CHAPTER 9. ROLE OF THE
         PHYSICIAN IN
         SMOKING CESSATION

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CONTENTS

Introduction

Patient Groups
  General Practice Patients
  Pregnant Patients
  Patients With Pulmonary Disease
  Patients With Cardiac Disease

The Use of Nicotine Chewing Gum

Discussion and Synthesis
  Methodological Considerations
  Trends in the Literature
  Patient Variables Related to Abstinence
Physician Variables Related to Effectiveness

Conclusions
  Recommendations for Physicians
  Future Research

Summary and Conclusions

References

453


Introduction

Although a variety of health care providers have attempted to
change the smoking behavior of the groups with whom they work
(USDHEW 1979), most of the research in this area, and this review,
is confined to patient populations or patient groups who provide
opportunities for physician intervention. The nature and extent of
the relationship between patient and physician enhances the oppor-
tunity for long-term behavior change. Major international studies on
utilization of health care reveal that 70 percent or more of North
Americans see a physician at least once a year (Kahn and White
1976; National Center for Health Services Research 1983; Pacific
Mutual 1978; National Center for Health Statistics 1982). Given this
frequency of contact between smokers and their physicians, some 38
million of the 54 million adults in the United States who smoke
could be reached annually with a smoking cessation message. Even if
only 5 to 10 percent quit on a long-term basis, the potential impact of
such contact is enormous. A recent study comparing free medical
care to insurance plans requiring shared cost by participants did not
show a beneficial impact on smoking (or other health habits
associated with coronary heart disease and some types of cancer)
from the average of one to two more encounters per year for several
years (Brook et al. 1983). The authors comment that "these health
habits, especially smoking, were at levels at which substantial health
benefit from behavior change was possible" (p. 1432). Thus, physician
contact alone does not increase smoking behavior change. Rather, a
mix of physician, motivation, educational, and training efforts are
doubtless called for.

Many techniques have been described in the literature to assist
physicians in treating cigarette smoking in their patients (Allaire
1983; Best 1978; Bohm and Powell 1982; Danaher et al. 1980; Fowler
1983; Hochbaum 1975; Hymowitz 1977; Indyke and Ellis 1980;
Luban-Plozza 19'77; Pechacek and Grimm 1983; Pechacek and
McAlister 1980; Pomerleau 1976; Rose 1975/76; Rosser 1977; Russell
1971; Seeker-Walker and Flynn 1983; Sherin 1982; Shipley and
3rleans 1982; Windsor et al. 1979). These range from supplying
nformation about smoking and health with advice to quit smoking
;o implementing complex behavior modification techniques with
-outine monitoring and long-term followups.
Lichtenstein and Danaher (1978) have described a hypothetical
node1 for the various roles that the physician can perform.
iccording to their formulation, the physician can "(1) act as a model
If a healthy lifestyle by not smoking, (2) provide information
larifying the risks associated with smoking and the risk reduction if
he patient stops, (3) encourage abstinence by direct advice and
uggestions, (4) refer the patient to a smoking cessation program,
nd (5) prescribe and follow up the use of specific cessation and

455


maintenance strategies in his or her own office management" (p.
233). This scheme is a hierarchical one, with each role subsuming the
behavior of the ones that precede it. Other roles such as political
lobbyist and researcher are related only indirectly to patient care
(Rosen and Ashley 1978).

In addition to advising their patients to quit, an overwhelming
majority of physicians have quit smoking; the prevalence of smoking
among physicians has most recently been estimated at 10 percent or
less in the United States, considerably below that of the general
population (Enstrom 1983; Fletcher and Doll 1969; Garfinkel 1976;
USDHEW 1976; Sachs 1983). Physicians are, therefore, carrying out
their role as exemplars. In a major national survey, over 90 percent
agreed that it was their responsibility to set a good example for
patients by not smoking cigarettes (USDHEW 1976). With regard to
other roles, the majority of reports (both research and advisory)
indicate that physicians usually function as information providers
and advice givers. However, evaluations of treatment procedures
that can be used for referral or in-depth treatment have also been
carried out. It is expected that as results become known and more
referral agencies are availa.ble, more physicians will be expanding
their roles.

The literature on rates at which physicians advise patients to quit
smoking shows a disparity between physician estimates and patient
reports. Over time, the proportion of physicians recommending
cessation has increased dramatically. A mid-1960s survey revealed
that 38 percent of physicians claimed that they advised "all" or
"almost all" (95 to 100 percent) of their patients who did not have
smoking-related disorders ,to quit or cut down (Green and Horn
1968). Eighty-eight percent of physicians claimed they gave this
advice to patients with lung and pulmonary conditions. In 1979,85 to
92 percent of physicians participating in the evaluation of a quit
smoking kit said they had spoken to smoking patients in the past few
weeks, advising quitting t,o 6 to 7 out of the last 10 smoking patients
seen (American Cancer Society 1981). In a 1981 survey of primary
care practitioners in Massachusetts, 90 percent of all physicians who
responded said they routinely asked about smoking; however, only
58 percent felt "very prepared" to counsel patients, and a mere 3
percent felt they were currently "very successful" in helping
patients to change their smoking behavior (Wechsler et al. 1983).
Ninety-eight percent of a Canadian sample of primary care physi-
cians surveyed in late 1981-1982 reported advising patients who
smoke to stop, with 45 percent claiming some success (Battista 1983;
Battista and Spitzer 1983). There is evidence that smoking physi-
cians feel less comfortable in dispensing advice to quit smoking and,
therefore, do it less forcefully (American Cancer Society 1981).

