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Group behaviour therapy programmes for smoking cessation

  1. Lindsay F Stead*,
  2. Tim Lancaster

Editorial Group: Cochrane Tobacco Addiction Group

Published Online: 20 APR 2005

Assessed as up-to-date: 8 OCT 2008

DOI: 10.1002/14651858.CD001007.pub2


How to Cite

Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001007. DOI: 10.1002/14651858.CD001007.pub2.

Author Information

  1. University of Oxford, Department of Primary Health Care, Oxford, UK

*Lindsay F Stead, Department of Primary Health Care, University of Oxford, Rosemary Rue Building, Old Road Campus, Oxford, OX3 7LF, UK. lindsay.stead@dphpc.ox.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 20 APR 2005

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This is not the most recent version of the article. View current version (31 MAR 2017)

 
Characteristics of included studies [ordered by study ID]
Bakkevig 2000

MethodsCountry: Norway
Recruitment: Community volunteers
Group size: not stated


Participants139 smokers; 67% female, av age 44, av. cpd 19
Therapists: ex-smokers who have previously used programme


Interventions1. Physician (GP) advice; participants instructed to visit their GP for support. GP told to offer NRT as appropriate and provide 1 follow-up visit.
2. Group therapy; participants asked to attend 'Smokenders'. 7 weekly sessions + 1 follow up 4w later. Quit day after 5w. Multifaceted including cognitive therapies


OutcomesAbstinence 1 yr post-quit date
Validation: < 83 mmol/L thiocyanate and/or < 75 ng/mL cotinine. Only 10% of group 1 and 35% of 2 attended 1 yr follow up.


NotesComparison 1.3.1. 'Real world' study. Treatment allocation refusers and other non-compliers included as smokers. 36% consulted GP, 75% attended Smokenders.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'randomly allocated', method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes90% of controls & 65% of intervention lost/withdrew by end of study, all included in ITT analysis

Batra 1994

MethodsCountry: Germany
Recruitment: Community volunteers
Group size: not stated


Participants232 smokers; 53% female, av age 41, av cpd 25


InterventionsBoth conditions received nicotine patch
1. Group therapy, 9 weekly 90 min sessions
2. Self-help materials


OutcomesContinuous abstinence at 12m
Validation: not described


NotesComparison 1.1.2, different S-H


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclearrandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
UnclearAll randomized participants included in analysis

Brown 2001

MethodsCountry: USA
Recruitment: Community volunteers
Group size: not stated


Participants179 smokers with history of MDD; 60% female, av age 45, av cpd 27
Therapists: 2 for each group, clinical psychologists


Interventions1. Standard group therapy. 8 x 2hrs over 6w, TQD session 5. Including nicotine fading, RP, homework
2. As 1. + CBT for depression. Same schedule + coping skills to control depressive symptoms


OutcomesSustained abstinence at 12m (confirmed at post-Rx, 1m, 6m). (PP abstinence was main trial outcome)
Validation: CO ≤ 10ppm + saliva cotinine ≤ 46ng/ml
(abstinence was only verified by significant others in 6.5% of cases)


NotesNo non-group control. Comparison 2.2.1 - testing effect of depression/mood management programme.
Direction of effect opposite for sustained and PP abstinence.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?YesRandomized, stratified on gender, current depressive symptoms, FTQ, using urn method

Allocation concealment?YesNo details given, but use of urn technique makes it likely that enrolment occurred before allocation known

Incomplete outcome data addressed?
All outcomes
Yes8% lost to follow up at 12m, included in ITT analysis

Brown 2007

MethodsCountry: USA
Recruitment: Community volunteers
Group size: not specified


Participants524 smokers; 48% female, av age 44, av cpd 25
Therapists: 2 PhD psychologists for each group. All conducted both types of treatment


InterventionsFactorial trial including bupropion versus placebo comparison
1. CBT for cessation; 12 x90 min over 12w, 2/week then 1/week then monthly. TQD session 7
2. As 1, plus CBT for depression, same contact time


OutcomesAbstinence at 12m (sustained at 2m & 6m)
Validation: CO ≤10 ppm & cotinine ≤15ng/ml (8.2% verified by 'significant other')


