Group behaviour therapy programmes for smoking cessation

Group behaviour therapy programmes for smoking cessation
Stead LF, Lancaster T
A substantive amendment to this systematic review was last made on 22 May 1998. Cochrane reviews are regularly checked and updated if necessary.
Background and objectives: Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support. The aims of this review were to determine the effects of smoking cessation programmes delivered in a group format compared to self-help materials, or to no intervention; to compare the effectiveness of group therapy and individual counselling; to determine the effect of adding group therapy to advice from a health professional or nicotinereplacement andto determine therate at which offers of grouptherapy aretaken up.
Search strategy: We searched the Cochrane Tobacco Addiction Group trials register.
Selection criteria: We considered randomised trials which compared group therapy with self-help, individual counselling, another intervention or usual care or waiting list control. We also considered trials which compared two group programmes with manipulation of the group interaction and social support components. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.
Data collection and analysis: We extracted data in duplicate on the type of subjects, the nature of the groups and the controls, the outcome measures, method of randomisation, and completeness of follow-up.
The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow-up were counted as smokers. Where possible, we performed meta-analysis using a fixed effects model.
Main results: Thirteen studies compared a group programme with a self-help programme. There was an increase in cessation with the use of a group programme (odds ratio 2.10, 95% confidence interval 1.64 to 2.70). Group programmes were more effective than no intervention or minimal contact interventions (odds ratio 1.91, 95% confidence interval 1.20 to 3.04). There was no evidence from two trials that group therapy was more effective than a similar intensity of individual counselling. There was no evidence that manipulating the social interactions between participants in a group programme had an effect on outcome. There was limited evidence that the addition of group therapy to other forms of treatment, including advice from a health professional or nicotine replacement produced extra benefit. There was variation in the extent to which those offered group therapy accepted the treatment.
Reviewers’ conclusions: There is evidence that groups are better than self-help, and other less intensive interventions. There is not enough evidence on their effectiveness compared to intensive individual counselling.
Background
A common method of delivering smoking cessation interventions is through group programmes. Over 100 group therapies have been described in the literature (Hajek, 1996). The purposes of group programmes have been summarised as; to analyse motives for group members’ behaviour, to provide an opportunity for social learning, to generate emotional experiences and to impart information and teach new skills (Hajek 1996; Hajek 1985). Group programmes may be led by professional facilitators; clinical psychologists, health educators, nurses or physicians, or occasionally by successful users of the programme.
The implementation of smoking cessation programmes in groups has been a popular method of delivering behavioural interventions. Behavioural interventions typically include such methods as coping and social skills training, contingency management, self-control, and cognitive-behavioural interventions. The use of a group format for the delivery of a behavioural intervention would appear to have two underlying rationales. Lying between self-help methods with minimal therapist contact and intensive individual counselling/therapy a group might offer better cessation rates than the former with lower costs per smoker than the latter. There may be a specific therapeutic benefit of the group format in giving smokers the opportunity to share problems and experiences with others attempting to quit. This might lead to increased quit rates even compared to individual face to face methods.
Suggested components of a ‘state of the art’ group cessation clinic programme include (a) setting a specific quit date, (b) learning to interrupt the conditioned responses which support smoking by self monitoring, (c) making plans for coping with temptations to smoke following cessation, and (d) providing follow-up contact and social support for quitting and continued abstinence (Fisher 1993). However group programmes vary greatly in their content, and may also include elements such as contingency contracting – the setting of rewards or punishments for achieving or failing to meet targets. Instructions for the effective use of nicotine replacement therapy may also be included. Programmes vary in their intensity; the number and length of sessions, and total duration. Programmes may be offered in health care settings or worksites, or by for profit organisations and voluntary agencies.
This review aims to evaluate the use of group delivered behavioural interventions to bring about smoking cessation.
Objectives
To determine the effectiveness of group delivered behavioural interventions in achieving long-term smoking cessation.
We wished to test the following hypotheses:
– Programmes including group meetings are more effective than programmes without group contact
– Programmes including group meetings are more effective than individual counselling
– Programmes including group meetings are more effective than no treatment or minimal interventions
– Group programmes as an adjunct to nicotine replacement therapy (NRT) are more effective than NRT alone
– Group programmes are more effective if there is increased group interaction
A second objective was to determine the rate of uptake of group therapy under different intervention conditions.
Criteria for considering studies for this review
Types of participants
Smokers of either gender irrespective of their initial level of nicotine dependency, recruited from any setting. Studies which randomised therapists, rather than smokers, to offer group therapy or control could be included providing that the specific aim of the study was to examine the effect of group therapy on smoking cessation.
Types of intervention
We considered studies in which smokers met and received some form of behavioural intervention, such as information, advice and encouragement or cognitive behavioural therapy delivered over at least two sessions. We excluded studies of interventions where participants met once for an orientation or information session. Studies which included group meetings as part of a treatment primarily using aversive smoking, acupuncture or hypnotherapy were excluded unless there were other relevant arms. They have been reviewed separately (Hajek 1997, White 1997, Abbott 1998). Trials in which smokers received group therapy in addition to active or placebo pharmacotherapy were excluded unless there were other relevant arms. The effect of nicotine replacement therapy has been evaluated in a separate review (Silagy 1997) but studies in which group therapy was tested as an adjunct nicotine replacement were included.
Types of outcome measures
The main outcome was abstinence from cigarettes at follow-up at least 6 months after initiation of treatment. Trials reporting only shorter follow-up were excluded. Trials which did not include measurement of smoking cessation were also excluded.
In each study the strictest available criteria to define abstinence were used. For example, in studies where biochemical validation of cessation was available, only those participants who met the criteria for biochemically confirmed abstinence were counted as abstinent. Wherever possible, a sustained cessation rate, rather than point prevalence, was used. Where patients were lost to follow-up they were regarded as being continuing smokers.
Types of studies
Trials were eligible for inclusion if participants were randomly allocated to treatment groups. Trials of worksite smoking cessation programmes which randomised work sites to different programmes were included.
Search strategy for identification of studies
See: Collaborative Review Group search strategy
We identified trials from the specialised register of trials held by the Tobacco Addiction Group. Details of the general search strategy for this are in the Tobacco Addiction module. Possible trials were retrieved using any of the keywords ‘Behaviour therapy’, ‘Group therapy’ and ‘Cognitive therapy’ or free-text terms ‘behav*’ and ‘group’. Included in the specialised register are trials derived from the Cochrane Controlled Trials Register which includes the results of handsearching of the following journals covering the Behavioural Sciences:
Behaviour Research and Therapy
Journal of Consulting and Clinical Psychology
Behaviour Therapy
Journal of Behavioural Medicine
We also looked at all the trials used by the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline on smoking cessation in meta-analyses assessing the efficacy of different treatment formats.
Methods of the review
Trials which met the screening criteria of having one group therapy arm and sufficient length of follow-up were identified by LS. All these were reviewed independently by LS and BB with disagreements referred to TL. Allocation of treatment arms to one or more comparison groups and data extraction was carried out by LS and BB, with disagreements referred to TL.
If a trial had both a comparable programme with non group delivery and a waiting list or minimal intervention control both were included in the appropriate comparisons. If two different group programmes were compared with another method or a control, the group interventions were combined in the comparison of group versus non group methods.
In studies comparing alternative delivery formats of more than one programme each was treated as a separate trial and entered separately into the meta-analysis. This was felt to be the most conservative approach, since even if the study had reported no significant difference between programmes the power to detect such a difference was generally low.
We made the following comparisons:
Groups vs self-help programmes
Group therapy plus self help manuals vs the same self-help programme alone
Group therapy plus self-help manuals vs a different self-help programme
Groups vs individual counselling sessions
Groups vs other interventions
Group therapy vs physician or nurse advice
Group therapy vs health education
Group therapy plus NRT vs NRT alone
Groups vs minimal intervention/ no contact control
Group therapy with increased group interaction vs a standard group therapy
In trials where details of the methodology were unclear, or where results were not expressed in a form which allowed extraction of the necessary key data, investigators were contacted for the required information.
For all meta-analytic comparisons the Peto method is used to derive a pooled odds ratio with 95% confidence intervals (Yusuf 1985).
Description of studies
See: Table of included studies, Table of excluded studies
Nineteen studies compared a group programme with another cessation treatment method, or a control. Several of these compared group therapy with more than one alternative and were used in each relevant comparison group. Three trials compared variants of group programmes to test the importance of the mutual support engendered in a group setting.
