PKEVEN’I‘IVEMEOIC,NE 6,130-133
Guidelines LLOYD American
(1977)
on Smoking A. SHEWCHUK AND
Health Foundation,
Cessation ERNST
L.
Clinics’ WYNDER
1370 Avenue of the Americas, New York 10019
New York,
The need is recognized for the development of a system for evaluating and approving safe, proven, and cost-effective methods for smoking cessation. An assessment model to determine the relative efficiency of different stop-smoking approaches is presented. It is suggested that major health agencies develop guidelines for an accreditation procedure to enable smokers seeking help in quitting smoking to find and be assured of effective programs.
INTRODUCTION
The need for developing procedures and programs to help people stop smoking has long been recognized (2,3). This need has not diminished in recent years; in fact, the trend towards an increasing number of smokers among younger people (4) makes this need more imperative than ever before. The mass media campaign and scientific community encouragement to urge people to stop smoking has resulted in a number of divergent programs, techniques, and quit-products developed and produced by both public and private sectors of the community. For the many millions of smokers who are constantly waging a daily battle of cutting down on their intake, stopping, starting, and generally fluctuating between an exsmoker and a smoker status, the myriad of stop-smoking aids and clinics has produced a help-seeker’s dilemma. Should the smoker seeking help turn to self-help products, private clinics, or public clinics? All present some disadvantages, and most tend to be misleading in terms of success rates and, thus, smoker expectations. Most self-help quit-products (such as nicotine chewing gum, books, and audio cassettes on how to quit smoking) provide little in the way of structure beyond the first brief period off cigarettes. Most clinics involve the smoker in an intensive, time-consuming, concentrated program which too often ends while the neonate exsmoker is just beginning to grapple with “addict-like” withdrawal symptoms. Help is available only in small doses or in large doses, there appears to be no in-between. Generally, a smoker doesn’t know what type of help he requires or how extensive it must be, frequently placing himself at the mercy of whatever promises the best results and the most guarantee. Much too often, the help-stop-smoking “industry” takes advantage of this situation by manipulating outcome data so as to attract the most customers. In order to better evaluate what is available to him, the smoker wanting to quit must be given ways of comparing help aids and clinics. Guidelines must 1This work was supported in part by Contract HSM-21-72-557from the National Clearinghouse for Smoking and Health, Bureau of Health Education, Center for Disease Control, DHEW; in part by Grant ACS MG-161 from the American Cancer Society, Inc.; and in part by Grant CA 17867-01from the National Cancer Institute, DHEW, NIH. 130 Copyright 0 1977 by Academic Press, Inc. All rights of reproduction in any form reserved.
ISSN 0091-7435
SMOKING
CESSATION
CLINIC
GUIDELINI
S
131
be made available, and some system of approving provt n, safe, cost-effective methods must be instituted and enforced. This paper outlines a model for program, evaluation, and cost-benefit assessmentsto determine the relative efficiency of different stop-smoking approaches. PROGRAM
GUIDELINES
Most formal smoking programs offer one intervention or approach at one level of interaction for all smokers. Quitting smoking is a complicated phenomenon. Some smokers never quit. Some do so only with great difficulty; very few do so with ease. Some require a great deal of support and aid. To place the smoker requiring very little aid into an all-inclusive, time-consuming program is a waste of resources, time, and money on everyone’s part. Similarly, graduating a smoker who needs a great deal of structure from simple self-help aids to ever-increasing complex programs can be frustrating and a waste of time for all concerned. Specific types of interventions must be matched to specific smoker characteristics so that smokers may be assigned or allowed to choose the most appropriate program with the greatest potential for success in their particular case. The American Health Foundation has developed an initial smoking history questionnaire and a follow-up questionnaire which have been analyzed to predict probable success at specific levels of intervention. This would necessitate offering a variety of approaches on a continuum of smoker-helper involvement, i.e., telephone message programs, structured audiovisuals, and various individual and group counseling procedures. Alternatively, the clinic offering only one approach should assess the smoker characteristics with which they have the greatest success and subsequently encourage the individuals with those characteristics to participate. The assignment criteria will undoubtedly include variables of general personality characteristics, individual styles of decision making and behavior change, as well as characteristics relating to the use of cigarettes. Second, every program must include a direct attack on the problem of recidivism. The fact that different techniques produce similar long-term success rates strongly suggests that the maintenance of smoking cessation must be viewed as a separate problem requiring separate solutions. The program which aids the smoker to quit initially is usually not the one which will help him maintain his cessation. Such maintenance approaches might include (a) long-term availability of trained support staff; (b) a “hot-line” telephone number one calls when feeling dangerously close to relapse; (c) ongoing graduate groups open on a need basis to all exsmokers; or (d) a buddy system; but (e), in all probability, a hierarchical series of programs will be called for. The results of such a series would also have to be enhanced by matching neonate exsmokers with specific levels and methods of maintenance. EVALUATION
