Behavioral Interventions to Enhance Smoking Cessation

Abstract

In the United States, the rate of cigarette smoking has significantly declined over the past 2 decades, but much more work is needed, as almost 20% of adults still smoke and smoking continues to be the leading preventable cause of death. Furthermore, rates of smoking in certain subpopulations have remained relatively stable and have historically been neglected in smoking cessation research. Pharmacotherapy (both prescription and over-the-counter) and behavioral support are known to aid cessation, and their combination is more effective than either alone. There are significant barriers to access, use, and adherence, however, especially with pharmacotherapy. Therefore, the purpose of this review is to provide an update and overview of the numerous behavioral approaches that have been used to enhance smoking cessation. The research described can be classified into the type of approach used, the setting in which it is delivered, and the population targeted. Regardless of the classification, all the approaches attempt to provide smokers with the information, motivation, and behavioral skills thought to be necessary for achieving initial cessation and sustained abstinence. Recommendations for future research on behavioral smoking cessation are also included.

‘. . . behavioral interventions continue to be vitally important for reducing smoking rates.’

Introduction

Cigarette smoking remains the leading preventable cause of death in the United States, ¹ and extensive resources continue to be used to examine ways to reduce the health burden of smoking. Fortunately, significant progress has been made and the smoking rate has gradually decreased over the past 15 years. ² This trend can be attributed to several factors, including changes in policy (eg, laws banning smoking in public places, increased taxes on cigarettes), the development of new smoking cessation medications, and improved behavioral treatments. ¹ More work is needed, however, as nearly 20% of the US population continue to smoke. ²

Over-the-counter nicotine replacement therapies and prescription medications, such as bupropion and varenicline, can significantly benefit smokers wishing to quit, as they can relieve nicotine withdrawal and have been shown to nearly double the success rate of smoking cessation when compared with a placebo.^3-5 However, these medications have side effect burdens and are not appropriate or have not been extensively studied in certain populations of smokers (eg, individuals with psychiatric comorbidities, adolescents, postpartum women). ⁴ Cost, access, adherence, and the perception of medication risk are known to reduce widespread medication use. ⁶ Importantly, the effectiveness of cessation medications can be improved with behavioral support. ⁷ Thus, behavioral interventions continue to be vitally important for reducing smoking rates. The purpose of this review is to provide an update on common behavioral treatments that can enhance smoking cessation.

Effects of Cigarette Smoking on Health

According to the 2010 Surgeon General’s Report on Smoking and Tobacco Use, tobacco smoke contains more than 7000 chemicals, making any exposure, including an occasional cigarette or inhalation of secondhand smoke, harmful. ¹ Cigarette smoking is known to cause cardiovascular disease, stroke, chronic obstructive pulmonary disease, low bone mineral density, and numerous types of cancer (eg, lung, bladder, cervix, stomach).^8,9 Although these effects are typically the result of long-term damage, early cardiovascular damage, retarded lung growth, and shortness of breath have been seen in young smokers. ¹⁰ Smoking has additional adverse effects on pregnancy and reproductive health, including increased rates of infertility, preterm delivery, and sudden infant death syndrome. ⁹ Overall, it is currently estimated that cigarette smoking and exposure to secondhand smoke causes 440 000 deaths annually, or 1 out of every 5 deaths in the United States.^1,11 Lung cancer claims the most lives, followed by ischemic heart disease, and chronic obstructive pulmonary disease. ¹¹ In total, more deaths are caused by tobacco use than by all deaths from illegal drug use, alcohol use, human immunodeficiency virus (HIV), motor vehicle injuries, murders, and suicides combined. ⁹ The resulting annual economic losses attributable to smoking-caused diseases are estimated to be $96 billion. ¹²

Prevalence of Smoking and Characteristics of Smokers

In the United States, 18.0% of all American adults aged 18 years and older smoke cigarettes, with rates higher in men (20.4%) than in women (15.8%). ¹³ Among the youth, 15.8% of high school students and 4.3% of middle school students currently smoke. ¹⁴ Smoking rates are known to differ by various other demographic variables. For example, 31.5% of American Indian or Alaska Native adults smoke, compared with 20.6% of non-Hispanic white adults, 19.4% of non-Hispanic black adults, 12.9% of Hispanic adults, and 9.9% of Asian adults. ¹² Rates are higher among those with a GED (45.3%) when compared with those with a high school diploma (23.8%), or a college (9.3%) or advanced (5.0%) degree. ¹² Household income is also a factor in smoking prevalence; those adults with an income below the poverty level have higher rates (29.2%) than those with an income 1 to 2 times above (25.7%), 2 to 4 times above (21.4%), or 4 or more times above (13.9%) the poverty level. ¹⁵ Cohabiting adults (34.6%) and divorced or separated adults (30.3%) are more likely than never-married adults (22.2%) and married adults (15.7%) to be current smokers. ¹⁵ Adults living in the West (16.5%) are less likely to be smokers than those living in the Northeast (19.0%), South (21.6%), or Midwest (22.5%); and those living outside a metropolitan statistical area are more likely to be current smokers (26.6%) than adults living in a small (21.2%) or large metropolitan statistical area (17.7%) ¹⁵ .

