Individual behavioural counselling for smoking cessation

Lancaster T, Stead LF
Cover sheet - Background - Methods - Results - Discussion - References - Tables & Graphs

A substantive amendment to this systematic review was last made on 18 February 1999. Cochrane reviews are regularly checked and updated if necessary. Background and objectives: Individual counselling from a smoking cessation specialist may help smokers to make a successful attempt to stop smoking. The objective of the review is to determine the effects of individual counselling. Search strategy: We searched the Cochrane Tobacco Addiction Group trials register for studies with counsel* in any field. Date of the most recent search: October 1998. Selection criteria: Randomised or quasi-randomised trials with at least one treatment arm consisting of face to face individual counselling from a health care worker not involved in routine clinical care. The outcome was smoking cessation at follow-up at least six months after the start of counselling. Data collection and analysis: Both reviewers extracted data. The intervention and population, method of randomisation and completeness of follow-up were recorded. Main results: We identified eleven trials. Ten compared individual counselling to a minimal intervention, two compared two intensities of counselling, and one compared individual counselling to group therapy. Individual counselling was more effective than control. The odds ratio for successful smoking cessation was 1.55 (95% confidence interval 1.27 to 1.90). There was no evidence that more intensive counselling was more effective than brief counselling (odds ratio 1.17, 95% confidence interval 0.59 to 2.34). There was no evidence of a difference in effect between individual counselling and group therapy (odds ratio 1.33, 95% confidence interval 0.83 to 2.13). Reviewers' conclusions: Smoking cessation counselling can assist smokers to quit.

Background
Psychological interventions to aid smoking cessation include self-help materials, brief therapist delivered interventions such as advice from a physician or nurse, intensive counselling delivered on an individual basis or in a group, and combinations of these approaches. Previous reviews have shown a small, but consistent, effect of brief, therapist-delivered interventions (Silagy 1998). There is less evidence for the effectiveness of self-help interventions (Lancaster 1998). More intensive intervention in a group setting increases quit rates (Stead 1998). In this review, we assess the effectiveness of more intensive counselling delivered by a smoking cessation counsellor to a patient on a one to one basis. One problem in assessing the value of individual counselling is that of confounding with other interventions. For example, counselling delivered by a physician in the context of a clinical encounter may have different effects from that provided by a non-clinical counsellor. One approach to this problem is to employ statistical modelling (logistic regression) to control for possible confounders, an approach used by the Agency for Health Care Policy and Research in preparing its Clinical Practice Guideline on

Smoking cessation (AHCPR 1996a). An alternative approach is to review only unconfounded interventions. This is the approach we have adopted in the Cochrane Tobacco Addiction Review Group. Accordingly, for the purposes of this review, we have specifically excluded counselling provided by doctors or nurses during the routine clinical care of the patient, and focus on smoking cessation counselling delivered by specialist counsellors. We define counselling broadly, based only on a minimum time spent in contact with the smoker, not according to the use of any specific behavioural approach.

Objectives
The review addresses the following hypotheses: 1. Individual counselling is more effective than no treatment or brief advice in promoting smoking cessation. 2. Individual counselling is more effective than self-help materials in promoting smoking cessation. 3. A more intensive counselling intervention is more effective than a less intensive intervention. We also consider how individual counselling compares to group therapy. Although we have no a priori reason to assume that one is better than the other, we tested the null hypothesis that individual counselling is more effective than group therapy.

Criteria for considering studies for this review

Types of participants
Any smokers, except pregnant women. (Smoking cessation interventions in pregnancy have been addressed by a separate review (Lumley 1998)).

Types of intervention
Individual counselling was defined as a face-to-face encounter between a smoking patient and a counsellor trained in assisting smoking cessation. This review specifically excludes counselling delivered by doctors and nurses as part of clinical care, which are covered in separate reviews (Silagy 1998; Rice 1998).