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The majority of persons who smoke feel that physician advice to
quit or cut down on smoking would be influential (American Cancer
Society 1977; Pacific Mutual 1978). In a 1978 survey of the public,
doctor's advice was perceived to be the most effective means of
prompting cessation or reduction among six alternatives considered,
the other five being prohibition of smoking at work and in public
places; urging by children, spouse, or relatives; higher taxes on
tobacco; antismoking informational campaigns at work; and anti-
smoking advertising on television (Pacific Mutual 1978). In this
survey, 76 percent of smokers reported that doctor's advice would be
"very" or "somewhat" effective in this regard. Given this general
level of enthusiasm and confidence in physician-delivered messages,
actual rates of reported advice are quite low. In the survey just
reported, only 8 percent of former smokers spontaneously mentioned
a doctor's recommendation as a cause of their cessation, although 51
percent cited health reasons (Pacific Mutual 1978). In the 1975 Adult
Use of Tobacco survey, a full 64.6 percent of male and 60.8 percent of
female current smokers claimed they had never received advice from
any doctor about quitting, cutting down, or continuing smoking
(USPHS 1976). About 20 percent of current smokers had been
advised to quit. Combining advice to quit or cut down, the percentage
rose to approximately 35 percent. A somewhat lower estimate of
physician advice was obtained from a nationwide study of approxi-
mately 8,000 people (Stewart et al. 1979). Advice to quit or cut down
was reported by 22.4 percent, and lack of advice by 77.6 percent.
However, patient recall for the details of a physician visit may be
flawed. In one study, almost complete recall of cessation advice was
reported 1 year later (Mausner 19701, but in a second study only 50
percent of patients recalled cessation advice 2 months after it was
given (Rose and Udechuku 1971).

It seems quite likely that physicians do offer varying degrees of
advice and guidance to their patients (Fowler and Jamrozik 1983;
Wechsler et al. 19831, and in view of the decrease in social
acceptability given to the smoker, more physicians will be spending
more of their time and energy in this way in the future. A growing
number of editorials in medical journals have been devoted to the
importance of primary prevention and to motivating physicians to
this task (Check 1979; Yankauer 1983).

This chapter reviews and summarizes studies of smoking cessation
in various groups of patients, with a special focus on physician
intervention. Four classes of patients are considered: general prac-
tice, obstetric, pulmonary disease, and cardiovascular disease. Re-
views of this literature show a positive relationship between severity
of disease and the likelihood of quitting smoking (USDHEW 1979,
1980; Lichtenstein and Danaher 1978; Pederson 1982). However,
Pederson cautions that a causal interpretation of this relationship

480-144 0 - 85 - 16


may not be warranted, as physician involvement may be greater and
the effect of physician advice more salient or intense with sicker
patients. In addition, a section on research using nicotine chewing
gum as a treatment is included. Suggestions regarding future
research and treatment are also presented.

Patient Groups
General Practice Patients

Unlike the physician whose practice involves mainly patients with
pulmonary or cardiac disease, a large proportion of the general
practitioner's time may be spent in lifestyle modification of a
preventive nature with patients who are not experiencing smoking-
related problems. It may be that compliance among these patients is
dependent upon diagnosis, but no available studies have related the
reason for the office visit to success or failure in quitting, although
most counseling is said to take place during regular checkups or
during visits for respiratory problems, much less often than during
visits for unrelated major medical problems or minor problems
(Battista 1983).

Nine studies have dealt specifically with general practice pa-
tients. Mausner et al. (1968) followed 157 smoking patients of two
physicians sharing an office. One physician advised all the smokers
in his practice who came to his office over a 2-month period to quit
(n=121). Patients were told that smoking was harmful, and were
given written information on quitting techniques as well as lobeline,
a nicotine substitute. The other physician made no special mention
of smoking (n= 36 patients). At a 6-month followup, 33 percent of
those who were told to quit had reduced the amount they smoked,
compared with 9 percent in the group without such cessation advice.
Reduction was defined as a decrease of at least 10 cigarettes per day.
There was no validation of self-report. The factors found to be related
to decrement in smoking were higher initial consumption and
number of pack-years; a marginally significant relationship with
being male was noted, and for both sexes it was the heavier smokers
who changed.

Porter and McCullough (1972) compared the smoking behavior of
101 randomly selected patients who were counseled by one general
practitioner about their smoking with 90 patients who were not
counseled. Counseling consisted of advice, discussion, and a leaflet.
There was no significant difference in quit rate after 6 months
between the two groups: 2.5 percent in the counseled group and 4.4
percent in the not counseled group quit. No validation was per-
formed.

Handel (1973) followed for 1 year a group of 100 patients whom she
had advised in l- to 7-minute messages to quit smoking. The advice

458


was followed by 38 percent of the men and 11 percent of the women.
Eighteen percent of the remaining male smokers and 22 percent of
the female smokers reported reducing consumption by more than 50
percent. No control group was included in this study.

Pincherle and Wright (1970) reported a smoking intervention in a
clinic that provided health examinations of business executives on
an annual or biannual basis. Physicians were encouraged to deliver a
strong antismoking message, and a booklet was made available.
Results varied among the 10 participating physicians; between 17
and 35 percent of the 1,493 smokers seen at a followup visit at
approximately 18 months had stopped smoking cigarettes or had
reduced their smoking more than 30 percent, There were no controls
or validation of self-report. The doctor's own past or present smoking
habits only partially accounted for the variation in success rates (cf.
American Cancer Society 1981). The quit rate of 19 percent reported
by Richmond (1977) in a similar setting is consistent with their
findings. In preliminary findings, Rosser (1979) reported that 10
percent of smokers counseled by family physicians about cardiovas-
cular risk reduction report smoking cessation 1 or 2 years later.