Impact and Prevalence of Smoking Cessation

Although quitting smoking earlier in life is associated with greater benefits, quitting at any age results in several immediate health benefits. For example, the risk for a heart attack drops sharply just 1 year after quitting; stroke risk can fall to about the same as a nonsmoker’s 2 to 5 years after quitting; risks for cancer of the mouth, throat, esophagus, and bladder are cut in half 5 years after quitting; and the risk for dying of lung cancer drops by half 10 years after quitting. ¹ In a recent study of 113 752 adult women and 88 496 adult men, it was found that those who had quit smoking at age 25 to 34, 35 to 44, or 45 to 54 years gained about 10, 9, and 6 years of life, respectively, when compared with those who continued to smoke. It was also shown that those who quit smoking before the age of 40 reduced their risk of death associated with continued smoking by about 90%. ¹⁶

For more than 10 years, the number of former smokers in the United States has exceeded the number of current smokers.^15-17 Recent estimates show that the majority of smokers would like to quit, with 45.8% having tried in the past year. ¹⁵ Unfortunately, fewer than 5% are able to maintain abstinence, ¹⁸ as rates decline over time, particularly after 6 months. ¹⁹ Data from the National Epidemiologic Survey on Alcohol and Related Conditions indicate that attempts to quit are higher among certain groups, such as females, those who were younger at first use, and those with the most symptoms of dependence. ¹⁸ Hispanics, Asians, individuals with high income, and those with college education report fewer quit attempts. ¹⁸ Previous research has also shown that cessation may be more likely among non-Hispanic whites, those with an increased level of education, and those with private health care plans. ¹⁷

Approaches Used in Behavioral Interventions for Smoking Cessation

The strategies used to alter smoking behavior vary widely in their target population, context, and scope. Given these differences, a social ecological model has been used to categorize the range of approaches used to date. In the next 4 sections of this article, interventions conducted at the community level, organizational level, interpersonal level, and individual level are summarized. A final section detailing how the application of the different approaches can be used for special populations is also included.

Interventions Conducted at the Community Level

Mass Media Campaigns

Mass media (eg, television, Internet, radio, billboards) can play a key role in shaping smoking-related attitudes and behaviors. ²⁰ The first mass media campaigns against smoking in the United States began in the late 1960s, shortly after the release of the 1964 Surgeon General’s report on smoking and health.^21,22 The goal of current antismoking mass media is to encourage smokers to quit, while also influencing the social and political landscape that helps form the cultural norms around smoking. ²³ Research investigating the effectiveness of mass media campaigns typically uses quasi-experimental or randomized trials, which often include whole communities as the unit of assignment. ²¹ For example, Vallone et al ²⁴ examined the relationship between having an awareness of a national mass media smoking cessation campaign and smoking outcomes in a sample of 4067 adult smokers. Participants from eight different “media markets” (ie, 8 different geographical areas where the population receives the same television, radio, and other media offerings) were surveyed at baseline and 6 months after the campaign launch. Results showed that there was 24% significantly greater chance of making a quit attempt among those aware of the campaign when compared with those who were not aware of the campaign. Overall, these results are similar to other studies that show mass media campaigns, particularly when theoretically based, are cost-effective and can promote changes in adult and youth smoking beliefs and behaviors.^25-28 Other research in this area indicates that mass media campaigns can also be highly effective when they are part of a comprehensive tobacco control program, ²¹ and they may be especially effective in promoting cessation among minority and disadvantaged smokers.^24,29,30 Future research is still needed to investigate the effects of social media, and strategies that will be able to improve the efficiency of mass media to optimize its impact on behavior.

Quit Lines and Telephone Counseling

Telephone counseling for smoking cessation is well known to be an effective strategy for helping smokers quit. Research has shown that when compared with self-help materials or minimal advice, telephone counseling can increase quit rates by about 60%.^3,31 There are 2 specific methods of telephone counseling: proactive and reactive. Proactive telephone counselors initiate telephone calls either as a cold-call or as a follow-up to a previous interaction. These calls can help motivate a quit attempt, they can directly support a smoker when trying to make a quit attempt, or they provide support to help prevent relapse once quit. There is some evidence for a dose–response relationship regarding the number of proactive calls, with 3 or more calls increasing the chances of quitting over other minimal interventions (eg, self-help materials).^31,32 To date, research shows that proactive telephone counseling may increase abstinence for up to 9 months in smokers interested in quitting; however, the long-term (12 months or longer) effect is less clear.^31,32 Reactive telephone counseling is limited to responding to calls made by smokers, usually to a quitline (eg, 1-800-QUIT-NOW). Quitlines effectively use mass media to attract calls ³³ that are answered by trained counselors who use a combination of techniques to enhance smoking cessation. ³⁴ Additional contact with callers may include future calls, mailed materials, recorded messages, or a mixture of these components. ³¹ Overall, the major benefit of telephone counseling is its ability to reach a large number of smokers at a low cost. ³⁵ New research in this area will need to determine the effect of including a quitline number on cigarette packs, ³⁶ while other research should explore how telephone counseling may extend and complement primary care,^37,38 particularly for hard-to-reach populations (eg, pregnant women).

