Intervention Method Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report Lectures and self-control 1 Year Powell and McCann 1981203 and excessive smoking and 4 week support 17 65 Washtenaw Co., MI group and 4 weeks of 17 59 telephone calls Kptween subjects and no contact control 17 65 Group therapy 1.356 27 18 Months Protivinsky 1981185 Open group therapy 742 54 6 Months Vienna, Austria Berg (smoking cessation clinic) Oscherslaben, 1982183 Group meetings and self- 54 15 3 Months Germany Perrin, Tarrant, 1982768 help manual Group program led by lay 478 23 1 Year Moreton, and East England Hackbarth, Gruder, 1983189 volunteers 4 options of group support 179 35 1 Year and Brickman Chicago, IL Brennan 198318' minimal intervention or self-quit and phone calls, messages, buddies Group meetings and lottery, r 1 Months New York, NY Stachnik and 98375' no-smoking contest, con- 80 Stoffelmayr tracts, 20 meetings over 85 Michigan 7 months ALA-FFS manual for some 18 33 1 Year Bishop and Fisher 1984170 subjects, trouble Eastern Missouri shooting for some, and 4 meetings for some ALA-FFS manuai and 48 33 group clinic ALA-FFS manual and 46 7 group cinic MEDICATION Injection of lobeline hydro- 1,012 23 6 Months Ejrup and Wikander 195941 chloride, meprobamate, anti-cholengeric substances, lectures, counseling Injection of lobeline hydro- 25 9 Months Stockholm, Sweden osenberg 960 chloride, restinil, silver Copenhagen, 196241 acetate, auto-suggestion Denmark Notes $25 fee, $30 deposit. Males-59 percent, females-66 percent. 5 days treatment. Vienna Counseling Center. Not clear how followup was done. Worksite program at two companies. 49 cessation clinics sponsored by 30 institutions. Worksite program. Metropolitan Life In- surance Company. Results for 3 different worksites. EASE (Employer Assisted Smoking Elimination). Worksite program. Original report was 61 percent success but a followup by the Norwegian Research Group found 23 per- cent success. Followup results based on about one-half the subjects found at followup. 165 TIMN 293493

Intervention Method Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report Lobeline, lectures, pamphlets 68 15 6 Months Yllo Stockholm, Sweden 195941 Methylphenidate 166 6 16 Months Whitehead and Davies Denver, CO 196241 Lobeline and physician counseling (40) 13 3 Months Edwards London, England 196241 Hypnosis and physician counseling ( ) 13 Methylphenidate 6 0 8 Months Whitehead and 196341 Diazepan 5 20 Davies Placebo 5 0 Denver, CO Lobeline, hydroxyzine, discussion 1.255 15 3-8 Months Hoffstaedt Newcastle upon Tyne, 196341 Lobeline, hydroxyzine, discussion 80 47 10 Months England 1964 Lobeline sulfate and placebos 50 10 4 Months Edwards London, England 196441 Lobeline, lectures, pamphlets 54 31 1 Year Arvidsson Stockholm, Sweden 196441 Lobeline and one of 4 methods: 1-educative; 2-psychotherapy; 3-repressive-inspira- tional group: 4-lecture and discussion 312 18 9 Months Leone, Musiker, Albala, and McGurk Providence, RI '196441 Lobeline nr 0 3 Months Graff, Hammett, 196641 Librium 22 Bash, Controls 11 Fackler, Goldman, and Yanovski Philadelphia, PA Injections of lobeline hydro- 155 20- 1 Year Ejrup 196741 chloride, amphetamines, counseling 26 New York, NY Preseription-meprobamate 36 8 1 Year Schwartz and 196748• Dubitzky 176 Prescription-placebo 36 25 Walnut Creek, CA Notes Results were based on all subjects. Employees and students of medical center; results based on all subjects. Followup rates were based on both methods combined. All males. Medical center employ- ees, students. Success- ful subjects did not take pill. 61 percent completed treatment. Success rate based on subjects com- pleting treatment was 31 percent. All females. 25 percent of subjects not followed up counted as failures. Results not based on all subjects. Combined results reported. Success rates based on nondropouts were 33 percent. Lobeline was ineffective. Results based on subjects completing treatment. $75 fee. Injections given 6 months to 2 years. Part of Smoking Con- trol Research Project. Subjects randomly assigned to prescription method. 166 T'I1VIN 293494

Intervention Method Number of Subjects Quit Rate (%) Follownp Period Investigators Location Year of Report Lobeline, amphetamine, (1,473) 6-27 3-12 Months Ross 196745 phenobarbital, metham- ( ) Buffalo, NY phetamine, meetings, discussion Lobeline 149 18 5 Years West, Graham, 197742 Amphetamine 160 13 Swanson, and Lobeline and 81 21 Wilkinson amphetamine Placebo 153 16 No education 126 15 Education 417 18 Methylscopolamine 491 50 1 Year Wilhelmsen 1968858 Methylscopolamine 290 19(M) 1 Year Goteborg, Sweden Wetterqvist 197 1859 12(F) Lund, Sweden Combination drugs and counseling: Received drugs 65 29 3 Months Jacobs, Spilken, 197142 No drugs 39 49 Norman, Wohlberg Group counseling 83 42 and Knapp Individual counseling 21 14 Boston, MA Atropine-like substances, 100 35 1 Year Arvidsson 1971880 groups, aversion theapy Stockholm, Sweden Fenfluramine 26 19 1 Year Fee 1977304 hydrochloride 24 25 Tayside, Scotland Placebo NICOTINE CHEWING GUM Nicotine chewing gum 92 24 6 Months Brantmark, Ohlin, 1973 548 Nicotine chewing gum 43 23 1 Year and Westling Lund, Sweden Russell, Wilson, 1976548 Clinic and nicotine 84 35 6 Months Feyerabend, and Cole London, England Puska, Bjorkqvist, 1979265 chewing gum Clinic and placebo 76 28 and Koskela Kuopio, Finland chewing gum Nicotine chewing gum 70 23 6 Months Malcolm, Siliett, 1980263 Placebo chewing gum 70 5 Turner, and Ball Controls 70 14 London, England Nicotine chewing gum 69 38 1 Year Raw, Jarvis, Feyera- 1980245 Rapid smoking 49 14 bend, and Russell London, England Notes Medicine given in various combinations. 24 withdrawal clinics. Attempt was made to reach 800 subjects who attended the last 11 clinics in 1964-1965; 599 subjects. Five-year result for Ross clinics. Males-56 percent, females-41 percent. The 5-year followup result was 9 percent. Drugs: Lobeline, imipramine, hydro- chloride, destroamphe- tamine sulfate. $10 deposit. Males-49 percent, females-22 percent. Results based on sub- jects completing treatment. Chemical verification. Carbon monoxide validation. 167 TIMN 293495

Intervention Method Number Quit of Rate Subjects (%) Followup Period Investigators Location Year of Report Psychotherapy and cessa- tion clinic 49 37 1 Year Fagerstrom Uppsala, Sweden 1982248 Psychotherapy and nico- tine chewing gum and cessation clinics 47 49 Group therapy and nico- tine chewing gum 180 13 1 Year Fee and Stewart Dundee, Scotland 1982241 Group therapy and placebo gum 172 9 Group therapy and nico- tine chewing gum 58 47 1 Year Jarvis, Raw, Russell, and 1982242 Group therapy and placebo gum 58 21 Feyerabend London, England Advice and booklet 675 4 1 Year Russell, Merriman. 1983 254 Advice and booklet and nicotine chewing gum 679 9 Stapleton, and Taylor London, England Control 584 4 Nicotine chewing gum 51 33 6 Months Toomes and Paul Germany 1983264 Nicotine chewing gum and clinic 30 30 1 Year Schneider, Jarvik, Forsythe, Read. 1983247 Placebo gum and clinic 30 20 Elliott, and Schweiger Nicotine chewing gum 13 8 Los Angeles, CA Placebo gum 23 11 Nicotine chewing gum 23 17 9 Months Bourke and Callaghan Dublin, Ireland 1983262 Nicotine chewing gum and clinic 140 12 1 Year Kunze, Schoberberger and 23 others Vienna, Austria 1983250 Advice 371 9 1 Year British Thoracic 1983252 Advice and booklet 377 9 Society Advice/booklet and placebo gum 402 11 95 centers in England Advice and booklet and nicotine chwing gum 400 10 Nicotine chewing gum and clinic (243) 20 1 Year Schlegal, Manske, and Shannon 1983249 Clinic (3 treatments) ( ) 29 28 Canadian military Full treatment (17 sessions) 25-38 bases Minimal contact (4 sessions) 17-29 Self-help 7-10 Notes Carbon monoxide or carboxyhemoglobin validation. No validation at one year. Carbon monoxide validation except for 12 subjects. Remaining subjects off smoking 1 year: nicotine chewing gum 31 percent, placebo 14 percent. Subjects did not indi- cate willingness to quit. Carboxyhemoglobin validation. Carbon monoxide validation. Subjects were hospital staff and respiratory patients. Only abstainers followed up. Of 52 ab- stainers, 33 percent re- mained nonsmokers. Carboxyhemoglobin and thiocyanate validation. 29 percent is quit rate for three treatments combined. 6 months program. 168 TIMN 293496

Intervention Method Number of Subjects Quit Rate (%) Followrup Period Investigators Location Year of Report Group therapy and nico- 106 29 1 Year Hjalmarson 1984244 tine chewing gum Goteborg, Sweden Group therapy and placebo gum 99 16 Nicotine chewing gum and (120) 37 1 Year Hall, Tunstall, Rugg, 1985248 4 group sessions/3 weeks Jones, and Benowitz Behavior treatment: aversive smoking, relapse pre- vention training/relaxation ( ) 28 San Francisco, CA Nicotine chewing gum and behavioral treatment ( ) 44 Nicotine chewing gum and 20-minute weekly clinic 22 23 10 Months Killen, Maccoby, and Taylor 1984281 Skills training 20 30 Palo Alto, CA Nicotine chewing gum and skills training 22 50 Nicotine chewing gum 105 12 3 Months Christen, McDonald, 1984273 Placebo gum 103 5 Olson, Drook, and Stookey Indianapolis, IN Nicotine chewing gum 101 10 1 Year Jamrozik, Fowler, 1984258 Placebo gum 99 8 Vessey, and Wald Oxford, England Nicotine chewing gum 161 11 1 Year Soul At Sea 1984 251 Acupuncture 224 8 13 Months Clavel, Benhamou, 1985257 Nicotine chewing gum 205 12 Company-Huertas, Control-Locked cigarette case 222 3 and Flamant Villejuif, France Nicotine chewing gum and 4 contacts (telephone call, 2 physician consultations, letter) 50 27 1 Year Backstrom. Bergman, and Edman Uppsala. Sweden 1985260 Nicotine chewing gum and 1 physician consultation 46 22 Four contacts as above 22 15 One physician consultation 27 3 Nicotine chewing gum and self-help materials 156 19 1 Year Lando, Kalb, and McGovern 1986243 Nicotine chewing gum and "dangers of smoking" pamphlet HYPNOSIS 148 22 Ames, IA Single hypnosis treatment 50 18 1-4 Years Moses Jamaica Plains, MA 1964298 Notes Carbon monoxide validation. Carbon monoxide and thiocyanate validation. 6 dropouts excluded from results. Carbon monoxide and thiocyanate validation. Dental patients. Carbon monoxide validation. Carbon monoxide vali- dation. General prac- tice patients. British naval seamen serving on HMS Hermes. 3 group meetings. This listing duplicated under acupuncture. 1%2 subjects validated by carbon monoxide. After quitting: Tele- phone call-7 days; physician consulta- tions-14 and 30 days; letter-3 months. One physician consulta- tion-14 days after quitting. Only 207 subjects used the gum. Validation by thiocyanate levels. Based on all subjects quit rate was 13 Males-26 percent, females-0 percent. percent. 169 TIMN 293497