Types of outcome measures

Sustained abstinence, or two point prevalence, was used where available. Studies using selfreport of cessation with or without biochemically validated cessation were included, and sensitivity analysis was performed to determine whether the estimates differed significantly in studies without verification.

Types of studies
Randomised or quasi-randomised controlled trials with a minimum follow-up of six months, where at least one treatment arm consisted of an unconfounded intervention from a counsellor.

Search strategy for identification of studies

See: Collaborative Review Group search strategy The Tobacco Addiction Group trials register was searched and studies with counsel* in title, abstract or keyword fields were checked for relevance. Previous reviews and meta-analyses were also checked: all the trials used in Tables 8 and 9 of the AHCPR guidelines (AHCPR 1996a, AHCPR 1996b) were considered.

Methods of the review

Data were extracted by both authors. The principal outcome was cessation rates. The information extracted included descriptive information (the population and intervention studied), method of randomisation, completeness of follow-up, and whether self-reported cessation was validated. Participants lost to follow-up were assumed to be continuing smokers.

Meta-analysis was performed using the Peto method (Yusuf 1985) to give a pooled estimate of effect as an odds ratio with 95% confidence intervals. The following comparisons were made: - Individual counselling versus no treatment, brief advice or self-help materials - More intensive versus less intensive individual counselling - Individual counselling versus group counselling

Description of studies
See: Table of included studies, Table of excluded studies Eleven studies were included in this review. Ten studies compared individual counselling to a minimal intervention. Support offered to the control comparison group ranged from usual care to up to 10 minutes of advice, with or without the provision of self-help materials. All the interventions which were classified as individual counselling involved more than 10 minutes of face to face contact. Five used a single session [Rigotti 1997, Simon 1997; Stevens 1993; Weissfeld 1991; Windsor 1988] but all of these included further telephone contact except the low intensity condition tested by Weissfeld and colleagues. Nicotine replacement therapy was systematically used in two trials. In one of these [Jorenby 1995] one of two different doses of nicotine patch was crossed with one of three levels of behavioural support (minimal, individual or group) in a factorial design. The minimal support group was given a self-help pamphlet by a physician and thereafter had weekly assessments but no further counselling. In one trial [Simon 1997] smokers randomised to receive counselling were given a prescription for nicotine gum if there were no contraindications. Although 65% used gum compared to 17% of the control group, its use was not significantly associated with quitting. In the control intervention, provision of written materials was generally confounded with brief advice. No trials directly addressed whether providing counselling in addition to a structured self-help programme increased efficacy. Therefore in the meta-analysis we have not distinguished between brief advice, usual care or provision of self-help materials as the control intervention with which counselling is compared. Effect of intensity of counselling Two studies which compared intensive counselling to less intensive intervention which still involved more than 10 minutes of face to face contact have been considered separately. One trial compared two intensities of counselling with a control - both intensities are combined in the first analysis but compared in this analysis [Weissfeld 1991]. The other trial assessed the additional benefit of a 16 session relapse prevention course when offered in addition to nicotine patch therapy and 4 meetings with a nurse practitioner who reviewed self-help materials, monitored patch use and provided counselling [Lifrak 1997]. Individual versus group counselling One study compared group counselling to individual sessions, both behavioural interventions being combined with use of a nicotine patch [Jorenby 1995]. A study using a health education lecture followed by a single session of individual counselling compared to a multi-session group behaviour therapy programme was excluded [Rabkin 1984]. Study populations Seven of the studies were conducted in hospitalised patients or outpatients. The level of motivation to quit smoking was difficult to assess from the details given. Unwillingness to attempt to quit was not an exclusion criteria in any study. However, only one trial enrolled all smokers admitted to hospital [Stevens 1993], whilst one enrolled 90% of smokers approached [Rigotti 1997]. In other studies a larger proportion of eligible smokers may have declined randomisation because of lack of interest in quitting. Of the trials in non-hospitalised smokers, two recruited community volunteers [Lifrak 1997; Jorenby 1995], one recruited smokers attending periodic health examinations [Bronson 1989] and one recruited employees volunteering for a company smoking cessation programme [Windsor 1988]. Intervention components The counselling interventions typically included the following components: review of a participants smoking history and motivation to quit, help in the identification of high-risk situations, and the generation of problem-solving strategies to deal with such situations.

