Evaluation of a multicomponent group smoking cessation program

PREVENTIVE

MEDICINE

20, 404-413 (191)

Evaluation

of a Multicomponent Group Smoking Cessation Program

MARGARETEDMUNDS, PH.D.,* HARRY CONNER, M.D., M.P.H. ,t CAMILLE JONES,M.D., M.P.H. ,* RICARDO GORAYEB, PH.D. ,*32 AND H. RICHARDWARANCH,PH.D.*,' *The Johns Hopkins School of Medicine and tSchoo1 of Hygiene Baltimore, Maryland 21205

and Public Health,

Background. Participants who had completed a multicomponent group smoking cessation program were interviewed to determine their smoking status and satisfaction with the program. Methods. The follow-up interviews occurred an average of 20 months after entry to the program, with a response rate of 80% (89 out of 111 enrollees). Most individuals interviewed (82%) were able to quit for at least 24 hr; 25% were able to maintain nonsmoking status for 1 year or longer. Results. Initial quit rates were comparable for both men and women, but women were more than twice as likely to have relapsed by the time of the follow-up interview. Participants rated self-monitoring as the most helpful of 10 program components, including nicotine fading, nicotine gum, group support, health information, and talks by ex-smokers. Ratings for the program overall were higher than the rating of any individual component. Conclusions. Since earlier studies have found that successful quitters use more coping strategies than relapsers, multicomponent programs offer participants an opportunity to learn a variety of techniques and choose the combination that works best for them. e WI Academic

Press. Inc.

INTRODUCTION

According to the U.S. Preventive Services Task Force, a smoking cessation program is most likely to be successful if it uses a team of physicians and nonphysicians, with multiple methods over multiple occasions (1). No single most effective method of smoking cessation has been found (2, 3) among physician counseling (4-6); educational approaches, emphasizing the health risks of smoking and behavioral techniques to modify smokers’ habits (7-10); and interventions to reduce craving and withdrawal symptoms, such as nicotine polacrilex (gum) (ll), acupuncture (12), and hypnosis (1). Regardless of the type of method used, most studies agree that higher rates of smoking cessation occur among males (9, 13, 14) and among individuals who have higher educational and occupational levels (15, 16), lower levels of stress (17), and fewer contacts with smokers (6). In his comprehensive review of smoking cessation methods, Schwartz (3) recommended that the determination of smoking cessation rates should be based on abstinence at a l-year follow-up, with biochemical validation of nonsmoking status and full descriptions of methods, participants, and procedures. Accordingly, ’ To whom reprint requests should be addressed. ’ Current address: University of Sao Paulo, Brazil.

404 0091-7435/91 $3.00 Copyright 0 1991 by Academic Press, Inc. All rigbts of rcpmduction in my form rfsfxvcd.

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this report describes the evaluation of a hospital-based multicomponent program that combined cognitivebehavioral techniques, health education, carbon monoxide monitoring, group support, talks by ex-smokers, and supervised use of nicotine chewing gum. In addition to determining the program’s long-term success rate, we assessedthe relationships of smoking history, smoking status at followup, stress levels, and demographic factors with participants’ ratings of the helpfulness of program components. METHOD Background

The Johns Hopkins Smoking Cessation Program was a multicomponent program that combined cognitive-behavioral techniques (self-monitoring, stimulus control, nicotine fading, and relapse prevention) with health education, carbon monoxide monitoring, group support, talks by ex-smokers, and supervised use of nicotine chewing gum. The program consisted of 10 sessionsheld over a 9-month period. Table 1 shows the sequencein which the various components were introduced. Program Components

Self-monitoring involved having participants keep written records of the number, timing, and location where cigarettes were smoked. Nicotine fading was done by gradually tapering the number of cigarettes smoked over several days and by switching to a brand with lower nicotine content. The stimulus control component involved changing habits to produce fewer cues for smoking, e.g., removing ashtrays, giving away lighters, and keeping cigarettes in an inconvenient location. Biochemical verification of smoking status has been recommended (3). We used a MiniCo (Catalyst Research Corp.) (18) to measure expired carbon monoxide TABLE 1 SEQUENCE OF PROGRAM COMWNENT~