Intervention Number Quit of Rate Followup Investigators Year of Method Subjects (%) Period Location Report Hypnotherapy (10 weekly nr 89 3 Months Hammett, Graff, 196641 visits, 4 treatments) Bash. Fackler, Goldman, and Individual hypnosis (3 con- 75 64 1-2 Years Yanovski Philadelphia, PA Hall and Crasilneck 1970303 secutive sessions and 1 session month later) Individual hypnosis 195 18 2 Years Dallas, TX Orr 1970305 (unlimited number of sessions; average 6 + ) Single session in which 616 35 1 Year Harwell, UK Spiegel 1970299 patient is taught self-hypnosis Individual hypnosis 97 25 6 Months New York, NY Nuland and Field 1970308 Meditation during 84 60 6 Months New York, NY hypnosis, self-hypnosis Group hypnosis (12-hour 60 88 1 Year Kline 1970312 session) relaxation, Imagery, self-hypnosis Individual hypnosis, self- 54 13 3 Months New York, NY Perry and Mullen 197542 hypnosis (1 session) Montreal, Canada Single group hypnosis 50 8 8-12 Months Pederson, Scrimgeour. 1975313 treatment Single group hypnosis and 16 50 10 Months and Lefcoe London, Ontario, group counseling Group counseling 16 0 Canada Wait list control 16 13 Individual hypnosis, nausea 1,000 68 - 1 Year Miller 1976302 suggestions, self-hypnosis Individual hypnosis, relax- 48 50 6 Months Washington, DC Watkins 1976307 ation, concentration, self-hypnosis (4 weeks) Self-hypnosis, single session 193 17 1 Year Missoula, MT Shewchuck, Dubren, 1977172 113 12 5 Months Burton, Forman, Group hypnosis, imagery 19 68 10 Months Clark, and Jaffin New York, NY Sanders 197731' self-hypnosis (4 sessions) Individual hypnosis 38 13 1 Year Chapel Hill. NC Fee 1977304 Group hypnosis, sugges- 8 25 9 Months Tayside, Scotland Barkley, Hastings, 1977316 tions, (7 sessions) and Jackson Bowling Green, OH Notes Patient phoned daily for one month. If based on all subjects, quit rate was 57 percent. Those answering followup-55 percent quit. Nonresponders counted as failed. 6 group counseling ses- sions and 6 monthly meetings. Sessions up to 6 months. Followup may be based on estimates. Patient phones daily. American Health Foundation, 170 TIMN 293498

Intervention Method Individual hypnosis, self- hypnosis (1 session) Group hypnosis, self- hypnosis (1 session) Individual hypnosis, aversive suggestions (3 sessions) Group hypnosis (3 sessions) Individual hypnosis (1 session) suggestions, visualization Individual hypnosis, self- hypnosis (1 session) Group counseling Single group hypnosis and counseling Video-hypnosis and counseling Single group hypnosis and relaxation and counseling Individual hypnosis, self- hypnosis Hypnosis and rapid smoking Hypnosis and desensitiza- tion as followup technique Hypnosis and suggestions Suggestions alone No treatment Group hypnosis and group counseling Group hypnosis and group counseling and rapid smoking Group counseling and rapid smoking Single group hypnosis session Individual hypnosis Group and individual hypnosis/suggestions, imagery (2 sessions) Number of Subjects Quit Rate (%) FolIowup Period Investigators Location Year of Report Notes 449 39 3 Months Grosz 1978881• Indianapolis, IN 862 141 31 12 50 6 Months MacHovec and Man 1978310 Patient phone calls. 10 40 Winnipeg, Manitoba, Canada 75 45 6 Months Stanton 1978301 Three or more sessions Tasmania, Australia offered, if needed. 40 25 6 Months Berkowitz, Ross- 197930° 6 8 Months Townsend, and Kohberger Boston, MA Pederson, Scrimgeour, 9793'4 17 53 and Lefcoe 16 19 London, Ontario, Canada 16 13 26 4 3 Months Perry, Gelfand, and 19791163 One session. 29 24 Marcovitch Montreal, Canada 23 17 6-9 Months Powell 1980309 10 60 - 3 Months Boston, MA Javel 1980864 12-15 followup calls. 10 40 Santa Cruz, CA 10 0 9 56 6 Months Pederson, Scrimgeour, 1980115 23 13 and Lefcoe London, Ontario, 21 38 Canada 468 28 6-9 Months Owens and Samaras 1981318 Damon Smoking Oklahoma City, OK Control Program. 100 21 15 Months Sheehan and Surman 1982308 Tape available for reinforcement. 64 9 6 Months Boston, MA Smith 1982865 Doctoral dissertation. Pasadena, CA 171 .TIMN 293499

Intervention Method Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report Notes Group hypnosis 783 14 1 Year Wagner, Hindi-Alex- 1983319 Damon Smoking Con- ander, and Horwitz Oklahoma City, OK trol Program. Hypnosis (1 session), visualization 63 22 3 Months Monday University, MS 1983866 Doctoral dissertation. Hypnosis (4 sessions) 29 41 4 Months Schubert 1984 292 Doctoral dissertation. Systematic relaxation (4 sessions) 29 38 Boulder, CO Wait list control 29 7 Hypnosis, self-hypnosis 29 30 6 Months Rabkin, Boyko, 1984154 Results based on sub- (single treatment) Shane, and Kaufert jects who answered Manitoba, Canada followup. 9 subjects not included in results. Hypnosis and counseling (1 session) 683 38 6 Months Ryde London, England 1985867 Hypnosis and group 35 31 3 Months Jeffrey, Jeffrey, 1985771 Military personnel and sessions Greuling, and Gentry dependents. 4 sessions. Wait list control 30 0 El Paso, TX Hypnosis 48 18 6 Months Frank, Umlauf, 1986'70 Univ. of Missouri- Group 15 20 Wonderlich, and Columbia. Worksite ACUPUNCTURE Ashkanazi Columbia, MO Program. Auricular staplepuncture 642 61 6 Months Sacks 1975341 Puncture at "lung Torrance, CA point" in both ears. Acupuncture in lung site area 44 21 3 Months Gilbey and Neumann Halifax, Nova Scotia 1977348 Acupuncture in kidney site area 49 15 Auricular acupuncture 200 24 1 Year Pene, Kelledjian, and Klein France 1977344 Placebo-site acupuncture 12 0 6 Months MacHovec and Man 1978310 Correct-site acupuncture 12 25 Winnipeg, Manitoba, Untreated controls 12 0 Canada Acupuncture at correct site for smoking withdrawal 25 8 6 Months Lamontagne and Annable 1980347 Acupuncture to enhance relaxation 25 16 Montreal, Canada Self-monitoring with counter 25 20 Acupuncture and sodium 335 34 6 Months Mabry and Fosbury 1981353 Of those reached at bicarbonate, procaine, B vitamins and diet suggestions El Paso, TX followup, 42 percent claimed they had quit. 172 TIMN 293500

Number Quit Intervention of Rate F'ollowup Investigntors Year of Method Subjects (%) Period Location Report Notes Acupuncture 405 5-15 6 Months Martin and Waite New Zealand 1981354 Acupuncture 194 30 2 Years Fuller Richmond, Australia 1982349 Auricular acupuncture and 514 30 2 Years Choy, Lutzger, and 1983342 instructions Meltzer New York, NY ~ Acupuncture and Nicogum, Nux vomica tablets, Tabacum 65 32 1 Year Labadie, Dones, Gachie, Freour, Perchoc, and Huynh 1983 345 Tranquilizer and Nicogum, Nux vomica tablets, Tabacum 65 31 Bordeaux, France Acupuncture 140 16 1 Year Cottraux, Harf, 1983351 Behavior therapy (stress 138 7 Boissel, reduction, self-control) Schbath, Bouvard, Placebo pill 140 14 and Gillet Wait list control 140 6 Lyon, France Acupuncture at correct site 28 18 6 Months Gillams, Lewith, and Machin 1984346 Control received acupunc- ture at ineffective site 27 15 Southampton, England Group therapy (4 weekly sessions) 26 11 Acupuncture 224 8 13 Months Clavel, Benhamou, 1985257 Nicotine chewing gum 205 12 Company-Huertas, Control-locked cigarette case SMOKE AVERSION 222 3 and Flamant Villejuif, France Smoke satiation-double rate 20 60 4 Months Resnick Philadelphia. PA 1968587 Smoke satiation-triple rate 20 65 Control 20 20 Hot smoky air, rapid smoking 78 19 1 Year Lublin and Joslyn Los Angeles, CA 1968560 Hot smoky air 20 0 6 Months Grimaldi and Lichtenstein Eugene, OR 196942 Results based on 90 percent who answered followup. Quit rate 34 percent at 1 year. Patient seen 1/week until abstained 4 weeks. Patient reported every 6 months for 2 years. 3 weekly sessions of 3 hours for 2 weeks. 45 percent of group subjects failed to com- plete the group sessions. 3 group meetings. This listing duplicated under nicotine chewing gum. 1/2 subjects validated by carbon monoxide. 173 TIMN 293501

Intervention Method Number Quit of Rate Subjects (%) Followup Period Investigators Location Year of Report Satiation: chain smoking 20 hours 11 55 4 Months Marrone, Merksamer and Salzberg 1970595 Satiation: chain smoking 10 hours 11 18 Sacramento, CA No treatment 10 10 Rapid smoking 18 72 3 Months Harris and 197142 Rapid smoking - deprived 18 1 Lichtenstein Eugene, OR Satiation or hierarchial reduction or aversive taste pill 65 14 6 Months Marston and McFall Madison, WI 1971888 Warm smoky air and 12 67 6 Months Schmahl, Lichten- 1972561 rapid smoking stein, and Harris 563 Rapid smoking 13 62 Eugene, OR Warm smoky air and 10 60 6 Months Lichtenstein, Harris, 1973562• rapid smoking Birchler, Wahl, and 563 Warm smoky air 10 60 Schwab Rapid smoking 10 60 Eugene, OR Regular paced aversive smoking 10 30 Warm smoky air or smoke satiation 105 31 2 Years Lublin and Barry Los Angeles, CA 197342 Rapid smoking (self- administration) 19 26 3 Months Kopel Euguene, OR 197442 Rapid smoking 22 41 Regular paced aversive smoking 12 17 Rapid smoking 18 38 3 Months Weinrobe and 197546 Rapid smoking. urge termination 11 81 Lichtenstein Eugene. OR Focus proced. for int./ext. locus of control and smoking stimulus satiation 89 32 6 Months Best Vancouver, BC, Canada 197542 Rapid smoking 13 0 3 Months Sutherland, Amit, 1975661 Rapid smoking and relaxation 26 19 Golden, and Roseberger or relaxation alone - Montreal, Quebec, Canada Rapid smoking 14 21 1 Year Lando 1975565 Excessive smoking 15 20 Ames, IA Regular paced aversive smoking 15 20 Notes Different treatments combined in results. 6 group meetings over 3 weeks. Result was 57 percent if based on all sub- jects. A 6-year followup located 16 subjects (9 abstinent) for quit rate of 57 percent. A 5-year followup located 16 aversion subjects (4 abstinent) for quit rate of 25 percent. Doctoral dissertation. A 2-year followup located 33 subjects (8 abstinent) for quit rate of 24 percent. A 2-year followup located 22 subjects (10 abstinent) for quit rate of 45 percent. Doctoral dissertation. $10 deposit. Urine samples col- lected but not ana- lyzed. Based on all subjects, quit rate was 12 percent. $20 deposit. Carbon monoxide breath test at 3 months. 174 TIMN 293502