Counsellors may also have provided non-specific support and encouragement. Additional components such as written materials, video or audiotapes may also have been provided. The main components used in each study have been listed in the Table of Included Studies. Intervention providers The therapists who provided the counselling were generally described as smoking cessation counsellors. Their professional backgrounds included social work, psychiatry and health education.

Methodological quality
See: Table of included studies Only three of the studies described a method of randomisation which could ensure that treatment assignment was blind until after allocation. In other trials randomisation was said to have been used but the method was not stated. One study has been included which has been described as a randomised trial (Meenan 1998). The primary report [Stevens 1993] makes it clear that the intervention was delivered to one of two hospitals, alternating on a monthly basis for 14 months. This design was used to avoid control patients hearing the intervention given to others in shared rooms. All eligible smokers in the intervention hospital were regarded as subjects whether or not the intervention was delivered, thus avoiding selection bias, and the intervention was not given by hospital staff. There were no significant differences between intervention and usual care groups at baseline; there were however a larger number of patients in the usual care group. As it seems unlikely that there would have been a high risk of systematic bias from this design the study is included but with a sensitivity analysis of the effect of excluding it. Biochemical validation of self reported non smoking was carried out for all quitters in five studies. In one the self report was validated by significant other in 6/29 quitters [Simon 1997]. In one study there were no self-reported quitters [Burling 1991]. A random sample of respondents were tested in one study [Pederson 1991], with 1/7 reported non smokers not confirmed. Quit rates were based only on self-report in three studies [Lifrak 1997; Bronson 1989; Stevens 1993].

Results
List of comparisons Pooling ten studies of counselling, including one [Burling 1991] in which there were no quitters, results in an odds ratio for the estimated effect of 1.55 (95% CI 1.27 to 1.90). The effect remains significant although the odds ratio is reduced if the trial without randomisation is excluded [Stevens 1993] (OR 1.41, 95% CI 1.11 to 1.80). A further sensitivity analysis including only trials with biochemical validation of self reported cessation gave similar results (OR 1.59, 95% CI 1.24 to 2.04). In two studies, there was no benefit of intensive compared to brief counselling, although the confidence intervals are wide and do not exclude the possibility of a clinically useful dose response effect (OR 1.17, 95% CI 0.59 to 2.34). One trial comparing individual counselling to group therapy as an adjunct to nicotine replacement therapy found no significant difference; there was a trend towards a higher quit rate in the counselling group and wide confidence intervals (OR 1.33, 95% CI 0.83 to 2.13).

Discussion
There is consistent evidence that individual counselling increases the likelihood of cessation compared to less intensive support. Whilst most of the trials were undertaken in hospitalised smokers, counselling was also shown to be effective in a workplace setting [Windsor 1988] and amongst community volunteers. These results are consistent with the conclusions of the review undertaken by the Agency for Health Care Policy and Research (AHCPR 1996a). Their analysis of 25 trials where treatment conditions differed in format (self-help, individual counselling with person-to-person contact or group counselling) found an odds ratio for successful cessation with individual counselling