Most studies recruited community volunteers prepared to participate in group programmes. Two studies recruited in primary care settings [Hollis 1993; McDowell 1985]. One study recruited participants with a diagnosed cardiovascular health problem [Rice 1994] and one people with diabetes [Sawicki 1993]. Three studies conducted at DePaul University recruited employees in worksites which had been randomly assigned to provide different programme formats. One other study [Omenn 1988] also recruited at a worksite, but individual smokers were randomised to treatment.
The length, format and content of the group programmes provided was very variable. For ease of reference we have tabulated this information in the Results section, whilst the description in the Table of Included Studies covers study methods and brief details of each intervention.
COMPARISON OF GROUP AND SELF-HELP PROGRAMMES
Three studies compared a group programme with the same content provided by written materials alone. Curry 1988 tested two approaches, one emphasising absolute abstinence and the other using a relapse prevention approach. Glasgow 1991 compared three different programmes suitable for self-help use. Two were manuals using a structured behaviour therapy approach, the third was a multimedia quit kit with tips for quitting. All of these programmes lasted for 8 weeks. Rice 1994 used the shorter Smokeless programme. In this study the self-help participants received 5 telephone calls during the two week programme to remind them to open the envelopes containing the appropriate booklet for the day.
Four trials used a group programme as an adjunct to a televised cessation programme as well as self-help materials. Three of these recruited smokers from worksites which had been randomly assigned to provide manuals or additional group meetings. In the fourth, smokers who had registered to receive a self-help manual were randomised to receive the materials alone or the additional offer of group programmes [Gruder 1993]. In this study two different group programmes were tested, both of three sessions. Their results are combined for comparison with self-help.
Three studies did not use an identical programme manual for the group and self-help conditions. In one the participants randomised to use self-help were allowed a choice of manuals [Hollis 1993]. In addition during a single meeting with the health counsellor they were encouraged to set a quit date, and one follow-up telephone call was arranged. They were then mailed tip sheets and 6 bi-monthly newsletters. Randomised participants who did not visit the health counsellor to receive their materials were mailed the appropriate programme, so a proportion of those assigned to group therapy effectively received a self help intervention. In a third treatment condition participants were randomised to make a choice between self-help materials and attending a group programme, but this has not been included in a formal comparison. In one trial [Hilleman 1993] there were no details of the programme used in the group format but the self-help component consisted of a brief pamphlet. In this factorial trial of behavioural components and clonidine there was no evidence for an interaction with the pharmacotherapy so the clonidine/placebo arms have been collapsed. In the remaining trial in this category [Omenn 1988] participants with a stated preference for a group programme, and participants with no preference, were randomised to attend either a 3 week or an eight week group programme, or use a self-help guide alone. The two group programmes are combined in the analysis.
COMPARISON OF GROUP AND INDIVIDUAL THERAPY
One trial [Rice 1994] also compared group treatment with an individual treatment intervention using the same Smokeless programme. Participants met with a clinical nurse specialist therapist for the same schedule of meetings as in the group format. Jorenby 1995 compared an 8 week group programme with 3 brief individual counselling sessions from a nurse at 1, 2 and 4 weeks. Participants in each format were also randomly assigned to receive one of two doses of nicotine patch.
COMPARISON OF GROUPS WITH OTHER TREATMENTS
Group therapy compared to physician or nurse advice alone
All five studies in this comparison recruited in a health care setting. Two of the studies which compared different programme delivery formats also included an advice only control [Hollis 1993; Rice 1994]. Hollis 1993 included a condition in which participants received the same 30 second health provider advice as other arms, and in addition a brief pamphlet from the health counsellor. Rice 1994 included a no intervention group, but this included advice from a clinical nurse specialist to quit smoking because of the patients’ cardiovascular health problems. In three other trials physician advice was an alternative to a group programme. McDowell 1985 compared two different group programmes with an intervention in which participants were asked to attend a 15 minute appointment with their physician for smoking cessation advice and a self-help booklet. Sawicki 1993 compared referral to a group programme to referral for a 15 minute physician advice session. Cottraux 1983 compared a three session group programme to two ten minute meetings with a doctor who prescribed a placebo. The authors describe this as a placebo control and the function of the doctor was to recommend the use of the tablets – which contained lactose – rather than to give other support.
Group therapy compared to health education
Rabkin 1984 compared a group programme to an intervention described as health education, consisting of a single group meeting which included a lecture on the health consequences of smoking. Participants decided on a method and made a commitment to quit, then had a single individual counselling session one week later.
Group therapy plus NRT compared to NRT alone
Ginsberg 1992 compared a prescription of nicotine gum plus a four week behavioural programme, to nicotine gum plus two group sessions at which participants were given educational materials. Jorenby 1995 included a minimal contact control group in which participants just used 22mg or 44mg nicotine patches and attended weekly assessment sessions without counselling.
GROUP PROGRAMMES COMPARED TO OTHER CONTROL INTERVENTIONS
Five trials included control groups which we considered to have little or no specific content to encourage cessation. Hill 1993 used an exercise programme as a placebo control condition, based on previous research indicating that this was not an effective cessation method. The exercise group did however receive a self-help stop-smoking pamphlet and encouragement to quit. McDowell 1985 included a control group of smokers who had volunteered for the study but were asked only to complete smoking diaries and questionnaires at follow-up. The remaining three trials had waiting list control groups [Cottraux 1983; Leung 1991; Pederson 1981].
GROUP DYNAMICS
Several studies have tried to determine which factors contribute to the effect of groups. Digiusto 1995 compared a group programme which emphasised social support with one emphasising self-control. The organisation of the groups differed, with the first emphasising contact with other participants, the other using a didactic format and discouraging contact with other attendees. However other components were also varied, for example skills training instruction was given only in the self control group. The study hypothesis was that the treatments would show differential treatment effect with smokers of different personality types. Etringer 1984 and Lando 1991 manipulated the group environment in a less extreme way. Their programmes were intensive, lasting for 16 sessions over 9 weeks. In an ‘enriched cohesiveness’ intervention, exercises were introduced designed to facilitate positive group interaction, focusing on the importance of self-disclosure and feedback to other group members. Etringer and colleagues also compared a programme which included a satiation smoking procedure, with one using nicotine fading. Their hypothesis was that group cohesiveness was already developed by the aversive smoking routine, so that the cohesiveness manipulation would be most effective in combination with nicotine fading. The two alternatives were therefore separately entered into the analysis.
Methodological quality
See: Table of included studies
Most trials gave insufficient detail to be sure that randomisation was effective and that the experimenter did not know which treatment a participant would receive before enrolling them. In cases where more than one group method was being compared, and recruitment was continuous, participants were generally allocated to treatment groups on the basis of their sequence of arrival. The group was then randomised to treatment. In studies in which randomisation was individual, randomisation schedules were in some cases reported to be interrupted in order to allocate families or friends to the same group. Both these features mean that people in a particular group may be more similar than would be expected by chance. This undermines the statistical assumption which is used to estimate the variance, which is that they are typical of the population as a whole. The same principle also applies when patients are treated in groups, because each person’s chance of success may be influenced by the group in which they find themselves. The possibility that success rates varied beyond chance between the groups given the same treatment can be tested, but the power to detect these differences will generally be very low.
All these features of group therapy trials are likely to lead to an underestimate of the true variance, and therefore the estimation of confidence intervals which are too narrow. In those trials which randomised entire worksites to programme type this factor is even more relevant.
The small number of trials in any comparison and the fact that studies of the same type tend to share the same shortcomings meant that sensitivity analyses based on any quality assessment were impractical.
Dropouts were not always identified by treatment group. Where the information was available we have included them to base the analysis on the numbers randomised. Since the same assumptions are made about drop outs, that they are continuing smokers whatever their treatment group, results will only be affected if there is differential drop out. If dropout rates are higher in a minimal treatment control group then the relative effectiveness of the treatment group may be inflated. We have noted in the Table of Included studies if there were substantial differences between the numbers randomised and those followed up. In one study the numbers followed up were so much lower than the numbers randomised that we have used the numbers followed up, but report also the effect of using numbers randomised [Gruder 1993].
Seven studies reported no use of any validation of self-report of smoking cessation. A number of studies used a mixture of biochemical measures and verification by family or colleagues, or only sought biochemical verification in a random sample of quitters. Where only a sample of was verified it was not always clear whether overall quit rates were corrected for the disconfirmation rate in the sample. One study gave self-reported and CO validated quit rates separately, when in most arms the self-reported rate was lower, so we have used this measure. In the only arm where the CO validated rate was more conservative, self-reported rates favour self-help over group treatment so is still conservative with respect to the hypothesis of the review.