Intervention Method Number of Subjects Quit Rate (%) Followrnp Period Investigators Location Year of Report Rapid smoking 14 42 6 Months Lando 1976568 Self-paced aversive 15 27 Ames, IA smoking Nonaversive condition 11 27 Rapid smoking and self- 9 56 3 Months McAlister- 1976569 control Rapid smoking and self- 8 63 Palo Alto, CA control over TV No treatment control 8 0 Rapid smoking or 54 12 4 Months Levenberg and 1976 662 systematic desensitiza• tion or relaxation Rapid smoking 11 18 6 Months Wagner Birmingham, AL Gordon 1976569 Rapid smoking and 11 18 New Brunswick, NJ message Self-control 11 18 Self-control and message 11 9 Rapid smoking 16 19 2 Years Tongas, Goodkind, 19768'2 Covert condition 16 19 and Patterson Rapid smoking and group 21 38 Los Angeles, CA and covert condition Rapid smoking and group 13 15 5 Months Curtis, Simpson, and 197642 discussion Group discussion 13 15 Cole Ft. Worth. TX (10 weeks) Rapid smoking and warm 32 41 6 Months Flaxman 1976647 smoky air and self- control and other procedures Attention control 2 2 Chicago, IL Rapid smoking 12 42 9 Months Barkley, Hastings, 1977318 Rapid smoking and warm 12 17 9 Months and Jackson Bowling Green, OH Dawley and Sardenga 1977564 smoky air and handling cigarette litter Satiation and rapid 72 38 6 Months New Orleans, LA Best 1977569 smoking and coping techniques and telephone calls Rapid smoking (high 6 7 Months Waterloo, Ontario, Canada Glasgow 97786 therapist contact) Eugene, OR Rapid smoking and self- 15 25 control manual, relaxation, counseling Rapid smoking and self- 15 10 control (self-administered) Notes 6 treatment, 4 maintenance group sessions. Serum thiocyanate validation. 7 group sessions. 9 sessions over 3 weeks. Doctoral dissertation. 19 treatments over 1 year. Based on subjects completing treatment, covert Q.R. = 29 percent and combined Q.R. = 64 percent. Doctoral dissertation. See hypnosis for other conditions. Subjects were VA hospital employees. $25 deposit. Carbon monoxide validation. $5 fee, $25 deposit. 6 sessions. Doctoral dissertation. 175 7'IAIN 293503

Intervention Method Number of Subjects Quit Rate (%) Follownp Period Investigators Location Year of Report Regular paced aversive 16 23 smoking (high therapist contact) Rapid smoking 8 38 3 Months Pechacek 1977569 Rapid smoking and self- 10 30 Austin, TX control Noninhaling rapid smoking 9 33 Noninhaling rapid smoking 9 33 Rapid smoking (3 20 30 3 Months Relinger, Bornstein, 197742 maintenance conditions: booster, phone booster, no maintenance) Rapid smoking 0 0 Months Bugge, Carmody, and Zohn Missoula, MT Saterfield 977589 Rapid smoking and self- 10 20 Palo Alto. CA instruction Rapid smoking and 10 30 distraction. Rapid smoking and nr 8 3 Months Hendrix 1977869 negative covert control Relaxation and positive 43 Louisville, KY instruction, coping, imagery, and self- reinforcement Rapid smoking-high aver- 7 0 Months orton and Barske 97742 sion and lectures Winnipeg, Canada Rapid smoking-low aver- 25 30 sion and lectures Rapid smoking and 14 36 3 Months Danaher 1977569• discussion Eugene, OR 671 Rapid smoking and self- 14 21 control Regular paced aversive 11 27 smoking Regular paced aversive 11 27 smoking and self-control Rapid smoking and self- 20 55 6 Months Best, Owen, and 1978570 control Trentadue Rapid smoking and satia- 20 45 Waterloo, Ontario, tion and self-control Canada Satiation and self-control 20 40 Rapid smoking 15 40 1 Year Barbarin 1978572 Covert sensitization 15 7 New Brunswick, NJ Rapid smoking and covert 15 7 sensitization Control 15 0 176 Notes 6 group sessions. Serum thiocyanate validation. 5 group sessions. Doctoral dissertation. - Doctoral dissertation. 9 sessions over 5 weeks. 7 sessions over 3 to 4 weeks. Validation by carbon monoxide. Doctoral dissertation. $25 deposit. 10 sessions over 1 month. Doptoral dissertation: ' TIMN 293504

Intervention Method Relaxation, antismoking messages, hypnosis for followup, individual counseling and taste satiation- smoke holding and rapid smoking Focused smoking and treatment program Focused smoking and counseling Rapid smoking and physical exams Rapid smoking and counseling Rapid smoking and counseling and hypnosis Number Quit of Rate Foilowup Investigators Year of Subjects (%) Period Location Report 25 68 6 Months i 10 60 Tori San Francisco Bay Area 1978604 9 56 6 Months Hackett and Horan 1978597 University Park, PA 30 40 6 Months Hackett and Horn 1979600 University Park, PA 27 52 6 Months Hall, Sachs, and Hall 1979573 Palo Alto, CA 21 38 6 Months Pederson, Scrimgeour, 19801811 and Lefcoe 23 13 London, Ontario, Canada Notes Average age of subjects = 20 years. Results verified by air carbon monoxide. Average 7 sessions. Purpose of trial to check effects of rapid smoking. Hypnosis and counseling 9 56 Rapid smoking and 16 6 1 Year Raw and Russell I980576 COHb validation. $25 support London, England deposit. Dropouts Cue exposure and support 17 18 counted as failures. and advice Support and advice 16 19 Rapid smoking and 16 38 8 Months Danaher, Jeffrey, 1980578 6-week program. relaxation audiotape and Zimmerman, and meetings with consultant Nelson Regular paced aversive 14 29 Palo Alto, CA smoking and relaxation and meetings with consultant Control 17 12 Regular paced aversive 26 20 6 Months Danaher smoking and self-control Dearborn, MI Rapid smoking 19 25 1 Year Rapid smoking and relaxation Rapid smoking and relaxation and contin- gency contracting Contingent rapid smoking Rapid smoking and education seminars 21 25 Poole, Sanson-Fisher, and German Nedlands, 18 22 Western Australia 17 14 172 28 6 Months Parker and Younggren Tacoma, WA Rapid smoking and 200 33 1 Year Massonnet, Frison, excessive smoking and and Llung individual therapy Lyon, France 1980745 Worksite program. Danaher and Lichten- stein book used. 1981575 Confederate validation. 1981577 4-week clinic in military setting. 1982571 6 daily treatments. 177 TIMN 293505

Intervention Method Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Repoct Focused smoking 12 0 6 Months Zumoff 1983601 Carbon monoxide feedback 12 20 University Park, PA Focused smoking and 12 50 carbon monoxide feedback Control 12 0 Rapid smoking/instruction: (79) 36 3 Months Sobata 1984870 use of timer Rapid smoking/instruction: ( ) 50 St. Louis, MO use of rapid smoking Rapid smoking with ( ) 30 no instructions Rapid smoking and relapse 29 52 1 Year Hall, Rugg, Tunstall, 1984580 prevention and skills and relaxation training Regular paced aversive 28 39 and Jones San Francisco, CA smoking and relapse prevention and skills and relaxation training Rapid smoking and 2 4 discussion Regular paced aversive 34 26 smoking and use of Self- Testing Kit Rapid smoking and 18 50 2 Years Hall, Sachs, Hall, and 1984 574 comprehensive physical examination including stress test Rapid smoking 3 3 Months Benowitz Cleveland, OH Corty and McFall 984 579 Response prevention 14 7 Bloomington, IN (diminish power of situations) Rapid smoking and relapse 36 28 1 Year Hall, Tunstall. Rugg. 1985248 prevention and skills and Jones, and Benowitz relaxation training San Francisco, CA Taste satiation-smoke (64) 63 6 Months Walker and Franzini 1985802 holding San Diego, CA Focused smoking and ( ) 50 physiological measures Taste satiation and ( ) 38 focused smoking and physiological measures and boosters Other 5 groups of ) 8 different combinations OTHER AVERSIVE TREATMENTS AND BEHAVIORAL TECHNI9UES Electric shock 10 10 6 Months McGuire and 1964 41 Vallance Glasgow, Scotland 178 Notes Doctoral dissertation. Doctoral dissertation. $65 deposit. 14 ses- sions. Validation by thiocyanate levels and expired air carbon monoxide. Feedback of carbon monoxide to subjects. Cardiopulmonary patients. Results vali- dated by cotinine. thiocyanate and COHb. Quit rate depends on subjects left out of followup. Doctoral dissertation. 14 sessions over 8 weeks. Results validated. 72 subjects enrolled, 67 completed treat- ment. 64 followed up. Overall, focused smok- ing quit rate was 19 percent, taste satiation quit rate was 28 percent. TIMN 293506

Intervention Method Number of Subjects Quit Rate (%) Follownp Period Investigators Location Year of Report Electric shock and breath 33 11 6 Months Mees 196641 holding Springfield, OR Electric shock 14 43 1 Year Russell London, England 197042 Electric shock and self- 11 55 1 Year Chapman, Smith, 197142 management and Layden Electric shock 12 25 Seattle. WA Electric shock 33 21 9 Months Best and Steffy Waterloo, Ontario, Canada 197142 Electric shock 43 63 1 Year Pope and Mount 197542 Self-administered shock on: Berecz 1976617 imagining triggering cognitions 5 60 2 Years Berrien Springs, MI imagining target behaviors 5 0 Electric shock and rapid smoking and education (4 weeks) 31 39 6 Months Younggren and Parker Tacoma, WA 1977779 Five-Day Plan and wrist band aversive 14 57 1 Year Berecz Berrien Springs, MI 1979818 Five-Day Plan and wrist band nonaversive therapy 14 7 Five-Day Plan 40 13 Five-Day Plan and nonusers of wrist band 14 21 Notes Subjects were soldiers. The quit rate for men equals 71 percent and for women equals 0 percent. Breath holding 28 0 6 Months Keutzer 196743 Results were based on Coverant therapy 30 20 Eugene, OR about 85 percent of Attention placebo 34 18 subjects. Negative practice 31 10 Combined treatment 18 19 Controls 31 6 Covert verbalization 12 41 6 Months Steffy. Meichenbaum, 197042 Overt verbalization with 12 17 and Best action Overt verbalization 12 0 Waterloo, Ontario, Canada without action Insight verbalization 12 8 control Covert sensitization 40 35 3 Months Hall and Denholtz 197342 Covert sensitization 16 19 3 Months Piscataway, NJ Rapid smoking 10 30 9 Months Severson, O'Neal, and 1977613 5 group sessions. Rapid smoking and covert 10 50 Hynd sensitization Modeling and covert 9 11 Northern Colorado sensitization Relaxation 8 0 179 TIMN 293507