compared to no intervention of 2.2 (95% CI 1.6 to 3.0) (AHCPR 1996a Table 9). The larger odds ratio found there than in our analysis may arise because their reference group included some trials with arms which received no intervention. Generally the comparison groups in the trials in this analysis did receive a minimal contact intervention or self-help materials. Individual counselling in their categorisation would have also included counselling from a physician, whilst this review is limited to non physician or nurse providers. However when AHCPR separately analyses the effect of different providers of care the estimates suggest that non medical care providers (a category including psychologists, social workers and counsellors) are at least as effective compared to a no provider reference group (OR 1.8, 95% CI 1.5 to 2.2) as either physicians (OR 1.5, 95% CI 1.2 to 1.9) or other medical health care providers (OR 1.4, 95% CI 1.1 to 1.8) (AHCPR 1996a Table 8). This may be due to confounding with intervention components, because non medical care providers are more likely to deliver intensive interventions than medical providers who more commonly give brief advice in a clinical setting. There was no evidence of significant heterogeneity between the odds of quitting in the different trials. Absolute quit rates did vary across interventions but this is likely to be related to the motivation of the smokers to attempt to quit and the way in which cessation was defined. Cessation rates were higher in trials where nicotine replacement therapy was also used [Jorenby 1995; Lifrak 1997] and amongst patients with coronary artery disease [Ockene 1992]. Quit rates tended to be lower in studies recruiting hospitalised patients unselected for their readiness to quit [Rigotti 1997; Stevens 1993]. All these features of a trial are likely to affect absolute quit rates, confounding a possible effect of the exact content of the intervention. The following description of the intervention used in the Coronary Artery Smoking Intervention Study (CASIS) [Ockene 1992] is broadly typical of the interventions used: The telephone and individual counseling sessions were based on a behavioral multicomponent approach in which counselors used a series of open-ended questions to assess motivation for cessation, areas of concern regarding smoking cessation, anticipated problems and possible solutions. Cognitive and behavioral self-management strategies, presented in the self help materials, were discussed and reinforced. Although it is impossible to exclude the possibility that small differences in components, and in the therapists training or skills, have an effect on the outcome, there is no evidence of this from the meta-analysis. Most of the counselling interventions in this review included repeated contact, but differed according to whether face to face or telephone contact was used after an initial meeting. There are too few trials to draw conclusions from indirect comparisons about the relative efficacy of the various strategies. Again, the homogeneity of the results suggests that the way in which contact is maintained may not be important. The two trials which directly compared different intensities of individual support did not show evidence of a dose response effect. These two studies had very different absolute quit rates; 6% in both treatments groups in a Veterans Medical Centre [Weissfeld 1991], compared to 36% and 28% amongst community volunteers given counselling as an adjunct to nicotine replacement [Lifrak 1997]. The comparison interventions may not have been sufficiently different to achieve different effects in these particular groups of smokers. We compared individual counselling with group therapy because this may be relevant to smokers seeking treatment, and to purchasers and providers of care. Smokers may have a preference for one or other format, and there may be differences in cost effectiveness even if success rates are similar. The cost effectiveness of group therapy in specialist smoking cessation clinics offering regular group programmes is likely to be higher than offering the same contact time to individuals, but brief counselling sessions with telephone follow up may be cost effective in different care settings or populations. Establishing the equivalence of treatment is more difficult than proving a difference, and there was very limited evidence in this comparison. All we can conclude is that at present there is no evidence for a difference between group and individual treatment.

Reviewers' conclusions
Implications for practice
Counselling interventions given outside routine clinical care, by smoking cessation counsellors including health educators and psychologists, assist smokers to quit.

Potential conflict of interest

None.

Acknowledgements
Our thanks to Peter Hajek and Roger Secker-Walker for their helpful comments.