Results
• List of comparisons
• Tables of other data
COMPARISON OF GROUP AND SELF-HELP PROGRAMMES
Pooling all studies which compared a group therapy programme with provision of the same self-help manual alone gives an estimated odds ratio for the effectiveness of the addition of group meetings of 2.44 (95% C.I. 1.78-3.36). Including the studies which used different programmes for the group and self-help formats reduced the OR to 2.10 (95% C.I. 1.64-2.70). There was no significant heterogeneity in these results. Four of the studies [Gruder 1993; DePaul 1987; DePaul 1989; DePaul 1994] were carried out during a televised smoking cessation series which all participants were encouraged to watch. The three DePaul studies also took place in workplace settings with workplaces rather than individuals randomised to condition. Statistically therefore their results may be less precise. When these studies were excluded, the OR for all other studies with the same or different programmes was 1.74 (95% C.I. 1.24-2.43) (data not displayed). The result is therefore robust whether or not workplace trials using cluster randomisation, or studies using group programmes as adjuncts to mass media interventions were included. A sensitivity analysis using numbers randomised rather than numbers followed up in Gruder 1993 also had no effect on the results.
COMPARISON OF GROUP AND INDIVIDUAL THERAPY
Only two studies compared group with individual treatment, and neither found a significant difference, although there was a trend towards higher quit rates with individual therapy. Jorenby 1995 used nicotine patches in combination with therapy and quit rates in both arms were relatively high. The pooled OR was 0.83 (95% C.I. 0.54-1.26).
COMPARISON OF GROUPS WITH OTHER TREATMENTS
Physician or nurse advice
Of the five trials only Hollis 1993 found a statistically significant superiority of the addition of a group programme compared to advice from a health care provider and a pamphlet. One trial [McDowell 1985] reported little difference, whilst three trials [Cottraux 1983; Rice 1994; Sawicki 1993] found trends towards greater efficacy of the advice intervention. Consequently the pooled OR (0.96, 95% C.I. 0.69-1.35) showed no evidence of an effect, but there was significant heterogeneity in this result.
Health Education
Rabkin 1994 found similar cessation rates for a full group programme compared to an intervention with a single session of health education and one individual counselling session.
Adding a group programme to NRT alone
Neither Ginsberg 1992 nor Jorenby 1995 found a significant difference between quit rates in a group programme compared to the control groups when both interventions included provision of NRT. In both studies the control intervention included other elements which could have contributed to cessation success.
GROUP PROGRAMMES COMPARED TO CONTROL INTERVENTIONS
All five trials produced higher quit rates with group programmes than no intervention or minimal contact, and the combined OR was 1.91 (95% C.I. 1.20-3.04).
EFFECT OF MANIPULATING GROUP DYNAMICS
There was no evidence from the three trials that outcomes had been affected by attempts to change the interaction between participants in a group programme.
TAKE UP RATES FOR GROUP PROGRAMMES.
The variation in take up rates for group therapy was partly determined by the method of recruitment and randomisation. However even in trials where eligible smokers agreed to attend group meetings prior to randomisation the non participation rate was often high. Curry 1988 enrolled participants who attended an information meeting. More group participants (88%) than self-help participants (59%) began treatment (defined as completing the first week of self-monitoring), and completed treatment. Because of the differential drop out the difference in quit rates is greater when an intent to treat analysis is used than when only those who began treatment are included. Participation in the Glasgow 1981 trial was higher, with almost all those enrolled taking part and available for 6 month follow-up.
Attrition following randomisation was particularly high in Gruder 1993 which was carried out in conjunction with a tv programme, because eligible smokers who had registered by mail for support materials were randomised before they were contacted. Only 70% could be reached and 62% scheduled for group meetings. Nonparticipation at this stage was due to lack of interest or problems with timing or location of meetings. Of those who were scheduled 50% then failed to attend any meetings.
The trial by Rice and colleagues also had a high non attendance rate even though participants were volunteers. Overall 34% dropped out of the trial on learning their treatment allocation. 31% of those randomised to the group treatment refused to participate, whilst the drop out from the follow up only group was 48%. Cottraux and colleagues reported that just over half those enrolled attended all three behaviour therapy sessions. Hilleman and colleagues do not report any drop out from group treatment, but this trial involved volunteers for a drug trial, and is probably not typical. The lowest participation rate was seen in Hollis 1993. This trial recruited smokers during visits to primary care offices. Of those randomised for referral to a group programme 11% chose to attend, whilst of those given a choice of self-help or groups just 8% attended a group programme.
Discussion
Two problems of conducting a systematic review of behavioural interventions should be noted. First, many trials of behavioural interventions use multiple treatment arms in an attempt to identify the precise therapeutic element leading to success. This makes the pre-definition of explicit comparison groups difficult. Second, as with all behavioural as opposed to pharmacological therapies, the choice of an appropriate control condition presents problems when evaluating efficacy. There is no obvious equivalent for the drug placebo to control for the non-specific effects of a treatment method. Evaluating group therapies against a waiting list control does not provide very good evidence for the specific effect of the group format.
The results of this meta-analysis provide evidence that providing group therapy as an addition to a self-help programme can increase long term quit rates. There are not enough studies to identify which elements of group therapy might contribute to the increased quit rates. The two trials in which different programmes were tested suggested that the content of the programme could affect the relative effectiveness of the group format. Of the three programmes used by Glasgow & colleagues two were structured manuals describing techniques to aid behaviour change, whilst one was an unstructured kit of motivational materials and tips. This was less successful when used in a group programme than for self-help, but the sample size is too small to draw firm conclusions, with just 6 self-reported quitters from the three group programmes. There is some indication that group programmes are more likely to improve quit rates compared to structured self-help programmes when they are used alongside other components such as mass media or worksite initiatives.
The pooled result from just two studies provides no evidence that group therapy is more effective than a similar schedule of individual counselling sessions. There was therefore no evidence that meeting with a group of other smokers was a critical element in an intensive smoking cessation programme.
The effectiveness of group treatment compared to brief advice is complicated by heterogeneity. One trial in which both sets of smokers received advice showed a benefit of additional referral to a group [Hollis 1993]. However the quit rate in the therapy group was still less than 6%, so the additional benefit of the group component was limited. The other trial in which a control group also received brief advice from a nurse produced higher quit rates in that arm than from more intensive individual or group treatment [Rice 1994]. The authors consider that the explanation for this was the presence in the ‘no intervention’ group of a disproportionate number of coronary artery bypass graft patients who were likely to have a greater motivation to quit. Of the two other trials which showed a trend to greater efficacy of physician advice, Cottraux 1983 was possibly atypical, in that the role of the physician was to recommend the use of lactose tablets. There was also no validation of self-reported non smoking in this trial, which may have lead to the relatively high quit rates, and hence the weight given to the trial in the meta-analysis.
There was no evidence, based on two trials, that group therapy as an adjunct to NRT increased quit rates. In both studies the comparison arm had some behavioural support – two meetings and materials in the case of Ginsberg 1992, and 8 weekly assessment sessions in the case of Jorenby 1995. Once again the evidence is too limited to draw substantial conclusions.
Comparison of group therapy with no intervention supports the conclusion that group programmes can aid smoking cessation, although it does not provide evidence for a specific benefit from the group therapy.
This review has taken a broad approach to group programmes, without distinguishing between programmes on the basis of their theoretical approach, therapists or intensity. A more detailed analysis of factors which might influence outcome could only become useful once there were enough trials using comparable methods for them to be combined. Currently there is insufficient evidence to make it possible to confidently identify effective and ineffective components of group programmes. Although group programmes have been widely offered for smoking cessation, often under the auspices of cancer prevention or lung health charities, we found relatively few studies meeting our criteria. The possibility exists that there are unpublished studies which would contribute to the available evidence.
Another recent meta-analysis (AHCPR 1996) used logistic regression to estimate the comparative cessation rates of different formats for delivering smoking cessation. This approach allowed the contribution of data from trials which did not directly compare different formats. In this analysis, the pooled odds ratio of success for group counselling compared to no intervention was 2.2 (95% C.I. 1.6-3.0, Table 9). This compares reasonably closely with the results of our comparison of the effectiveness of groups with controls (OR 1.91, 95% C.I. 1.20-3.04).