Session number

Weeks into the program

1

1

2

2 3 4 5 6 8 12 24 36

Components introduced Self-monitoring Nicotine fading I (cut down) Stimulus control; health risks Nicotine fading II (switch brands) Talks by ex-smokers Quit date; nicotine gum Diet and exercise Group support and relapse prevention Group support and relapse prevention Group support and relapse prevention Group support and relapse prevention Group support and relapse prevention

0 The Fagerstrom Scale (21) and carbon monoxide monitoring were done at every session. Each subsequent week utilized and built on the previous week’s activities.

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(CO) at every session;participants reported viewing this as a kind of biofeedback while they were cutting down. Nicotine gum was prescribed to ease withdrawal symptoms after quitting, and participants were instructed in relapse prevention techniques (19,20), such as stress managementand coping strategiesfor high-risk situations. The program was co-led by behavioral medicine fellows and preventive medicine residents, some of whom were former smokers. Eight groups of 10-15 participants were conducted over a 3-year period. Baseline

After smokers responded to print media announcements of the hospital-based smoking cessation program, they completed baseline questionnaires on smoking history and medical history. Measurements of weight, blood pressure, CO, and respiration rate were recorded. Prospective participants also completed the Fagerstrom Tolerance Questionnaire, an 11-item self-report measure of nicotine addiction (21). If there were any medical questions about the participant’s ability to participate or to use nicotine gum, that individual was asked to provide written permission from his or her personal physician. Follow-up

Smoking status of participants was determined after the completion of the program through telephone interviews conducted by the authors over a 3-month period. Self-report of nonsmoking status was confirmed with breath samples of CO. Follow-up interviews were initiated after a minimum of 100participants had completed the program, to allow a sufficient number for statistical analyses. The averagetime to follow-up was 20 months from program initiation, with a range of 12 to 31 months (SD 5.8). The response rate was 80% (89 of 111 eligible interviewees). Participants were asked about their current smoking status, smoking status 12 months after completing the program, and experience with quitting, including withdrawal symptoms, perceived benefits obtained from quitting, and use of nicotine gum. They were asked to rate both the program overall and each program component on a lo-point scale, indicating how useful that component was in their effort to stop smoking. Analytical Approach

We examined two general aspects of the program: (a) program outcomes, as measuredby current smoking status and the natural history of quitting, including withdrawal symptoms and perceived benefits of quitting; and (b) satisfaction with the program in relation to smoking status, smoking history, demographic and psychosocial factors, including reported stress levels, social support, and contact with other smokers. Analytical techniques included t tests and x2 analyses to assessbaseline differences among participants (see Table 2), logistic regression to predict smoking status at follow-up, and linear regression to predict program ratings.

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SMOKING CESSATION PROGRAM TABLE 2

CHARACTERISTICS OF PARTICIPANTS

Mean age (years) White-collar occupation Mean years of education Advised by physician to stop smoking Mean age of starting to smoke (in years) Number of cigarettes smoked per day* 20 or less 21 to46 41 or more Number of previous quit attempts Longest time previously abstinent from smoking (mean number of days)** One or both parents were smokers

(N = 55)

Men (N = 34)

42.0 94.5% 15.9 75.0% 18.7

41.9 82.4% 16.5 61.3% 17.4

42.0 89.9% 16.1 70.0% 18.2

22.6% 69.8% 7.6% 1.9

18.8% 53.1% 28.1% 3.2

21.2% 63.5% 15.3% 2.4

34 88.2%

110 78.2%

62 82.0%

-

Total (N = 89)

* Significantly different for men and women; x2 = 6.54; df = 2, P = 0.038. ** Significantly different for men and women; 1 = 2.25, P = 0.035(two-tailed).

