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Debate:
Proposer: Gerard Hastings, Director, Institute for Social Marketing and Centre for Tobacco Control Research, University of Stirling and Open University, Stirling.
Seconder: Christine Owens, Head of Tobacco Control, Roy Castle Lung Cancer Foundation, Liverpool
Opposer: Jonathan Foulds, Associate Professor, University of Medicine and Dentistry of New Jersey, School of Public Health and Director, Tobacco Dependence Program, USA
Seconder: Agnes McGowan, Principal Health Promotion Officer, Smoking Concerns, Glasgow
Listen to the speech (Introduction & Gerard Hastings) 
Listen to the speech (Jonathan Foulds)
Listen to the speech (Christine Owens)
Listen to the speech (Agnes McGowan)
Listen to the speech (Q&A followed by vote)
View Powerpoint Presentation - Gerard Hastings Part 1 Part 2 
View Powerpoint Presentation - Christine Owens
View Powerpoint Presentation - Agnes McGowan
Jonathan Foulds PhD
Abstract
The advantages of 6-session smoking cessation groups
Smoking cessation groups (both open and fixed session) are an effective part of tobacco dependence treatment. Reviews of randomized trials find groups to be at least as effective as individual treatment but group treatment has advantages in cost/time effectiveness. So why aren't more patients in the UK's smoking cessation service receiving group treatment? Comparisons of non-randomized treatment in 6-session groups versus individual treatment typically finds the group to be more effective (McEwen et al, 2006). In our treatment clinic in New Jersey, those participating in group treatment had better outcomes than those attending individual treatment (58% vs 48% abstinent at 4 weeks and 41% vs 29% at 6 months, p<0.01, Foulds et al, 2006). Advantages of 6-session groups are: 1. Patients go through the quitting process together (rather than each patient being at a different stage). 2. Group facilitators can ensure that content matches stage of treatment (e.g. information on proper use of medications at the first and second group meetings), rather than having to repeat similar information week after week to new arrivals. 3. Initial treatment has a clear beginning and end, and importantly a clear Target Quit Date early in the process. 4. If there is demand for ongoing open group support, patients can be encouraged to attend a separate open "relapse prevention" group at the same service once they have completed the closed group. 5. If there is sufficient volume of new patients at the service, patients should have only a fairly short wait for the next group to start (e.g. 1-3 weeks). 6. Patients who want to go ahead and quit immediately are welcome to do so, and may still attend the 6 group sessions, having quit a little earlier than the rest of the group. The main perceived disadvantage of the 6-session group format is that unless the service has a high volume of new clients, there may be a wait before the next group starts, whereas with an ongoing open group, new patients can join at any time. Given the successful experience of many services, and the published results from different clinics showing good results with the 6-session groups format, (finding that they are popular with patients, can be linked with subsequent open relapse prevention groups, and are easy for facilitators to run) there is no good reason to abandon them. Rather, more smoking cessation services should be providing group treatment on a regular basis, whether in a 6-session or an open format (or preferably both).
References:
Foulds J, Gandhi KK, Steinberg MB, Richardson D, Williams J, Burke M, Rhoads GG. Factors associated with quitting smoking at a tobacco dependence treatment clinic. American Journal of Health Behavior 2006; 30:400-412
McEwen A, West R, McRobbie H. Effectiveness of specialist group treatment for smoking cessation vs. one-to-one treatment in primary care. Addict Behav. 2006 Jan 26; [Epub ahead of print]
Biography
Dr Foulds obtained a first class honors degree in psychology at the University of Aberdeen in Scotland before being trained as a Clinical Psychologist at the University of Glasgow. At that time his main research interests were on the psychophysiology and treatment of blood-injury phobia and fainting.
In 1989 he moved to the world-renowned tobacco research group at the Institute of Psychiatry in London and focused his research and clinical work on tobacco addiction. While there he published the first placebo-controlled trials of nicotine patches in the UK, and also studied the psychological effects of nicotine in smokers and non-smokers.
In 1994 he moved to St George's Hospital Medical School in London where he became the UK's first "Lecturer in Tobacco Addiction". While at St George's, Dr Foulds was an investigator in the world's first randomized trial to directly compare nicotine patch, gum, inhaler and nasal spray, and also a large randomized trial of brief smoking cessation advice in pregnant women. He was also on the Management Group of the Hungarian Anti-Smoking Campaign (1995-6).
In 1997 he moved to the University of Surrey where he helped run a doctoral training course for Clinical Psychologists and was also a Principal Clinical Psychologist at Broadmoor Hospital, a large maximum security psychiatric hospital for mentally disordered offenders. However, he maintained a strong research interest in tobacco addiction, became technical leader of a World Health Organization project to improve the regulation of tobacco dependence treatment in Europe, and also became Director of Research
for the charity, Quit, which runs the largest telephone helpline for smokers in the world.