NotesNew for 2009 update. No non-group control. Comparison 2.2.1 for effect of mood management. Pharmacotherapy conditions collapsed


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'Participants were randomly assigned to one of two
treatment sites, where they were to receive one of two
manualized group treatments ... Participants
were then randomly assigned to receive one of two
medication conditions, bupropion or placebo, using
the urn randomization technique'

Allocation concealment?Unclear'Whereas we were able to balance the drug and placebo conditions on an individual basis, behavioral treatments were randomized by group and thus were more susceptible to fluctuations in recruitment and to the availability at both sites of pairings of a senior and a junior therapist trained in CBTD'. Knowledge of behavioural assignment was probably not concealed but seems unlikely to have lead to individual selection bias.

Incomplete outcome data addressed?
All outcomes
Yes81% provided complete outcome data at all follow ups, not related to treatment condition. All participants included in ITT analyses

Bushnell 1997

MethodsCountry: USA
Recruitment: Community volunteers
Group size: max 50 ACS or 15 Vanderbilt University Medical Center (VUMC)


Participants314 military and civilian smokers, excludes 198 people, assignment NS, who did not attend any sessions after randomization. 44% female, age and smoking not described
Therapists: ACS- trained volunteers. VUMC- healthcare professionals


InterventionsAll participants offered free NRT (in group 2 conditional on attending 75% classes)
1. ACS: 4 x1hr large group sessions, no TQD
2. VUMC: 8 x1hr sessions, RP model including stress management, diet, exercise


OutcomesAbstinence at 6m (PP)
Validation: CO < 8ppm, salivary cotinine ≤ 10mg/ml


NotesNo non-group control. Results not shown in graphs. No sig diff in 6m quit ,12% (17/143) for ACS vs 13% (22/171) for VUMC.
Take up rate: 61% of screened population attended 1 or more classes.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'randomly assigned', method not stated, stratified by military or civilian

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesPeople who attended no classes were not included, other noncompleters included in ITT analysis

Camarelles 2002

MethodsCountry: Spain
Recruitment: Primary care
Group size: 10-14


Participants106 smokers (any amount); 54% female, av age 47, av cpd 25
Therapists: 1 doctor, 3 nurses, trained and experienced


Interventions72 participants eligible for nicotine patch, 53 used.
1. Group therapy, 7 x2 hrs over 3w, TQD after w3.
2. Individual counselling, not matched for intensity, 2 sessions over 2w, with S-H materials


OutcomesSustained abstinence at 6m
Validation: none


NotesComparison 1.2.2 between group and shorter individual therapy
Slightly higher and longer use of NRT in group condition


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearSealed opaque envelopes, but chosen by patient. Since all received a cessation intervention, potential for selection bias probably low

Incomplete outcome data addressed?
All outcomes
UnclearNo information on losses to follow up but all participants included in denominators

Cottraux 1983

MethodsCountry: France
Recruitment: Community volunteers
Group size; 15


Participants558 (418 in arms of interest) community volunteers; 24% female, av cpd 31
Therapists; 2 per group, qualifications not described


Interventions1. Behaviour therapy. Includes discussion, training in relaxation. 3 x 3 hr sessions over two weeks. Relaxation and stress-desensitization audiotape for daily use.
2. Acupuncture (not included in MA)
3. Placebo - lactose capsules for 2w. Met 2 x10min with a doctor.
4. 1 yr waiting list control.


OutcomesAbstinence at 12m
Validation: none. Assessor blind to treatment condition


NotesAlthough 3 described by authors as placebo the two meetings with a doctor make it more comparable with an advice intervention so 1 vs 3 used in comparison 1.3.1 and 1 vs 4 in comparison 1.5


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, stratified by presence of another smoker in household, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes5% lost to follow up, included in ITT analysis

Curry 1988

MethodsCountry: USA
Recruitment: Community volunteers
Group size: 12


Participants139 smokers: 51% female, av age 41, av cpd 28
Therapists: 2 teams of 2 PhD psychologists. Each team led 1 group in each programme.