RESULTS Participants The average age of participants was 42 years; 61% were female; and 95% were Caucasian. The majority (74%) were in the health professions, including administrators, researchers, nurses, and physicians; 18% held clerical, sales or service jobs; and 7% were housewives and retired persons. Forty-five percent were college graduates, and an additional 20% also held advanced degrees. Smoking histories of participants are summarized in Table 2. As seen in the table, male participants smoked significantly more than female participants when they entered the program (x2 = 6.54, df = 2, P = 0.038). Program Outcomes Quitting rates. Participants were considered to be nonsmokers if they reported having been abstinent from cigarettes 1 year after the program and also were not smoking at the time of the follow-up interview. At the time of the interviews, 15 men and 13 women were still not smoking. Those who were not reached for follow-up were assumed to be still smoking. Thus, a conservative estimate of the program’s long-term quit rate was 25%, based on 28 nonsmokers of 111 possible interviewees. Logistic regression was used to predict smoking status at the time of follow-up. This showed that individuals who successfully quit smoking were less dependent smokers (P = 0.002) who were more educated (P = 0.025), had lower levels of stress (P = 0.036), and had fewer friends who were smokers (P = 0.006). Women were more than twice as likely to be smokers at the l-year follow-up than were men (odds ratio = 2.55, P = 0.015). Duration of abstinence. Of the 89 participants interviewed, 82% quit for at least

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24 hr after the designated quit date. Initial quit rates were comparable for both men and women. Figure 1 shows that the majority of the relapsesoccurred within the first 60 days after quitting. In 57% of the smokers who relapsed, the relapses occurred during periods of stress at home or at work. Withdrawal symptoms. Commonly reported symptoms of abstinence from smoking were intense urges to smoke (77%), irritability (68%), and problems with concentration (54%). Depression and fatigue were each reported by approximately one-third (3l%), and sleepingdifficulty and gastrointestinal problems were each reported by approximately one-fourth of respondents (23%). The only withdrawal symptom that was significantly different for men and women was depression. Forty percent of the women reported that they felt depressedwhen they quit smoking, compared with 16% of the men (x2 = 5.1, df = 1, P = 0.02, N = 89). Frequencies of withdrawal symptoms were comparable for successful quitters and for those who were still smoking. However, individuals with high baseline scores on the Fagerstrom scale were significantly more likely to report the withdrawal symptoms of irritability (x2 = 3.9, df = 1, P = 0.05) and intense urges to smoke (x2 = 5.9, df = 1, P = 0.02) than individuals with low initial scores. Nicotine gum. Approximately 60% of the 89 interviewees tried the nicotine chewing gum: 24% used it for less than a week; 17%used it for 1 week to 1 month; 13%used it for l-3 months; and only 6% used it longer than 3 months. There were no significant differences between gum users and nonusers in duration of abstinence from smoking or in current smoking status. Rates of gum use were comparable among light, moderate, and heavy smokers. Urges to smoke. Nonsmokers (N = 28) were asked whether they continued to have the urge to smoke under several common conditions. The urge to smoke occurred most frequently when under stress (36%), when drinking alcohol (36%), and when around others who were smoking (14%). Benefits of quitting. Nonsmokers (N = 28) were asked whether they had noticed specific social, psychological, and health benefits after quitting smoking. Most respondents indicated that they felt a sense of personal accomplishment (88%), had made their family and friends happy (88%), and had learned new ways IOOz a, .c_ 7-i < = % &I a

806040-

20I

0

60

120

180

240

Time Since Quitting Smoking

300

,

360

(in days)

FIG. 1. Duration of abstinence from smoking among 89 participants in a group smoking cessation program. The high rate of relapse over the first 30-60 days suggests that smoking cessation programs should intensify their efforts during that period of time.