There is further evidence from studies which did not meet our inclusion criteria that group programmes are effective. The Lung Health Study (Kanner 1996) was a trial of a smoking intervention and a bronchodilator in smokers with mild pulmonary obstructive disease. The programme consisted of 12 weeks of group therapy with a cognitive behavioural approach, and nicotine gum was available to all participants. In addition they all received a strong physician message about quitting followed by a meeting with a smoking intervention specialist. A maintenance programme was also provided. We excluded the study from our meta-analysis because the effect of the group was confounded by the effects of nicotine replacement. However the quit rate achieved is greater than might be expected from the use of NRT alone and it is reasonable to assume that the group programme contributed to the effect. Twenty-two percent of the intervention participants achieved smoking cessation for 5 years compared to 5% of the usual care control group.
The drawback to group programmes as a public health strategy is their limited reach to the smoking population. Participation rates in a number of the studies considered here were low. Participating smokers need to be sufficiently motivated not only to attempt to stop, but also to commit themselves to the time and effort involved in attending meetings.
Reviewers’ conclusions
Implications for practice
There is reasonable evidence that groups are better than self-help, and other less intensive interventions, although they may be no better than advice from a health care provider. There is not enough evidence on their effectiveness compared to intensive individual counselling. From the point of view of the consumer who is motivated to make a quit attempt it is probably worth joining a group if one is available – it will increase the likelihood of quitting. Group therapy may also be valuable as part of a comprehensive intervention which includes NRT.
From the public health perspective, the impact of groups on smoking prevalence will depend on their uptake. Providers need to make a judgement about the cost-effectiveness of the gains achieved by group therapy compared to other interventions.
Potential conflict of interest
None
Acknowledgements
Dr B. Bonevski for assistance with data extraction. Prof V. Rice for additional data.
References
References to studies included in this review
Cottraux 1983 (published data only)
Cottraux JA, Harf R, Boissel JP, Schbath J, Bouvard M, Gillet J. Smoking cessation with behaviour therapy or acupuncture – a controlled study. Behav Res Ther 1983;21(4):417-24.
Curry (AA) 1988 (published data only)
See Curry (RP) 1988
Curry (RP) 1988 (published data only)
Curry SJ, Wagner EH, Grothaus LC. Evaluation of intrinsic and extrinsic motivation interventions with a self-help smoking cessation program. J Consult Clin Psychol 1991;59(2):318-24.
DePaul 1987 (published data only)
*Flay BR, Gruder CL, Warnecke RB, Jason LA, Peterson P. One year follow-up of the Chicago televised smoking cessation program. Am J Public Health 1989;79:1377-80.Jason LA, Gruder CL, Martino S, Flay BR. Work site group meetings and the effectiveness of a televised smoking cessation intervention. Am J Community Psychol 1987;15:57-72.Jason LA, Gruder CL, Buckenberger L, Lesowitz T, Belgredan J, Flay BR, Warnecke RB. A 12-month follow-up of a worksite smoking cessation intervention. Health Educ Res 1987;2:185-94.
DePaul 1989 (published data only)
Salina D, Jason LA, Hedeker D, Kaufman J, Lesondak L, McMahon SD, et al. A follow-up of a media-based, worksite smoking cessation program. Am J Community Psychol 1994;22:257-71.*Jason LA, Lesowitz T, Michaels M, Blitz C, Victors L, Dean L, et al. A Worksite Smoking Cessation Intervention Involving the Media and Incentives. Am J Community Psychol 1989;17:785-99.
DePaul 1994 (published data only)
Jason LA, Salina D, McMahon SD, Hedeker D, Stockton M. A worksite smoking intervention: A 2 year assessment of groups, incentives and self-help. Health Educ Res 1997;12:129-38.*Jason LA, McMahon SD, Salina D, Hedeker D, Stockton M, Dunson K et al. Assessing a smoking cessation intervention involving groups, incentives, and self-help manuals. Behav Ther 1995;26:393-408.McMahon SD, Jason LA, Salina D. Stress, coping, and appraisal in a smoking cessation intervention. Anxiety, Stress and Coping 1994;7(2):161-71.
Digiusto 1995 (published data only)
DiGiusto E, Bird KD. Matching smokers to treatment: Self-control versus social support. J Consult Clin Psychol 1995;63(2):290-5.
Etringer (Fading) (published data only)
Etringer 1984 (published data only)
Etringer BD, Gregory VR, Lando HA. Influence of group cohesion on the behavioral treatment of smoking. J Consult Clin Psychol 1984;52:1080-6.
Glasgow D+L (published data only)
Glasgow RE, Schafer L, O’Neill HK. Self-help books and amount of therapist contact in smoking cessation programs. J Consult Clin Psychol 1981;49(5):659-67.
Glasgow IQK (published data only)
Glasgow P+P (published data only)
Gnsberg 1992 (published data only)
Ginsberg D, Hall SM, Rosinski M. Partner support, psychological treatment, and nicotine gum in smoking treatment: an incremental study. Int J Addict 1992;27(5):503-14.
Gruder 1993 (published data only)
*Gruder CL, Mermelstein RJ, Kirkendol S, Hedeker D, Wong SC, Schreckengost J, et al. Effects of social support and relapse prevention training as adjuncts to a televised smoking-cessation intervention. J Consult Clin Psychol 1993;61(1):113-20.Warnecke RB, Flay BR, Kviz FJ, Gruder CL, Langenberg P, Crittenden KS, Mermelstein RJ, Aitken M, Wong SC, Cook TD. Characteristics of participants in a televised smoking cessation intervention. Prev Med 1991;20:389-403.
Hill 1993 (published data only)
Hill R, Rigdon M, Johnson S. Behavioral smoking cessation treatment for older chronic smokers. Behav Ther 1993;24:321-9.
Hilleman 1993 (published data only)
Hilleman DE, Mohiuddin SM, Delcore MG, Lucas BD. Randomized, controlled trial of transdermal clonidine for smoking cessation. Ann Pharmacother 1993;27(9):1025-8.
Hollis 1993 (published data only)
Hollis JF, Lichtenstein E, Vogt TM, Stevens VJ, Biglan A. Nurse-assisted counseling for smokers in primary care. Ann Intern Med 1993;118(7):521-5.
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.
Lando 1991 (published data only)
Lando HA, McGovern PG. The influence of group cohesion on the behavioral treatment of smoking: A failure to replicate. Addict Behav 1991;16(3-4):111-21.
Leung 1991 (published data only)
Leung J. Smoking cessation by auricular acupuncture and behavioural therapy. Psychologia 1991;34:177-87.
McDowell 1985 (published data only)
Mothersill KJ, McDowell I, Rosser WW. Subject characteristics and long term post-program smoking cessation. Addict Behav 1988;13(1):29-36.Rosser WW. The role of the family physician in smoking cessation. Can Fam Physician 1984;30:160-7.*McDowell I, Mothersill KJ, Rosser WW, Hartman R. A randomized trial of three approaches to smoking cessation. Can Fam Physician 1985;31:351-5.
Omenn 1988 (published data only)
Omenn GS, Thompson B, Sexton M, Hessol N, Breitenstein B, Curry S, Michnich M, Peterson A. A randomized comparison of Worksite-sponsored smoking cessation programs. Am J Prev Med 1988;4:261-7
Pederson 1981 (published data only)
Pederson LL, Baldwin N, Lefcoe NM. Utility of behavioral self-help manuals in a minimal-contact smoking cessation program. Int J Addict 1981;16:1233-9.
Rabkin 1984 (published data only)
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):157-73.
Rice 1994 (published and unpublished data)
Rice VH, Fox DH, Lepczyk M, Sieggreen M, Mullin M, Jarosz P, Templin T. A comparison of nursing interventions for smoking cessation in adults with cardiovascular health problems. Heart Lung 1994;23(Nov-Dec.):473-86.
Sawicki 1993 (published data only)
Sawicki PT, Didjurgeit U, Muhlhauser I, Berger M. Behaviour therapy versus doctor’s anti-smoking advice in diabetic patients. J Intern Med 1993;234(4):407-9.
* indicates the major publication for the study
References to studies excluded from this review
Bernstein 1970
Bernstein DA. The modification of smoking behavior: a search for effective variables. Behav Res Ther 1970;8(2):133-46.
Bertera 1990
Bertera RL, Oehl LK, Telephak JM. Self-help versus group approaches to smoking cessation in the workplace: Eighteen-month follow-up and cost analysis. Am J Health Promot 1990;4:187-92.