InterventionsTest of group vs S-H format, and traditional vs relapse prevention programme. Groups met for 8 x 2hr weekly meetings which included relaxation training, enlisting social support and practising alternative behaviours.
1. Relapse Prevention Group. Focused on smoking as learned behaviour. Quit day at 3rd session. Additional elements included identifying high risk situations, cognitive restructuring and role playing.
2. Relapse Prevention Self help. 8 workbook units.
3. 'Absolute Abstinence' (AA) Group. Focused on addictive component of smoking. Quit day at 5th session. Additional elements included focused smoking, health education and contingency contract.
4. Absolute Abstinence Self help. 8 workbook units.


OutcomesAbstinence from months 9 to 12 of follow up.
Validation: saliva TCN and 2 collateral verifiers.


NotesFrom 2009 RP & AA conditions collapsed so 1&3 vs 2&4 entered in comparison 1.1 instead of two substudies


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearPart by coin toss and part random number table. Friends co-randomized to same programme but not necessarily same format. More assigned to S-H than group by design

Allocation concealment?UnclearNo details given, but randomization procedue makes it likely that it was not concealed

Incomplete outcome data addressed?
All outcomes
YesOnly 69% began treatment but all assigned to treatment included in ITT analysis

DePaul 1987

MethodsCountry: USA
Recruitment: Employees at 43 worksites, recruited prior to a 3w television smoking cessation programme.


Participants233 smokers in group discussion worksites, 192 in non-group worksites; 72% female, av age 43, av cpd 30
Groups led by employee with 3 hrs training


InterventionsAll participants were given S-H manuals by company co-ordinators and instructed to view the televised segments
1. Twice weekly 45 min group meetings for 3w
2. S-H alone


OutcomesAbstinence at 12m (multiple PP)
No validation


NotesPercentage quit rates estimated from graphs and denominator assumed to be numbers followed up.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearCluster randomization by worksite, matched for size. 3 worksites did not enter allocated condition but excluding them did not alter findings

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Unclear8% lost to follow up in each group

DePaul 1989

MethodsCountry: USA
Recruitment: Employees at 38 worksites, recruited prior to a 3w television smoking cessation programme


Participants419 smokers who participated in the worksite programmes; 63% female in groups, 54% female in S-H, av age 38, av cpd 21


Interventions1. 6 x twice-weekly group meetings to coincide with the 3w television series, then monthly meetings for 1 yr. Abstinent smokers and 5 of their family and 5 co-workers entered for a lottery at the final group meeting and 12m follow up.
2. S-H manuals only


OutcomesAbstinence from end of programme to 12m
Validation; saliva cotinine and co-worker or relative confirmation.


NotesData based on participants in the programmes. Attrition was defined as not attending any group meetings, not reading the manual, not being located for post-testing, refusing to be interviewed or changing jobs. The attrition rate was 17% for group worksites and 29% for non-group worksite participants so correcting the data for attrition would increase the apparent efficacy of the group condition.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearCluster randomization by worksite, matched for size

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesAttrition rates reported, only those followed up used in MA, see Notes

DePaul 1994

MethodsCountry: USA
Recruitment: Employees in 61 worksites who expressed interest


Participants564 smokers in relevant comparisons, 58% female, av age 38, av cpd 21


InterventionsThe worksite interventions were timed to coincide with a mass media intervention consisting of a week-long smoking cessation series on TV, and a complementary newspaper supplement.
1. S-H manual (ALA Freedom from Smoking in 20 days)
2. S-H manual and incentive payment of US$1 for each day abstinent up to US$175
3. 6 group meetings over 3w followed by 14 booster meetings over 6m. Incentive payments. Handouts from same S-H manual. Maintenance manual (ALA A Lifetime of Freedom from Smoking)


OutcomesSustained abstinence at 12m
Validation: CO < 9ppm. Saliva cotinine at 6m only.