Intervention Method Rapid smoking, covert sen- sitization, cognitive re- structuring, role playing, relaxation and behavior rehearsal Number Quit of Rate Followup Investigators Year of Subjects (%) Period Location Report Notes 20 45 6 Months Elliott and Denney 1978614 Doctoral dissertation. Lawrence, KS Also self-reward and punishment. 1/3 of subjects had booster sessions. Satiation or rapid smoking 18 17 Nonspecific procedures, 17 12 lectures Control 6 0 Sensory deprivation 5 60 197342 3 Months Suedfeld and Ikard Sensory deprivation and 20 30 1 Year Suedfeld and Ikard 197492 Started as doctoral messages New Jersey dissertation. Fred Ikard Sensory deprivation/no 17 24 died suddenly June 26, messages 1972. Messages confined at home 17 6 No treatment-encouraged to seek other ways of 18 17 quitting REST 15 21 1 Year REST and messages and 15 53 self-management and satiation Messages and self-man- 15 27 agement and satiation Sensory deprivation-6 20 20 9 Months hours Sensory deprivation-12 21 24 hours Sensory deprivation-24 15 0 hours Placebo-24 hours isolation 16 31 Satiation and covert 19 5 1 Year condition Satiation and REST 19 5 Satiation and 24 hours 18 28 recuperation Satiation demonstration 18 6 and REST Best and Suedfeld 1982866 $25 deposit. REST = re- Waterloo, Ontario, stricted environmental Canada stimulation therapy (sensory deprivation). Christensen and 198266' Social Isolation sub- DiGiusto jects could read and New South Wales, listen to music. 10 ad- Australia ditional sub,f eets were not followed up. Suedfeld and 1986669 24 hours recuperation- Baker-Brown relaxation was placebo Vancouver, BC condition. 6 subjects lost to followup. Self-control and monitoring 36 5 6 Months McFall and Hammen Madison, WI Individual counseling and 55 46 6 Months Morrow, Sachs, self-control and stimulus Gmeinder, and satiation Burgess Sacramento. CA Negative practice Self-control Negative practice and self- control 1971623 1973 648 9 22 6 Months Delahunt and Curran 1976871 9 22 Lafayette, IN 9 56 Control 13 0 Nonspecific with group 9 11 support 180 TIMN 293508

Intervention Method Self-management Self-monitoring and social reinforcement No treatment Habit reversal (some self- reinforcement) Educational, films Self-control and relaxation Self-control and covert sen- sitization Self-control Self-control and cue extinction Cue extinction Self-reinforcement or self- monitoring Self-punishment or self- punishment and self- reinforcement Stimulus control and self-control Stimulus control and muscle relaxation exer- cises (5 sessions over 3 weeks) Health motivation and self-management Normal paced aversive smoking and relaxation training Self-monitoring and relax- ation training and smoke aversion and maintenace (urge controls) Signal device and groups Mechanical counter and groups Signal device (no group) Mechanical counter (no group) Timer (eliminate smoking) Timer (reduce smoking) Control Group and stimulus satia- tion and self-control Number of Subjects Quit Rate (%) Follownp Period Investigators Location Year of Report 10 0 11 Weeks McGrath and Hall 1976872 10 0 Milwaukee, WI 9 0 19 27 3 Months Katz, Heiman, and Gordon 1977873 9 11 Stockton, CA 15 33 6 Months Lowe, Green, Kurtz, 1980615 15 13 Ashenberg, and Fisher St. Louis, MO (40) 29 ( ) 27 ( ) 8 22 0 3 Years Murray and Hobbs Tulsa, OK 1981874 22 50 74 23 4 Years Colletti, Supnick, and 1982875 29 28 3 Years Rizzo Binghamton, NY 34 24 6 Months Rabkin, Boyko, Shane, and Kaufert Manitoba, Canada 1984154 19 26 6 Months Hall, Bachman, Henderson, Barstow, 1983599 16 6 and Jones San Francisco, CA 94 31 . 3 Months Manley and Boland Kingston, Ontario, Canada 1983663 9 33 3 Months Levinson, Shapiro, 1971644 11 0 Schwartz, and Tursky Boston, MA 10 10 8 0 10 0 2 Months Bernard and Efran 1972643 10 40 Rochester, NY 8 0 16 63 1 Year Record • Sacramento, CA 197442 Notes Followup quit rate at 2 years 29 percent for 56 subjects. Quit rate for self- punishment was 25 percent if based on all subjects. Carbon monoxide validation. $20 fee and $10 deposit. 5 sessions over 4 weeks and maintenance. Results based only on subjects answering followup. Cardiovascular and pulmonary patients. $75 fee, $25 deposit. Validation by carbon monoxide. Master's thesis. 181 TIM.N 293509

Intervention Method Mechanical timer measured interval between cigarettes Stimulus control and rapid smoking and daily partner phone contact and ad lib partner phone contact and controlled phone contact Cognitive stimulus control Stimulus control Control Relaxation tape, normal paced aversive smoking and group and 20 letters mailed over 3 months Regular paced aversive smoking and relaxation tape Nicotine fading Self-monitoring tar and nicotine Nicotine fading and self- monitoring Modified ACS program Brand fading and feedback of CO and SCN levels Nicotine fading and anxiety management training Nicotine fading Brand fading and abstinence training Wait list control Brand fading for W.L. controls Brand fading and absti- nence training and feed- back and public posting carbon monoxide levels Nicotine fading Self-monitoring Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report 51 6 3 Months Kaplan Tallahassee, FL 1976®45 1 Year Rodrigues and Lichtenstein 1977829 8 0 Eugene, OR 8 13 8 0 18 33 3 Months Blittner, Goldberg, 197887e 18 11 and Merbaum 18 6 Kibbutz in Israel 22 20 6 Months Shipley Durham, NC 198 1603 22 30 10 10 18 Months Foxx and Brown 1979625 8 0 College Park, MD 10 40 10 10 9 22 6 Months Prue, Krapfl, and• Martin Jackson. MS 1981635 17 6 6 Months Beaver. Brown, and 1981832 - Lichtenstein 11 27 Eugene, OR 21 23 1 Year Prue, Davis, Martin, and Moss 1983631 10 10 6 Months Jackson, MS 10 30 6 Months 18 33 9 Months Scott, Denier, and Prue Jackson, MS 1983636 5 40 1 Year Foxx and Axelroth 1983828 7 29 Baltimore, MD Notes Doctoral dissertation. Breath sample for analysis. VA outpatients and staff. Doctoral dissertation. VA outpatients. 85 percent had cardiac or pulmonary disease. VA hospital nurses. 26 subjects but not all subjects carried out treatment. CO validation. Subjects not quitting put on cigarette fading procedure. 182 TIMN 293510

Intervention Method Number Quit of Rate Subjects (%) Followup Period Investigators Location Year of Report Nicotine fading and self- monitoring 11 9 1 Year Nicki, Remington, and McDonald 19846311 Nicotine fading and self- monitoring and self-talk 13 8 New Brunswick, NJ Nicotine fading and self- monitoring and self- efficacy 13 46 Nicotine fading and self- monitoring and self- efficacy and self-talk 12 25 Nicotine fading and relapse 24 46 6 Months Brown, Lichtenstein, 1980833 prevention and group McIntyre, and 634 support Harrington-Kostur Group support 6 0 Eugene, OR Nicotine fading and group 15 7 1 Year 1984634 Relapse prevention 15 0 Nicotine fading and relapse prevention 16 19 Group cohesion and satiation 19 32 1 Year Etringer, Gregory, and Lando 1984638 Group cohesion and nicotine fading 22 45 Ames, IA Standard cohesion and satiation 16 6 Standard cohesion and nicotine fading 15 40 Nicotine fading and coping strategies 123 42 1 Year McGovern, McIntosh, and Lando 1985637 Oversmoking and coping strategies 42 38 Ames, IA Oversmoking 24 46 1 Year Lando and McGovern 1985606 Nicotine fading 42 19 Des Moines, IA Nicotine fading and smoke holding 41 44 Nicotine fading (no maintenance) 23 26 Nicotine fading (8 sessions) 3 Months Abrams, Pinto, Monti 1985742 and health education 18 33 Jacobus, Brown, and and stress management 18 27 Elder and social support 18 6 Providence. RI Threatened loss of money 14 38 15 Months Elliott and Tighe 1967652 Lecture, quit pledges and stimulus control 11 36 4 Months Hanover, NH Contingency contracting 28 50 6 Months Winett 1973653 Noncontingent contract 17 24 Stoney Brook, NY Contingency management and self-control (stimulus satiation optional) 48 46 11 Months Pomerleau and Ciccone Philadelphia, PA 1974655 Notes $5 fee, $20 deposit. 7 weekly meetings. $20 fee, $20 deposit. 7 weekly meetings. Carbon monoxide measured on some subjects. Enriched group cohe- sion vs. standard group cohesion. 9-week program. Subjects chose method. 17 sessions over 9 weeks conducted by lay leaders. 7 maintenance sessions over 6 weeks. Carbon monoxide checked at 2 months. CO validation. Worksite program $50-$65 deposited by college students. $55 deposit returned if kept contract. 1/2 sub- jects had maintenance. Urinary nicotine on subgroup. 183 TIMN 293511

Intervention Method Number of Subjects Quit Rate (%) Follownp Period Investigators Location Year of Report Contingency management 17 25 6 Months Lando Ames, IA 1976587 Stimulus control and contingency management and covert conditioning and relaxation and pocket timers 100 32 1 Year Pomerleau, Adkins, and Pertschuk Philadelphia, PA 1978650 Satiation and contractual 17 76 6 Months Lando 1977592 management, group sup- port (1 week treatment) Ames, IA Satiation (1 week treatment) 17 35 Satiation and contractual management and group support 17 71 6 Months Lando and McCullough Ames, IA 1978594 Behavioral program and contingency contract 33 42 6 Months Paxton Glasgow, Scotland 1980857 Behavioral program-no contract 27 44 Behavioral program and 33 40 6 Months Paxton 1981658 40 pounds deposit. 27 43 Glasgow, Scotland Various returns for abstinence 23 50 Desensitization and relaxa- tion and counseling 42 10 6 Months Koenig Palo Alto, CA 1966859 Desensitization training in 22 13 4 Months Pyke, Agnew, and 196641 group sessions (10-11 Kopperud weeks) Saskatchewan, Canada Systematic desensitization 27 19 6 Months Wagner 1971660 and satiation and role playing Columbia, SC Individual psychological 36 31 1 Year Schwartz and 196746176 counseling and placebo Dubitzky pill Walnut Creek, CA Individual psychological counseling and tranquilizer 36 14 Control 36 17 Control 36 19 Notes $50 deposit returned if abstinent. 1/2 of sub- jects R.S., 1/2 regular smoking. Group support/10 per- cent had satiation. $50 fee return deposit. Urine determination at end of treatment. 6 treatment sessions over 1 week. 7 addi- tional sessions over 2 months. 3 subjects had rapid smoking boosters. $10 fee, $10 deposit. 250 to $3 for each cigarette smoked. 2 subjects booster RS. 40 pounds deposit returned for abstinence; 5 pounds/week. Valida- tion by urine analysis. Repayment either over 2 months or 4 months at rate of 5 pounds/ week, 5 pounds/2 weeks or 10 pounds/2 weeks. All subjects not includ- ed in followup. 184 TIMN 293512