References
References to studies included in this review Bronson 1989 (published data only)

*Secker-Walker RH, Lynn BS, Solomon LJ, Vacek PM, Bronson DL. Predictors of smoking behavior change 6 and 18 months after individual counseling during periodic health examinations. Prev Med 1990;19:675-85Bronson DL, Flynn BS, Solomon LJ, Vacek PM, Secker-Walker RH. Smoking cessation counselling during periodic health examinations. Arch Intern Med 1989;149(7):1653-6
Burling 1991 (published data only)

Burling TA, Marshall GD, Seidner AL. Smoking cessation for substance abuse inpatients. J Subst Abuse 1991;3:269-76
Jorenby 1995 (published data only)

Jorenby DE, Smith SS, Fiore MC, Hurt RD, Offord KP, Croghan IT, Hays JT, Lewis SF, Baker TB. Varying nicotine patch dose and type of smoking cessation counseling. JAMA 1995;274(17):1347-52
Lifrak 1997 (published data only)

Lifrak P, Gariti P, Alterman AI, McKay J, Volpicelli J, Sparkman T, OBrien C. Results of two levels of adjunctive treatment used with the nicotine patch. Am J Addict 1997;6:93-8
Ockene 1992 (published data only)

*Ockene JK, Kristeller J, Goldberg R, Ockene IS, Merriam P, Barrett S, et al. Smoking cessation and severity of disease: The coronary artery smoking intervention study. Health Psychol 1992;11:119-26Rosal MC, Ockene JK, Ma YS, Hebert JR, Ockene IS, Merriam P, Hurley TG. Coronary Artery Smoking Intervention Study (CASIS): 5-year Follow-up. Health Psychol 1998;17(5):476-8
Pederson 1991 (published data only)

Pederson LL, Wanklin JM, Lefcoe NM. The effects of counseling on smoking cessation among patients hospitalized with chronic obstructive pulmonary disease: a randomized clinical trial. Int J Addict 1991;26(1):107-19
Rigotti 1997 (published data only)

Rigotti NA, Arnsten JH, McKool KM, WoodReid KM, Pasternak RC, Singer DE. Efficacy of a smoking cessation program for hospital patients. Arch Intern Med 1997;157:2653-60
Simon 1997 (published data only)

Simon JA, Solkowitz SN, Carmody TP, Browner WS. Smoking cessation after surgery A randomized trial. Arch Intern Med 1997;157:1371-6
Stevens 1993 (published data only)

*Stevens VJ, Glasgow RE, Hollis JF, Lichtenstein E, Vogt TM. A smoking-cessation intervention for hospital patients. Med Care 1993;31(1):65-72Meenan RT, Stevens VJ, Hornbrook MC, LaChance PA, Glasgow RE, Hollis JF, Lichtenstein E, Vogt TM. Costeffectiveness of a hospital-based smoking cessation intervention. Med Care 1998;36:6708
Weissfeld 1991 (published data only)

Weissfeld JL, Holloway JL. Treatment for cigarette smoking in a Department of Veterans Affairs outpatient clinic. Arch Intern Med 1991;151:973-7
Windsor 1988 (published data only)

Windsor RA, Lowe JB, Bartlett EE. The effectiveness of a worksite self-help smoking cessation program: a randomized trial. J Behav Med 1988;11:407-21
* indicates the major publication for the study References to studies excluded from this review Lando 1992

Lando HA, Hellerstedt WL, Pirie PL, McGovern PG. Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation. Am J Public Health 1992;82(1):41-6
Rabkin 1984

*Rabkin SW, Boyko E, Shane F, Kaufert J. A randomized trial comparing smoking cessation programs utilizing behaviour modification, health education or hypnosis. Addict Behav 1984;9(2):157-73Kaufert JM, Rabkin SW, Syrotuik J, Boyko E, Shane F. Health beliefs as predictors of success of alternate modalities of smoking cessation: results of a controlled trial. J Behav Med 1986;9(5):475-89
Schwartz 1967

Schwartz JL, Dubitzky M. Clinical reduction of smoking: a California study. Addiction 1967;14: 35-44
Additional references

AHCPR 1996a

Fiore MC, Bailey WC, Cohen SJ et al. Smoking Cessation. Clinical Practice Guideline No 18. Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. AHCPR Publication No. 96-0692. April 1996.
AHCPR 1996b