Notes3 vs 2 in Group vs S-H. Including 1 would increase effect. Treated as same S-H programme, since same approach used although group participants not given complete cessation manual.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearCluster-randomized by company

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
UnclearLoss to follow up high, but lower in group condition. All included in ITT analysis

Digiusto 1995

MethodsCountry: Australia
Recruitment: Community volunteers and physician referral


Participants137 smokers; 56% female, av cpd 26, av age 44


Interventions1. Social support. Emphasized interaction, social coping strategies. 5 treatment meetings of which 2 held after quit date
2. Self control. Interaction discouraged. Taught cognitive-behavioral self-control strategies. 4 meetings, one 7 days after quit day


OutcomesAbstinence for 7 days at 6m.
No validation at 6m. (At 1w 5/82 claiming abstinence had cotinine > 250 nmol/L)


NotesNo non-group control. Study designed to test specific effects of social support aspect of group treatments. Included in comparison 2.3 - effect of manipulating group dynamics.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Unclear12% of social support & 10% of self control lost to follow up, included in ITT analysis

Etringer 1984

MethodsCountry: USA
Recruitment: Community volunteers
Group Size: 7-13


Participants72 smokers; 57% female, av age 36, av cpd 25
Therapists: doctoral candidates with 2 yrs in counselling psychology


InterventionsFactorial design using 2 cessation programmes and an intervention on group cohesiveness. Not clear whether session patterns identical for each. 9w course of 45-60 min sessions
1. Enriched cohesiveness using written commitments, exercises and video. Satiation smoking in preparation for cessation
2. Enriched cohesiveness. Nicotine fading in preparation phase
3. Standard group. Satiation smoking
4. Standard group. Nicotine fading


OutcomesAbstinence at 1 yr
Validation by randomly contacting approx half of the 3 informants nominated


NotesNo non-group control. 1&2 vs 3&4 in comparison 2.3. Originally treated as 2 studies in MA but due to small size now collapsed


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?No'For the most part, subjects were assigned to treatment on a random basis. However for logistical reason the requests of couples and friends who wished to be assigned to the same group were honoured'

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesNo mention of losses to follow up, all recruited participants included in analyses

Garcia 1989

MethodsCountry: Spain
Recruitment: Primary care clinic volunteers
Group size: maximum 15


Participants68 smokers (in relevant arms); 41% female, av age 34, av cpd 25


Interventions1. Group therapy, 7 sessions over 3m, nicotine gum 2 mg
2. Individual counselling in clinic, same schedule as groups, nicotine gum as in 1.
(A 3rd arm receiving group therapy and placebo gum is not included)


OutcomesSustained abstinence (quit at previous follow ups) at 6m
Validation: CO < 7ppm


NotesContributes to comparison 1.2.1 vs individual counselling


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not stated

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes81 (43%) did not begin treatment and are not included, no differences detected between drop-outs, or between treatment groups

Garcia 2000

MethodsCountry: Spain
Recruitment: Community volunteers
Group size: 7-16


Participants162 volunteers for a multi-session programme, smoking > 10 cpd; 52% female, av age 32, av cpd 26
Therapist: Psychologist


Interventions1. Multicomponent programme, 10x 1hr sessions over 5w
2. Multicomponent, 5x 1hr over 5w
3. As 2 plus S-H manual
4. S-H manual, 1 orientation session


OutcomesPP (7 day) abstinence at 12m
Validation: CO < 8ppm + confirmation by informant


Notes1+2+3 vs 4 in comparison 1.1.1 for effect of any group programme. 1 vs 2 described in text


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesDrop-outs who did not attend any sessions after randomization were not included. Losses to follow up included in analyses

George 2000

MethodsCountry: USA
Recruitment: People with schizophrenic disorders
Group size: 4-6


Participants45 smokers with schizophrenia or schizo-affective disorder;
67% male, av age 40, av cpd 30. More people were prescribed atypical antipsychotics in ALA group


InterventionsAll used 21 mg nicotine patches from quit day in w3
1. ALA 7x 60 min sessions + 3x supportive counselling
2. Special schizophrenia programme. 3x 60 min weekly sessions motivational enhancement + 7x psycho-education, social skills, RP


OutcomesPP abstinence 6m from therapy completion
Validation: CO < 10ppm


NotesNo non-group control. 2 vs 1 in comparison 2.5.1 evaluating enhanced programme in specific population


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'Assigned to groups by using a block randomization procedure such that when 4-6 subjects were ... considered eligible ... they were assigned together [to one of the programmes].'