GUIDELINES
There is no standard method of reporting the effectiveness of a particular cessation program. Some smokers enter a program and faithfully attend every session, others attend most, and still others drop out after their first visit. Over time, all of these individuals are affected to some degree by the program. In each group, there will be smokers who quit smoking, smokers who reduce their intake, smokers who
132
SHEWCHUK
AND
WYNDER
seem to fluctuate between quitting and starting again, and smokers who continue smoking as much as ever. With the passage of time, many of the successes become recidivists; Hunt et al. (1) indicate that 90% of recidivism occurs during the first 3 months after treatment. Many smoking-cessation programs report treatment effectiveness in a very misleading manner. For example, by counting only those smokers who attend all sessions of a program and only those who respond to mailed follow-up questionnaires, clinics are able to report near-perfect success rates. However, these data involve only a relatively small percentage of the population initially attending the program. Thus drop-outs, failures during the initial treatment, and those lost to follow-up are not counted. In reporting results of smoking-cessation activities, it is recommended that the following standards be utilized. (i) All individuals registering and attending even one session are counted and every effort is made during follow-up data collection to reach all persons who began the program. (ii) Those persons who cannot be reached within a reasonable time or after several attempts are counted as failures; (iii) Follow-up data collection periods extend to 1 year after treatment (including separate maintenance programs) with interim data collection points at 1 month and 6 months after treatment ends. (iv) At least four basic status groups are reported upon: (a) those individuals who quit by the end of treatment and who have not smoked more than one whole cigarette at any one time for the entire year (Success Group); (b) those individuals who make no change by the end of treatment and continue smoking the same or more throughout the entire year (Failure Group); (c) those individuals who quit at the end of a treatment but fluctuate between smoking and not smoking throughout the entire year (Recidivist Group); and (d) those individuals who do not quit at the end of a treatment program but who experience temporary cessation periods throughout the year (Fluctuator Group). COST-BENEFIT
ASSESSMENTS
The neglect of cost-effectiveness considerations in smoking-cessation evaluations is largely attributable to the difficulty of estimating costs and benefits and a tendency on the part of workers to ignore such economic calculations. Efforts in this direction, however crude and limited, are clearly valuable and need to be made. Given limited resources in the smoking-cessation field, investments should be made in programs which will do the most good. Such determinations require a balancing of effects against costs. Ideally, a formal evaluation would assess the potential value to the participant of a clinic program by means of a statistical decision model. The decision to continue or enter a program would be determined by weighing the cost benefits against the probability of success for specific smokers. As a minimum step, every smoking-cessation approach should include a brief account of the clinic operating costs (personnel and expenditures) and the success rates of each method of intervention. This would allow for an assessment of the relative efficiency of different clinic approaches.
SMOKING
CESSATION
CLINIC
GUIDELINES
133
Estimating the benefits of clinic programs is a formidable task. The benefits to an exsmoker are legion and include increased life expectancy, improved health, reduced hospital and medical costs, financial savings from ending cigarette purchases, etc. It is possible to convert all these benefits into a monetary figure based upon estimated decreased medical costs and increased life earnings. SUMMARY
AND CONCLUSIONS
The need was recognized for the development of a system of evaluating and approving safe, proven, and cost-effective methods for smoking cessation. An assessment model to determine the relative efficiency of different stop-smoking approaches was presented. It was suggested that the major health agencies such as the American Cancer Society develop guidelines for an accreditation procedure to enable smokers seeking help in quitting smoking to find and be assured of proven, safe, and costeffective programs. REFERENCES 1. Hunt, W. A., Barnett, L. W., and Branch, L. G. Relapse rates in addiction programs. J. C[in, Psychol. 27,455-456 (1971). 2. Shewchuk, L. A. Special report: Smoking cessation programs at the American Health Foundation. Prev. Med. 5, 454-474 (1976). 3. U.S. DHEW, National Clearinghouse for Smoking and Health, “Adult Use of Tobacco-1970,” xi-31 pp. DHEW Publ. No. HSM 73-8727, 1973. 4. U.S. DHEW, “Teenage Smoking: National Patterns of Cigarette Smoking, Ages 12 through 18, in 1972 and 1974.” DHEW Pub. ERATI-OCC-NCI, Department of Health, Education and Welfare, Public Health Service, 1975.