In a large-scale study of 2,138 patients of 28 London physicians in
five practices, Russell et al. (1979) assessed the effectiveness of
physician smoking advice in comparison with no advice. Assignment
to group was by day of attendance at practice. Four groups were
used: a nonintervention control, a questionnaire-only control, an
advice-only group, and an advice group receiving a two-page
pamphlet and a warning of subsequent followup. Advice was
delivered in the physician's own style in a l- or 2-minute message. At
l-year followup, the overall quit rate was 14.4 percent-respectively
for each group, 10.3, 14.0, 16.7, and 19.1 percent. The percentages of
patients who stopped within 1 month of the initial visit and who
were still abstinent at followup were 0.3, 1.6, 3.3, and 5.1 percent,
respectively. These results were statistically significant, indicating
that advice to quit was effective and enhanced by written material
and information about a subsequent followup. The major effect was
to increase motivation in terms of the percentage of patients in each
group attempting to quit but not the success rate of quit attempts,
and to reduce relapse at the l-year point compared with the initial l-
month assessment. One can interpret this as due to the limited scope
of advice, focused on health education, and not to quitting skills. Quit
rates differed markedly among physicians and were inversely
related to the patient's initial consumption. Validation of the verbal
report of abstinence on a very small subsample of patients, using a
measure of nicotine concentration in saliva, revealed a low deception
rate (7 percent), which may have been unreliable, owing to patient
selection methods.

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In an attempt to replicate findings of Russell et al. (1979) in a
Canadian sample, Stewart and Rosser (1982) randomly assigned 691
patients to one of three groups: control, advice, and advice plus
pamphlet. There were no differences between the groups; only 3 to 4
percent of patients had stopped smoking at the 5-month followup
and were still abstinent at 1 year. At that later followup, the overall
success rate was 11.7 percent; no objective measure of smoking
status was included. The researchers note that the control group had
a higher rate of long-term quitting (3.1 percent) than in the Russell
group's 1979 study (0.3 and 16 percent).

A second study by Russell et al. (1983131 enrolled a sample of 1,938
cigarette smokers, aged 16 and older, who visited 34 general
practitioners in six group pra.ctices in Kent and London in November
1980. All smokers were included and were assigned in balanced
design by week of attendance to one of three groups; nonintervention
controls, 1 to 2 minutes of advice in the physician's own style plus
booklet and warning of followup, and similar advice plus booklet
plus offer of a nicotine gum prescription. A questionnaire was mailed
and a personal followup was performed after 4 months and 1 year.
Patients who did not provide adequate data at both points were
counted as smokers. Two-thirds of those who claimed to have quit at
each time point were checked by measurement of expired air carbon
monoxide. At 1 year, self-reported quit smoking rates in the three
groups were 13.4, 10.8, and 16.2 percent (p ~0.021, respectively. For
those patients not smoking at 4 months and at 1 year, the cessation
rates were 6.0, 6.4, and 11.9 percent, respectively (p ~0.02). After
correction for those who refused or failed chemical validation (22
percent) and for those who switched from cigarettes to pipes or
cigars, the cessation rates were 3.9, 4.1, and 8.8 percent (p <O.OOl).
Compared with this group's earlier study (Russell et al. 19791,
cessation rates in these nonintervention controls (also see Stewart
and Rosser 1982) are much higher (3.9 versus 0.3 percent), but the
rates are not directly comparable because the initial followups are
not identical (1 month versus, 4 months). However, cessation rates in
the advice/booklet/warning groups are quite similar (5.1 versus 4.1
percent). Cessation rates in the nicotine gum group are discussed
later in this chapter.

Wilson et al. (1982) reporteld that a simple followup procedure may
enhance the effects of physician advice. A group of 211 smokers over
16 years of age attending two middle-class, university-based prac-
tices in Hamilton, Ontario, #over a 6-month period were recruited.
Nonsmokers, pregnant women who smoked, and smokers with
communication disorders or terminal illness were excluded. All
participating patients received brief (3 to 5 minute) intensive
counseling to quit smoking and a pamphlet and, subsequently, were
randomly assigned to one of' two groups. The 106 smokers in the

460


treatment group were given followup appointments at 1, 3, and 6
months to review and discuss problems, while the control group of
105 smokers received followup appointments as needed for com-
plaints, but no further smoking cessation counseling. In the treat-
ment group, 23 percent reported cessation at 6 to 14 months,
compared with 12 percent of the control condition (p ~0.05). When
losses at followup were counted as continuing smokers, the success
rates dropped to 19.8 and 10.5 percent, respectively. No objective
validation was included. Success in quitting was significantly related
to several factors: having made previous attempts to quit, judging
that it would not be extremely difficult to quit, and smoking regular
tar cigarettes (versus low tar).

Pregnant Patients

A number of studies concern smoking cessation and pregnant
women, a group of patients who are not experiencing smoking-
related disease, but for whom continued smoking has serious
implications. It has been documented that smoking during pregnan-
cy, especially in the last trimester, can result in such consequences
as reduced birthweight and increased fetal and neonatal mortality
(Landesman-Dwyer and Emanuel 1979; USDHHS 1980; USPHS
1973). Some evidence also suggests that lactation in smoking
mothers is inhibited and that smoking during pregnancy may be
related to childhood hyperkinesis (Denson et al. 1975) and develop-
mental retardation (Landesman-Dwyer and Emanuel 19791. Accord-
ing to Fielding and Yankauer (19781, the pregnant woman has been
largely ignored as a target for smoking cessation techniques because
evidence concerning the dangers to the fetus is just beginning to
emerge. Increasing concern is being expressed for the pregnant
smoker (USDHHS 19801, and many smoking cessation strategies
have been described to assist women (Gastrin 1983; King and Eiser
1981; Kretzschmar 1980).

