NIHR Signal Group therapy may help a few extra people quit smoking, if other methods fail

Published on 11 July 2017

Smokers who receive six to eight sessions of a group behaviour treatment were almost twice as likely to quit as those using self-help programmes. However this represents only about four extra successes in every 100 who try.

The quit rates after individual advice or brief support were very similar, but adding nicotine replacement gum and patches to group therapy or individual therapy did provide further benefits. The logistics of setting up these groups might be a deterrent for commissioners of these services.

Giving smokers the chance to share the difficulties they face when trying to quit may help to increase their chances of quitting successfully and allow them to choose a group programme if available.

Healthcare providers should continue to consider group behaviour therapy in combination with other interventions, such as nicotine replacement therapy, as an option for helping smokers to quit, especially in settings such as the workplace, where support to attend sessions can also be given.

Group therapy may help a few extra people quit smoking, if other methods fail

Why was this study needed?

In the UK, just under 96,000 people a year die from smoking. Hospital admissions for conditions thought to be caused by smoking are rising. Recent estimates in England show an increase from 1.6 million admissions in 2013 to 1.7 million in 2014.

The researchers wanted to find out how effective group behaviour therapy is for smoking cessation in the long-term. Previous Cochrane reviews have shown that group behaviour therapy is more effective than self-help. This is the third version of the review, and updates the 2005 version with 13 new studies and a summary table.

Behavioural interventions are known to be effective for smoking cessation, but it’s unclear which specific psychological components contribute the most to improving quit rates. If these components can be identified, it may be possible to create programmes that are particularly beneficial for people known to be less successful at quitting (for example, people with depression).

What did this study do?

This Cochrane systematic review identified 66 randomised controlled trials that examined the effectiveness of group behaviour therapy in 22,303 adult smokers (men and non-pregnant women).

Group behaviour therapy involves delivering interventions, such as cognitive behavioural therapy or training in social and coping skills, to groups of smokers during scheduled meetings.

The researchers compared group behaviour therapy with self-help, brief advice, health education, pharmacotherapy (NRT or bupropion), individual counselling and no intervention. Most trials involved six to eight sessions of therapy and the follow-up period was at least six months.

Randomisation was often interrupted by putting family members and friends into the same groups, which could have biased results in favour of group therapy.

Overall, the main outcome was supported by evidence of moderate quality, suggesting we can be moderately confident that the precise quit rate is close to a true effect.

What did it find?

  • Group behaviour therapy may improve the estimated quit rate from five people per 100 with self-help to nine per 100 people. This was a relative increase of 88% compared with self-help (relative risk [RR] 1.88, 95% confidence interval [CI] 1.52 to 2.33; 13 studies, 4395 participants).
  • Group therapy plus pharmacotherapy was similar to brief support plus pharmacotherapy, which helped around 18 to 20 people per 100 quit (RR 1.11, 95% CI 0.93 to 1.33; five studies, 1,523 participants).
  • Group therapy (six per 100 quitting) may be slightly more effective than brief advice from a healthcare professional (five per 100), but this finding needs to be interpreted with caution because there was significant variability between the studies. There was no difference in effectiveness between face-to-face individual therapy and group therapy. Both types of programme led to about 11 per 100 quitting.
  • There was insufficient evidence to compare the cost-effectiveness of group therapy with other interventions.

Anticipated quit rates for group-format versus other behavioural programmes to help people stop smoking

What does current guidance say on this issue?

The NICE 2013 guidelines on stop smoking services recommend offering everyone who smokes or uses tobacco in any other form behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective. Other effective treatments include telephone counselling, brief interventions, mass media campaigns, and self-help using materials in written or electronic format.

The NICE 2013 guidelines on reducing harm from smoking recommend offering behavioural support to people who want (or need) to abstain temporarily. This support may be provided in one-to-one or group sessions by specialist services.

The NICE Quality statement on supporting people to stop smoking recommends commissioning evidence‑based smoking cessation services that offer people who smoke behavioural support with pharmacotherapy.

What are the implications?

Group therapy could be considered as one component of a local smoking cessation strategy that offers other interventions. For example, NRT combined with individual counselling or group therapy. But practicalities in setting up group programmes will need consideration.

There doesn’t appear to be a difference in effectiveness between group behaviour therapy plus pharmacotherapy and pharmacotherapy combined with brief support. Absolute quit rates when including NRT seem better than counselling alone.