Number Quit Intervention of Rate Followup Investigators Year of Method Subjects (%) Period Location Report Notes Classes using behavioral 36 25 6 Months Pomerleau and methods Pomerleau Camden, NJ Insight development, relaxation training and covert sensitization (9 sessions) 13 8 3 Months Miller Tuscarawas County, OH Above and cognitive 13 31 restructuring Above and regular paced smoking Above and cognitive re- structuring and regu- lar paced smoking 12 33 12 33 Maintenance strategies: 15 7 2 Years Colletti and Kopel 1979832 Modeling (attend ses- sions for new sub- jects about to receive treatment) Participant observer: new group Therapist phone calls Relaxation, coverant control and problem solving, self-control, rapid smoking New Brunswick, NJ 14 29 13 39 12 8 6 Months Hamilton and Bornstein Missoula, MT Above and social 12 25 support, buddies All above and became group leader Control monitor smoking 3 weeks, then given above program Control given above program 12 33 12 50 12 33 Nonaversive treatment 13 54 6 Months Colletti and Supnick 1980833 package and minimal New Brunswick, NJ contact maintenance Treatment package-no 16 19 maintenance Aversion and maintenance: Intensive contact and 24 46 1 Year contract Minimal contact 18 17 Stimulus control/fear appeals: Intensive contact and 21 19 contract Minimal contact 31 19 Preparation, aversion, and 52 18 maintenance Lando Ames, IA 1980745 Worksite program. 1978598 $20 deposit. Doctoral dissertation. Also included were self- control and assertiveness. 1979664 1981874 Validation by breath samples. Minimal: stimulus control 1 ses- sion; aversion 2 ses- sions; maintenance 1 session; Intensive: Forfeit $ for each ciga- rette smoked; contract- booster session of rapid smoking; self-con- tracts-rewards and punishment. 185 TIMN 293513

Number Quit Intervention of Rate Followup Investigators Year of Method Subjects (%) Period Location Report Notes Lectures and stress man- 36 61 1 Year Powell- 1985204 agement and negative smoking and relaxation 48 44 (Smokeless Program) Dearborn, MI and snap rubber band 46 43 and maintenance meet- 51 45 ings, positive rewards 39 49 and self-control Preparation, stimulus 12 42 1 Year Lando 1982651 control and fear Ames, IA Aversion (satiation) 13 15 Maintenance, contracts, 7 14 forfeit $ and booster ses- sion of rapid smoking Preparation and aversion 11 27 Preparation and 9 22 maintenance Aversion and maintenance 11 36 Preparation, aversion and 10 50 maintenance Social learning (7 meetings) 66 27 3 Months Coleho 1984877 Controlled smoking (brand 12 25 6 Months Lansing, MI Malott, Glasgow, 1984"s fading, reduce number and amount of cigarette smoking Controlled smoking and 2 7 O'Neill, and Klesges Fargo, ND partner support Controlled smoking (7 Glasgow, Klesges, 1984774 meetings) Gradual reduction 12 33 6 Months Godding, Vasey, and O'Neill Abrupt reduction 13 0 Fargo, ND Gradual reduction and 11 0 feedback Controlled smoking 13 25 6 Months Glasgow, Klesges, 1985776 Controlled smoking and 16 23 and O'Neill social support Controlled smoking 16 14 6 Months Fargo. ND Klesges, Vasey, and 1986738• Controlled smoking, 91 18 Glasgow 742 worksite competition, and posted feedback MISCELLANEOUS Medical student smokes 3 1 Months Fargo, ND Poussaint. Bergman, 966*' while counseling and not smoking Gradual reduction, sug- 18 11 6 Months and Lichtenstein Los Angeles,CA Pumroy and March 196641 gestions (5 weeks) College Park, MD Ford Motor Co. employees. Results based on subjects attending at least 2 treatment sessions and subjects who answered followup. Validation by breath samples and informants. Preparation-2 sessions. Aversion-6 sessions. Maintenance-7 ses- sions over 8 weeks. Subjects chose buddies. Worksite program. CO validation. Worksite program. Choice of abstinence or controlled smoking. CO validation. Worksite program. 2 meetings. CO/SCN validation. Worksite program. CO/SCN validation. Followup based on 53 percent of subjects. Results based on subjects answering followup. Treatment was 5 weeks. 186 TIMN 293514

Intervention Method Number of Subjects Quit Rate (%) Follownp Period Investigators Location Year of Report Emotional role playing 26 23 18 Months Mann and Janis New Haven, CT 1968878 Transcendental medita- tion 886 38 9 Months Benson and Wallace Boston, MA 197242 Cruise ship: groups, hypno- sis, lectures, exercise, breathing therapy, social activities and literature 85 32 6 Months Blasko and Nemon Caribbean 197242 Antidotal treatment 98 20M 1 Year Wetterqvist 1973548 11F Lund, Sweden Peer pressure and groups 222 45 1 Year Hall Malmo, Sweden 1975548 Biofeedback 6 33 8 Months Griffith and Crossman Utah 1983879 Fear videotape and quit smoking booklet 28 14 3 Months Sutton and Eiser London, England 1984780 Control video and quit smoking booklet 33 0 Fear video and quit smoking booklet 33 3 12-15 Months Sutton and Hallet 779 Control video and quit smoking booklet nr 0 Fear video and quit smoking booklet nr 11 Control video and quit smoking booklet nr 11 Fear video and quit smoking booklet nr 8 3-5 Months Control video and quit smoking booklet nr 4 Fear video and quit smoking booklet nr 3 Control video and quit smoking booklet nr 6 PHYSICIAN ADVICE-COUNSELING INTERVENTIONS Notes Transcendental medita- tion was not under- taken as a quitting method. Rate increased. 13-day no-smoking cruise. "Dying for a Fag?" was fear film. Control films on alcohol, seat belts, or political and com- mercial aspects of smoking. Separate studies conducted at five firms. The N for last four firms com- bined was: fear video group = 183, control video group= 224. All results were verified by expired air Co. Physician advice 121 5 6 Months Mausner, Mausner, 1968412 No advice 36 0 and Rial Philadelphia, PA Antismoking message during examination 1,493 13 1-2 Years Pincherle and Wright London, England 1970413 Worksite program with business executives. Brief physician advice 101 5 6 Months Porter and 1972414 No advice 90 4 McCullough Small Town. England Physician counseling 63 14 3 Months Baric, MacArthur, and 19763es Prenatal clinic. No counseling 47 4 Sherwood Manchester, England 187 TIMN 293515

Number Quit Intervention of Rate Followup Investigators Year of Method Subjects (%) Period Location Report Notes Physician advice, pamphlet, warning of patient followup Physician advice ` Questionnaire only 'controls Controls 408 5.1 1 Year Russell, Wilson, - Taylor, and Baker 389 3.3 London, England - 430 1.6 340 0.3 (691) 3 1 Year Stewart and Rosser ( ) 3 Ottawa, Ontario, ( ) 3 Canada (675) 4 1 Year Russell, Merriman, (679) 9 Stapleton, and Taylor (584) 4 London, England 361 4 1 Year Li, Coates, Kim, and 215 8 Ewart Baltimore, MD 389 • 4 307 10 165 9 3 Months Larsen. Gumstrup- 508 7 1 Year Hughes. and Lewis Englewood, CO Ledwith and Howie 191 10 Edinburgh, Scotland 1979"' Quit rates are for sub- .jects quit at 1 month and 1 year. A small subsample was vali- dated. Abstinent at 1 year followup: advice- warning-19 percent: advice- 17 percent: controls- 12 percent. Brief physician advice Physician advice, pamphlet Controls Physician advice, leaflet Physician advice, leaflet and nicotine chewing gum Non-intervention controls Physician advice during examination Physician examination and behavior counseling Physician advice Physician counseling Physician warning, materials Physician counseling Physician counseling, doctor letter, mailed questionnaire PHYSICIAN INTERVENTIONS INCLUDING MORE THAN COUNSELING Physician counseling, 32 30 5 Months Cruickshank smoking records kept by London, England patients and weekly checks. Physician advice and strong 100 23 1 Year Handel antismoking message Physician examination, ad- 543 19 2 Years London. England Richmond vice and warning to quit Physician advice and risk- 23 22 1 Year Columbus. OH Rosser assessment questionnaires Information only 62 21 1 Year Ottawa, Canada Ovhed Information and therapy 42 31 Karlskrona, Sweden Information and therapy for 28 38 patients requesting help in quitting 1982418 1983zs4• 255 Quit rate for 4 months and 1 year. Validation by expired air carbon monoxide. 1983415 Shipyard workers. CO validation. 1983416 Family planning clinic. 1983417 1984420 53-62 percent response rate. 10 group practices studied. 196541 1973422 1976424 1979425 197990 Worksite program. 188 TIMN 293516

Intervention Method Number of Subjects Quit Rate (%) Fo1loMrap Period Investigators Location Year of Rcport Patients with smoking- 55 25 related diseases told to stop smoking Controls 43 14 Smoking program with 42 27 3 Months Paxton and Scott 1981881 lung function test Physician counseling and 106 23 6-14 Months Glasgow, Scotland Wilson, Wood, 1982421 followups at 1, 3, and 6 months Physician counseling 105 12 Johnston, and Sicurella Hamilton, Ontario, Physician antismoking 77 23 1 Year Canada Langford, Thompson, 1983 392 information at prenatal class, pamphlet Controls 39 5 and Trip Toronto, Ontario, Canada Physician advice and be- 63 29 6 Months Orleans and Rotberg 198459 havioral counseling by psychologist Physician antismoking (2,110) 15 1 Year Durham, NC Jamrozik, Vessey, 1984426 verbal and written Physician advice and ( ) 17 Fowler, Wald, Parker, and Van demonstration of exhaled air Physician advice and help ( ) 13 Vunikis Oxford, England from health visitor Controls ( j 11 Physician counseling, self- 63 16 3 Months Strecher, Becker, 1984881 help manual, diaries, phone calls Controls 56 9 Kirscht, Eraker, and Graham-Tomasi Ann Arbor, MI Prenatal class and 7 35 29 3 Months Aaronson, Ershoff, 1985391 weekly mailings of type- set booklet and telephone answering taped messages and Danaher Hawthorne, CA PATIENTS WITH PULMONARY DISEASE* Multidimension treatment 134 34 6 Months Baker et al. 1970 Private 94 47 3 Months Burns 1969 Private nr 25 5 Years Burnum 1974 Respiratory 33 36 CS Cooperstock and 1982 Thom •Source for patients with pulmonary disease was Linda Peterson (pp. 466-467).-46O Risk factor studies not included nor were comments about control group. CS = Cross-sectional. Notes Verification by urine testing. Some women had home visits. Motivational counsel- ing, self-help materials, compliance contract. Validation by urinary cotinine showed some misrepresentations. Results based on sub- jects followed up. Study conducted at HMO. Validation by urine thiocyanate. TIMN 293517 189