The prevalence of smoking during pregnancy and rates of physi-
cian advice to quit or cut down have been previously summarized
(USDHHS 19801. Almost 60 percent of physicians specializing in
obstetrics and gynecology who participated in the 1975 CDC Survey
of Physician Advice claimed that they advised most to all of their
pregnant patients to quit or to cut down (Danaher 1978). As in the
general population estimates of remembered physician advice cited
earlier, fewer women report such advice given during pregnancy.
About 24 percent of women last pregnant during the 5 years from
1970 to 1975 remembered such advice (Harris 1979).
Rates of cessation among regular smokers during pregnancy
ranged from 0.9 to 35 percent, with a median of approximately 20
percent, in the 11 studies summarized in the 1980 Report of the
Surgeon General The Health Consequences of Smoking for Women

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(USDHHS 1980). Results of m.ore recent studies were consistent with
the median figure. Hackett (I9791 interviewed 57 women at various
stages of pregnancy, and 16 percent reported quitting at some time
in the prenatal period. Fried et al. (1980) reported a similar quit rate
in a group of 67 smokers. The 1980 National Natality Survey (NNS)
examined changes in smokin.g and drinking behavior among 4,405
mothers during pregnancy (NCHSR 1983). Questionnaires were
mailed 6 months after delivery to married mothers who delivered
live-born infants. Nonmarried mothers were not included in the
analysis because of problems with the State government require-
ment of confidentiality. Mothers were much more likely to stop
drinking than to stop smoking during pregnancy. Of those who
engaged in the behavior before pregnancy, 30 percent stopped
drinking compared with almost 18 percent who stopped smoking.
White mothers had the highest smoking rates before pregnancy (32.0
percent) when compared with blacks (24.8 percent), Hispanics (23.3
percent), and others (19.9 percent). No significant differences by age,
race, or Hispanic origin were found in the proportion who stopped
smoking, although blacks appeared to have slightly lower quit rates
(13 percent) than either whites (18 percent), Hispanic (25 percent), or
other mothers (21 percent). Educational attainment, however, was
directly related to the tendency to stop smoking. Of white mothers
who smoked, the proportion who stopped during pregnancy ranged
from 10 percent for mothers with the least education (did not
graduate from high school) to 24 percent of mothers with the most
education (16 or more years education).

Three studies have combined observations of smoking discontin-
uance in pregnancy with some interventional tactic. Baric et al.
(1976) found that their entire sample of 134 pregnant British women
thought smoking could be harmful to the fetus, but only 16 percent
received this information from a doctor; most had received it from
the media. A total of 24 patients (18 percent of the sample) quit
smoking on their own; 63 of the remaining women participated in an
intervention program involving exposure to educational material by
a "doctor," and 47 served as controls. Subsequent analysis revealed
that while the groups did not differ significantly in the number of
women who quit smoking 11 weeks following treatment (14 percent),
significantly more in the intervention group modified their consump-
tion.

Dalton et al. (1981) surveyled smoking behavior (using self-report
only) in 282 pregnant British women, of whom 49 percent smoked at
the beginning of pregnancy. Thirty-two percent of the smokers in the
sample claimed they were given no medical advice to quit smoking.
Ten percent reported quittin.g smoking during pregnancy. A local
and a national poster and leaflet campaign designed to increase
smoking cessation rates at a prenatal clinic had no effect. The advice

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to curtail smoking was given in a minimal fashion, and rarely by
general practitioners. Knowledge of the hazards of smoking was
higher among those who acknowledged receiving advice than among
those not acknowledging advice. Also, those who quit were better
informed about fetal hazards than those who continued to smoke.

Using a breath test for carbon monoxide to validate self-report,
smoking status was assessed in 179 pregnant women of moderate to
low socioeconomic status in Pittsburgh (Hughes et al. 1982). Most
women (61 percent) were in the third trimester of pregnancy. At the
beginning of pregnancy, 55 percent of the women reported smoking;
of these, 19 percent reported that they had quit and 37 percent
reported that they had reduced their smoking rate during pregnan-
cy. The rate of false positive results among self-reported nonsmokers
was 12 percent, and the rate of false negative results among self-
reported smokers was 12.5 percent. Both continuing smokers who
reduced consumption and quitters made those changes in the first
trimester, and gave pregnancy-related reasons for changing their
smoking behavior. However, none of the pregnancy-related factors
examined were statistically associated with quitting or cutting down.
Most of the continuing smokers expressed a desire to quit or to cut
down and wished to receive treatment, but only 1 woman (of 801
attended a free cessation program nearby. The authors note that
interventions scheduled early in pregnancy during prenatal outpa-
tient visits would be optimal for such a group.

A fourth test of an intervention designed for pregnant smokers
was reported by Danaher et al. (1978). Eleven women participated in
a 6-week program delivered by behavioral scientists that included
instruction in behavior modification, deep muscle relaxation, and
educational information. Of the eight women who completed the
program, four quit smoking and another three markedly reduced
consumption. At a g-month followup, three women were completely
abstinent, and one women was smoking less than one cigarette daily.
No control group was included in this study, so it is not possible to
evaluate the relative effectiveness of the treatment package.

Finally, three randomized trials of smoking cessation interven-
tions with pregnant women have been reported. Donovan (1977) and
co-workers (Donovan et al. 19751 randomly assigned 588 pregnant
British women to a control or an intervention group receiving
intensive antismoking information. Unfortunately, the number of
patients achieving abstinence at least for the duration of their
pregnancies was not reported. There was a significantly larger
reduction in amount smoked by the intervention group than by
controls, however. Almost one-third of a group of women who
voluntarily quit resumed smoking before the end of pregnancy, a
finding not replicated in 1J.S. women by Sexton and Hebel (1984).