Technology-Driven Programs

Internet interventions

In the United States, 93% of youth aged 12 to 17 years, and 85% of adults aged 18 years or older use the Internet, with rates of use being equal between genders and consistent across race/ethnicity. ³⁹ As a result, Internet-based smoking cessation interventions have been proposed as a low-cost way to reach a large number of smokers.^40,41 There is also great potential for the Internet to provide smokers with cessation support that can be accessed at any time or on any day, unlike many other forms of counseling (eg, group).^42,43 Unfortunately, the research to date has not consistently shown significant effects. A recent meta-analysis of 28 trials concluded that multicomponent interventions with Internet and non–Internet-based elements were more efficacious than self-help manuals, but the overall evidence was insufficient-to-moderate in adults and insufficient in college students and adolescents. Key limitations in this area are inherently common for both smoking cessation and Internet research, including significant barriers to recruitment and/or poor engagement and retention of participants. ⁴⁴ Future research will therefore need to investigate various ways of engaging users while providing retention support throughout the quitting process. ⁴⁵ More information on factors such message tone, content, and dose–response effects will also be important. ⁴⁶

Mobile phone and text message interventions

It is estimated that 78% of American teenagers and 91% of American adults own a cell phone, with about 60% of owners using a smartphone and at least 80% using text messaging regularly. ⁴⁷ Despite this widespread use, research examining mobile phone and text messaging interventions for smoking cessation is still relatively new. The earliest studies established the feasibility and acceptability of text messaging for smoking cessation, while more current research has aimed to determine the efficacy of using newer mobile phone technology (ie, video messaging). ⁴⁸ The benefits of using a mobile phone/text-based smoking cessation intervention include ease of delivery to a large numbers of smokers, messages sent during the most appropriate or convenient times, and low cost. ⁴⁹ Studies conducted to date have typically modified smoking cessation counseling statements into short messages and sent tailored content to the smoker on based on their age, gender, ethnic group, and/or smoking-related characteristics.^50,51 A 2012 review of 5 studies found that mobile phone interventions (4 text, 1 video) increase long-term quit rates (ie, greater than 6 months) when compared with a control. ⁴⁸ A number of studies are ongoing, with many of these testing interventions for specific groups (eg, young adults, ⁵¹ underserved smokers, ⁵² primary care ⁵³ ). Like other areas of smoking cessation research, participant engagement is difficult and retention rates have been low.^54-56 Future research will need to determine how to better engage smokers, how to sustain the abstinence effects over longer periods of time, and how to adapt smoking cessation interventions to increasing advances in mobile phone technology.

Interventions Conducted at the Organizational Level

Workplace Programs

Research shows that there are numerous negative workplace effects associated with employees who smoke, such as increased health care costs, greater absenteeism, poorer job performance, and an increased risk of injury. ⁵⁷ Although workplace policies against smoking help reduce cigarette consumption by employees during work hours, there is currently not a substantial amount of evidence to suggest that these policies alter smoking habits outside of work. As such, a workplace smoking cessation program is seen as an ideal complement to support employees adhering to an antismoking policy. There are also several advantages to conducting a cessation program in such an environment. These may include (a) access to a large, stable population; (b) the potential for high participation and compliance; (c) a socially reinforcing network and positive atmosphere; (d) an opportunity to include diverse or hard-to-reach populations; and (e) the ability to run a program that can be tailored to meet the needs of a particular group. ⁵⁸ Research conducted to date indicates that participation rates in workplace smoking cessation programs are low, but that an incentivized, multicomponent approach, using both counseling and pharmacological treatment, can increase quit rates that are at least comparable to off-site programs.^{58 -61} Additional studies will be needed, however, as a recent meta-analysis showed that the most effective and successful workplace health promotion programs tailor the content of the intervention to the population studied. ⁶² For example, programs with at least weekly contact with participants or those targeting younger workers have been shown to be more effective. ⁶² Given the well-known demographic and socioeconomic differences among smokers, future studies will likely need to test the effects of targeting specific groups with workplace cessation programs, as this could increase the level of engagement and effectiveness.