Number Quit Intervention of Rate Followup Investigators Year of Method Subjects (%) Period Location Report Notes Hospitalized 107 63 CS Daughton et al. 1980 Lung or cancer 52 25 5 Years Davison and Duffy 1982 Chest clinic 174 76 CS Dudley et al. 1977 Chest clinic 123 20 3-24 Months Guzman 1978 Health motivation 19 10 6 Months Hall et al. 1983 Objective verification. Aversion condition 16 30 Cardiopulmonary patients. Private 136 51 3-12 Months Mausner 1970 Not given nr 25 nr Peabody 1971 Private 117 27 6 Months- 7 Years Pederson et al. 1980 Newly diagnosed pulmonary 308 13 6 Months Pederson et al. 1982 Motivating advice and interview 40 13 3 Months Raw 1976 "White coat vs. no white coat." Hospital-chronic bronchitis 29 25 nr Rose and Udechuku 1971 Chest clinic 204 23 6 Months Williams 1969 Advice from respiratory specialist 35 17 6 Months Pederson, Wood, and Lefcoe 1983 Advice-respiratory special- ist and self-care 40 26 PATIENTS WITH CARDIAC DISEASE* Private 525 42 5 Years Burnum 1974 Post-MI-strong advice 125 62 1-3 Years Burt et al. 1974 conventional advice 85 28 Patients-circulatory 377 73 CS Cooperstock and 1982 problems Thom Post MI 205 51 8 Years Croog et al. 1977 Post MI 137 29 6 Months- Hay and Turbott 1970 Coronary insufficiency 44 11 2 Years Arterial disease 39 44 9 Months Kirk et al. 1980 Objective validation. Deception rate = 11 percent. Patients after coronary 39 bypass 67 9 Months Kornfeld et al. 1982 Post MI 64 36 4 Months Lloyd and Cawley 1980 Post MI 321 22 1 Year Mallaghan and Pemberton 1977 *Source for patients with cardiac disease was Linda Peterson (pp. 471-474).3eO Risk factor studies not included nor were comments about control group. CS = Cross-sectional. 190 TIMN 293518

Number Intervention of Method Subjects Quit Rate (%) Foilo.rnp Period Investigators Location Year'of Report Post MI 100 45 1 Year Mayou et al. 1978 Post MI-group therapy 22 33 4 Years Rahe et al. 1979 Control 22 42 Post MI 111 47 4-18 Years Ronan' et al. 1981 Hospitalized with athero- sclerotic disease 56 44 nr Rose and Udechuku 1971 Post MI 91 51 1 Year Sillett et al. 1978 Post MI-exercise 88 31 6 Months Sivarajan et al. 1983 Exercise and counseling 86 34 Control 84 41 Post MI 202 28 2-6 Years Sparrow et al. 1978 Post MI 283 50 4.5 Years Weinblatt et al. 1971 Angina 146 50 Non-CHD 432 19 Post MI 564 53 3 Months Wilhelmsson et al 1975 RECENT STUDIES WITH CARDIAC PATIENTS Advice to stop smoking 33 20 1 Year Wielgosz and Durham Ottawa, Ontario, Canada 1983882 Physician advice and coun- seling by psychologist 16 69 6 Months Orleans and Rotberg Durham, NC 198459 Firm recommendation to quit from physician and cessation instructions from nurse 46 65 6 Months Stanford Cardiac Rehabilitation Program Palo Alto, CA 1983 408 Standard care 16 69 Nicotine fading and self- management and relapse prevention and feedback 8 50 1 Year Sirota, Curran, and Habif Providence, RI 1985883 RISK FACTOR INTERVENTIONS Individual counseling 10 10 3 Months Meyer and Henderson 1974772 Physician advice 14 15 Palo Alto, CA Behavior modification 12 9 Notes Objective validation (COHb). Possible decep- tion rate = 9 percent. Objective validation. Possible deception rate = 23 percent. Patients undergoing angiography. Cardiopulmonary inpa- tients. Patients quit on their own and then received advice and counseling. N and quit rates by estimates based on brief report. Thiocyanate verification. Chronic pulmonary- cardiac patients. VA hospital. disease. Worksite program. Subjects screened as high risk of heart 191 TIMN 293519

Intervention Method Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report Notes Intervention on several risk 43 53 6 Months Malotte, Fielding, and 1981468 Residential program at factors (chronic disease) Danaher UCLA. Behavioral self-management Six 1-hour group sessions Primary emphasis on diet 191 23 2 Years Los Angeles. CA Cooper and 7 others 1982467 39 percent of smokers modification Chicago Coronary were dropouts. 43 of Smoking cessation deferred Prevention Evaluation 116 nondropouts quit. until diet and weight loss 5 sessions of behavior mod- 22 50 1 Year Program Powell and Arnold 1982`"1 Subjects were subjects ification and self-control, New York, NY of the MRFIT who had negative aversive smoking 3 maintenance sessions, telephone calls, contin- gency contract not quit smoking. Validation by SCN . levels. 192 TIMN 293520

RISK FACTOR INTERVENTION TRIALS* Intervention Four 15-minute meetings with physi- cian in 10 weeks; 6-month visit Additional help if needed Control not told of high risk or trial participa- tion Five biweekly small group sessions 2nd session nicotine chewing gum One CG sent questiQn- naires Other CG-2 percent screened Initial session with physician Group sessions for men with wives 5-day cessation program for continuing smokers CG screened; yearly examinations Session with physician 10 group intervention sessions Maintenance for quitters Extended intervention for continuing smokers Followups at least every 4 months CG screened, yearly examination Mass media for factory workers Antismoking clinics High risk smokers offered individual counseling, 4 sessions CG- 10 percent invited for screening Balance CG not told of trial Mass media for factory workers High risk smokers offered counseling and exam by physician 2 times a year CG-10 percent invited for screening Quit Number of Rate FoIIo.vup Population Subjects (%) Period Trial Notes 1,445 healthy men aged 40-59 High risk for CHD and/or chronic bronchitis based on risk score 30,000 males aged 47-54 Assignments based on smoking, hyperten- sion, low physical activity, and high cholesterol 1,232 healthy males aged 40-59 High risk for CHD based on smoking and cholesterol 12,866 healthy males aged 35-57 High risk for CHD based on smoking, cholesterol, and blood pressure 18,210 factory workers aged 40-59 24 industrial groups paired for similarities 16,222 factory work- ers aged 40-59 30 industrial groups paired Intervention 51 1 Year London Civil No group = 714 36 3 Years Servants objective Normal care 46 9 Years Smoking Trial measures = 714 10 ' 1 Year used. 14 3 Years Intervention 31 4 Years Goteborg No group = 26 4 Years Study objective 10,000 Sweden measures 4,846 smokers used. CG = 20,000 Intervention 29 3 Years Oslo Study SCN, but group = 604 31 5 Years Norway rate not CG = 628 13 3 Years reported. 18 5 Years Intervention 40 1 Year Multiple Risk 29 SCN group = 6,428 40 3 Years Factor 35 adjust- Usual care = 43 6 Years Intervention 42 ment 6,428 13 1 Year Trial 11 rates. 16 3 Years United States 15 26 6 Years 24 Intervention 9 5 Years WHO European No group = 9.734 12 hi-risk Collaborative objective CG = 8,476 7 non hi- risk Trial United measures used. 0 5 Years Kingdom Intervention 13 2 Years WHO European No group = 7,398 19 hi-risk Collaborative objective CG = 8,240 13 2 Years Trial measures 12 hi-risk Belgium used. 'Source for risk factor intervention trials was Judy Ockene (pp. 252-25fi. 275, 278).46s 193 293521 TIMN

APPENDIX B DOCTORAL DISSERTATIONS RELATING TO SMOKING CESSATION 1977-1984 Agne, C.: The Effects of Follow-Up Procedures on the Maintenance of Non-Smoking Behavior of the Participants in a Smoking Cessation Program. Texas Woman's University, College of Health, Physical Education and Recreation, Denton, Univ. Microfilms Intl. GAX82-08752, 1981, 98 pp. Alevy, M.A.: Subject Suggestibility and Stop Smok- ing Treatments. St. Louis University, Univ. Microfilms Intl. 78-469, 1977, 166 pp. Ashenberg, Z.S.: Smoking Recidivism: The Role of Stress and Coping. Washington University, Department of Psychology, St. Louis, Missouri, Univ. Microfilms Intl. 84-02189, 1983, 167 pp. Bailey, G.J.A.: The Effect of Stress on Smoking Cessation. University of Washington, Seattle, Univ. Microfilms Intl. 84-19109, 1984, 164 pp. Batson, H.W.: The Effects of Cigarette-Withdrawal and a Related Verbal Stimulus on REM Sleep and Dreaming. City University of New York, Univ. Microfilms Intl. 80-23687, 1980, 148 pp. Baugh, C.L.: Prediction of Smoking Behavior Using the HBM, Health Locus of Control and Self- Esteem. Indiana University, Bloomington, Indiana, Univ. Microfilms Intl. 84-00846, 1983, 100 pp. - Baumgartner, T.K.: The Effects of an Abstinence Self-Efficacy Induction Programmatic Focus on Cigarette Smoking Relapse. University of Missis- sippi, University, Mississippi, Univ. Microfilms Intl. 84-25093, 1984, 172 pp. Beck, K.H.: The Effects of Positive and Negative Affect-Arousing Communications Upon Attitudes, Belief Acceptance, Behavioral Intention, and Ac- tual Behavior. Syracuse University, Univ. Microfilms 78-11,632, 1978, 341 pp. Bier, R.S.: Assisted Covert Sensitization and Smok- ing Cessation. University of Texas Health Science Center, Dallas, Univ. Microfilms Intl. 79-02523, 1978, 138 pp. Boelens, D.M.: Relapse Prevention in the Treatment of Cigarette Smokers. University of Washington, Univ. Microfilms Intl. 80-29735, 1980, 199 pp. Bowers, T.B.: Nicotine Fading, Behavioral Contract- ing, and Extended Treatment: Effects on Smok- ing Cessation. Virginia Polytechnic Institute and State University, Blacksburg, Univ. Microfilms Intl. 84-21851, 1984, 174 pp. Bredehoft, W.P.: Smoking Abstention or Relapse: The Role of Causal Attributions and Self-Efficacy Expectations. Boston University, Univ. Microfilms Intl. 83-09749, 1983, 99 pp. Brod. M.: Stress, Coping and Smoking Cessation. University of California, San Francisco, Univ. Microfilms Intl. 84-00023, 1983, 112 pp. Carl, L.S.: Self-Planned Smoking Cessation: A Retrospective Study of the Strategies and Resources Used by Individuals in Quitting and Remaining Quit. University of Illinois, Urbana, Univ. Microfilms Intl. 81-08458, 1980, 227 pp. Catchings, P.M.: Studies of Smoking Topography. University of Minnesota, Minneapolis, Univ. Microfilms Intl. 82-13963, 1982, 190 pp. Christenson, P.D.: Quantitative and Qualitative Results of a Utah Smoking Risk Reduction Pro- gram, University Of Utah, Salt Lake City, Univ. Microfilms Intl. 84-00463, 1984, 184 pp. Cochran, N.N.: A Methodological Analysis of Two Self-Control Procedures: Self-Monitoring and Thought Stopping Applied to Smoking Behavior. University of Mississippi, Mississippi Station, Univ. Microfilms Intl. 77-11,181, 1977, 129 pp. Colletti, G.: The Relative Efficacy of Participant Modeling, Participant Observer, and Self- Monitoring Procedures as Maintenance Strategies Following a Positive Behaviorally Based Treat- ment for Smoking Reduction. Rutgers Universi- TIMN 293522 195