It may not be practical to run group therapy sessions in rural locations so individual interventions are an essential alternative. Whereas workplaces may be better placed to offer support for group attendance. NICE suggests that group therapy is more cost-effective than individual counselling as the cost of therapist time is shared.

Citation and Funding

Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking cessation.
Cochrane Database Syst Rev. 2017;(3):CD001007.

The Cochrane Tobacco Addiction Group receives funding from the NIHR.

Bibliography

Health and Social Care Information Centre. Statistics on Smoking. England, 2016. Leeds: NHS Digital; 2016.

Health and Social Care Information Centre. Statistics on Smoking. England, 2014. Leeds: NHS Digital; 2014.

NICE Smoking: harm reduction. PH45. London: National Institute for Health and Clinical Excellence; 2013.

NICE Smoking: supporting people to stop. QS43. London: National Institute for Health and Clinical Excellence; 2013.

NICE Stop Smoking Services. PH10. London: National Institute for Health and Clinical Excellence; 2008.

NICE. Smoking: workplace interventions. PH5. London: National Institute for Health and Clinical Excellence; 2007.

NICE. Smoking: brief interventions and referral. PH1. London: National Institute for Health and Clinical Excellence; 2006.

Welsh Government. Smoking. Cardiff: Welsh Government; updated April 2017.

Why was this study needed?

In the UK, just under 96,000 people a year die from smoking. Hospital admissions for conditions thought to be caused by smoking are rising. Recent estimates in England show an increase from 1.6 million admissions in 2013 to 1.7 million in 2014.

The researchers wanted to find out how effective group behaviour therapy is for smoking cessation in the long-term. Previous Cochrane reviews have shown that group behaviour therapy is more effective than self-help. This is the third version of the review, and updates the 2005 version with 13 new studies and a summary table.

Behavioural interventions are known to be effective for smoking cessation, but it’s unclear which specific psychological components contribute the most to improving quit rates. If these components can be identified, it may be possible to create programmes that are particularly beneficial for people known to be less successful at quitting (for example, people with depression).

What did this study do?

This Cochrane systematic review identified 66 randomised controlled trials that examined the effectiveness of group behaviour therapy in 22,303 adult smokers (men and non-pregnant women).

Group behaviour therapy involves delivering interventions, such as cognitive behavioural therapy or training in social and coping skills, to groups of smokers during scheduled meetings.

The researchers compared group behaviour therapy with self-help, brief advice, health education, pharmacotherapy (NRT or bupropion), individual counselling and no intervention. Most trials involved six to eight sessions of therapy and the follow-up period was at least six months.

Randomisation was often interrupted by putting family members and friends into the same groups, which could have biased results in favour of group therapy.

Overall, the main outcome was supported by evidence of moderate quality, suggesting we can be moderately confident that the precise quit rate is close to a true effect.

What did it find?

  • Group behaviour therapy may improve the estimated quit rate from five people per 100 with self-help to nine per 100 people. This was a relative increase of 88% compared with self-help (relative risk [RR] 1.88, 95% confidence interval [CI] 1.52 to 2.33; 13 studies, 4395 participants).
  • Group therapy plus pharmacotherapy was similar to brief support plus pharmacotherapy, which helped around 18 to 20 people per 100 quit (RR 1.11, 95% CI 0.93 to 1.33; five studies, 1,523 participants).
  • Group therapy (six per 100 quitting) may be slightly more effective than brief advice from a healthcare professional (five per 100), but this finding needs to be interpreted with caution because there was significant variability between the studies. There was no difference in effectiveness between face-to-face individual therapy and group therapy. Both types of programme led to about 11 per 100 quitting.
  • There was insufficient evidence to compare the cost-effectiveness of group therapy with other interventions.

Anticipated quit rates for group-format versus other behavioural programmes to help people stop smoking

What does current guidance say on this issue?

The NICE 2013 guidelines on stop smoking services recommend offering everyone who smokes or uses tobacco in any other form behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective. Other effective treatments include telephone counselling, brief interventions, mass media campaigns, and self-help using materials in written or electronic format.

The NICE 2013 guidelines on reducing harm from smoking recommend offering behavioural support to people who want (or need) to abstain temporarily. This support may be provided in one-to-one or group sessions by specialist services.

The NICE Quality statement on supporting people to stop smoking recommends commissioning evidence‑based smoking cessation services that offer people who smoke behavioural support with pharmacotherapy.

What are the implications?

Group therapy could be considered as one component of a local smoking cessation strategy that offers other interventions. For example, NRT combined with individual counselling or group therapy. But practicalities in setting up group programmes will need consideration.