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesAll randomized participants included in analysis

Ginsberg 1992

MethodsCountry: USA
Recruitment: Community volunteers
Group size: 3-6


Participants99 smokers with an acquaintance willing to participate as a support partner; 54% female, av age 38, av cpd 26
Therapists: PhD psychologist or MSc health educator


Interventions1. Nicotine gum (NG) and educational materials, 2 sessions over 2w
2. NG and behavioural programme including skill training, 5 sessions over 4w
3. NG and behavioural programme and partner support programme, 8 sessions over 5w


OutcomesAbstinence at 52w (not clear if abstinence required at prior assessment at weeks 4,12, 26)
Validation: CO < 10ppm, urine cotinine < 50ng/mL. Paper states that cotinine levels failed to confirm self report in 7 people, 3 of whom were still coded as abstinent on the balance of evidence.


NotesIntervention 1 had only 2 brief sessions so not classified as group therapy, 2+3 vs 1 in comparison 1.4, effect of addition of group support to NG (excluding group 3 would increase effect size).


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'Subjects were randomly assigned to 3-6 member groups in order of entrance into treatment within time constraints. Treatment for each group was randomly selected with the constraint that each cohort [of 9] have one group of each condition and an equal number of smoking partners across conditions'. Potential for systematic bias probably low.

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesTreatment drop-outs and losses to follow up included in analyses, 1 death excluded.

Glasgow 1981

MethodsCountry: USA
Recruitment: Community volunteers
Group size: 4-6


Participants88 smokers (85 included in analysis)
Therapists: A clinical psychologist and 2 graduate students in behaviour therapy, crossed with treatment conditions.


Interventions3x2 factorial design for treatment programme and delivery format
1. Therapist adminsitered programme based on either Danaher & Lichtenstein manual, Pomerleau & Pomerleau manual or I Quit Kit . 8 sessions over 8w
2. Self-administered using same 3 manuals


OutcomesAbstinence at 6m
Validation: CO <15ppm. At follow up, self report gives lower success rates in 3/6 arms than using CO measure, so self-report data used.


NotesEarly versions of review had a substudy for each programme; all 3 programmes now combined in comparison 1.1.1 vs self-help format. There is a negligible change to MA.
The comparison between different programmes is discussed in text.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomly assigned, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes97% of participants completed treatment and available for follow up

Glasgow 1989

MethodsCountry: USA
Recruitment: Media advertisements
Group size: 4-8


Participants66 smokers; 56% female av age 40, av cpd 26
Therapists: 2 research assistants. Crossed with treatments.


InterventionsBoth programmes had 6 weekly meetings
1. Abstinence-based condition. TQD at 4th session. Post-quit sessions emphasize RP.
2. Cessation-Controlled Smoking. Quitting recommended but alternative of controlled smoking offered. Quit date between sessions 4 and 5.


OutcomesAbstinence for 7 days at 6m follow up.
Validation: CO ≤9ppm. 11 people disconfirmed


NotesNo non-group control. Compares difference in emphasis on abstinence. Not shown in graphs. Quit rates 5/31 vs 6/35


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized by group, no other information

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes26% lost in 1 and 14% in 2, all included in ITT analysis

Goldstein 1989

MethodsCountry: USA
Recruitment: Community volunteers
Group size 6-13.


Participants107 smokers
Therapists: all sessions co-led by psychiatrist and clinical psychologist


InterventionsAll groups met for 10 x 1hr sessions over 11w.
1. Behavioural treatment (including intensive skills training) + fixed schedule nicotine gum
2. Same as 1, but ad lib schedule of gum
3. Educational group, no specific skills training, didactic presentation, non-specific group support + fixed schedule gum
4. Same as 3. + ad lib gum


OutcomesAbstinence at 6m follow up
Validation: saliva cotinine <10ng/ml, or expired CO <8ppm in people still using nicotine gum


NotesNo non-group control; Nicotine schedule arms collapsed.
1+2 vs 3+4 in comparison 2.1.1 evaluating greater complexity of group programme.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized in 2x2 factorial design, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes18 early treatment drop-outs reincluded in ITT analysis here