Cinciripini 1994
Cinciripini PM, Lapitsky LG, Wallfisch A, Mace R, Nezami E, van Vunakis H. An evaluation of a multicomponent treatment program involving scheduled smoking and relapse prevention procedures: initial findings. Addict Behav 1994;19:13-22.
Cinciripini 1995
Cinciripini PM, Lapitsky LG, Seay S, Wallfisch A, Kitchens K, Vanvunakis H. The effects of smoking schedules on cessation outcome – can we improve on common methods of gradual and abrupt nicotine withdrawal? J Consult Cli Psychol 95;63:388-99.
Davis 1986
Davis JR, Glaros AG. Relapse prevention and smoking cessation. Addict Behav 1986;11:105-14.
Decker 1989
Decker BD, Evans RG. Efficacy of a minimal contact version of a multimodal smoking cessation program. Addict Behav 1989;14:487-91.
Elliott 1978
Elliott CH, Denney DR. A multiple-component treatment approach to smoking reduction. J Consult Clin Psychol 1978;46(6):1330-9.
Glasgow 1978
Glasgow RE. Effects of a self-control manual, rapid smoking, and amount of therapist contact on smoking reduction. J Consult Clin Psychol 1978;46(6):1439-47.
Glasgow 1989
Glasgow RE, Morray K, Lichtenstein E. Controlled smoking versus abstinence as a treatment goal: The hopes and fears may be unfounded. Behav Ther 1989;20(1):77-91.
Goldstein 1989
Goldstein MG, Niaura R, Follick MJ, Abrams DB. Effects of behavioral skills training and schedule of nicotine gum administration on smoking cessation. Am J Psychiatry 1989;146:56-60.
Hall 1984
Hall SM, Rugg D, Tunstall C, Jones RT. Preventing relapse to cigarette smoking by behavioral skill training. J Consult Clin Psychol 1984;52(3):372-82.
Hall 1985
Hall SM, Tunstall C, Rugg D, Jones R, Benowitz N. Nicotine gum and behavioral treatment in smoking cessation. J Consult Clin Psychol 1985;53:256-8.
Hall 1987
Hall SM, Tunstall CD, Ginsberg D, Benowitz NL, Jones RT. Nicotine gum and behavioral treatment: a placebo controlled trial. J Consult Clin Psychol 1987;55(4):603-5.
Hall 1994
Hall SM, Munoz RF, Reus VI. Cognitive-behavioral intervention increases abstinence rates for depressive-history smokers. J Consult Clin Psychol 1994;62(1):141-6.
Hall 1996
Hall SM, Munoz RF, Reus VI, Sees KL, Duncan C, Humfleet GL, Hartz DT. Mood management and nicotine gum in smoking treatment – a therapeutic contact and placebo-controlled study. J Consult Clin Psychol 1996;64:1003-9.
Hamilton 1979
Hamilton SB, Bornstein PH. Broad-spectrum behavioral approach to smoking cessation: Effects of social support and paraprofessional training on the maintenance of treatment effects. J Consult Clin Psychol 1979;47(3):598-600.
Katz 1977
Katz RC, Heiman M, Gordon S. Effects of two self-management approaches on cigarette smoking. Addict Behav 1977;2(2-3):113-9.
Killen 1984
Killen JD, Maccoby N, Taylor CB. Nicotine gum and self-regulation training in smoking relapse prevention. Behav Ther 1984;15:234-48.
Lando 1990
Lando HA, McGovern PG, Barrios FX, Etringer BD. Comparative evaluation of American Cancer Society and American Lung Association smoking cessation clinics. Am J Public Health 1990;80(5):554-9.
Lowe 1980
Lowe MR, Green L, Kurtz SMS, Ashenberg ZS, Fisher EB. Self-initiated, cue extinction, and covert sensitization procedures in smoking cessation. J Behav Med 80;3(4):357-72.
Martin 1997
Martin JE, Calfas KJ, Patten CA, Polarek M, Hofstetter CR, Noto J, Beach D. Prospective evaluation of three smoking interventions in 205 recovering alcoholics: One-year results of project SCRAP-tobacco. J Consult Clin Psychol 1997;65:190-4.
McIntyre 1986
McIntyre KO, Lichtenstein E, Mermelstein RJ. Self-efficacy and relapse in smoking cessation: a replication and extension. J Consult Clin Psychol 1983;51(4):632-3.
Mogielnicki 1986
Mogielnicki RP, Neslin S, Dulac J, Balestra D, Gillie E, Corson J. Tailored media can enhance the success of smoking cessation clinics. J Behav Med 1986;9(2):141-61.
Nyborg 1986
Nyborg KF, Nevid JS. Couples who smoke: A comparison of couples training versus individual training for smoking cessation. Behav Ther 1986;17:620-5.
Pirie 1992
Pirie PL, McBride CM, Hellerstedt WL, Jeffery RW, Hatsukami DK, Allen S, Lando HA. Smoking cessation in women concerned about weight. Am J Public Health 1992;82:1238-43.
Powell 1981
Powell DR, McCann BS. The effects of a multiple treatment program and maintenance procedures on smoking cessation. Prev Med 1981;10:94-104.
Schwartz 1968
Schwartz JL, Dubitzky M. One-year follow-up results of a smoking cessation program. Can J Public Health 1968;59(Apr.XX.):161-5.
Stevens 1989
Stevens VJ, Hollis JF. Preventing smoking relapse, using an individually tailored skills-training technique. J Consult Clin Psychol 1989;57:420-4.
Supnick 1984
Supnick J, Colletti G. Relapse coping and problem solving training following treatment for smoking. Addict Behav 1984;9:401-4.
Thompson 1988
Thompson RS, Michnich ME, Friedlander L, Gilson B, Grothaus LC, Storer B. Effectiveness of smoking cessation interventions integrated into primary care practice. Med Care 1988;26:62-76.
Tiffany 1986
Tiffany ST, Martin EM, Baker TB. Treatments for cigarette smoking: An evaluation of the contributions of aversion and counseling procedures. Behav Res Ther 1986;24(4):437-52.
Zelman 1992
Zelman DC, Brandon TH, Jorenby DE, Baker TB. Measures of affect and nicotine dependence predict differential response to smoking cessation treatments. J Consult Clin Psychol 1992;60:943-52.
Additional references
Abbot 1998
Abbot NC, Stead LF, White AR, Barnes J, Ernst E. Hypnotherapy for smoking cessation. (Cochrane Review) In: The Cochrane Library, Issue 2. Oxford: Update Software; 1998. Updated quarterly.
AHCPR 1996
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, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No.96-0692. April 1996
Fisher 1993
Fisher EB, Jr., Lichtenstein E, Haire-Joshu D, Morgan GD, Rehberg HR. Methods, successes, and failures of smoking cessation programs. Annu Rev Med 1993;44:481-513.
Hajek 1985
Hajek P, Belcher M, Stapleton J. Enhancing the impact of groups: An evaluation of two group formats for smokers. Br J Clin Psychol 1985;24(4):289-94.
Hajek 1996
Hajek P. Current issues in behavioral and pharmacological approaches to smoking cessation. Addict Behav 1996;21:699-707.
Hajek 1997
Hajek P, Stead LF. Aversive smoking for smoking cessation. (Cochrane Review) In: The Cochrane Library, Issue 3. Oxford: Update Software; 1997. Updated quarterly.
Kanner 1996
Kanner RE. Early intervention in chronic obstructive pulmonary disease. A review of the Lung Health Study results. Med Clin North Am 1996;80(3):523-47.
Silagy 1998
Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation (Cochrane Review). In: The Cochrane Library, 1998, Issue 3. Oxford: Update Software.