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to manage their stress (64%). The majority also experienced an improvement in breathing (7%), had less nasal congestion (73%), had less coughing (55%), more energy (55%), and had better smelling house, clothes, and car (67%). Food tasted better (64%) and caffeine and alcohol consumption were reduced (21 and 18%, respectively). Among nonsmokers, average weight gain was 17 pounds among men (SD = 10.1) and 12 pounds among women (SD = 5.8). Since information on weight gain was not collected from those who relapsed, we could not determine whether participants who were gaining substantial amounts of weight after quitting were more likely to return to smoking. Evaluation of Program Components

Participants were asked to rate the helpfulness of each of the 10 program components on a scale of 1 to 10 (1 = not at all helpful and 10 = extremely helpful). As Table 3 shows, the highest ratings were for self-monitoring, group support, cutting down the number of cigarettes, and CO monitoring. The lowest ratings were for information on health risks, nicotine gum, and information on diet and exercise. The rating for the program overall was higher than the rating of any individual component. Linear regression was used to determine whether demographic variables (education, age, sex), smoking history (level of addiction, amount smoked at program entry, years as a smoker), stress levels (during the program and at follow-up), social support (from friends, family, co-workers), and smoking status at follow-up were associated with participants’ ratings of the helpfulness of each component and of the program overall. The self-monitoring component was rated more highly by men than women (P = 0.05) and by participants who were younger (P = O.Ol), TABLE 3 PARTICIPANTS’RATINGSOF PROGRAMCOMPONENTS Outcome category

All participants (N = 89)

Nonsmokers (N = 28)

Smokers (N = 61)

7.7 7.2 7.2 6.8 6.0 6.0 5.7 5.1 4.7 4.6 8.0

a.5 7.6 7.3 6.7 6.2 5.9 6.1 4.9 3.9 3.6 9.2

7.3* 6.9 7.1 6.9 5.9 6.0 5.4 5.1 5.1 5.0 7.4**

Self-monitoring cards Group support Reducing number of cigarettes Carbon monoxide monitoring Switching brands Talks by ex-smokers Limit places you smoke Information on health risks Nicotine gum Information on diet and exercise Overall program Note. All ratings are based on a scale of l-10. * P < 0.05, based on t test (two-tailed). ** P < 0.001, based on t test (two-tailed).

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were more educated (P = 0.006), and had been smokers for fewer years (P = 0.02). Mean ratings of the importance of self-monitoring were significantly different for smokers and nonsmokers (P = 0.05, Table 3). However, smoking status did not reach statistical significance as a predictor variable (P = 0.09). The more addicted smokers gave higher ratings to switching brands and to CO monitoring (P = 0.004 and 0.005, respectively). Participants who felt that support from friends was helpful while quitting also gave higher ratings for the group support component of the program (P = 0.02). Nicotine gum received higher ratings from people who were younger (P = 0.005) and had been smoking for fewer years (P = 0.006). Information on the health risks of smoking was rated more highly by those with fewer years of education (P = 0.03). Talks by exsmokers were rated more highly by younger people (P = 0.007) and by those who had been smoking for fewer years (P = 0.008). The rating for the program overall was higher among those who reported lower stress levels at the time of the program (P = 0.03) and at the time of the follow-up interview (P = 0.008). The overall program rating was also higher among those who were successful at quitting (P = 0.004). DISCUSSION Several differences emerged between men and women. While men and women were equally able to quit smoking, women were two and a half times more likely to relapse and twice as likely to report depression as a withdrawal symptom. We did not measure depression at baseline, so it is not possible to distinguish whether the higher rates of depression among women represent a higher prevalence of dysphoric moods or metabolic changes due to the absence of nicotine, or are an indication of the tendency for women to have higher reporting rates for depression and emotional distress in general (22). Experiences of nicotine withdrawal symptoms were not significantly different for successful quitters. No differences in withdrawal symptoms were found on the basis of amount smoked at baseline, perhaps because of the gradual reduction in nicotine intake that occurred over the 3 weeks before quitting (23). This suggests that the discomfort of withdrawal had less influence on relapse rates than other factors, particularly perceived levels of stress (7, 8). Over half of the reported relapses occurred during times of stress, and 36% of the successful quitters reported still having an urge to smoke when under stress a year or more after quitting. The high rate of relapse during the first 30 to 60 days after quitting indicates that smokers are at a higher risk of relapsing at that time, and that smoking cessation programs should intensify their relapse prevention efforts after participants quit. Our program increased the time period between sessions after quit night, and the attendance rates were quite low for the later sessions. We encouraged participants to come regardless of their smoking status and to reset their quit date if they had relapsed. However, follow-up telephone calls from group leaders or an informal support system (e.g., buddy system) available on an as-needed basis might have helped to reduce the relapse rate as the formal sessions became less frequent. The role of nicotine gum in maintaining abstinence needs further clarification,