Programs Used in the Medical Setting

Health care providers

As reviewed above, cigarette smoking contributes to a wide variety of medical illnesses. Thus, it is not surprising that smoking is common in a variety of medical populations. ⁶³ Smoking cessation is also an important target for secondary prevention in many conditions. For example, quitting smoking after being diagnosed with lung cancer greatly reduces risk for both recurrence and mortality. ⁶⁴ Likewise, smoking appears to significantly increase the secondary complications of diabetes (eg, neuropathy). ⁶⁵

The 5 As of smoking cessation (Ask, Advise, Assess, Assist, and Arrange) were developed to serve as a simple framework through which a variety of providers can support smoking cessation, even if visits are brief. ³ The 5 As instruct providers to ask about smoking status at each visit (ie, Ask). This can be accomplished by treating smoking status as a “vital sign” or using prompts in medical records that remind providers to inquire about smoking status.^66,67 Not surprisingly, identifying more smokers can increase provision of cessation treatment.^13,68 The next 5 As step is to provide clear, personalized advice to quit smoking (ie, Advise), which can take just a few minutes and has clear empirical support. ⁶⁹ In fact, providing 3 or fewer minutes of advice can prompt cessation. ³

It may be obvious to medical providers that many of their patients who smoke are not interested in quitting at a given visit. Therefore, it is critical that providers assess a given patient’s willingness to make a cessation attempt (ie, Assess) and proceed with techniques that fit that patient’s level of willingness. ⁷⁰ For patients who are interested in quitting in the near term, the clinician can Assist: develop a quit plan, set a quit date, discuss using pharmacotherapy, refer the patient to additional counseling or quitlines, and provide practical counseling. If any cessation related action is planned, the provider would ideally follow-up in person or by phone in the weeks following the quit date (Arrange). ³ This additional contact allows the provider to reinforce cessation and help motivate another quit attempt for those that have relapsed.

For medical patients who are not interested in quitting, brief counseling may be useful, as it has been shown to increase quit attempts. ⁷¹ In addition, the 5 Rs (Relevance, Risks, Rewards, Roadblocks, and Repetition) provide an empirically supported framework for increasing motivation to quit among medical patients currently unwilling to plan a quit attempt, that can be applied by a provider without specialized motivational interviewing training.^3,72 In the 5 Rs framework, patients and providers discuss the personal Relevance of smoking, perceived personal Risks of smoking and Rewards of quitting, and perceived Roadblocks to quitting (for which the provider suggests possible solutions). These 4 steps can then be repeated during subsequent visits (Repetition).

Providers may question the usefulness of continuing to discuss smoking cessation with the same unmotivated to quit patient over multiple visits. However, it is important to note that readiness to quit can vary from week to week. ⁷³ Thus, discussing smoking at each visit will make it more likely that the provider will catch the patient when they are most ready for an intervention. Likewise, providers could worry that addressing smoking cessation at every visit may be alienating and interfere with the patient provider relationship. However, research findings suggest that smokers (even those not ready to quit) are more satisfied with tobacco specific and overall care when providers address smoking cessation. ⁷⁴ Finally, many providers may be concerned that they do not have time in their caseload to follow-up with patients attempting to quit, or will not be reimbursed for such follow-ups. Research suggests that proactive quit lines may be a viable option for follow-up care.^75,76

Lack of education and training in smoking cessation can be a major barrier to implementation of the above recommendations,^77,78 and this may be especially true in medical settings that have not traditionally be involved in smoking cessation counseling (eg, pharmacy or dental settings^79,80). A recent meta-analysis of 17 studies indicates that training medical personnel in smoking cessation techniques increases provision of cessation services and significantly increases the likelihood of patient abstinence. ⁸¹ More structured, empirically supported smoking cessation training integrated into medical training ⁸² may help address this training issue.

Importantly, the Affordable Care Act requires all insurance plans to pay for and adhere to the tobacco cessation treatments recommended by the US Preventive Services Task Force. Currently, the US Preventive Services Task Force recommends that health care providers (a) ask all adults about tobacco use and provide tobacco cessation interventions for users; (b) offer augmented, pregnancy-tailored counseling to pregnant women who smoke; and (c) provide interventions, including education or brief counseling, to prevent the initiation of tobacco use in school-aged children and adolescents. ⁸³ In addition, to meet the stage 1 requirements of Meaningful Use (ie, incentives for meeting electronic health record criteria), providers must also document the smoking status of more than 50% of all unique patients ≥13 years old. ⁸⁴ Although the effects of these requirements on practice are not yet known, it is likely they will help to improve the prevention and treatment of smoking within the health care setting.