463


Bauman et al. (1983) reasoned that exposure to alveolar carbon
monoxide (CO) levels in pregnancy would provide a concrete
demonstration of a current and personal consequence of smoking.
All pregnant women attending a public prenatal clinic over a 6-
month period were randomized to experimental and control groups;
47 percent of the 170 women were smokers. Experimental subjects,
both smokers and nonsmokers, observed their CO levels in a group
setting. Control subjects did not have the CO intervention. All
subjects were read a script on smoking, CO, and adverse effects of
smoking during pregnancy; health educators implemented all proce-
dures. In the experimental group, there were 36 women smokers
exposed to their own CO; the control group contained 43 smokers.
Six weeks after the intervention, there was no difference in quit
rates between the two groups (7 percent of experimental subjects and
13 percent of control subjects had quit) or on five other measures of
smoking behavior. After adjusting for covariates used in assessing
attrition effects and comparison group equivalence, CO levels were
significantly lower in the treatment group. The authors concluded
that the intervention had either a small or no influence on cigarette
smoking.

The first prospective, randomized, controlled clinical trial demon-
strating that a reduction of smoking produces a favorable change in
infant birthweight contained an effective smoking intervention
(Sexton and Hebel 1984). Pregnant women who smoked at least 10
cigarettes per day at the beginning of pregnancy and who had not
passed their 18th week of gestation were eligible for entry into the
trial. A total of 935 women w'ere recruited from the practices of 52
private obstetricians and a university hospital's obstetric clinic in a
large metropolitan area; subjects were randomly assigned to experi-
mental and control groups. Subjects in both groups reported smoking
an average of a pack a day at the beginning of pregnancy, but to have
reduced their smoking to about 11 cigarettes per day by the time of
randomization. The smoking intervention was delivered by health
educators, and consisted of encouragement and assistance to stop
smoking through informational and behavioral strategies. Each
woman received a minimum of one personal visit, supplemented by
telephone and mail contacts. The control subjects received no contact
until followup. A questionnaire and saliva sample (for thiocyanate
analysis) were obtained at randomization and during the followup in
the eighth month of pregnancy'. At followup, 43 percent of women in
the treatment group and 20 percent of women in the control group
reported quitting smoking. Overall, there was a significantly greater
reduction of smoking in the treatment group; group means for
number of cigarettes smoked per day were 6.4 for experimental
subjects and 12.8 for control subjects, respectively. Mean thiocyanate
levels were significantly lower in the experimental group than in the

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control group, verifying self-report on a group level. Cessation
results in the control group, contrary to the findings of Donovan
(19771, showed that very few women who quit smoking in the first
trimester resumed smoking during the pregnancy; also, very few
who had not quit in the first trimester quit on their own later in the
pregnancy. This study clearly demonstrated that an "antismoking
intervention is feasible to conduct, accepted by pregnant women, and
effective in producing a reduction in smoking, and most important of
all, that cessation even during pregnancy improves the birthweight
of the baby" (Sexton and Hebel 1984, p. 915). These are important
results, obtained in a relatively high risk study group, and deserve to
be followed up.

Patients With Pulmonary Disease

A large proportion of the patients seen by a pulmonary specialist
are experiencing, firsthand, the health problems resulting from
continued smoking (Pederson 1982; Windsor et al. 1979). The
literature cited below demonstrates that the presence of serious
illness adds credence to the physician's message and is related to
increased compliance (Cooper-stock and Thorn 1982; Daughton et al.
1980; Davison and Duffy 1982; Hall et al. 1983; Pederson and
Baskerville 1983; Pederson et al. 1982). The evidence continues to
accumulate that smoking cessation is followed by favorable changes
in cardiopulmonary functioning (Ball and Turner 1974; Buist et al.
1976, 1979; Peterson et al. 1968; &human 1971; World Health
Organization 1975) and in morbidity and mortality (Hammond 1965,
1966; Kuller et al. 1982; USDHHS 1981; UUSDHEW 1979; Weinblatt
et al. 1971; Wilson 1973).

A number of studies (Baker et al. 1970; Burns 1969; Burnum 1974;
Dudley et al. 1977; Guzman 1978; Mausner 1970; Peabody 1972;
Pederson et al. 1980; Raw 1976; Rose and Hamilton 1978; Rose and
Udechuku 1971; Williams 1969) have investigated smoking cessation
among patients with respiratory disease. Table 1 summarizes these
studies, including data on subject groups, sample sizes, quit rates,
and duration of followup.

Eleven studies have investigated quit rates among pulmonary
disease patients following physician advice (Baker et al. 1970; Burns
1969; Burnum 1974; Cooperstock and Thorn 1982; Daughton et al.
1980; Davison and Duffy 1982; Guzman 1978; Mausner 1970;
Peabody 1971; Trahair 1967; Williams 1969). Compliance rates vary
from 15 percent to 51 percent, but none of these studies included no-
advice control groups as a test of the effectiveness of physician
counseling. A trend toward lower quit rates has occurred in the more
recent studies.

None of the investigations attempted to identify patient character-
istics associated with compliance, although some results suggest that

465


5 TABLE I.-Studies assessing smoking cessation rates among patients with pulmonary disease

                                  Quit rate           Duration of
  Study                  CrOUps            @ercent)          fouowup                   Commenta '

   Baker et al. (2970)         Multidimensional              34           6 months           No control group
                    treatment, N = 134

   Burns (2969)           Private, N=94               41           3 months           No control group; su- related ta less
                                                       withdrawal, lower neuroticism, and beii
                                                                          male

   Burnum (1974            Private                    25         Average, 5 years        No control group
  Cooperstock and        Respiratory, N =33             36          Cnxsectional         Quit rates compared with circulatory and
   ,Tiiom @YZ~                                                    mtwculoekeletal groups
  Daughton et al.         Hoepitalized, N = 107            63           -ional         No control groups, retmepective; ex-
   W3Ol                                                               smokera and smokers differed in
                                                       psychoeocial factors, pack years
  Davison and Duffy       Lung or cancer,               25          5Ye=3            No control group
   U982)                 N=52