There doesn’t appear to be a difference in effectiveness between group behaviour therapy plus pharmacotherapy and pharmacotherapy combined with brief support. Absolute quit rates when including NRT seem better than counselling alone.

It may not be practical to run group therapy sessions in rural locations so individual interventions are an essential alternative. Whereas workplaces may be better placed to offer support for group attendance. NICE suggests that group therapy is more cost-effective than individual counselling as the cost of therapist time is shared.

Citation and Funding

Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking cessation.
Cochrane Database Syst Rev. 2017;(3):CD001007.

The Cochrane Tobacco Addiction Group receives funding from the NIHR.

Bibliography

Health and Social Care Information Centre. Statistics on Smoking. England, 2016. Leeds: NHS Digital; 2016.

Health and Social Care Information Centre. Statistics on Smoking. England, 2014. Leeds: NHS Digital; 2014.

NICE Smoking: harm reduction. PH45. London: National Institute for Health and Clinical Excellence; 2013.

NICE Smoking: supporting people to stop. QS43. London: National Institute for Health and Clinical Excellence; 2013.

NICE Stop Smoking Services. PH10. London: National Institute for Health and Clinical Excellence; 2008.

NICE. Smoking: workplace interventions. PH5. London: National Institute for Health and Clinical Excellence; 2007.

NICE. Smoking: brief interventions and referral. PH1. London: National Institute for Health and Clinical Excellence; 2006.

Welsh Government. Smoking. Cardiff: Welsh Government; updated April 2017.

Group behaviour therapy programmes for smoking cessation

Published on 1 April 2017

Stead, L. F.,Carroll, A. J.,Lancaster, T.

Cochrane Database Syst Rev Volume 3 , 2017

BACKGROUND: Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support. OBJECTIVES: To determine the effect of group-delivered behavioural interventions in achieving long-term smoking cessation. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register, using the terms 'behavior therapy', 'cognitive therapy', 'psychotherapy' or 'group therapy', in May 2016. SELECTION CRITERIA: Randomized trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting-list control). We also considered trials that compared more than one group programme. 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: Two review authors extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in participants smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. We analysed participants lost to follow-up as continuing smokers. We expressed effects as a risk ratio for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study and comparison, using the Cochrane 'Risk of bias' tool and GRADE criteria. MAIN RESULTS: Sixty-six trials met our inclusion criteria for one or more of the comparisons in the review. Thirteen trials compared a group programme with a self-help programme; there was an increase in cessation with the use of a group programme (N = 4395, risk ratio (RR) 1.88, 95% confidence interval (CI) 1.52 to 2.33, I2 = 0%). We judged the GRADE quality of evidence to be moderate, downgraded due to there being few studies at low risk of bias. Fourteen trials compared a group programme with brief support from a health care provider. There was a small increase in cessation (N = 7286, RR 1.22, 95% CI 1.03 to 1.43, I2 = 59%). We judged the GRADE quality of evidence to be low, downgraded due to inconsistency in addition to risk of bias. There was also low quality evidence of benefit of a group programme compared to no-intervention controls, (9 trials, N = 1098, RR 2.60, 95% CI 1.80 to 3.76 I2 = 55%). We did not detect evidence that group therapy was more effective than a similar intensity of individual counselling (6 trials, N = 980, RR 0.99, 95% CI 0.76 to 1.28, I2 = 9%). Programmes which included components for increasing cognitive and behavioural skills were not shown to be more effective than same-length or shorter programmes without these components. AUTHORS' CONCLUSIONS: Group therapy is better for helping people stop smoking than self-help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Brief interventions generally take 10 minutes or less to deliver. They may involve:

  • giving smokers opportunistic advice, encouragement and self-help materials
  • assessing their commitment to quitting
  • pharmacotherapy
  • behavioural support; and
  • referral for more intensive interventions (such as NHS Stop Smoking Services)

Expert commentary

Smokers wanting to quit, smoking cessation services and policy makers should all be interested in the most effective methods of quitting smoking. Group behaviour therapy is a common component of many approaches and this review reinforces the effectiveness of this at an individual level.

However, the review is unable to identify for smoking cessation services the most important component of the approach - be it therapist, intensity of intervention or theoretical underpinning of the approach.

More importantly for policy makers is the fact that the take-up of group behaviour therapy can be as low as 10% and although effective may not be cost-effective in today’s cash strapped health system.

Dr Rupert Suckling, Director Public Health, Doncaster Metropolitan Borough Council

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