Hospital inpatients

Being hospitalized for medical reasons can serve as a “teachable moment” when the negative health effects of smoking are more difficult to ignore. Further, US hospitals are now smoke free ⁸⁵ and national accreditation bodies now track the rate at which hospitals provide cessation treatment. ⁸⁶ Clinical guidelines ⁷⁰ state that smoking should be assessed at intake and included on the problem list and discharge summary. Inpatients should be offered nicotine replacement therapy or cessation medication if not contraindicated (eg, Food and Drug Administration package insert recommends that nicotine replacement therapy is “used with caution” following a heart attack). While the 5As and 5Rs (described above) should be used at inpatient contacts, there is evidence that inpatient smoking cessation programs that do not extend beyond discharge are not effective. Specifically, a recent meta-analysis showed that only those cessation programs that started during the inpatient stay and continued at least one month post discharge significantly affected quit rates. Such treatments increased the odds of abstinence by 65%. ⁸⁵

Interventions Conducted at the Interpersonal Level

Individual Counseling

Individual or face-to-face counseling is one of the most widely used techniques in behavioral interventions. It is highly versatile and commonly used in smoking cessation treatment because it can be (a) conducted by practitioners with various levels of training (eg, physicians, nurses, tobacco treatment specialists); (b) delivered in multiple formats (eg, in person, over telephone), using a different number of sessions (eg, one or more), for different lengths of time (eg, 10-60 minutes); and (c) easily combined with other counseling techniques (eg, group). Previous studies have shown that individual counseling increases quit rates when compared with minimal contact or a control; however, there does not seem to be an incremental increase in the effectiveness of individual counseling with an increasingly intense intervention (ie, brief counseling vs multiple sessions). ⁸⁷ More recent research has focused on testing the effects of combining individual counseling with other forms of treatment, such as exercise or incentives.^88,89 Results are consistently positive, and given that even a brief individual counseling session (eg, 10-20 minutes) can make an impact, it should be encouraged. ⁸⁷ Going forward, new studies will need to determine how advances in technology can be used to enhance individualized smoking cessation counseling. For example, studies will need to determine how to adapt existing individual counseling techniques for use over the Internet (eg, using video conferencing or Skype). Advances in these areas could be particularly important for hard-to-reach smokers, such as the disabled or those living in rural areas.

Motivational Interviewing

Motivational interviewing (MI) was developed in the early 1980s as a therapy for treating alcohol and other drug abuse. ⁹⁰ It is an individually administered counseling approach that aims to elicit behavior change by helping individuals to explore and resolve ambivalence. ⁹¹ MI seeks to change behavior by reducing resistance to change by developing a discrepancy between an individual’s current behavior and his or her values and goals. There are 5 core principles underlying this approach: (a) identify discrepancies between thought and action, (b) support client autonomy, (c) express empathy, (d) roll with resistance, and (e) avoid confrontation. ⁹⁰ To date, there have been nearly 60 published trials that have tested the efficacy of using MI for nicotine dependence. A 2010 Cochrane review ⁹² found modest support for MI when compared with brief advice or usual care, with greater effects occurring when delivered by primary care physicians and trained counselors (rather than hospital clinicians or nurses), or when contact was longer (ie, greater than 20 minutes) or more frequent (ie, 2 or more sessions). In addition, other research has found that MI may be more ideal for those with low levels of motivation to quit, for individuals living outside the United States, adolescents, and those with medical comorbidities.^93,94 Overall, treatment fidelity and internal validity have been a challenge for MI research,^92,95 and future research will need to more rigorously test standardized MI protocols, include fidelity assessments, and determine the independent effects of MI when compared with other behavioral smoking cessation treatments.^{92 -95}

Group Counseling

Group therapy has been practiced for more than 60 years, and smoking cessation interventions have been delivered in a group format for nearly that long. Overall, the group format can provide attendees with a unique opportunity to connect with other smokers and learn about the challenges they have faced when trying to quit. To date, there is fair amount of evidence supporting group counseling for smoking cessation. For example, a 2005 meta-analysis reviewed 55 randomized controlled trials and found group counseling to be more effective than self-help methods or no intervention controls. ⁹⁶ More recent studies have examined the effects of group counseling when delivered by health care providers ⁹⁷ and when delivered in a community setting. ⁹⁸ Results are mixed, but given the potential for group counseling to be less expensive than other types of counseling, more work is warranted. Moreover, with advancing technology, new research needs to determine the effectiveness of different modes of group counseling (ie, using social media), and whether or not the method of interaction among group participants affects smoking outcomes.

