ATTUD Journal Club Postings

Does specialist, in‐person treatment improve quit rates?

Many of us in ATTUD provide in‐person individual counseling and believe that, for some smokers, increased intensity treatment provided by specialists increases quit rates. Many studies have shown that in‐person therapy provides higher outcomes than no treatment, brief advice, internet and self‐help materials. However, fewer studies have compared in‐person vs telephone counseling. I think showing in‐person counseling more effective than phone‐counseling, at least in some smokers, is essential to justifying the work many of us do.

One can break down this belief into two questions: a) is more intensive treatment better than less intensive, b) is treatment by a specialist more effective than treatment by a non­specialist. Unfortunately, as discussed below, in most studies, specialists administer the more intense treatment and non‐specialists the less intense treatment, thus, we often do not know whether increased efficacy is due to face to face or specialist training.

The most recent version of the USPHS Clinical Practice Guidelines (2008) stated “individual, group and telephone counseling are effective, and their effectiveness increases with treatment intensity (pvii)”. In contrast, the Cochrane review “Individual behavioral counseling for smoking cessation” published in 2009 stated “We failed to detect a greater effect of intensive counselling compared to brief counselling (5 trials, RR 0.96, 95% CI 0.74 to 1.25).” The major reason for this difference is that the USPHS was based on a comparison across a large number of different studies; whereas the Cochrane was based on five studies that directly compared more vs less intensive treatment. Neither the USPHS nor the Cochrane reviewed studies on specialists vs non‐specialist treatment.

So let me update my prior blog on what data have appeared since these two reviews. One observational study by ATTUD’s own Chris Sheffer compared the outcomes of those that chose in‐person treatment vs those who chose phone quitline treatment in her Arkansas state treatment programs (AJPH 103:e4‐82). She found that those seeking in‐person treatment were more dependent smokers and, interestingly, the less motivated smokers. Adjusting for these and other differences, she found in‐person treatment more effective early on but not at long term followup. A second observational study of smokers enrolled in a MN HMO found that few chose in‐person treatment (< 1%) but, after adjusting for dependence, smoking rate, etc, that in‐person treatment was not better than the helpline (NTR 12:989‐996).

Two studies of the English stop smoking services have compared outcomes between more highly vs less highly trained counselors. In one observational study, specialist counselors had higher quit rates than less trained counselors (64% vs 50% at 4 wks)(NTR 15:1239‐1247). This appeared to be due to their greater use of abrupt rather than gradual cessation, longer first session and advice on medications, and amount of training received. Another very recent study found that quit rates increased over time but that this was especially true if the site had more therapists who had completed training.(Prev Med 69: in press)

Two randomized controlled trials have been done since the above reviews. A Swedish study conducted in a dental practice randomized smokers to a low intensity in‐person program (one 30 min session by briefly trained dental hygienist vs a low intensity program (eight 40 min sessions)(BMC Pub Hlth 9:121). The high intensity condition were twice as likely to quit (18 vs 9% at 6 mo). In the most direct test, a very recent Spanish study randomized 600 smokers to several groups including phone and in‐person treatments (Prev Med 57:183‐186). At one year, continuous quit rates were 1.4 times higher in the in‐person condition (28% vs 20%). Interestingly, this may be because those in the in‐person condition completed more, not fewer, sessions (5.8) than those in the phone condition (3.1).

Unfortunately, none of the above studies examined whether in‐person counseling was especially effective in a subgroup of smokers (e.g. those who have failed phone counseling, who have psychiatric problems, or who are more dependent.)

Clearly we cannot make a definitive conclusion based on two randomized studies, especially when the outcomes from observational studies have been mixed. However, it does appear that, although the early evidence did not show a clear advantage of in‐person treatment by specialists, more recent evidence is more encouraging. I know of at least one large randomized trial that directly compared in‐person and phone treatment and I anxiously await its results.

Thoughts anyone?