White 1997
White AR, Rampes H. Acupuncture for smoking cessation (Cochrane Review). In: The Cochrane Library, Issue 4, 1997. 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
Group behaviour therapy programmes for smoking cessation
Reviewer(s)
Stead LF, Lancaster T
Date of most recent amendment 12 July 1999
Date of most recent substantive amendment 22 May 1998
Contact address Mrs Lindsay Stead
ICRF General Practice Research Group
Division of Public Health and Primary Health Care
Institute of Health Sciences
Old Road, Headington
Oxford
UK
OX3 7LF
Telephone: +44 1865 226997
Facsimile: +44 1865 227137
E-mail: lindsay.stead@dphpc.ox.ac.uk
Cochrane Library number CD001007
Editorial group Coch. Tobacco Addiction Group
Editorial group code HM-TOBACCO
This review should be cited as :
Stead LF, Lancaster T. Group behaviour therapy programmes 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 National Cancer Programme, England UK
Intramural sources of support to the review
• Imperial Cancer Research Fund General Practice Research Group UK
Keywords
HUMAN; SMOKING-CESSATION / methods; BEHAVIOR-THERAPY; PROGRAM-EVALUATION; SELF-HELP-GROUPS; TREATMENT-OUTCOME;
Tables & Graphs
• MetaView graphs
• List of comparisons
• Tables of other data
• Table of included studies
• Table of excluded studies
List of comparisons
Fig 01 GROUP FORMAT BEHAVIOURAL PROGRAMMES VS OTHER FORMAT
01.01.00 Smoking cessation. Group programme vs self-help programme
01.02.00 Smoking cessation. Group programme vs individual therapy
01.03.00 Smoking cessation. Group programme vs Other treatment
01.04.00 Smoking cessation. Group plus NRT vs NRT alone
01.05.00 Smoking cessation. Group vs other controls
Fig 02 COMPARISONS BETWEEN GROUP PROGRAMMES
02.06.00 Smoking cessation. Manipulation of group dynamics
Fig 03 TABULATION OF PROGRAMME CHARACTERISTICS
03.01.00 Programme characteristics See: Tables of other data
Tables of other data
Tabulation of programme characteristics: Programme characteristics

Study PROGRAMME LENGTH TOTAL PERIOD MAIN FOCUS SPECIAL FEATURES
Cottraux 1983 Not a named programme
15/ group with two therapists 3 Sessions of 3 hrs each
9 hours in total 2 weeks Behaviour therapy Given relaxation and stress-desensitization audiotape for daily use
Curry (AA) 1988 Traditional programme emphasising absolute abstinence (AA) 8 Sessions of 2 hrs each
16 hours in total 8 weeks Addictive nature of smoking and the necessity for complete abstinence. Included focused smoking, health education and contingency contracting
Curry (RP) 1988 Experimental relapse prevention programme
12/group with two therapists 8 sessions of 2 hrs each
16 hours in total 8 weeks Smoking as a maladaptive learned behaviour. Focus on skills acquisition
DePaul 1987 American Lung Association ‘Freedom from Smoking in 20 days’
5-9/group, led by a company employee who had had a 3 hour training session in leading groups 6 x 45 min sessions twice/week Three weeks Supportive setting for smokers who were using the self-help manual to share experiences, obtain advice from other smokers and ask questions. Group programmes concurrent with 20 daily television programmes following the same approach.
DePaul 1989 American Lung Association ‘Freedom from Smoking in 20 days’ 6 x 45 min session twice/week, then 1 hour monthly sessions for next 12 months 12 months Initial meetings focused on reviewing techniques discussed in the television programme and self-help manuals. Follow-up meetings emphasised how participants could utilize the supportive aspects of their social environment to aid quitting or remaining abstinent. Participants used ALA manual and watched concurrent tv programme. Also eligible for incentives in the form of monthly lotteries from the end of the intervention for 12 months
DePaul 1994 Based on American Lung Association ‘Freedom from Smoking in 20 days’
Groups leaders came from university psychology departments or had led Chicago Lung Association groups 6 Sessions in first 3 weeks followed by 14 booster meetings over following 6 months at a gradually reducing frequency 6 months Cognitive behavioural orientation. Participants were given handouts based on ALA manual, and instructed in self monitoring, relaxation, establishing a buddy system, generating coping strategies. Booster sessions included goal-setting, role-playing and problem solving. Televised 1 week cessation series ‘Smoke-free in the 90s, and a newspaper supplement. Continued quitters were eligible to earn $1/day for each day abstinent between the 14 booster sessions, up to $175 over 6 months.
Digiusto 1995 Two programmes designed to be comparably effective and appropriate for ongoing prevision. Social support: 5 meetings and 3 mail follow-ups
Self-control:4 meetings Not clear. Final meeting one week after quit date Comparing emphasis on social supprt elements of the group, with didactic presentation and limited interaction. Focus of study was on differential effectiveness among subgroups of smokers. No predictions made as to relative efficacy of either programme
Etringer 1984 Cessation using either nicotine-fading or satiation procedure plus maintenance
+/- and procedure for enriching group cohesiveness 9 x 45-60mins 9 weeks, but differing schedule depending on cessation procedure. Quit day in third week Self-reward and punishment contracts, problem-solving. Attempted to manipulate the group interaction process. (See also Lando 1991)
Glasgow D+L Danaher & Lichtenstein programme
4-6/group. Therapists: a clinical psychologist or behaviour therapy students. 8 sessions, length not specified Approx 8 weeks. Progressive relaxation, alternative quit strategies including aversive smoking option, managing thoughts.

A published manual suitable for self-help use. In the group format the therapists previewed the material for the next meeting and led subjects in demonstrations of treatment procedures
Glasgow P+P Pomerleau & Pomerleau
4-6/group 8 sessions, length not specified Approx 8 weeks Gradual reduction by eliminating smoking in gradually more difficult situations. Stimulus control techniques and a modification of covert sensitization used. A published manual suitable to self-help use. In the group treatment format the therapist reviewed and rehearsed the contents.
Gnsberg 1992 Not a named programme
3-6/ group, lead by a psychologist of health educator 5 or 6 sessions 4 weeks (standard) or 5 weeks (partner support) Quitting strategy, RP skill training, public commitment.
Plus partner empathy and support exercises. Nicotine gum also provided
Gruder 1993 American Lung Association ‘Freedom from Smoking in 20 days’
Two group variants – Discussion, and Social support
Leaders were primarily nurses and health educators 3 x 90 min Sessions Three weeks Discussion – review of self-help manual
Social Support – instructions on how to get help from buddies and others, specific scenarios discussed. Concurrent with a televised cessation programme. participants also scheduled to receive telephone calls at 1 and 2 months after end of programme. Social supprt participants also received a Quitter’s Guide whilst buddies received a Buddy Guide.
Hill 1993 Adapted from programme used by the Lung Health Study
comparing effect of additional exercise programme 12 x 90min sessions
18 hours in total 3 months Tailored health information, setting a quit date, RP training including identifying and role playing high risk situations. Targetted at older smokers
Hilleman 1993 Behaviour modification training 12 x 1hr sessions
12 hours in total 12 weeks Described only as a standardised behaviour modification training. States that participants had to attend a minimum of two classes before making a cessation attempt Factorial design with clonidine/placebo drug therapy
Hollis 1993 Freedom from Cigarettes (Kaiser Permanente HMO)
9 meetings, length not specified 8 weeks Multicomponent programme Participants randomised to this programme, and who visited the counsellor, were shown a video encouraging them to use it.
Jorenby 1995 Programme not specified
Trained smoking cessation counsellors 8 x 1hr sessions
8 hours in total 8 weeks Identification of high risk situations, coping skill training, emotional support Also received nicotine gum
Lando 1991 Same basic laboratory programme as Lando 1990 16 x 45-60min sessions
Approx 14 hours in total 9 weeks Self monitoring and developing active coping strategies, nicotine fading. Unstructured group discussion with emphasis on shared problem solving Trial manipulated group cohesion via addition of written exercises to facilitate positive group interaction. Used a positive modeling video.
Leung 1991 ‘behavioral therapy’ 10 x 90min sessions
15 hours in total Two weeks Self monitoring, stimulus control, coping skill training, assertion training and relaxation.
McDowell 1985 Cognitive Behaviour modification (CBM) or
Operation Kick-It (British Columbia Lung Association) CBM: 9 x 90min session
OKI: 9 x 90min session CBM: 10 weeks
OKI: 8 weeks CBM: Behavioral rehearsal, cognitive restructuring, relaxation procedures
OKI:Foster mutual support, discuss information and review problems CBM was conducted by M.Ed psychologists, whilst OKI was lead by a public health nurse or a special education teacher.
Omenn 1988 Two different programmes: Multiple Component (MCP) or Relapse Prevention (RPP) were compared to the self-help control. MCP – 3 Sessions of 2 hrs
RPP – 8 Sessions of 2 hrs MCP – 3 weeks
RPP – 8 weeks MCP – Combined behavioural skills training, aversive stimuli, imagery and stress management. Highly structured didactic programme. Focus on initial cessation
RPP – Emphasised the prevention of copiing skills to prevent relapse. Choice of immediate or phased cessation. Interactive format.