Financial Incentives

The use of financial incentives to change behavior, a form of contingency management, has been shown to be effective strategy for a wide range of addictions. With respect to smoking, abstinence or a reduction in smoking is rewarded with a financial incentive contingent on the result of an objective test, such as breath carbon monoxide or urine cotinine. Key factors such as the threshold for receiving a reward in response to a change in smoking, the size of the reward, and the schedule of payments vary considerably by study. ⁸⁹ Overall, this behavioral approach to smoking cessation has been examined for about 30 years with consistently favorable results. There are important limitations with this work, however, which have prevented more widespread use. As outlined by Sigmon and Patrick, ⁸⁹ there are far fewer studies showing that incentive-based cessation can work on a large scale than there are studies showing its effectiveness in small, controlled environments. There are also significant financial challenges that come with escalating payments in order to continually reward an individual for maintaining abstinence, a factor that has been shown to increase effectiveness. ⁹⁹ Currently, it is not clear whether incentive-produced abstinence can be sustained after the rewards are discontinued, as studies have shown an increase in relapse with discontinued incentives. ⁸⁹ As such, new research will need to explore these and other limitations to determine the long-term utility of financial incentives for cessation.

Interventions Conducted at the Individual Level

Exercise

The US Department of Health and Human Services currently promotes exercise as an aid for smoking cessation, ¹⁰⁰ as there have been a number of clinical trials and acute laboratory-based studies showing some positive effects of exercise when trying to abstain from or quit smoking. ⁸⁸ In addition to the well-known health effects of exercise, it is hypothesized that exercise can also be helpful acutely for managing the withdrawal symptoms and negative mood states that often lead to relapse ¹⁰¹ ; and chronically for managing the weight gain that often accompanies quitting. ¹⁰² The existing evidence for the efficacy of exercise to aid smoking cessation is currently not strong; however, there have been numerous methodological issues among the various studies preventing a clear consensus. While there is more agreement among the acute laboratory-based studies that consistently show significant effects for a reduction in withdrawal symptoms or cravings after a single bout of exercise, few studies have shown long-term differences in quit rates. A 2012 meta-analysis ⁸⁸ of 15 randomized controlled trials concluded that only 1 study offered sufficient evidence for exercise aiding long-term smoking cessation (ie, 12 months). Key limitations of the other trials included small sample sizes, insufficiently intense interventions, and unequal contact control groups. While more recent research has begun to examine the effects of different types of exercise on smoking cessation,^103,104 the effects of exercise for mentally ill smokers, ¹⁰⁵ and the role of exercise for adolescents who smoke, ¹⁰⁶ future studies will need to address the limitations of previous research in order to more fully determine whether or not exercise can enhance smoking cessation.

Abrupt Quitting Versus Gradual Reduction

Choosing a “quit day” to abruptly stop smoking all cigarettes has been the long-standing behavioral method used in smoking cessation research. New investigations into the efficacy of gradually reducing the number of cigarettes smoked prior to quitting have recently been conducted. There are several reasons why this alternative method could be useful, most prominently, that a gradual reduction in nicotine intake could reduce cravings and withdrawal, which often lead to relapse.^107,108 There is concern, however, that short-term decreases will not be maintained because the few remaining cigarettes could become more rewarding and harder to give up.^107,108 This could ultimately undermine motivation to quit and prevent abstinence. ¹⁰⁹ Despite this, research shows that smokers using the reduction method have been able to maintain abstinence ¹⁰⁷ and this technique may be more attractive to smokers less motivated to quit.^107,110,111 A 2012 meta analysis ¹⁰⁷ investigated whether reduction or abrupt quitting had superior abstinence rates and found no difference across 10 trials. These results held even when the method of quitting was used in conjunction with behavioral support or self-help therapy. ¹⁰⁷ As such, there is empirical support to suggest that smokers should be given a choice of quitting methods, either by reducing smoking before quitting or by using the abrupt quitting technique. ¹¹² An area of future research will be to investigate which types of smokers benefit the most from each method, and how this can help inform future policy and intervention development. ¹⁰⁷

Electronic Cigarettes

In 2004, the first electronic cigarette or e-cigarette was released. An e-cigarette is a battery-powered device that is similar in size and shape to a tobacco cigarette. The user inhales a vaporized solution of nicotine and propylene glycol and/or vegetable glycerin, and exhales as he or she normally would when smoking a tobacco cigarette. It is estimated that 2.5 million Americans use e-cigarettes, with total sales approaching $300 million a year. ¹¹³ Controversy over the safety of e-cigarettes exists, as a Food and Drug Administration analysis found small amounts of carcinogenic nitrosamines, along with diethylene glycol (toxic to humans) in a sample of the e-cigarette cartridges. ¹¹⁴ Additional concerns include variability in the amount of nicotine delivered per puff, the potential for dual addiction (adding e-cigarettes to tobacco cigarettes), low amounts of nicotine present in cartridges listed as containing no nicotine, and marketing to children and adolescents. ¹¹⁵ In response to these reports, some smoking cessation scientists have called for additional research and a harm-reduction approach, especially given that e-cigarettes may pose much lower carcinogenicity than regular cigarettes and are similar in carcinogenicity to current Food and Drug Administration–approved nicotine replacement products. ¹¹⁶ To date, there have only been a few studies investigating the use of e-cigarettes for smoking cessation, and it appears that e-cigarettes may be a potential behavioral replacement for smoking, as they resemble a cigarette and provide sensations similar to smoking (eg, taste). ¹¹⁷ Most recently, Barbeau et al ¹¹⁸ identified 5 behavioral-related themes that describe users’ perceptions of why e-cigarettes are efficacious in quitting smoking: (a) biobehavioral feedback, (b) social benefits, (c) hobby elements, (d) personal identity, and (e) distinction between smoking cessation and nicotine cessation. Other research has shown beneficial effects, with reductions in smoking desire, withdrawal, and increased quit rates being reported.^115,119-121 Given the insufficient amount of research in this area, however, the US Department of Health and Human Services currently does not recommend the use of e-cigarettes as an aid for smoking cessation. There is a significant need to conduct future high-quality, well-designed, rigorous research that will determine the safety and efficacy of e-cigarettes, with a specific focus on the long-term effects of use.