Dr Foulds came to the School of Public Health at University of Medicine and Dentistry of New Jersey (UMDNJ) in the United States in 2000 to be the Director of the Tobacco Dependence Program. The program is funded by New Jersey Department of Health and Senior Services to train health professionals in New Jersey to treat tobacco dependence, and also runs its own Tobacco Dependence Clinic. In 2003 Dr Foulds was elected to be Vice President of the Association for the Treatment of Tobacco use and Dependence. Dr Foulds has therefore been conducting research on tobacco for over 16 years. While most of it has focused on treatment for addicted smokers, his work has also addressed such topics as the measurement of passive smoke exposure, the uptake of smoking in young people, the effects of nicotine on mental performance and the health effects of tobacco products. He has published over 50 articles in peer-reviewed journals.
Associate Professor & Director
Tobacco Dependence Program
317 George Street, Suite 210
New Brunswick
Middlesex
08901
USA
Christine Owens
Abstract
Roy Castle Fag Ends Community Stop Smoking Service (RCFE) is commissioned by three primary care trusts to provide stop smoking support in Liverpool.
There are several principles governing RCFE, which maintains a client-led, person-centred philosophy. The overarching principle is immediate access to support. As well as being referred by health professionals, clients can self-refer by calling a helpline or walking into a meeting. This common-sense, community approach removes any potential professional barriers and allows interaction between clients who are at different stages of the quit process. Since new and established clients meet together in RCFE, at any one time a new attendee is in direct contact with ex-smokers at different stages of abstinence. This situation is believed to be beneficial as it reinforces information given by the RCFE advisor and provides motivation from peers.
RCFE is a community-based initiative following a social, rather than medical model. The group was originally formed by lay people within the community who had attended a six week stop-smoking course and required further support from their peers to remain smoke free.
Following relapse, clients returning to RCFE are welcomed without fear of criticism or the need for an appointment. More importantly, clients can return after a single lapse or when they simply feel the need for further support and/or encouragement.
Self-referral offers a real chance for a smoking-cessation advisor to meet and discuss options with a client while the decision to stop smoking is fresh in the client's mind. Taking immediate action on the decision catches the client in his/her most motivated state. The clear increase in the number of self-referrals since 2001 suggests that the removal of barriers such as a waiting list to access the service has helped increase the number of people accessing stop smoking support. This is in agreement with investigators who report that flexibility and accessibility to smoking-cessation aids or services are believed to increase reach [1].
Anecdotal evidence suggests that word of mouth within the community has increased the profile of RCFE and promoted the self-referral of new clients. The correlation observed between the increased number of self-referrals and an increased referral:quit attempt ratio also suggests that the type of referral determines the likelihood of success. Therefore, easy access to attend RCFE coupled with a high desire to stop smoking resulted in a greater number of referred clients making a quit attempt.
Introducing this common-sense approach into other stop-smoking services may help make services more accessible and increase the overall smoking-cessation rate in England.
References
1. West R. and Raw M. (2003) Meeting Department of Health smoking cessation targets. Recommendations for Service providers. Health Development Agency, London.
Biography
Back in 1992 Christine worked in the Health Promotion Department of Liverpool City Council with a remit for general health promotion. When the City Council disseminated their no smoking policy for implementation in 1993, she asked "what about some support for smokers wanting to quit?" This question was to define Christine's career for the next 14 years (and beyond) as the reply was "Why don't you do something". She did and as they say "the rest is history". > In 1999 Christine joined The Roy Castle Lung Cancer Foundation as Head of Tobacco Control, with a remit to oversee and develop their tobacco control work. As Head of Tobacco Control at the Roy Castle Lung Cancer Foundation she is currently responsible for the management and development of the stop smoking service, the children's smoking prevention programme KATS, the Youth Advocacy Project (ATYC)and the National Clean Air Award. She is the media spokesperson on tobacco issues for the charity with responsibility for the strategic development of Tobacco Control within the charity. > She has been involved in the recruitment and development of a team of stop smoking advisors who have consistently exceeded the department of health targets. The team includes specialist hospital and prison-based, workplace and young persons support. The service ensures that the community's needs are met including the provision of support for mental health patients in a variety of settings, support for the homeless and for those in within the probation service. Recently an advisor has been recruited to develop the service to meet the needs of Black and Minority Ethnic communities in Liverpool.