ty, New Brunswick, New Jersey, Univ. Microfilms Intl. 78-5068, 1977, 153 pp. Cooney, N.L.: Controlled Relapse: Teaching Recent Exsmokers to Cope With Relapse. Rutgers, The State University of New Jersey, New Brunswick, Univ. Microfilms Intl. 82-04204, 1981, 117 pp. Coppotelli, H.A.: Spouse Support in Smoking Cessa- tion by Women. Duke University, Durham, North Carolina, Univ. Microfilms Intl. 83-25662, 1983, 166 pp. Corn, J.R.: Self-Efficacy and Behavioral Self-Control in a Smoking Cessation Program. University of Maryland, Univ. Microfilms Intl. 79-17121, 1978, 141 pp. Corty, E.: Response Prevention to the Treatment of Cigarette Smoking, Indiana University, Depart- ment of Psychology, Univ. Microfilms Intl. 84-01561, 1983, 210 pp. Dahm, P.J.: Development, Implementation, and Evaluation of a Grief Work Program for Cigarette Smokers Desiring to Quit Smoking. North Texas State University, Denton, Univ. Microfilms, Intl. 80-00780, 1979, 138 pp. Davis, J.R.: Relapse Prevention and Smoking Cessa- tion. Wayne State University, Detroit, Univ. Microfilms Intl. 83-15586, 1984, 562 pp. Delahunt, J.P.: A Smoking Cessation Treatment In- vestigation: A Replication and Assessment of Therapist Effect. Purdue University, West Lafayette, Indiana, Univ. Microfilms Intl. 81-13667, 1980, 142 pp. Derden, R.H.: The Effectiveness of Follow-Up Strategies in Smoking Cessation. University of Pittsburgh, Pennsylvania, Univ. Microfilm Intl. 77-23,582, 1977, 202 pp. Dobbs, S.D.: An Assessment of the Learning and Physiological-Addiction Theories of Smoking. University of Mississippi, Univ. Microfilms Intl. 82-25434, 1982, 97 pp. Dropkin, D.: Smokers, Stopped Smokers and Multi- dimensional Health Locus of Control. Hofstra University, Hempstead, New York, Univ. Microfilms Intl. 84-18831, 1984, 143 pp. Durham, T.R.: Health Beliefs and Behavior: Adult Cigarette Smoking. Syracuse University, Syra- cuse, Univ. Microfilms Intl. 79-08530, 1978, 159 PP• Edwards, J.R.: The Effects of Induced Affect and Relaxation Response Training on the Self- Management of Cigarette Smoking. University of Georgia, Athens, Univ. Microfilms Intl. 78-14939, 1977, 117 pp. 196 Elliott, C.H.: Multiple Component Treatment Ap- proach to Smoking Reduction. University of Kan- sas, Lawrence, Kansas, Univ. Microfilms Intl. 77-16272, 1977, 115 pp. Fee, A.F.: Positive Versus Aversion Hypnotic Sug- gestion for Smoking Cessation. Texas A&M University, College Station, Texas, Univ. Microfilms Intl. 82-06623, 1981, 121 pp. Flow, D.L.: A Comparison of Two Smoking Cessa- tion Techniques Conducted in an Occupational Setting. Oregon State University, Univ. Microfilms Intl. 80-21937, 1980, 204 pp. Friedlander, R.B.: The Helper-Therapy Principle in a Smoking Cessation Program. Texas Tech University, Lubbock, Univ. Microfilms Intl. 83-02160, 1982, 389 pp. Gardner, P.B.: An Investigation of Couples Train- ing in Smoking Cessation With Implications for the Televised Delivery of Behavioral Medicine Counseling. Stanford University, California, Univ. Microfilms Intl. 82- 14572, 1982, 104 pp. Garson, E.B.: The Application of Positive Imagery in the Maintenance of Smoking Reduction Follow- ing a Broad-Spectrum Treatment. Rutgers, State University of New Jersey, New Brunswick, Univ. Microfilms Intl. 79-10384, 1978, 77 pp. Glad, W.R.: A Comparison of Four Smoking Treat- ment Programs and a Maintenance Procedure on a Community Population. University of Wiscon- sin, Milwaukee, Univ. Microfilms Intl. 79-05045, 1978, 440 pp. Glasgow, R.E.: Effects of a Self-Control Manual, Rapid Smoking, and Amount of Therapist Con- tact on Smoking Reduction. University of Oregon, Eugene, Univ. Microfllms Intl. 78-2521, 1977, 135 PP• Goeckner, D.J.: A Multifaceted Approach to Smok- ing Modification: Training in Alternate Response Strategies. University of Illinois at Urbana- Champaign, Univ. Microfilms Intl. 79-15354, 1979, 122 pp. Gordon, J.R.: The Use of Rapid Smoking and Group Support To Induce and Maintain Abstinence From Cigarette Smoking. University of Washing- ton,Univ. Microfilms Intl. 78-20725,1978,198pp. Gottlieb, N.H.: Smoking Behavior in College Women. Boston University Graduate School, Univ. Microfilms Intl. 81-12199, 1981, 262 pp. Gregory, V.R:: The Effect of a Cognitive-Behavioral Treatment Aimed at Relapse Prevention in Smok- ing. Iowa State University, Ames, Iowa, Univ. Microfilms Intl. 84-23635, 1984, 195 pp. TIMN 293523

Griffith, E.E.: Biofeedback: A Possible Substitute for Smoking. Utah State University, Logan, Univ. Microfilms Intl. 81-21910, 1981, 200 pp. Grimstead, O.A.: Preventing Weight Gain Follow- ing Smoking Cessation: A Comparison of Be- havioral Treatment Approaches. University of California, Los Angeles, Univ. Microfilms Intl. 82-06024, 1981, 174 pp. Gust, S.W.: Relationship of Puff Volume to Other Topographical Measures in Smoking Behavior. University of Minnesota, Minneapolis, Univ. Microfilms Intl. 82-13982, 1982, 112 pp. Hackbarth, D.P.: A Process Model of Smoking and Quitting Behaviors. University of lllinois at Chica.- go, Univ. Microfilms Intl. 84-04403, 1984, 304 pp. Hamilton, S.B.: The Effects of Social Support and Paraprofessional Training on the Outcome of a Multicomponent Smoking Abstinence Program. University of Montana, Univ. Microfilms Intl. 78-19147, 1978, 241 pp. Hanks, D.T.: Physician Modeling Influences on Pa- tient Smoking. North Texas State University, Denton, Univ. Microfilms Intl. 84-04317, 1984, 184 pp. Hansen, B.A.: Empirical and Phenomenological Analyses of Addictive Tobacco Use: Implications for Theory and Educational Therapy of Addictive Smoking Behavior. University of California, Ber- keley, Univ. Microfilms Intl. 80-29420, 1980, 187 PP• Hendrix, E.M.: A Comparison of Tivo Group Behav- ioral Approaches to the Treatment of Chronic Heavy Cigarette Smoking. University of Louis- ville, Louisville, Kentucky, Univ. Microfilms Intl. 77-13,766, 1977, 298 pp. Hill, J.S.: Effect of a Program of Aerobic Exercise on the Smoking Behaviour of a Group of Adult Volunteers. Ohio State University, Univ. Microfilms Intl. 83-05340, 1982, 180 pp. Hill, R.W.: Hypnosis: A Group Treatment for Smok- ing, Obesity and the Perception of Stress. Virginia Commonwealth University, Richmond, Univ. Microfilms Intl. 81-18963, 1981, 108 pp. Howley, T.J.: A Comparative Evaluation of Aerobic Exercise and Self-Management Strategies in the Treatment of Cigarette Smoking. West Virginia University, Morgantown, Univ. Microfilms Intl. 81-18423, 1981, 111 pp. Incagnoli, T.: The Relation Between Locus of Con- trol, Smoking Behavior and Death Anxiety in a Chronic Lung Population. St. John's University, New York, Univ. Microfilms Intl. 79-00267, 1978, 155 pp. Johns, P.A.: A Study of the Smoking Behavior of Participants in the Stop Smoking Program of the American Cancer Society. University of Georgia, School of Education, Athens, Univ. Microfilms Intl. 79-15490, 1978, 146 pp. Johnson, R.F.: An Assessment of Selected Variables Related to Smoke Stopping Success and Smoke Stopping Failure. University of Utah, College of Health, Univ. Microfilms Intl. 77-21,950, 1977, 124 pp. Keech, S.M.: The Effect of Role Playing Involvement on Modifying Smoking Behavior. University of Denver, Univ. Microfilms Intl. 79-27107, 1979, 130 pp. Kenigsberg, M.I.: Multicomponent Long-Term Pro- grams for the Maintenance of Smoking Cessation: Efficacy of Rapid Smoking and Self-Control Proce- dures. Gradual Versus Target-Date Quitting, and Booster Sessions. Pennsylvania State University, Univ. Microfilms Intl. 78-18766, 1978, 122 pp. Killen, J.D.: Psychological and Pharmacological Ap- proaches to Smoking Relapse Prevention. Stan- ford University, School of Education, California, Univ. Microfilms Intl. 83-01237, 1982, 92 pp. Koller, D.G.: The Relationships of Nurse Educator Smoking Beliefs, Attitudes, Behavior and Com- mitment to Promote Cessation in Students and Patients/Clients. University of Wisconsin, Madi- son, Univ. Microfilms Intl. 84-02032, 1983, 163 PP• Koman, S.L.: Treatment of Smoking Addiction: The Effect of Treatment Goal and Properties of Addic- tion on Achieving and Maintaining Smoking Modification. Duke University, Department of Psychology, Durham, North Carolina, Univ. Microfilms Intl. 81-24804, 1981, 275 pp. Lennon, L.B.: Covert Sensitization as a Means of Treating Problem Smoking. Miami University, Oxford, Ohio, Univ. Microfilms Intl. 80-01441, 1979, 188 pp. Lieberman, L.A.: The Effect of Cigarette Smoking Withdrawal on Sleep. Yeshiva University, New York, Univ. Microfilms Intl. 80-01233,1979, 86 pp. Litynsky, M.E.: A Comparison of the Effectiveness of Rapid Smoking and Self-Control on the Con- trol of Cigarette Smoking. University of Vermont, Univ. Microfilms Intl. 80-25901, 1980, 115 pp. Lowe, J.B.: An Investigation of the Possible Rela- tionship Between Certain Physiological and Psy- chological Measures and Smoking Cessation in a Self-Selected Population. University of Texas, School of Public Health, Houston, Univ. Microfilms Intl. 82-23557, 1982, 129 pp. 197 TIMN 293524