Application to Special Populations

Child and Adolescent Smokers

According to the 2011 National Youth Tobacco Survey, 4.3% of middle school students and 15.8% of high school students currently smoke cigarettes. ¹⁴ Given that the majority of smokers begin smoking before the age of 18 years, ¹²² prevention and cessation initiatives are a public health priority. To date, school-based interventions focused on preventing smoking have not shown consistent effects, although there seem to be key aspects of these programs that may be helpful (eg, a social competence curriculum). ¹²³ Cessation interventions for teens have been somewhat more successful, with quit rates increasing, on average, by 4.26%. ¹²⁴ In a 2009 review, Sussman and Sun ¹²⁴ analyzed the findings from 64 published studies and provided a number of recommendations for conducting smoking research targeting children and adolescents. These included conducting interventions in an environment structured for youth (e.g., school, sports club), consisting of at least 5 sessions, while using methods to make it fun and increase engagement (eg, involve games). Other recommendations were to use cognitive–behavioral, motivation theory–related, and social influence contents (eg, mass media), as well as focusing on ways to cope with stressful situations. ¹²⁴ More recent studies have shown significant promise using various behavioral techniques, such as extended treatment, ¹²⁵ combined treatment (eg, financial incentives and cognitive–behavioral therapy), ¹²⁶ and tailored interventions. ¹²⁴ Additional rigorous research is needed in this area, however, as few studies have included racial/ethnic differences, long-term outcomes, control groups, biochemically verified indicators of abstinence, or measures of nicotine dependence.^124,127

Racial/Ethnic Minority Smokers

The tobacco industry has a long history of aggressively targeting and marketing its products to racial/ethnic minorities. ¹²⁸ While various behavioral smoking cessation interventions have been shown to be effective for minority groups (eg, individual counseling), ¹²⁹ a disproportionate number of minorities still suffer from smoking-related diseases. ¹³⁰ As such, research is needed to more fully examine the smoking characteristics and unique needs of minority smokers prior to developing or recommending new interventions to increase cessation rates. To date, a number of studies have revealed significant differences in smoking topography and sociodemographic factors that could be used to advance this area. For example, a recent study showed that when compared with whites, African Americans and American Indians were more likely to both undervalue the effectiveness of formal smoking treatment and underestimate the difficulty of quitting. ¹³¹ Other research has found educational attainment to be inversely related to the number of cigarettes smoked per day in African Americans, but not in Hispanics/Latinos. ¹³² Additional research has shown that African Americans, Asians, and Hispanics/Latinos are significantly more likely to be intermittent or light smokers when compared with Whites. ¹³⁰ Given these and other differences, it appears that minority smokers will benefit most from highly tailored interventions, particularly those that can address the specific needs of their racial/ethnic group. Future research will therefore need to develop culturally relevant, evidence-based initiatives, ¹³³ while also continuing to monitor smoking rates and health disparities across all US racial/ethnic groups. ¹³¹

Smokers With Mental Illness

The prevalence of smoking among those with any diagnosed mental illness is estimated to be at 36.1%, with more males (39.6%) smoking than females (33.8%). ¹³⁴ These high rates contribute greatly to the increased early mortality among the mentally ill. ¹³⁵ The reasons for these differences in smoking rate are complex, but they may include multiple neurobiological, social, and psychological causes.^135,136 It is notable that nicotine has some positive psychological effects (eg, improved concentration, relief from negative affect) that may be particularly salient to those with a mental illness.^137,138

The presence of psychiatric symptoms, even at low levels, has been shown to predict cessation treatment failure.^139,140 Historically, there has been concern that smoking cessation in those with mental illness will increase psychiatric symptoms ¹⁴¹ ; however, more recent studies suggest that this might not be the case. ¹⁴² Several recommendations for adapting cessation treatments for the mentally ill have been suggested, including increased treatment intensity, integration of cessation treatment into mental health care, more individualized and flexible treatments, and inclusion of smoking reduction as an acceptable initial treatment goal.^142-144 More research is needed on smoking in individuals with mental illness, especially on how the function of smoking may be different in the this population, how to integrate smoking cessation into the culture of mental health care, and when and how to address smoking cessation in the context of psychiatric symptoms (eg, should smoking cessation attempts precede, follow, or be concurrent with treatment for depression).