As Head of Tobacco Control she oversaw the development of The National Clean Air Award, the only national smoke free places award which is endorsed by the Chartered Institute of Environmental Health. Launched two years ago the award is currently held by in excess of 2500 organisations from all areas of the UK.
Head of Tobacco Control
The Roy Castle Lung Cancer Foundation
200 London Road
Liverpool
Merseyside
L3 9TA
Agnes McGowan
Abstract
Why Closed Group Smoking Cessation Services Should Be Retained
It is well known from a range of research that smokers who live in more deprived circumstances are more likely to be heavily addicted (smoke more, time to first cigarette is shorter, CO readings higher) and less likely to quit.
An unpublished study by Bauld et al (2006) examined the smoking cessation services in Glasgow and the type of client accessing these services. Over half of the clients were unemployed, most had low levels of education and a significant number were entitled to income support. The study also demonstrated some interesting differences between the clients in the recent study of the English national smoking cessation services and clients accessing Glasgow services.
In the Glasgow sample, 45% of clients smoked within 5 minutes of wakening in comparison to 34% in the English sample. In addition, when asked whether they smoked ‘mainly for pleasure’, ‘mainly to cope’ or ‘about equally’, 51% of the Glasgow sample stated ‘mainly to cope’ in comparison with 21% of respondents in the English study.
The results of the Glasgow study confirm that higher levels of smoking prevalence are being dealt with in combination with higher levels of dependence than in other areas of the country. The smokers attending services in Glasgow have complex needs and require more intensive support in order to quit successfully.
An evidence-based approach to smoking cessation has been established across NHS Greater Glasgow. Advisers have been trained by Smoking Concerns (NHSGG’s specialist tobacco team) in the evidence based Maudsley model. This model is based on 7 weeks of closed group model with a focus on setting a quit date. This training is further extended to include a mentoring and support programme for advisers to assist them apply the skills developed on Maudsley training. In addition, attendance at twice yearly update sessions are a requirement to continue to practise in the Glasgow Intensive services. These operate in the acute and maternity hospitals and local community health and care partnerships (CHCPs) with dedicated staff time.
Referral systems, processes and flowcharts have been developed for ease of access to the services. Clients may self refer, or be referred by health professionals or voluntary sector workers. All work is to agreed protocols with reporting mechanisms for monitoring and data collection; thus ensuring an equitable and quality service for all.
All clients attending community services, pregnancy service (“breathe”) or hospital in-patient cessation service receive the same intensive intervention by advisers trained as above including up to 12 weeks supply of NRT free or at prescription cost. Only the community services provide a 7 week closed group format i.e. closed to new members after week 3. The “breathe” service provides 1 to 1 intensive support for pregnant women with NRT, if required, at time of booking with follow on support by telephone.
The recently launched hospital service offers 1to 1 intensive support for in-patients with continued follow-on telephone support on discharge provided by CHCPs advisers.
Practitioners’ skills throughout the service are compatible, the same protocols are applied and client demographics are similar, yet the groups get consistently better results. The table below demonstrates the outcomes achieved.
What Is The Secret Ingredient of Groups?
The majority of smokers smoke in a social setting therefore making a social connection with other smokers, these collective group norms seem best addressed within a group setting. Strong bonds are formed with the same group of people meeting and supporting each other, this is lost if the group members are constantly changing. Anecdotal reports from practitioners indicate that they too feel supported when a group gels and encourages enthusiasm in their practice. Closed groups with NRT are the best treatment we can offer at this time to heavily addicted smokers.
References:
NHS Health Scotland 2005
Judge K, Bauld L, Chesterton J, Ferguson J. The English smoking treatment services: short time outcomes. 2005 Society for the Study of Addiction.Addiction,100(suppl,2)46-58
Biography
Agnes’ background is in health. She is a qualified registered nurse, midwife and health visitor. On completing her Masters in Public Health, she moved into health promotion where she developed and implemented various programmes for disadvantaged and minority groups to address health inequalities. She has over 30yrs NHS service, officially only 26yrs having cashed in her pension to go travelling in OZ when young and foolish. Pay back for this adventure is she will now have to work till she is 70 to survive!!
Agnes became involved in helping smokers stop smoking in the late eighties initially to support workplace smoking policies. Following the publication of Hilary Graham’s work on women smoking and disadvantage, she established and supported a programme of work for women smokers using a community development approach. Agnes took up her post as manager of Smoking Concerns, NHS Greater Glasgow’s specialist tobacco team in 2002 and has been instrumental in establishing an integrated evidence- based cessation service across the whole of NHS Greater Glasgow.
This includes innovative work in partnership with the voluntary sector within one of the most deprived areas of the city where smokers are supported throughout all the stages of change in close partnership with the established specialist cessation services that provide the intervention.
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