Grant 2003

MethodsCountry: USA
Recruitment: Substance abuse treatment centre volunteers
Group size: not stated


Participants20 alcoholic smokers; 93% male, av age 44, 77% smoked 11-30 cpd


InterventionsAll participants were attending an outpatient alcohol treatment programme
1. Education & group therapy, 5 weekly sessions, 8w trial of NRT offered unless contra-indicated.
2. No formal treatment, access to standard cessation resources including NRT


OutcomesAbstinence at 12m follow up (7 day PP)
Validation: no biochemical, collateral informants at 6m only


NotesComparison 1.5. Use of NRT high in both conditions, 6/20 in treatment, 10/20 in control


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not stated

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes2 withdrawals not included in denominators

Gruder 1993

MethodsCountry: USA,
Recruitment: Smokers registering to receive S-H materials during advance promotion of a televised cessation programme, who indicated willingness to attend group sessions and had a non-smoking 'buddy'.


Participants1440 smokers completing a registration form and assigned to this study.
Therapists: Mainly nurses and health educators randomly assigned and trained to lead either Social Support or Discussion meetings.
Group size varied from 3-22, mean approx 11


InterventionsAll participants sent ALA Freedom from Smoking in 20 days manual and instructed to watch TV programme.
1. Social Support. 3 x90 min group meetings and copy of Quitters Guide for smokers, and 1 group meeting + Buddy Guide for buddies. Participants were instructed on how to get help from their buddies and others. Telephone calls to subjects and buddies at 1 and 2m
2. Discussion. Same schedule of meetings and phone calls as 1, but general information and review of self-help manual.
3. No-contact control


OutcomesMultiple PP abstinenence (post-intervention, 6m and 12m). 24m rates also given but substantial loss to follow up by this time so 12m rates used here. Validation attempted but abandoned due to participant refusal to provide samples.


Notes1&2 vs 3 in comparison 1.1. Social support manipulation reviewed in Park 2004. Although group participants also scheduled to receive phone calls these occurred after the first follow up so will not have differentially affected the multiple PP quit rates


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomization to group or no-group at time of registration. No details on method. 1205 subjects assigned to a group condition, and attempts made to contact them to schedule group meetings. Randomization between the two group conditions was by site. 26 sites offered social support condition, 24 discussion control.

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesQuit rates for group vs self-help comparison based on numbers assigned to group treatments who were scheduled to a meeting, and includes 'no shows' who were still assessed

Hall 1994

MethodsCountry: USA
Recruitment: Community volunteers or referrals


Participants149 smokers ( >10 cpd)
52% female, av age 41, av cpd 25, 31% had history of MDD
Therapists: physician, psychologist. Both received training


Interventions2 mg nicotine gum was prescribed for both groups
1. Standard group therapy. 5 sessions over 8w. Information and group support for planning and implementing individual strategies.
2. Mood Management. 10 sessions over 8w. Similar to 1, plus specific cognitive-behavioural components for developing skills for coping with situations leading to poor mood. Thought stopping, rational-emotive techniques, relaxation etc


OutcomesContinuous abstinence at 52w. (Confirmed quit at all prior assessments and no smoking in previous week)
Validation: CO ≤10ppm and urine cotinine ≤60ng/ml


NotesNo non-group control; 2 vs 1 in comparison 2.3.2 evaluating additional mood management component


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesDrop-outs included as smokers, numbers not specified

Hall 1996

MethodsCountry: USA
Recruitment: Community volunteers
Group size; 5-12


Participants201 smokers ( >10 cpd)
48% male, Av age 40, Av cpd 24; 22% had history of MDD
Therapists: not described


Interventions2 x 2 factorial design. Nicotine gum/placebo arms collapsed
All groups had 10 sessions over 8w. TQD at 3rd session.
1. Standard group therapy including written exercises, handouts, homework. Group discussion.
2. Cognitive behavioural Mood Management. Same programme as Hall 1994 arm 2.