Fiore MC, Bailey WC, Cohen SJ et al. Smoking Cessation. Guideline Technical Report No 18. Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. AHCPR Publication No. 97-N004. October 1996.
Lumley 1998

Lumley J, Oliver S, Waters E. Smoking cessation programs implemented during pregnancy (Cochrane Review). In: The Cochrane Library, Issue 1, 1999. Oxford: Update Software.
Meenan 1998

Meenan RT, Stevens VJ, Hornbrook MC, La Chance PA, Glasgow RE, Hollis JF,et al. Cost-effectiveness of a hospital-based smoking cessation intervention. Med.Care 36(5):670-678, 1998.
Rice 1998

Rice VH, Stead LF. Nursing interventions for smoking cessation (Protocol for a Cochrane review). In: The Cochrane Library, Issue 1, 1999. Oxford: Update Software.
Silagy 1998

Silagy C, Ketteridge S. Physician advice for smoking cessation (Cochrane Review). In: The Cochrane Library, Issue 1, 1999. Oxford: Update Software.
Yusuf 1985

Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis 1985;27:335-71.

Cover sheet Individual behavioural counselling for smoking cessation

Reviewer(s) Date of most recent amendment Date of most recent substantive amendment Contact address Lancaster T, Stead LF 07 May 1999 18 February 1999 Dr Tim Lancaster ICRF General Practice Research Group Division of Public Health and Primary Health Care

Cochrane Library number Editorial group Editorial group code

Institute of Health Sciences Old Road, Headington Oxford UK OX3 7LF Telephone: +44 1865 226997 Facsimile: +44 1865 227137 E-mail: tim.lancaster@dphpc.ox.ac.uk CD001292 Cochrane Tobacco Addiction Group HM-TOBACCO

This review should be cited as :

Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation (Cochrane Review). In: The Cochrane Library, Issue 4, 1999. Oxford: Update Software.

Sources of support
Extramural sources of support to the review NHS Research and Development Programme UK Intramural sources of support to the review Imperial Cancer Research Fund General Practice Research Group UK

Keywords
HUMAN; *SMOKING-CESSATION; *BEHAVIOR-THERAPY; TREATMENT-OUTCOME; *COUNSELING;

Tables & Graphs

MetaView graphs List of comparisons Table of included studies Table of excluded studies

List of comparisons
Fig 01 INDIVIDUAL COUNSELLING COMPARED TO COMPARISON INTERVENTION

01.01.00 Smoking cessation at longest follow-up

Fig 02 INDIVIDUAL VS GROUP COUNSELLING

02.02.00 Smoking cessation at longest follow-up

Tables of other data

Tables of other data are not available for this review

Table of included studies

St ud Method y Br Setting: internal on medicine practice, so USA n Recruitment: 19 attenders for 89 periodic health examinations Randomisation: method not stated Participants 155 smokers (38% male) av. age 42, av. cigs/day 25 Therapist: smoking cessation counsellor Interventions Outcomes Notes

B Setting: Inpatient ur substance abuse lin treatment centre, g USA 19 Recruitment: 91 inpatient volunteers Randomisation: method not specified Jo Setting: clinical re research centres, nb USA (2 sites) y Recruitment: 19 community 95 volunteers Randomisation: double-blind for pharmacotherapy, method not stated

39 male veteran inpatients Therapist: paraprofessional counsellor (Social Work Master's candidate) 504 smokers >= 15 cigs/day av. age 44, av. cigs/day 26-29 Therapists: Trained smoking cessation counsellors