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since it can be addictive if used improperly (24). Although it has been suggested that nicotine gum makes only a small contribution to smoking cessation (1l), and its ratings in our program were relatively low, anecdotal reports from our participants suggestthat the gum was extremely helpful to a small percentage of people who used it properly and over an extended period of time. High ratings for self-monitoring provide further support for its use as a reliable method of behavior change (25-27). Self-monitoring is required by most smoking cessation programs becauseit provides information on baseline levels of smoking and changes due to treatment. However, studies of self-monitoring have found that paying attention to behavioral patterns can increase self-awarenessand lead to behavioral changes (27, 28); thus, it is widely used in the treatment of addictions and other psychophysiological disorders such as obesity, hypertension, and headache (29, 30). If smoking is seen as a psychophysiological problem (31), the high rating for self-monitoring may be regarded as an indicator of skills, ability, or readiness to change smoking behavior. Smoking status at follow-up influenced the overall rating of the program but did not predict participants’ preferences for any of the individual components. This may have been a halo effect, in that participants who successfully quit might retrospectively attribute their successto public commitment to a smoking cessation program. However, earlier studies (32,33) have found that successfulquitters use a greater variety of coping strategies than individuals who relapse. It seems likely that our successful quitters chose and implemented a combination of techniques that worked best for them, making the value of the whole program greater than any single component (3, 34). CONCLUSION

Participants in formal smoking cessation programs represent less than 10% of successful quitters (26). However, group smoking cessation programs still represent a viable alternative for those who choose a supportive group educational approach or feel unable to quit independently. The high rating for the overall program suggests that multicomponent programs, which give the participants a range of skills and techniques, have greater appeal than a single method. REFERENCES 1. Kottke TE, Battista RN, Defriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice: A met&analysis of 39 controlled trials. JAMA 1988;259:28822889. 2. Schwartz JL. A critical review and evaluation of smoking control methods. Public Health Rep 1%9; 84:483-506. 3. Schwartz JL. Review and Evaluation of Smoking Cessation Methods: The United States and Canada, 1978-1985. Bethesda, MD: U.S. Public Health Service, 1987; NIH Publication 872490. 4. Wilson DM, Taylor DW, Gilbert JR, Best JA, Lindsay EA, Willms DG, Singer J. A randomized trial of a family physician intervention for smoking cessation. JAMA 1099; 260~1570-1574. 5. Kottke TE, Brekke ML, Solberg LI, Hughes JR. A randomized trial to increase smoking intervention by physicians: Doctors helping smokers, Round 1. JAMA 1989; 261:2101-2106. 6. Venters MH, Solberg LI, Kottke TE, Brekke ML, Pechacek TF, Grimm RH. Smoking patterns

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33. Marlatt GA, Curry S, Gordon JR. A longitudinal analysis of unaided smoking cessation. J Consult Clin Psycho1 1988; 56:715-720. 34. Elliot CH, Doan RE, Olson RA, Beckham EE. Behavioral medicine: Litestyle and prevention. In: Walker CE, Ed. The Handbook of Clinical Psychology: Theory, Research and Practice. Homewood, IL: Dow Jones-Irwin, 1983. 35. Novotny TE. Cessation of smoking and the social milieu. Mayo Clin Proc 1988; 634:72%731. Received May 7, 1990 Revised September 26, 1990 Accepted October 8, 1990