Rabkin 1984 Behaviour modification
5 x 45-90mins 3 weeks Self monitoring, stimulus control and strategies for change.
Rice 1994 Smokeless (American Institute for Preventive Medicine)
5-7/group 5 Sessions of 1hr each
5 hours in total, 4 in 1st week 2 weeks Offers a variety of skills that individuals can elect to develop including aversive puffing, stimulus control, relaxation training, contingency contracting, thought stoppage, eating and stres management, exercise and behavioral rehearsal.
Sawicki 1993 Extensive structured behaviour therapy 10 x 90min session 10 weeks Gradual decrease in smoking with quit date after 5th session.
Table of included studies

Study Method Participants Interventions Outcomes Notes
Cottraux 1983 Country: France
Recruitment: Media advertising
Randomisation: no details, stratified by presence of another smoker in household
558 (418 in arms of interest) community volunteers
Av. cigs/day: 31 1. Behaviour therapy. Included discussion, training in relaxation. Groups of 15Ss with two therapists (qualifications not described). 3 x3hr sessions over two weeks. Given relaxation and stress-desensitization audiotape for daily use.
2. Acupuncture
3. Placebo – lactose capsules for 2 weeks. Met 2 x10min with a doctor.
4. 1 year waiting list control. Abstinence at 12 months, assessor blind to treatment condition
Validation: none Although 3. described by authors as placebo the two meetings with a doctor make it more comparable with an advice intervention so 1 vs 3 used in Group vs physician advice.
Curry (AA) 1988 Same study as Curry (RP) 1988
Dummy study used to enter results for comparison of ‘Absolute Abstinence’ Group vs self-help delivery.
Curry (RP) 1988 Country: USA
Recruitment: media advertising
Randomisation: Part by coin toss and part random number table. More assigned to self-help than group. Friends co-randomised to same programme but not necessarily same format. 139 community volunteers
Therapists: 2 teams of 2 PhD psychologists. Each team led one group in each programme. Test of group vs self-help format, and traditional vs relapse prevention programme. All groups met for 8 x 2hr weekly meetings which included relaxation training, enlisting social support and practising alternative behaviours.
1. Relapse prevention Group. Focused on smoking as learned behaviour. Quit day at 3rd session. Additional elements included identifying high risk situations, cognitive restructuring and role playing.
2. Relapse Prevention Self-help. Eight workbook units.
3. ‘Absolute Abstinence’ (AA) Group. Focused on addictive component of smoking. Quit day at 5th session. Additional elements included focused smoking, health education and contingency contract.
4. Absolute Abstinence Self-help. Eight workbook units. Abstinence from months 9 to 12 of follow-up.
Validation: saliva thiocyanate and two collateral verifiers. Results include all assigned to treatment; only 69% began treatment.
1. vs 2. and 3 vs 4. [in graph as Curry (AA)] contribute to effect of delivery format.
DePaul 1987 Country: USA
Recruitment: Employees at 43 worksites, recruited prior to a 3-week television smoking cessation programme.
Randomisation: Cluster randomisation by worksite, matched for size 233 smokers in group discussion worksites, 192 in non group work sites All participants were given self-help manuals by company coordinators and instructed to view the televised segments
1. Twice weekly group meetings
2. Self-help alone Abstinence at 12 months (multiple point prevalence)
No validation Percentage quit rates taken from graphs and denominator assumed to be numbers followed up.
DePaul 1989 Country: USA
Recruitment: Employees at 38 worksites, recruited prior to a 3-week television smoking cessation programme.
Randomisation: Cluster randomisation by worksite 419 smokers who participated in the worksite programmes. 1. 6 x twice weekly group meetings to coincide with the 3 week television series, then monthly meetings for a year. Abstinent smokers and 5 of their family and 5 co-workers entered for a lottery at the final group meeting and 12 month follow-up.
2. Self-help manuals only Abstinence from end of programme to 12m
Validation by saliva cotinine and co-worker or relative confirmation. Data based on participants in the programmes. Attrition was defined as not attending any group meetings, not reading the manual, not being located for post testing, refusing to be interviewed or changing jobs. The attrition rate was 17% for Group worksites and 29% for non group worksite participants so correcting the data for attrition would increase the apparent efficacy of the group condition.
DePaul 1994 Country: USA
Recruitment: Employees in 61 worksites
Randomisation: Cluster randomisation by company
564 smokers in relevant comparisons The worksite interventions were timed to coincide with a mass media intervention consisting of a week long smoking cessation series on tv, and a complementary newspaper supplement.
1. Self-help manual (ALA Freedom from Smoking in 20 days0
2. Self-help manual and incentive payment of $1 for each day abstinent up to $175
3. 6 group meetings over 3 weeks followed by 14 booster meetings over 6 months. Incentive payments. Handouts from same S-H manual. Maintenance manual (ALA ‘A Lifetime of Freedom from Smoking) Sustained abstinence at 12m
Validation: CO 250 nmol/L) Study designed to test specific effects of social support aspect of group treatments. Included in comparison of group programmes – effect of manipulating group dynamics.
Etringer (Fading) Same study as Etringer 1988
Dummy study used to enter results for comparison of Nicotine Fading cessation Cohesive Group vs standard group.
Etringer 1984 Country: USA
Recruitment: advertisements
Randomisation: couples and friends assigned together and evenly distributed between groups. 72 community volunteers
av.age 36, cigs/day 25
Therapists: doctoral candidates with 2 years in counselling psychology Factorial design using two cessation programmes and an intervention on group cohesiveness. Not clear whether session patterns identical for each
1. Enriched cohesiveness using written commitments, exercises and video. Satiation smoking in preparation for cessation
2. Enriched cohesiveness. Nicotine fading in preparation phase
3. Standard group. Satiation smoking
4. Standard group. Nicotine fading Abstinence at 1 year
Validation by randomly contacting approx half of the three informants nominated 1 vs 3 and 2 vs 4 [Ettringer (fading) 1984] in comparison of group programmes – effect of manipulating group dynamics.
Glasgow D+L Country: USA
Recruitment: media advertisements
Randomisation: no details
88 community volunteers (85 included in analysis)
Therapists: A clinical psychologist and 2 graduate students in behavior therapy, crossed with treatment conditions.
3×2 factorial design for treatment programme and delivery format
Treatment programme: A. Danaher & Lichtenstein manual, B. Pomerleau & Pomerleau manual, C. I Quit Kit (minimum treatment control)
Delivery format: 1. Groups of 4-6 during 8 sessions over 8 weeks
2. Self administered using manuals. Abstinence at 6 months
Validation by CO <15 ppm. At follow-up self-report gives lower success rates in 5/6 arms than using CO measure, so self-report data used. Therapist administered vs self administered compared as separate studies (see GLASGOW P &P, GLASGO IQK) in comparison of group vs self-help format.
Glasgow IQK Same study as GLASGOW D &L
Dummy study used to enter results for comparison of the American Cancer Society I Quit Kit in group and self-help formats. This programme was intended by authors to be a minimal intervention, controlling for the non specific effects of participantion Using self report, 2 quit in the self-help arm and none in the group, but according to CO measurements one person quit in each. For consistency with the other arms where self-report gave more conservative numbers we have used this measure, which is most conservative in assessing the impact of the group.
Glasgow P+P Same study as GLASGOW D &L
Dummy study used to enter results for comparison of Pomerleau & Pomerleau programme in group and self-help formats
Gnsberg 1992 Country: USA
Recruitment: media, flyers and word of mouth
Randomisation: Groups of 3-6 randomised to treatment 99 community volunteers with an acquaintance willing to participate as a support partner.
Therapists: PhD psychologist or MSc health educator
1. Nicotine gum (NG) and educational materials, 2 sessions over 2 weeks
2. NG and behavioural programme including skill training, 5 sessions over 4 weeks
3. NG and behav. prog. and partner support programme, 8 sessions over 5 weeks Asessment at weeks 4,12,26, 52
Outcome used: Abstinence at 52 weeks (not clear if abstinence required at prior points)
Validation by CO <10ppm, urine cotinine <50ng/mL. Paper states that cotinine levels failed to confirm self-report in seven subjects, three of whom were still coded as abstinent on the balance of evidence. interventions 1. had only 2 sessions this does not meet criteria for group therapy, so 2+3 combined are compared to 1 for effect of addtion of group support to NG.