1. Two 20 min Abstinence counselling sessions at 18 months during a periodic (sustained health examination from 6-18 (benefits of quitting, months) assessment of Validation: motivation, quit plan, no high risk/problem biochemical solving) validation 2. Control (completed smoking behaviour questionnaire) Physicians carrying out health examinations were blind to group assignment and would have given similar advice to all participants. 1. Smoking Abstinence 6 cessation months after programme; daily 15 discharge min counselling Validation session and none - no computer guided self-reported nicotine fading with quitters at contingency contract 6m 2. Wait list control. Compared 22mg/d 7 day point No significant vs 44 mg/day prevalence difference in dose nicotine patch and 3 abstinence related outcome and types of adjuvant at 26 weeks no dose-counselling treatment. All Validation; interaction at 26 participants had 8 CO <10ppm. weeks reported, so weekly assessments patch arm collapsed by research staff in analysis. 2 vs 1, 1. Minimal - Given counselling vs NRT self-help pamphlet alone, 2 vs 3, by physician during individual vs group screening visit for counselling trial entry, and instructed not to smoke whilst wearing patch. No further contact with counsellors. 2. Individual - Given

Lif Setting: substance ra abuse outpatient k facility, USA 19 Recruitment: 97 community volunteers Randomisation: method not specified

O Setting: cardiac ck catheterization labs en at 3 hospitals, USA e Recruitment: 19 Smokers or recent 92 quitters with coronary artery stenosis, following arteriography Randomization: method not stated Pe Setting: Chest unit, de USA rs Recruitment: on Inpatients with 19 COPD 91 Randomization:

self-help pamplet at screening visit along with motivational message. Also met nurse counsellor 3 times following quit date. Counsellor helped generate problem solving strategies and provided praise and encouragement. 3. Group - Given self-help pamplet at screening visit along with motivational message. Received 8x 1hr weekly group sessions. Skills training, problem solving skills. 69 smokers Both interventions Abstinence 12 administrative av. age 39, included use of at 12 dropouts/exclusions av.cigs/day 25 nicotine patch (24hr, months, 1 not included, Therapists: 10 week tapered week point treatment group not nurse dose) prevalence specified. practitioner for 1. 1. Moderate Validation: Both interventions and 2, clinical intensity - 4 urine regarded as social worker or meetings with nurse cotinine for counselling, used in psychiatrist who reviewed self- some comparison of experienced in help materials and participants, intensity. addiction instructed in patch but no treatment for 2. use. corrections 2. High intensity. As made for 1 plus 16 weekly misreporting. 45min cognitive behavioural relapseprevention therapy 267 smokers 1. Minimal Abstinence Average length of (256 surviving at intervention - 10 at 12 months contact for 12m follow-up) minutes advice and (sustained intervention was av. age 53, av. review of an for 6m) 1.22 hr (20min to cigs/day 25 information sheet Validation: >5hr) Therapists: 2. Inpatient saliva Masters level counselling session, cotinine health educators 30 mins, outpatient <20ng/ml visits and telephone calls. Opportunity to attend group program 74 cigarette 1. Advice to quit Abstinence 8 deaths (6 in 1, 2 in smokers 2. Individual at 6 months 2.) excluded, 8 lost av. age 53, 75% counselling; Sample to follow-up included smoked 20+/day between 3 & 8 15- validated by Therapist: Non 20 min sessions on COHb specialist trained alternate days

method not stated

in counselling

Ri Setting: hospital, go USA tti Recruitment: 19 Inpatients in 97 medical or surgical services, smoking >1 cig in month before admission Randomisation: method not stated

Si Setting: Veterans m Administration on hospital, USA 19 Recruitment: 97 smokers undergoing noncardiac surgery Randomisation: random list of treatment assignments in sealed opaque envelopes

St Setting: 2 health ev maintenance en organisation s hospitals, USA 19 Recruitment: All 93 hospitalised smokers or recent exsmokers with stay >36hrs Randomisation: not random; intervention team alternated between hospitals on a monthly basis.