  Dudley et al. (1977)         Cheat clinic                 76           Cronwwtional         No control group, retrospective; ex*mokers
                  Never smokers, N=66                               and smokers differed in psychosocial
                  Smokers, N = 42                                  aaaeta. at&My. and expression of
                  Quitters, N=132                                   depression

   Guman (1978)          Cheat clinic, N=123            20           3 to 24 month        No control group

   Hall et al. (1983)        Cardiopulmonary                          6 monthe           No signiticant difference in quit rate;
                  Health motivation, N= 19         10                      mood atatea related to reduction; objective
                  Aversion condition, N = 16         30                            verification

   Mauaner (1970)           Private                    51           3 to 12 months        No control group; exsmokers and smokers
                 Eight physicians, N=136                             differed in ewe&y of diewe


`FAHLE: 1 .--Continued

Study                  GrOUps

Quit rate
(percent)

Duration of
followup

Comments'

Not given

25

Not given

Only quit rate reported

Pedemn et al.
i 1980)

Private. N= 117

27.4

Retrospective
6 months to 7 years

No control group; multivariate analysis;
ex-emokers and smokers differ on
diagnosis. age, and sex

Pederson et aI
(1.9&n

Newly diagnosed
pulmonary, N = 3013

12.9

6 months

No control group; multivariate predictive
model developed, 92 prcent nczuracy

Raw (1476)           Motivating advice-"white coat"    Overall           3 months            R~~~ulta not presented for individual groups
               Motivating advice-%0 white coat"   12.5
                  Interview-"white coat"
                 Interview-"no white coat,"
               N-10 per group
             ~____          -. -~-                         -----__-.__ ~-~            ----
&me and Hamilton        Normal caee, N=731            14          3 years             High risk for cardiompirutory dmeas
197m               Intervention, N=714            36

Hospitalized with chronic bronchitis,   25          Not pven            No control group
N=29                             ~.--__  -___
Chest clinic, N=204            23            6 months             No control group


such relationships may exist (Burns 1969; Mausner 1970). Two
retrospective studies (Dudley et al. 1977; Pederson et al. 1980) used
multivariate techniques to determine the sociodemographic, physio-
logical, and psychological variables that are related to quitting.
Dudley et al. (1977) found that "good psychosocial assets, psychologi-
cal stability, and the ability to express depression openly" (p. 367)
discriminated between quitters and nonquitters. Since their mea-
surements were made cross-sectionally, the question remains wheth-
er these variables are causes or effects of smoking cessation. In a
sample of 117 pulmonary patients, 27 percent of whom quit after
physician advice, Pederson et al. (1980) found that abstinence was
related to primary diagnosis (t.hose with COLD were more likely to
quit), age (older or younger versus middle-aged), and sex (women
were more likely to quit) in order of predictive power. These results
could have been biased, however, because a number of patients were
lost to followup and no objective verification of smoking status was
used.

Pederson et al. (1982) conducted a prospective study of 308 newly
diagnosed respiratory patients, and using multivariate statistical
models, accurately categorized 92 percent of the samples as continu-
ing smokers or quitters, following physician advice. This model was
subsequently validated in a second group of similar patients with 89
percent accuracy. In both groups, cessation rates (self-report only)
were approximately 15 percent (Pederson and Baskerville 1983). The
variables from entry questionnaires useful for discriminating smok-
ers from quitters at followup were prediction of the patient as to
smoking status at followup, age, addiction as the major reason for
smoking, desire to quit, educational level, socioeconomic status,
number of children at home, and being married. Prediction of
quitting, increasing age, desire for quitting, socioeconomic status,
and being married were positvely associated with quitting. Addic-
tion, having children at home, and middle educational level were
negatively associated.

Three investigators (Hall et al. 1983; Raw 1976; Rose and
Hamilton 1978) tried to vary the type of advice given in order to
increase compliance. Raw 11976) found that increasing the motivat-
ing information about the risks of smoking and the benefits of
cessation by a psychologist subsequent to physician advice to quit did
not have a positive effect on compliance, but donning a white coat
did. The physician advice itself reduced smoking significantly among
advised patients compared with among nonadvised patients. Addi-
tionally, the group for whom the psychologist wore the white coat
during the interview (motivating or placebo) reduced smoking
significantly more than the no-white-coat group did. The dependent
variable was the percent reduction in smoking level (number of
cigarettes smoked) at 3-month followup by self-report alone. Unfor-

468


tunately, the sample was small (n =40), and abstinence rates were
not reported. The author suggests that the white coat is an advisor
characteristic that can increase effectiveness of advice.

Hall et al. (1983) found no difference in 6-month abstinence rates
between two groups of cardiopulmonary patients (n=35) randomly
assigned to a health motivation and self-management treatment (26
percent abstinence) or to an aversive smoking treatment (6 percent
abstinence), both led by nonphysician health professionals. Results
summarizing attrition rate and outcome (post-treatment and at 6-
month followup) generally favored the health motivation group,
however.