Pregnant Smokers

The percentage of American women who smoke while pregnant is estimated to be 11% to 15%. ¹⁴⁵ Behavioral support is the most widely used smoking cessation treatment for this population, and a 2009 Cochrane review of 72 smoking cessation trials found that behavioral interventions increase rates of cessation by up to 6%. ¹⁴⁶ Importantly, women who smoke when pregnant are a hard-to-reach group. When compared with nonsmoking pregnant women, those who smoke while pregnant are more likely to be younger (aged <25 years), have <12 years of education, and have an annual income of <$15 000. ¹⁴⁷ Recent research has found that there are a number of key components to an effective behavioral smoking cessation program for pregnant women, including quit guides, counseling, peer support, and incentives. ¹⁴⁸ Among those women who do quit while pregnant, there is a high rate of relapse by 6 months postpartum. ¹⁴⁹ This distinct pattern of quitting while pregnant and relapsing after the baby’s birth is likely the result of both social pressure to quit while pregnant and motivation to protect the fetus during the gestational period. ¹⁵⁰ Future research will need to continue to examine interventions that will increase cessation prior to and during pregnancy, as well as those that will help to prevent relapse during and/or after the postpartum period. To date, few studies have addressed these and other factors known to be associated with long-term abstinence. ¹⁵¹

Smokers With HIV/AIDS

In the United States, the rate of cigarette smoking among persons living with HIV/AIDS has been reported to be between 59% and 85%.^152,153 Like the general population of smokers, smokers with HIV/AIDS have higher rates of mortality and are more likely to develop cardiovascular disease, cancer, and/or lung disease.^154,155 Smokers with HIV are also at an increased of opportunistic infections (eg, pneumocystis pneumonia), as smoking appears to disrupt the therapeutic effects of antiretroviral treatment.^154,155 Fortunately, smoking abstinence is associated with reduced disease and HIV-related symptoms; however, quitting may be more difficult for this population, as smokers with HIV/AIDS are more likely to have comorbid conditions (eg, illicit drug use, mental illness) and lack access to health care because of limited socioeconomic resources.^156-158 As such, in 2008, the Public Health Service Guideline for Treating Tobacco Use and Dependence specifically called for studies that would determine the effectiveness of smoking cessation interventions for smokers with HIV/AIDS. ¹⁵⁹ To date, there have been 12 studies published, with the majority using prescription medication, rather than behavioral support, as the primary form of treatment. Overall, results have been modest suggesting that more intense programs, such as combined behavioral support and pharmacological interventions, are needed.^156,160-163 A clear gap in this area is the lack of smoking cessation counseling by HIV clinicians and providers who are known to assess their patients’ smoking status less often than other health care providers. ¹⁵⁴ More behavioral research is needed, particularly studies that can engage clinicians in the smoking cessation process, and examine the underlying factors that contribute to persistent smoking. ¹⁶⁴

Conclusion

Throughout this article, a wide range of behaviorally based approaches and strategies commonly used to prompt smoking cessation have been described. Overall, the results of this review highlight the need for additional, rigorous research that will advance the field and further reduce the rate of smoking in the United States.

Given the complex relationship between smoking and demographic factors, it is likely that the most effective future behavioral smoking cessation interventions will focus on the entrenched social and cultural issues that operate to support continued smoking behavior. Incorporating smoking cessation programs into existing community-based organizations and increasing the training and engagement of health care providers will help to increase the likelihood that effective strategies will be disseminated and received by the populations that have the greatest need for smoking cessation assistance. More specifically, with the implementation of the Affordable Care Act, health care providers will be at the forefront of this change. Not only will they begin to engage new groups of patients that previously did not have access to care, but they will also be required to discuss tobacco use with their current patients. While it is clear that medications can significantly benefit smokers wishing to quit, it is also clear that the effectiveness of these medications is improved with behavioral support. An individualized behavioral plan, therefore, one based on one or more of the strategies described in this review could significantly enhance a patient’s likelihood of achieving cessation.

Finally, changes in technology (eg, widespread Internet access and smartphone use, the development of e-cigarettes) present both challenges and opportunities for behavioral smoking cessation that deserve exploration. As such, future research will be needed to investigate the best ways to incorporate the advances in technology at the individual interpersonal, organizational, and community levels.