Luke, A.E.H.: Self-Control Methods in Suppression of Smoking Behavior. University of Texas, Austin, Univ. Microfilms Intl. 82-27684, 1982, 97 pp. Marotta, L.J.: Expanding the Locus of Control/In- put Congruence Hypothesis to the Clinical Task of Smoking Cessation,. Florida Institute of Tech- nology, Melbourne, Univ. Microfilms Intl. 84-04032, 1983, 108 pp. McClay, M.K., Cadwalder, G.R.: An Investigation of Smoking Cessation as a Viable Medical Interven- tion for Patients with Health Related Needs to Stop Smoking. University of Texas, School of Public Health, Houston, Univ. Microfilms Intl. 81-12525, 1980, 296 pp. McIntyre, K.O.: Spouse Involvement in a Multicom- ponent Treatment Program for Smokers. Univer- sity of Oregon, Eugene, Univ. Microfilms Intl. 84-08183, 1983, 91 pp. McKee, D.G.: The Effects of Family and Public Health Education on Preventive Health Behavior: The Case of Changes in Smoking, Exercise, and Dietary Behaviors. University of Minnesota, Min- neapolis, Univ. Microfilms Intl. 84-04203, 1983, 286 pp. Menapace, R.H.: The Effects of Fear Arousal and Subjective Probability of Coping Success on At- titudes, Behavioral Intention, and Behavior. Tem- ple University, Philadelphia, Univ. Microfilms Intl. 77-13,573, 1977, 76 pp. Miller, J.I.: The Role of Cognitive Restructuring and Regular Paced Smoking in Smoking Cessation. Kent State University, Graduate College, Kent, Ohio, 1978, 180 pp. Monday, L.M.: An Investigation of Pretreatment Ef- ficacy Expectations and Smoking Motives With a Population of Hypnotically Treated Cigarette Smokers. University of Mississippi, Univ. Microfilms Intl. 84-04276, 1983, 76 pp. Morgan, G.D.: Abstinence From Smoking and the Social Environment. Washington University, St. Louis, Missouri, Univ. Microfilms Intl. 83-20567, 1983, 225 pp. Muscatel, K.M.: The Relation of Attitudinal Factors to the Decision to Stop Smoking. University of Washington, Seattle, Univ. Microfilms Intl. 80-13571, 1979. 204 pp. Nellis, M.J.: An Interresponse Time Analysis of Smoking in the Natural Environment. Universi- ty of Chicago, Chicago, Joseph Regenstein Library Department of Photoduplication, Thesis No. T27976, 1981, 138 pp. 198 Nepps, M.M.: An Evaluation of the Effectiveness of a Minimal Contact Self-Help Smoking Cessation Program in an Industrial Setting. Rutgers, The State University of New Jersey, New Brunswick, Univ. Microfilms Intl. 82-19038, 1982, 169 pp. Neptune, C.: An Investigation of the Effect of Medita- tion Training in a Cigarette Smoking Extinguish- ment Program. Kansas State University, College of Education, Manhattan, Univ. Microf lms Intl. 78-11433, 1977, 100 pp. Nethercut, G.E.: Smoking Behavior of Pregnant Women: The Role of Self-Efficacy, Partner Sup- port and Maternal Adaptation. University of California, San Francisco, Univ. Microfilms Intl. 84-25955, 1984, 174 pp. Ockene, J.K.: A Study of the Psycho-Social Factors Involved in Changing Smoking Behavior: Risk Factor Alteration in a Coronary Heart Disease Prevention Program. Boston College, Boston, Univ. Microfilms Intl. 79-22078, 1979, 286 pp. Ozyurt, Y.G.: Effects of Short-Term Deprivation and External Cues on Light and Heavy Smokers. Northwestern University, Evanston, Illinois, Univ. Microfilms Intl. 79-03337, 1978, 60 pp. Palmatier, J.R.: The Effects of Subliminal Stimula- tion of Symbiotic Fantasies on the Behavior Ther- apy Treatment of Smoking. University of Mon- tana, Univ. Microfilms Intl.81-00054,1980, pp. Palmer, R.D.: A Multiple Stage Treatment Program for Smoking Reduction. University of Kansas, Lawrence, Univ. Microfilms Intl. 83-03906, 1982, 103 pp. Pechacek, T.F.: An Evaluation of Cessation and Maintenance Strategies in the Modification of Smoking Behavior, University of Texas, Austin, Univ. Microfilms Intl. 77-23013, 1977, 83 pp. Peltier, B.N.: The Effects of Differential Recruitment Procedures, Reinforcement Methods, and Fo- cused Smoking on the Cigarette Smoking Be- havior of Adolescents; An Experimental Study. Wayne State University, Detroit, Michigan, Univ. Microfilms Intl. 80-10163, 1979, 178 pp. Perlick, D.A.: The Withdrawal Syndrome: Nicotine Addiction and the Effects of Stopping Smoking in Heavy and Light Smokers. Columbia University, Faculty of Pure Science, Univ. Microfilms Intl. 77-14,833, 1977, 10 pp. Pierce, J.P.: Formative Research on Health Com- munication: Reducing the Prevalence of Cigarette Smoking. Stanford University, Stanford, Califor- nia, Univ. Microfilms Intl. 82-08889, 1981, 212 PP• TIMN 293525

Powell, D.R.: The Effect of a Multiple Treatment Pro- gram and Maintenance Procedures on Smoking Cessation. University of Michigan, Ann Arbor, Univ. Microfilms Intl. 79-16795, 1979, 191 pp. Rickard, K.M.: Assessment of Smoking Urge and Its Concomitants Under an Environmental Smoking Cue Manipulation. University of Georgia, Athens, Univ. Microfilms Intl. 83-26428, 1983, 107 pp. Riddell, J.C.: Smokers and Smoking: An In-Depth Interview Study of Initiation, Transition, Main- tenance, and Cessation. University of New Hamp- shire, Durham, Univ. Microfilms Intl. 84-03939, 1983, 262 pp. Ritow, J.K.: Transcontextual Commumication and Therapeutic Change, With an Application to Therapy for the Cigarette Smoker. University of Montana, Missoula, Montana, Univ. Microfilms Intl. 82-14498, 1982, 244 pp. Rodgers, M.P.: The Effect of Social Support on the Modification of Smoking Behavior. University of Michigan, Ann Arbor, Univ. Microfilms Intl. 77-18,105, 1977, 289 pp. Rothmeier, R.C.: Commitment to Change: Effects of Contractual and Scanning-Focusing Tech- niques on Smoking Behavior. University of Nebraska, Lincoln, Univ. Microfilms Intl. 81-22602, 1981, 90 pp. Russell, P.O.: Behavioral and Physiological Effects of Low Nicotine Cigarettes During Rapid Smok- ing. University of Pittsburgh, Pennsylvania, Univ. Microi3lms Intl. 82-08686, 1981, 97 pp. Saterfield, H.D.: Self-Instruction as a Treatment Component in the Maintenance of Non-Smoking Behavior. Stanford University, School of Educa- tion, Univ. Microfilms Intl. 78-14227,1977,119pp. Schmookler, E.K.: A Study of Spontaneous Smok- ing Cessation. University of California, Berkeley, Univ. Microfilms Intl. 83-00642, 1982, 146 pp. Schopp, R.F.: The Effects of Experimenter Knowledge on Self-Monitoring and Self- Reinforcement Approaches to Control of Smok- ing. North Carolina State University, Raleigh, Univ. Microfilms Intl. 77-29674, 1977, 90 pp. Schultze, M.J.: Paradoxical Aspects of Cigarette Smoking: Physiological Arousal, Affect, and In- dividual Differences in Body Cue Utilization. Clark _ University, Worcester, Massachusetts, Univ. Microfilms Intl. 82-08416, 1981, 79 pp. Shapiro, R.M.: The Freedom Line: A Relapse- Prevention Intervention for the Control of Smok- ing. University of Rochester, New York, Univ. Microfilms Intl. 84-27950, 1984, 118 pp. Simpson, P.E.T.: The Cognitive and Affective Results of Participation in a Risk Reduction Peer Education Program on Tobacco. Texas Woman's University, Denton, Univ. Microfilms Intl. 82-19624, 1982, 130 pp. Singer, J.: Development and Evaluation of Four Ap- proaches to a Smoking Modification Program for High School Students. Boston University, School of Education, Boston, Masschusetts, Univ. Microfilms Intl. 77-11,377, 1977, 241 pp. Smith, D.K.: Hypnosis for Smoking Control: A Com- parison of Aversive and Positive / Motivational Imagery and Suggestions in Group and Individual Settings. Fuller Theological Seminary, School of Psychology, Pasadena, California, Univ. Microfilms Intl. 82-16116, 1982, 118 pp. Smith, K.A.: Cigarette Smoking: A Phenomenologi- cal Analysis of the Experience of Women in Their Successful Versus Unsuccessful Attempts to Quit Smoking. University of Pittsburgh, School of Edu- cation, Univ. Microfilms Intl. 82-13185, 1981, 350 PP- Sobota, P.M.: Comparison of Self-Control Maintenance Procedures as an Adjunct to Labora- tory Rapid-Smoking Satiation in the Treatment of Smoking Behavior. Washington University, Graduate Institute of Education, Saint Louis, Mis- souri, Univ. Microfilms Intl. 82-23818, 1982, 241 PP• Sperduto, W.S.: Development and Evaluation of Treatment Paradigms for the Control of Smoking Behavior. Hofstra University, Hempstead, New York, Univ. Microfilms Intl. 82-12273, 1981, 137 PP• Taylor, P.W.: Cigarette Smoking Behavior: Self- Managed Change. North Texas State University, Clinical Psychology Department, Univ. Microfilms Intl. 77-19,688, 1977, 66 pp. Tiffany, S.T.: Treatments for Cigarette Smoking: An Evaluation of the Contributions of Aversion and Counseling Procedures. University of Wisconsin, Madison, Univ. Microfilms Intl. 84-19972, 1984, 110 pp. Todd, G.D.: Evaluation of Tolerance to a Behavioral Effect of Nicotine. University of Kentucky, Lex- ington, Univ. Microfilms Intl. 82-07800, 1981, 168 pp. Walker, G.R.: Self-Awareness and Cigarette Smok- ing: The Interaction of Public and Private Deter- minants. University of Florida, Gainsville, Univ. Microfilms Intl. 81-24462, 1981, 71 pp. 199 TIMN 293526

Whitson, E.R.: Oral, Obsessive, and Hysterical Per- sonality and Cigarette-Smoking Behaviors. State University of New York at Buffalo, Univ. Microfilms Intl. 84-01710, 1983, 273 pp. Wilmot, M.H.: A Comparison of Hypnotic Strategies for the C,)ntrol of Smoking: Individualized 5ug- gestions vs. a Desensitization Technique. Fuller Theological Seminary, Pasadena, California, Univ. Microfilms Intl. 84-25770, 1984, 188 pp. Wolynic, L.C.: Restraint and Reaction to Preload in Cigarette Smokers. Hofstra University, Hemp- stead, New York, Univ. Microfilms Intl. 82-12990, 1981, 135 pp. Zumoff, P.J.: The Separate and Combined Effects of the Focused Smoking and Carbon Monoxide Feedback Interventions on Cigarette Smoking. Pennsylvania State University, University Park, Univ. Microfilms Intl. 83-20948, 1983, 86 pp. 200 *U.S. GOVERNMENT PRINTING OFFICE: 1987-181-317/B3508 TIMN 293527

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Serq,ice National Institutes of Health Blair Building, Room 427 Bethesda, Maryland 20892-4200 Official Business Penalty for Private Use $300 004811panzer Fred Institute •tobac;°St N.W• 1875 reet~ washin9ton ® DC 20006 NIH Publication No. 87-2940 April 1987 Special Fourth-Class Rate Postage & Fees Paid PHS/NIH/C Permit No. G-291 TIMN 293528