The London Civil Servants Smoking Trial (Rose and Hamilton
1978) was a randomized controlled trial of 1,445 men at high risk for
cardiorespiratory disease. Following a screening examination, 714
men were randomized to an intervention group and 731 to a normal
care group. For the normal care group, the results of the examina-
tion were forwarded to the general practitioner, leaving further
action to him. The men were not aware they were in the trial. They
were invited to return for the l-year and 3-year examinations as part
of the research. Men in the intervention group were invited by letter
to discuss the results of their examination with a physician (all
accepted). The 15-minute appointment consisted of strong advice to
quit smoking, risk appraisal (oriented to fitness and well-being more
than to disease), benefits of cessation, and the practicalities of
stopping-choice and personalized motivation. Two booklets were
provided, prepared especially for the study. Three further int,erviews
were scheduled at l-week, lo-week, and 6month points. All men
(intervention and controlj who attended the l-year and 3-year
examinations completed a self-administered questionnaire; some
were completed by mail. No validation of self-report was made. At
the l-year examination, 51 percent of intervention subjects and 10
percent of control subjects reported cessation of cigarette smoking;
excluding those men who had switched to pipes or cigars, rates of
tobacco abstinence drop to 38 and 8 percent, respectively. Of all the
men who stopped within the first year, 80 percent did so immediately
after the first interview. At 3 years, 36 percent of intervention
subjects and 14 percent of control subjects were not smoking
cigarettes; total tobacco abstinence rates were 23 and 10 percent,
respectively. A number of personal characteristics assessed at entry
were associated with increased probability of cessation: smoking less
than 20 cigarettes per day, not inhaling, use of filter tips, prior
attempts to stop, marital status "other than married," professional
or executive employment category, and neuroticism (Eysenck Per-
sonality Inventory). The level of abstinence achieved in the treat-
ment group is comparable to several other studies with similar

469


patients (Baker et al. 1970; Burns 1969; Mausner 1970; Pederson et
al. 1980) and is closer to the remainder than control group results.

Patients With Cardiac Disease

The studies concerned with smoking cessation among cardiac
patients further support the notion that presence of disease may be
an important precursor of compliance. The occurrence of a myocardi-
al infarction (MI) is a dramatic event that, in many patients, should
add credence to the physician's admonishments. Evidence demon-
strates that reduction or cessation of smoking is positively related to
survival in MI patients (Hickey et al. 1983; Mulcahy et al. 1975,
1977; Pentecost 1980; Salonen 1980; Sparrow et al. 1978; USDHHS
1983) and is negatively rela.ted to a coronary event following
uncomplicated angina (Hubert et al. 1982). It appears that smoking
cessation decreases mortality, among post-MI patients, so that
attempts to increase compliance among this group could have life-or-
death ramifications.

Table 2 summarizes the studies on this patient group. Successful
smoking cessation is relatively high among survivors of MI (Baile et
al. 1982; Burnum 1974; Burt et al. 1974; Cooperstock and Thorn 1982;
Croog and Richards 1977; Halhuber 1978; Hay and Turbott 1970;
Kirk et al. 1980; Kornfeld et al. 1982; Lloyd and Cawley 1980;
Mallaghan and Pemberton 1977; Mayou et al. 1978; Ronan et al.
1981; Sillett et al. 1978; Weinblatt et al. 1971; Wilhelmsson et al.
1975). Cessation rates range from 22 to 94 percent, with the majority
of studies falling in the 40 to 60 percent range. The discrepancies in
rates are partially attributable to sample size variations or duration
of followup. A trend is apparent, however, with more recent studies
reporting lower rates.

In a recent review of the literature on smoking following myocar-
dial infarction, Burling et al. (I9841 discuss four major methodologi-
cal limitations in these studies. First, the definition of abstinence
varies among studies, ranging from zero to five cigarettes per day;
also, the period over which abstinence is measured, from the MI
continuously to followup, should be specified.

Second, self-report of smoking status is rarely verified; a few
studies have used biochemical validation Baile et al. 1982; Burling et
al. 1982; Kirk et al. 1980; Ronan et al. 1981; Sillett et al. 1978; Wilcox
et al. 1979). Rates of deception have varied from approximately 25
percent of patients claiming abstinence (Sillett et al. 1978; Wilcox et
al. 19791 to much lower estimates of discrepancy between self-report
and objective measure (Baile et al. 1982; Burling et al. 1982; Kirk et
al. 1980; Ronan et al. 1981).

Third, specification of the treatment-the time and amount of
antismoking advice delivered--is not always explicit. Advice can be
verbal or verbal plus written, and the intensity of the message has

470


TABLE 2.-Studies assessing smoking cessation rates among patients with cardiac disease

Study                  GrOUpE

Quit rate
bxcent)

Duration of
followup

Comments '

Bade et al. U98ZJ

PC&Ml

62

Approximately
10 day8

In-hospital relapse among patients
receiving standard advice, no control
group; probability of relapse inversely
related TV severity of MI; objective
validation (breath CO) on a parallel series
of patients (unpublished), 9.2% deception
rate

Bumum (2974

Burt et al. (1974

Private, N=52

PostMI
Strong advice, N = 125
Conventional advice,
N=l35

42

62

27.5

Average, 5 years
lto3yem

No contml group

Cooper et al. U98ZI       High risk, N=519             24          2Y=@             No control group

Cooperstock and Thorn
u9m

Patienb with
circulatory problems.
N=317

13

Cmweectional

Quit ratea compared with respiratory and
mwwloekeletal groups

croog et al. (1977)        PC&MI, N=205              51         6 or 9 yeara

No control group; no differences between
ex-smokere and smokers for health beliefs
or so&demographic characteristics

Hay and Turbott
(297ol

P&MI, N = 137
Coronary inauff~ciency.
N=44

29

11

6 months to 2 years       Control for severity of disease

Halhuber (1978)         CHD, N=935                94            4 weeks            No control group

P
-1
I


rp
2   TABLE Z-Continued

                                     Quit rate           Duration of
   Study                  Groups            (percent)           followup                   Comments '

Kirk et al. (1980

Komfeld et al. (J99Zl

Arterial diseaee,
N=39

Patients after
coronary bypana
surgery. N = 100
(39 smokers)

49 repolted
44 verified

67

9 months

9 months

Objective validation Wum SCNI; pwslble
deception rate, 10.5 percent
           ___-..--. ~-
No control group