Gruder 1993 Country: USA,
Recruitment: Smokers registering to receive self-help materials during advance promotion of a televised cessation programme, who indicated willingness to attend group sessions and had a non smoking buddy.
Randomisation: Randomisation to group or no group at time of registration. No details on method. 1205 subjects assigned to a group condition, and attempts made to contact them to schedule group meetings. Randomisation between the two group conditions was by site. 26 sites offered social support condition, 24 discussion control. 1440 smokers completing a registration form and assigned to this study.
Therapists: Mainly nurses and health educators randomly assigned and trained to lead either Social Support or Discussion meetings.
Group size varied from 3-22, mean approx 11 All participants sent ALA Freedom from Smoking in 20 days manual and instructed to watch tv programme.
1. Social Support. 3 x90min group meetings and copy of Quitters Guide for smokers and 1 group meeting and Buddy Guide for buddies. Subjects were instructed on how to get help from their buddies and others. Telephone calls to subjects and buddies at 1 and 2 months
2. Discussion. Same schedule of meetings and phone calls as 1. but general information and review of self-help manual.
3. No contact control Multiple point prevalence abstinenence (post intervention, 6 m and 12m). 24m rates also given but substantial loss to follow-up by this time so 12m rates used here. Validation attempted but abandoned due to participant refusal to provide samples. Although group subjects also scheduled to receive phone calls these occurred after the first follow-up so will not have differentially affected the multiple point prevalence quit rates
Quit rates for group vs self-help comparison based on numbers assigned to group treatment who were scheduled to a meeting, and includes 'no shows'.
Hill 1993 Country: USA
Recruitment: radio and newspaper adverts
Randomisation: block assignment to treatment
Therapists: Each group had two instructors from a pool of six all with experience in smoking cessation and/or exercise training. 82 community volunteers aged 50+ who had smoked for over 30 years
1. Behavioral Training (BT) adapted from Lung Health Study program. Included quit date setting, relapse prevention training with role play of coping responses. 12 x 90m session over 3 months
2. BT and nicotine gum
3. BT with additional physical exercise. 20+ x 45-135m sessions over 3 months
4. Exercise and self-help pamphlet. This was a placebo control matched for contact time to 3. Therapist, who was blind to study hypothesis encouraged smokers to quit at the exercise meetings. 5 day abstinence at 12m f/up. (Abstinence at previous f/ups not required)
Validation: CO = 15 cigs/day
Therapists: Trained smoking cessation counsellors Compared 22mg/d vs 44 mg/day nicotine patch and 3 types of adjuvant treatment. Patch groups collapsed. All participants had 8 weekly assessments by research staff
1. Minimal – Given self-help pamphlet by physician during screening visit for trial entry, and instructed not to smoke whilst wearing patch. No further contact with counsellors.
2. Individual – Given self-help pamplet at screening visit along with motivational message. Also met nurse counsellor 3 times following quit date. Nurse 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.
7 day point prevalence abstinence at 26 weeks
Validation; CO <10ppm. No significant difference in dose related outcome and no dose-counselling interaction at 26 weeks reported, so patch arm collapsed in analysis. 3 vs 1 in group plus NRT vs NRT with minimal support. 3 vs 2 in group vs individual (different programme).
Lando 1991 Country: USA
Recruitment: media advertising
Randomisation: intake groups randomised to treatment 353 community volunteers
Therapists: Trained facilitators, mainly graduates, including some who had quit through clinic programme. Both interventions included 16 45-60min sessions over a 9 week period. Nicotine fading schedule prior to quit date at 3 weeks.
1. Enriched cohesiveness intervention – included written commitments and exercises designed to facilitate positive group interaction
2. Standard group treatment 1 year sustained (relapse free) abstinence
Validation: randomly selected subsample of those claiming abstinence, but not clear whether reported data includes a correction for false reporting. Originally a factorial design comparing satiation and nicotine fading in addition to cohesiveness manipulation, but satiation arm abandoned. Only data for nicotine fading procedure arms reported in paper. P values reported in the paper were corrected for the design effects of clustering.
Leung 1991 Country: Hong Kong
Recruitment: media advertisements
Randomisation: no details
95 community volunteers (63 in relevant arms)
Av. age 35-39
Cigs/day: 25-30 1. Behavioral program including self monitoring, management techniques, coping skills. 10 x 1.5 hr sessions over 2 weeks.
2. Auricular acupuncture. Same no of sessions.
3. Waiting list control Abstinence (not defined) at 6 months
Validation by cohabitant and work colleague report. 1 vs 3, group vs waiting list control.
McDowell 1985 Country: Canada
Recruitment: Volunteers visiting family practices for scheduled appointments
Randomisation: method not stated
Groups of 10-15 366 smokers in nine group family practices
Therapists: depended on intevention 1. Physician advice by one of 12 family physicians. 15 minutes counselling session with U.S. 'NCI Helping Smokers Quit Kit' and one postal follow-up.
2. Operation Kick-It programme '. 9 sessions. Therapists: public health nurse or health educator
3. Cognitive Behavior Modification programme. 9 sessions. Therapists: one of two M.Ed psychologists
4. Self-monitoring control followed up at 2, 6 and 12 months. Abstinence (over 1 week diary period) at 12 months
Validation: Ss warned that saliva thiocyanate might be tested, but only a few sampled. No results reported. No evidence of a difference between 2 and 3 so combined and compared with 1 in group vs physician or rurse advice/counselling, and with 4 in minimal intervention control.
Omenn 1988 Country: USA
Recruitment: Single worksite (13,000 workers, 9 employers)
Randomisation: by nurses at aid stations using randomised assignment lists generated by research centre, within preference for format. 159 smokers (av. age 43, 66% male, av.cigs/day 25) with preference for group programme or no preference. (Smokers with preference for self-help were not allocated to group programmes.)
Lead by instructors trained in both programmes. 1. Multiple Component programme. 3 sessions over 3 weeks
2. Relapse Prevention programme. 6 sessions over 6 weeks
3. Minimal Treatment programme. Self-help materials only. American Cancer Society's 22 page 'Quitter's Guide' 7-day plan.
Abstinence at 12 months (single point prevalence)
Validation: saliva cotinine 1 group session, and includes a session of individual counselling.
Drop outs reincluded.
Rice 1994 Country: USA
Recruitment: Health professional and self-referral
Randomisation: No details. Stratified by sex, smoking history and history of cardiovascular incident. 406 smokers with a cardiovascular health problem
Therapists: Clinical nurse specialist who had undergone a 1-week teaching workshop for Smokeless. All except control received Smokeless, a multicomponent intervention in 6 booklets including elements of skills training, behavioral rehearsal, aversive puffing.
1. Individual Intervention – Met with nurse for 4x 1hr sessions in first week and singlemaintenance session in second week.
2. Group Intervention – Met in groups of 5-7 on same schedule
3. Written intervention – Given Smokeless materials in labelled envelopes to open on same schedule. Prompted by call from project secretary.
4. No Intervention – Advice from nurse to quit smoking Point prevalence at 1 year
Saliva thiocyanate tested but not used to correct self-report The published data was based on 255 subjects willing to participate in the treatment allocated. Numbers randomised to treatment provided by author.
2 vs 3, group vs self-help; 2 vs 1, group vs individual therapy, 2 vs 4, group vs minimal intervention.
Sawicki 1993 Country: Germany
Recruitment: From a university diabetic outpatients clinic
Randomisation: no details Diabetic smokers prepared to participate in a stop-smoking programme 1. Extensive behaviour therapy including self control. 10 x 90 min weekly sessions. Led by a psychotherapist
2. Physician advice, 15min unstructured session.
Nicotine replacement offered in case of severe addiction. Abstinence at 6 months.
Validation by serum cotinine 85%, not complete abstinence, and no period of continuous reduction was required at follow-up. The study compared combinations of group vs individual vs no counselling and tranquilizer (equanil) vs placebo vs no prescription. It is included in the review of anxiolytics and antidepressants (Hughes 1997).
Stevens 1989 Compares relapse prevention programmes after success in a cessation programme. No non-group control.
Supnick 1984 Compared 4 maintenance strategies.
Thompson 1988 A complete factorial design included combinations of physician advice, self help materials and referral to American Health Foundation Smoking cessation classes. Not primarily a trial of group therapy. Take up of group programme was very low.
Tiffany 1986 Primarily a trial of different forms of rapid smoking, included in aversion review. No non-group control.
Zelman 1992 Comparison of different forms of counselling and nicotine gum or rapid smoking in a factorial design. No non-group control.

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