7.15 Individual and group-based cessation assistance

Last updated: October 2016 

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.15 Individual and group-based cessation assistance. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-15-methods-services-and-products-for-quitting-mo

Smokers who are motivated to quit sometimes seek intensive cessation support, such as individual counselling or group programs. Such interventions are more limited in their reach than phone and internet-based services, and may be less accessible or desirable to smokers due to time and money constraints.1 Nonetheless, evidence-based intensive support can increase quit rates and help people to stop smoking.

7.15.1 Individual counselling

For interventions delivered by healthcare professionals see Section 7.10, or for interventions delivered in mental health settings, see Section 7.12

7.15.1.1 Cognitive behavioural therapy

Individually delivered smoking cessation counselling can assist smokers to quit.2 Such counselling has traditionally been based on the principles of cognitive behavioural therapy (CBT), which also forms the basis of Quitline counselling. CBT for smoking cessation aims to break the situational and emotional connections that have been established with smoking.3 Behavioural strategies target the pleasurable associations and situational cues that reinforce and maintain smoking, while cognitive strategies target the cognitions and emotions that may also play a role in the person’s tobacco use (for example, the person may believe he or she does not have any control over smoking, or that it relieves stress).4 A number of studies have supported the use of CBT for smoking cessation, both for quitting and for preventing relapse.5 One small study found that progressive muscle relaxation—a behavioural technique used to reduce stress by concentrating on achieving muscle relaxation—reduces cigarette craving, withdrawal symptoms, and blood pressure in smokers who have recently quit.6

7.15.1.2 Acceptance and commitment therapy

An emerging body of research suggests that acceptance and commitment therapy (ACT) is another effective form of counselling for smoking cessation. ACT focuses on increasing willingness to experience physical cravings, emotions, and thoughts that trigger smoking (i.e., acceptance) while making values-guided behaviour changes (i.e., commitment).7 Promising evidence, albeit with some methodological limitations, suggests that face-to-face ACT for smoking cessation has 30%–35% quit rates at one year follow-up.8-10 Two small studies in the US found that ACT is also feasible to deliver by phone or by smartphone application, and shows higher engagement and promising quit rates compared with usual care.7, 11

7.15.1.3 Motivational interviewing

Motivational interviewing is a is a person-centered, goal-oriented style of counselling, which aims to elicit and strengthen people's own motivation and commitment towards behaviour change by helping them resolve their ambivalence and evoking their reasons for change.12 This approach is widely used to help people to quit smoking.13 Common components of motivational interviewing include: exploring ambivalence, decision balance (i.e., weighing pros and cons), assessment of motivation and confidence to quit, eliciting ‘change talk’ (i.e., statements that indicate the person has the desire, motivation, and/or commitment to change their behaviour), and supporting self-efficacy.13

A 2015 Cochrane review concluded that motivational interviewing may assist people to quit smoking, and appears to help more people to quit than brief advice or usual care when provided by general practitioners (GPs) and by trained counsellors. Shorter motivational interviewing sessions (less than 20 minutes per session) were more effective than longer ones. A single session of treatment appeared to be marginally more successful than multiple sessions, but both delivered successful outcomes. The evidence for the value of follow-up telephone support was unclear, and face-to-face counselling was no more helpful than telephone counselling. Both approaches were more successful than brief advice or usual care.13 One study suggests that including family in motivational interviewing-based interventions may be a useful addition to cessation interventions.14

7.15.1.4 Mindfulness

A growing body of research supports the effectiveness of mindfulness-based interventions for smoking cessation. The concept of mindfulness has roots in Buddhist and other contemplative traditions. It is often described as the state of being attentive to and aware of what is taking place in the present.15 Mindfulness is an inherent human capability that can be learned and trained, and its practice has been linked with a range of improved health outcomes.16 It allows people to increase their positive affect, and improve their overall wellbeing.17 Smokers, especially female smokers, have lower levels of mindfulness and wellbeing than non-smokers, leading researchers to suggest that mindfulness-based interventions may help smokers to deal with treatment and abstinence by increasing their level of wellbeing.17

Mindfulness strategies for managing nicotine cravings involve present-moment, non-judgemental awareness of cravings without acting on them.18 A review of addiction research found that exercises aimed at increasing self-control, such as mindfulness meditation, can decrease the unconscious influences that cause cigarette cravings. For example, one study showed that mindfulness meditation training led to a subconscious reduction in smoking; that is, although participants who had completed the training reported smoking the same number of cigarettes, an objective measure of carbon dioxide percentage in their lungs suggested a 60 per cent reduction in the amount smoked over two weeks after the study.19 Researchers in the US found that mindfulness training led to significantly higher abstinence rates among a group of socioeconomically disadvantaged smokers.20 Mindfulness practice appears to reduce negative affect, craving, and cigarette use among smokers who are trying to quit,21 and may also be particularly effective for promoting recovery from lapses.22 A 2015 systematic review concluded that mindfulness-based interventions show promise for the treatment of smoking, especially for cessation, relapse prevention, number of cigarettes smoked, moderating the relationship between craving and smoking, and the development of coping strategies to deal with triggers to smoke. The positive effects of mindfulness on mental health might contribute to the maintenance of tobacco abstinence.23 Findings from a 2016 meta-analysis of randomised controlled trials of mindfulness-based interventions for smoking cessation showed that about one quarter (25.2%) of participants remained abstinent for more than 4 months in the mindfulness group, compared to 13.6 percent of those who received usual care.24