Guidelines LLOYD American
(1977)
on Smoking A. SHEWCHUK AND
Health Foundation,
Cessation ERNST
L.
Clinics’ WYNDER
1370 Avenue of the Americas, New York 10019
New York,
The need is recognized for the development of a system for evaluating and approving safe, proven, and cost-effective methods for smoking cessation. An assessment model to determine the relative efficiency of different stop-smoking approaches is presented. It is suggested that major health agencies develop guidelines for an accreditation procedure to enable smokers seeking help in quitting smoking to find and be assured of effective programs.
INTRODUCTION
The need for developing procedures and programs to help people stop smoking has long been recognized (2,3). This need has not diminished in recent years; in fact, the trend towards an increasing number of smokers among younger people (4) makes this need more imperative than ever before. The mass media campaign and scientific community encouragement to urge people to stop smoking has resulted in a number of divergent programs, techniques, and quit-products developed and produced by both public and private sectors of the community. For the many millions of smokers who are constantly waging a daily battle of cutting down on their intake, stopping, starting, and generally fluctuating between an exsmoker and a smoker status, the myriad of stop-smoking aids and clinics has produced a help-seeker’s dilemma. Should the smoker seeking help turn to self-help products, private clinics, or public clinics? All present some disadvantages, and most tend to be misleading in terms of success rates and, thus, smoker expectations. Most self-help quit-products (such as nicotine chewing gum, books, and audio cassettes on how to quit smoking) provide little in the way of structure beyond the first brief period off cigarettes. Most clinics involve the smoker in an intensive, time-consuming, concentrated program which too often ends while the neonate exsmoker is just beginning to grapple with “addict-like” withdrawal symptoms. Help is available only in small doses or in large doses, there appears to be no in-between. Generally, a smoker doesn’t know what type of help he requires or how extensive it must be, frequently placing himself at the mercy of whatever promises the best results and the most guarantee. Much too often, the help-stop-smoking “industry” takes advantage of this situation by manipulating outcome data so as to attract the most customers. In order to better evaluate what is available to him, the smoker wanting to quit must be given ways of comparing help aids and clinics. Guidelines must 1This work was supported in part by Contract HSM-21-72-557from the National Clearinghouse for Smoking and Health, Bureau of Health Education, Center for Disease Control, DHEW; in part by Grant ACS MG-161 from the American Cancer Society, Inc.; and in part by Grant CA 17867-01from the National Cancer Institute, DHEW, NIH. 130 Copyright 0 1977 by Academic Press, Inc. All rights of reproduction in any form reserved.
ISSN 0091-7435
SMOKING
CESSATION
CLINIC
GUIDELINI
S
131
be made available, and some system of approving provt n, safe, cost-effective methods must be instituted and enforced. This paper outlines a model for program, evaluation, and cost-benefit assessmentsto determine the relative efficiency of different stop-smoking approaches. PROGRAM
GUIDELINES
Most formal smoking programs offer one intervention or approach at one level of interaction for all smokers. Quitting smoking is a complicated phenomenon. Some smokers never quit. Some do so only with great difficulty; very few do so with ease. Some require a great deal of support and aid. To place the smoker requiring very little aid into an all-inclusive, time-consuming program is a waste of resources, time, and money on everyone’s part. Similarly, graduating a smoker who needs a great deal of structure from simple self-help aids to ever-increasing complex programs can be frustrating and a waste of time for all concerned. Specific types of interventions must be matched to specific smoker characteristics so that smokers may be assigned or allowed to choose the most appropriate program with the greatest potential for success in their particular case. The American Health Foundation has developed an initial smoking history questionnaire and a follow-up questionnaire which have been analyzed to predict probable success at specific levels of intervention. This would necessitate offering a variety of approaches on a continuum of smoker-helper involvement, i.e., telephone message programs, structured audiovisuals, and various individual and group counseling procedures. Alternatively, the clinic offering only one approach should assess the smoker characteristics with which they have the greatest success and subsequently encourage the individuals with those characteristics to participate. The assignment criteria will undoubtedly include variables of general personality characteristics, individual styles of decision making and behavior change, as well as characteristics relating to the use of cigarettes. Second, every program must include a direct attack on the problem of recidivism. The fact that different techniques produce similar long-term success rates strongly suggests that the maintenance of smoking cessation must be viewed as a separate problem requiring separate solutions. The program which aids the smoker to quit initially is usually not the one which will help him maintain his cessation. Such maintenance approaches might include (a) long-term availability of trained support staff; (b) a “hot-line” telephone number one calls when feeling dangerously close to relapse; (c) ongoing graduate groups open on a need basis to all exsmokers; or (d) a buddy system; but (e), in all probability, a hierarchical series of programs will be called for. The results of such a series would also have to be enhanced by matching neonate exsmokers with specific levels and methods of maintenance. EVALUATION