during hospitalisation. Selfhelp manual, support & encouragement. 615 smokers or 1. Single bedside Abstinence recent quitters counselling session at 6 months (excluding 35 (motivational Validation: deaths). 37% of interviewing, saliva intervention and cognitivecotinine 32% of controls behavioural and had a current relapse prevention smoking related techniques), av 15 health problem. mins, self-help Therapist: materials, chart research prompts, 1-3 assistant telephone calls post supervised by a discharge nurse 2. Usual care 299 smokers 1. Multicomponent: Abstinence 65% of 1. and 17% (98% male) single counselling at 12 months of 2. reported using av. age 54, av. session (30-60m) NRT, but use of cigs/day 20 prior to discharge Validation: NRT was not Therapist: public (based on social serum or significantly health educator learning theory and saliva associated with stages of change). cotinine quitting in either Video, prescription <15ng/ml. 6 group for nicotine gum if self-reports no contraindications. confirmed Five follow-up only by counselling calls 'significant over 3 months other'. 2. Brief counselling (10 min) and selfhelp materials. 1119 smokers or 1. 20 minute Abstinence A sensitivity recent quitters counselling session, at 12 months analysis on the (5%) 12 min video, quit (2 point effect of exclusion of av. age 44, av. kit, choice of selfprevalence, this non random cigs/day 20 help materials, 1-2 3 & 12m) study is reported. Therapists: follow-up telephone Validation: There were no Masters level calls, access to due to low statistically cessation hotline, bimonthly success in significant baseline counsellors newsletter mailings. obtaining differences between To reduce 2. Usual care samples for patient contamination cotinine characteristics in between analysis, intervention and intervention and data are control groups, but control periods based on there are no details hospital staff self-report. of whether quit rates members were were similar not involved in amongst patients intervention receiving the intervention in each hospital/monthly period.

W Setting: Veterans 466 male ei Administration OP smokers ss clinics, USA av. age 55 fel Recruitment: years, av. d veterans attending cigs/day 26 19 walk-in and general Therapists: 91 medicine clinics smoking invited to attend cessation quit smoking counsellors program Randomisation: numbered envelopes containing treatment assignment derived from random number table. Randomisation to high or low intensity occurred after delivery of low intensity session.

1. Control pamphlet on hazards of smoking 2. Low Intensity counselling - single session 20-30 minutes and selfhelp booklet 3. High intensity counselling - same initial session, with sustained contact of 3 months. One further face to face session, telephone calls and mailings, behavioural selfhelp manual. Prescription and sample of nicotine gum and instructions for use.

Abstinence for 1m at 6 months (9 months for high intensity group, 6m after last contact) Validation: nicotine metabolites in urine

Using validated quit rates there was no difference between 2 and 3, although self reported quitting was greater in 3. 2 &3 vs 1 with sensitivity analysis of 2 vs 1. 3 vs 2 in analysis of intensity

Wi Setting: University 378 smokers All groups received Abstinence There was no nd worksite, USA av. age 37, av. a 10 minute session at 1 year apparent effect of so Recruitment: cigs/day 23-27 of brief advice (sustained at monetary incentives r Employees Therapist: health 1. + self-help 6w, 6m, 1y) so this arm is 19 volunteering for a educator manuals Validation: collapsed. 4 &2 vs 3 88 quit smoking 2. + self-help and saliva &1. No. of quitters programme another session of thiocyanate from graphs, Randomisation: counseling (20<100ng/ml at checked against sealed numbered 30mins) with skills all followAHCPR data envelopes training, buddy ups. (AHCPR 1996b). containing selection and a computer contract. generated 3. as 1. with assignment, prior to monetary awards for baseline interview. cessation 4. as 2. with monetary rewards for cessation NRT - Nicotine replacement therapy

Table of excluded studies

Study Reason for exclusion Lando There was no face to face contact with counsellors. Contact was by proactive telephone 1992 calls. Rabkin The health education arm of the trial included a group meeting with didactic lecture, film 1984 and discussion, followed by a single individual session with a therapist. It was decided that this did not meet the criteria for indiviual counselling. Schwar Success was defined as reduction in smoking of over 85%, not complete abstinence. tz 1967

The Cochrane Library