7.15.1.5 Positive psychotherapy

Given the importance of affect to the success of quit attempts, incorporating strategies from positive psychology has been suggested as a means of addressing moods in smoking cessation treatment.25 Positive psychology interventions aim to enhance positive feelings, behaviours, or cognitions, and a large body of research supports the benefits of positive psychology strategies for enhancing people’s wellbeing and functioning, and for reducing depressive symptoms.26 One small study examining the effectiveness of positive psychotherapy for smoking cessation found that attendance and satisfaction with treatment were high, and most participants reported using and benefiting from the positive psychology interventions. Almost one-third of participants sustained smoking abstinence for 6 months.25 Findings from a pilot randomised controlled trial also supported incorporating positive psychotherapy into smoking cessation treatment.27

7.15.2 Group therapy

Group therapy can provide people who smoke with the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with social support. A Cochrane review published in 2005 concluded that group therapy was more effective than self-help and other less intensive interventions for quitting smoking, but there was not enough evidence to compare it to intensive individual counselling. Courses that include strategies to increase cognitive and behavioural skills and avoid relapse may increase their effectiveness.28 A recent review of family-based smoking cessation interventions did not find evidence that such interventions are effective.29

Fresh Start courses, a smoking cessation course developed by Quit Victoria, are run in many settings, such as workplaces, prisons, the community, and health centres. The group course is led by a trained educator, and typically has eight sessions of 60–90 minutes over a four-week period. There is also a short version of the course, which includes the same content as the longer Fresh Start course, but is run in two three-hour sessions. Sessions are 2–3 weeks apart, with Quitline support in between.

An evaluation of the Fresh Start courses found that about one quarter (23%) of participants had quit at one year (18% of the original sample).30 One study suggested that such multi-session group programs are about twice as effective as self-help alone.28 However there have been relatively few trials that compare such programs with other forms of help. This may be partly because groups take considerable time and effort, while other, less intensive methods are now much more readily available and popular.

7.15.3 Workplace-based interventions

There are significant costs to the workforce associated with tobacco use, due to increased unproductive time, absenteeism, illness, and premature mortality among smoking employees.31 Smokers’ workplaces are a potentially useful and wide-reaching setting for delivering cessation interventions, particularly in blue collar occupations where smoking prevalence in substantially higher (see Chapter 1 Section 1.7). A Cochrane review of workplace interventions published in 2014 found strong evidence that some interventions, including individual and group counselling, pharmacological treatment, and multiple interventions targeting smoking cessation, increase the likelihood of quitting. All these interventions appear to be similarly effective whether offered in the workplace or elsewhere. The review also concluded that self-help interventions and social support are less effective.32 Research in NSW found that telephone-based coaching and group sessions designed around cognitive behavioural therapy principles successfully assisted employees of the passenger rail network to quit smoking.33

A qualitative review of employees’ views of workplace interventions highlighted the importance of smokers’ readiness to change in quitting, and noted that employees’ expectations regarding employers’ support for, and enforcement of, interventions or restrictions might facilitate smoking cessation.34 Another evidence review concluded that interventions should target workers that actively want to stop smoking, use elements that workers have identified as useful, and/or focus on altering beliefs about smoking and the need to stop.35

7.15.4 Peer support programs

Peer support programs aim to provide social support to people in a variety of settings. Peer support can take many forms, such as self-help groups, internet support groups, peer-delivered services, peer-run or operated services, peer partnerships, and peer employees or volunteers within traditional healthcare settings, such as peer companions, peer advocates, consumer case managers, peer specialists, and peer counsellors.36 In the context of smoking cessation, several reviews have concluded that more rigorous research is needed to support the use of this method.37-39 A Cochrane review of interventions aiming to enhance partner support to improve smoking cessation concluded that such interventions do not appear to increase quit rates, nor do they appear to effectively increase partner support.40 Emerging evidence suggests that peer support programs may be of greater help to priority populations, such as economically and socially disadvantaged populations,41 and people with serious mental illness.39, 42

7.15.5 Residential treatments

Residential treatment program for tobacco dependence are rare and costly, but can provide intensive behavioural and pharmacological treatment, especially in early days of a quit attempt when people are more likely to relapse.43 One such program is run by the Mayo Clinic in the US, which runs for eight days and comprises a multidisciplinary treatment team consisting of physicians, nicotine dependence counsellors, psychologists, nurses, pulmonary therapists, and exercise physiologists.44 An examination of the effectiveness of the program found that it was associated with a significantly greater odds of 6-month smoking abstinence compared with outpatient treatment.43 Another study found that at the completion of the program, perceived stress was significantly lower, while partner support and self-efficacy were significantly higher among participants.44


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