GUIDELINES
There is no standard method of reporting the effectiveness of a particular cessation program. Some smokers enter a program and faithfully attend every session, others attend most, and still others drop out after their first visit. Over time, all of these individuals are affected to some degree by the program. In each group, there will be smokers who quit smoking, smokers who reduce their intake, smokers who
132
SHEWCHUK
AND
WYNDER
seem to fluctuate between quitting and starting again, and smokers who continue smoking as much as ever. With the passage of time, many of the successes become recidivists; Hunt et al. (1) indicate that 90% of recidivism occurs during the first 3 months after treatment. Many smoking-cessation programs report treatment effectiveness in a very misleading manner. For example, by counting only those smokers who attend all sessions of a program and only those who respond to mailed follow-up questionnaires, clinics are able to report near-perfect success rates. However, these data involve only a relatively small percentage of the population initially attending the program. Thus drop-outs, failures during the initial treatment, and those lost to follow-up are not counted. In reporting results of smoking-cessation activities, it is recommended that the following standards be utilized. (i) All individuals registering and attending even one session are counted and every effort is made during follow-up data collection to reach all persons who began the program. (ii) Those persons who cannot be reached within a reasonable time or after several attempts are counted as failures; (iii) Follow-up data collection periods extend to 1 year after treatment (including separate maintenance programs) with interim data collection points at 1 month and 6 months after treatment ends. (iv) At least four basic status groups are reported upon: (a) those individuals who quit by the end of treatment and who have not smoked more than one whole cigarette at any one time for the entire year (Success Group); (b) those individuals who make no change by the end of treatment and continue smoking the same or more throughout the entire year (Failure Group); (c) those individuals who quit at the end of a treatment but fluctuate between smoking and not smoking throughout the entire year (Recidivist Group); and (d) those individuals who do not quit at the end of a treatment program but who experience temporary cessation periods throughout the year (Fluctuator Group). COST-BENEFIT
ASSESSMENTS
The neglect of cost-effectiveness considerations in smoking-cessation evaluations is largely attributable to the difficulty of estimating costs and benefits and a tendency on the part of workers to ignore such economic calculations. Efforts in this direction, however crude and limited, are clearly valuable and need to be made. Given limited resources in the smoking-cessation field, investments should be made in programs which will do the most good. Such determinations require a balancing of effects against costs. Ideally, a formal evaluation would assess the potential value to the participant of a clinic program by means of a statistical decision model. The decision to continue or enter a program would be determined by weighing the cost benefits against the probability of success for specific smokers. As a minimum step, every smoking-cessation approach should include a brief account of the clinic operating costs (personnel and expenditures) and the success rates of each method of intervention. This would allow for an assessment of the relative efficiency of different clinic approaches.
SMOKING
CESSATION
CLINIC
GUIDELINES
133
Estimating the benefits of clinic programs is a formidable task. The benefits to an exsmoker are legion and include increased life expectancy, improved health, reduced hospital and medical costs, financial savings from ending cigarette purchases, etc. It is possible to convert all these benefits into a monetary figure based upon estimated decreased medical costs and increased life earnings. SUMMARY
AND CONCLUSIONS
The need was recognized for the development of a system of evaluating and approving safe, proven, and cost-effective methods for smoking cessation. An assessment model to determine the relative efficiency of different stop-smoking approaches was presented. It was suggested that the major health agencies such as the American Cancer Society develop guidelines for an accreditation procedure to enable smokers seeking help in quitting smoking to find and be assured of proven, safe, and costeffective programs. REFERENCES 1. Hunt, W. A., Barnett, L. W., and Branch, L. G. Relapse rates in addiction programs. J. C[in, Psychol. 27,455-456 (1971). 2. Shewchuk, L. A. Special report: Smoking cessation programs at the American Health Foundation. Prev. Med. 5, 454-474 (1976). 3. U.S. DHEW, National Clearinghouse for Smoking and Health, “Adult Use of Tobacco-1970,” xi-31 pp. DHEW Publ. No. HSM 73-8727, 1973. 4. U.S. DHEW, “Teenage Smoking: National Patterns of Cigarette Smoking, Ages 12 through 18, in 1972 and 1974.” DHEW Pub. ERATI-OCC-NCI, Department of Health, Education and Welfare, Public Health Service, 1975.