Lloyd and Cawley
(1980

MaIlaghan and
Pemberton (1977)

P&MI, N = 105
(64 smokers)

Post-MI. N=321

36

22

4 months

1 Y-

No control group

No control group; tilerewes between ex-
smokers for perceived severity and
memory of adviw

Malotte et al. (1981)       Hiah risk. N=43              53           6 montha            No control group; reaidentlal pmnqam

Mavou et al. (1978)        P&MI, N=lOO               45          1 Y=              No control group

Meyer and
Henderson (1974

Behavior Gadification.
N=5
Individual munaeIing,
N=4
Physician counseling,
N=6

20

25

3 montha

High risk patients; no wgmficant
difference between groups

33

Ockene et al. W62b)

High rink group
Special intervention,
N=4,103
Uellal care,
N=4,OSl

40 repQrted
35 verified
21 reported
19 verified

4Y-3             MRIW objective validation WN)


TABLE 2.-Continued

Study                 Gmupe

Qmt rate
(percent)

Duration of
followup

Powell and Amold
mm

High risk, N=42

50 verified

1 year

Objective validation (XN); hard core
smokers

Rahe et al. (1979)

P&MI
Croup therapy, N=22
Control, N=22

33
42

4 years             No sgnlficant difference

Bonan et al. (1981)

P&MI, N=117           51 reported
(111 smokers)             47 verified

4 to 18 years

Objective vahdation COHb~; possible
deception rate, 6.8 percent

Bose and Hamilton
(1978)

Raw et al. WWI

Normal care. N=731            14
Intervention, N=714            36

Normal cam, N=731        Not reported
Intervention, N=714            36

3YW

BY-

High risk for cardiorespiratory diseaee

            _____-
Followup of Roee and Hamilton (1978)

Rose and Udeehuku
(1971)

Hospitalized with
atherceclemtic diwnae,
N=56

44          Not given            No control group

Bcee et al. (198OJ        High ri&, N=736              29          4Y=-               Part of WHO tnal

Sillett et al. (1978)        P&Ml, N=Sl

65 reported
51 verified

1 Y=

Objectwe vahdation; pceeible deception
rate. 21 w-cent

Sivarqian et al.
UW

PC&Ml
Eherciee. N=66
Ekerciee and
counseling, N=66,
Control. N=&d

31

34
41

6 months            No significant differences

   Sparrow et al. (1978)       PC&MI, N=XJ2               El           Variable            Followup of smokera developing MI in the
%                      emokem                          2to6yeam        Fra+r&un study; no control group


4
-1   TABLE 2.-Continued

Study

Groups

Quit rate
(percent)

Duration of
foUowup

Comments '

Weinblatt et al.
(1971)

P&-MI, N=283
Angina, N=146
Nor&I-ID, N=432

50
50
19

4.5 year0

Control for severity of disease

WHO European
Collaborative Group
(lS!E?l

High risk, N=4,770             6          4Y-               No control condition

Wilhehnsson et al.
(1975)

PC&MI, N=M4

53

3 months

Differences between er-amokers and
smokers for increasing age and severity of
disease

' Objective validation of self-report of smoking abtinence wan performed only in thcee studies 80 indicated


varied from routine to strong. Results have generally been better
when stronger advice was delivered (Burling et al. 1982).

For example, in an experimental test of the effect of intense advice
on post-MI cessation, Burt et al. (1974) routinely assigned 210 male
patients to intense or to routine advice conditions. Abstinence rates
were higher in the intense advice condition, 62 versus 27.5 percent.
The intense intervention consisted of telling the patient repeated-
ly-in the critical care unit, during convalescence, and during
followup-never to smoke again in his lifetime, plus giving him a
pamphlet. However, other attempts to increase cessation rates by
using group counseling (Rahe et al. 1979) or exercise with or without
counseling (Sivarajan et al. 1983) showed no differences in absten-
tion rates for treatment groups and control groups.

Fourth, a variety of subject and environmental factors that may
influence cessation have rarely been systematically examined or
controlled. These include age, sex, race, severity of the MI, and
personality and environmental factors. Age is not found to be related
to cessation in most studies (e.g., Baile et al. 1982; Croog and
Richards 1977; Salonen 1980; Sparrow et al. 1978; Weinblatt et al.
1971). Both of the studies presenting data on sex differences in post-
MI cessation have noted somewhat higher cessation rates among
males; however, sample sizes were small and the differences were
not statistically significant (Baile et al. 1982, Sparrow et al. 1978).
Racial data have not been available for nonwhite populations.
Greater severity of an MI has been associated with higher smoking
cessation rates (Baile et al. 1982, Wilhelmsson et al. 1975). Personali-
ty and environmental factors are complex, and only a few relation-
ships have been explored. For example, neither Baile et al. (1982) nor
Croog and Richards (1977) found associations with any of the
sociodemographic or Health Belief Model variables measured, but
Baile et al. (1982) did identify an environmental factor-being
offered cigarettes by visitors-that influenced resumption of smok-
ing among hospitalized post-MI patients.

The descriptive study by Baile et al. (1982) provided several
suggestions for intervention with post-MI patients-introducing the
intervention prior to hospital discharge and as early in the hospitali-
zation as is feasible, even in the critical care unit, and involving
family members and visitors in the effort to prevent resumption of
smoking. This study was not designed to assess the mechanism by
which relapse was negatively associated with severity of the MI, but
the authors offered several possibilities: the presence of subjective
factors such as specific illness symptoms, general malaise or level of
fear, communications from the medical staff regarding severity of
heart attack, intense and specific advice to quit smoking, or
differential medical treatment that might have affected the patients'
smoking behavior. These factors should be considered in the design

475