OutcomesContinuous abstinence at 52w. (Confirmed quit at all prior assessments and no smoking in previous week.)
Validation: urine cotinine ≤60 ng/ml


NotesNo non-group control; 2 vs 1, in comparison 2.3.1 evaluating additional mood management component, controlling for contact time, nicotine/placebo arms collapsed.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized after stratification by depression history and number of cigs smoked.

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesDrop-outs included as smokers, numbers not specified

Hall 1998

MethodsCountry: USA
Recruitment: Community volunteers. Exclusion criteria included MDD within 3m of baseline
Group size; 5-11


Participants199 smokers of ≥10 cpd
55% female, av age 40, av cpd 21-25; 33% had history of MDD
Therapists: 3 doctoral level clinical psychologists


Interventions2 x 2 factorial design. Alternative pharmacological interventions were nortriptyline titrated to therapeutic levels - usually 75-100 mg/day for 12w or placebo. Collapsed in this analysis
1. Health Education
2. Cognitive behavioural mood management
(See Hall 1994 for description of each intervention)


OutcomesAbstinence at 64w (1 yr post-treatment). Continuous abstinence rates not reported by psychological treatment group.
Validation: CO <10ppm and cotinine <341 nmol/L


NotesNo non-group control; same behavioural interventions compared as Hall 1994, 2 vs 1 in comparison 2.3.2 evaluating additional mood management component. Nortriptyline/placebo arms collapsed, no drug X psychological treatment interaction.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?YesRandomized by computer, after stratification on history of MDD and number of cigs smoked

Allocation concealment?YesComputer randomization after data collection.

Incomplete outcome data addressed?
All outcomes
Yes17% lost to follow up at 1yr, no difference by group, included in ITT analysis

Hall 2002

MethodsCountry: USA
Recruitment: Community volunteers. Exclusion criteria included current MDD
Group size 3-11


Participants220 smokers of ≥10 cpd
40-47% female, av age 37-43, av cpd 20-23; 33% had history of MDD
Therapists: masters level counsellors


Interventions3 x 2 factorial design with pharmacotherapies: bupropion, nortriptyline, or placebo
1. Medical Management (MM) control: physician advice, S-H, 10-20 min 1st visit, 5 min at 2,6,11w)
2. Psychological Intervention (PI) as MM plus 5x 90 min group sessions at 4,5,5, 7,11w)


OutcomesProlonged abstinence at 1 yr (47w post-quit date). PP also reported
Validation: CO ≤10 ppm, urine cotinine ≤60 ng/mL


NotesComparison 1.3, group versus physician advice.
No significant interaction between pharmacotherapy and behaviour therapy, so pharmacotherapy arms collapsed in analysis.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not specified, 'double blind'

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes19% lost to follow up at 1y, no difference by group, included in ITT analysis

Hill 1993

MethodsCountry: USA
Recruitment: Community volunteers


Participants82 community volunteers aged 50+ who had smoked for over 30 yrs
Therapists: Each group had 2 instructors from a pool of 6, all with experience in smoking cessation and/or exercise training.


Interventions1. Behavioural Training (BT) adapted from Lung Health Study programme. Included quit date setting, RP training with role play of coping responses. 12 x 90 min session over 3m
2. BT + nicotine gum
3. BT + additional physical exercise
4. Exercise and S-H pamphlet. This was a placebo control matched for contact time to 3. Therapist, who was blind to study hypothesis, encouraged smokers to quit at the exercise meetings.


Outcomes5 day abstinence at 12m. (Abstinence at previous follow ups not required)
Validation: CO <10 ppm or informant confirmation


Notes1 vs 4 in comparison 1.4 vs minimal intervention control. Exercise component considered in separate review (Ussher 2008)


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandom assignment in blocks of 8-12 individuals

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes8 non participants & 4 drop-outs not included in analysis

Hilleman 1993

MethodsCountry: USA
Recruitment: Community volunteers


Participants150 smokers; 67% female, av age ˜50, av cpd ˜32
Therapists; not described


Interventions1. Behaviour modification training, 12 x 1hr classes over 3m + transdermal clonidine
2. Same behaviour modification as 1, + placebo patches
3. S-H printed material (I Quit Kit), transdermal clonidine
4. S-H printed material, placebo patches


OutcomesCessation at 1 yr
Partial validation by random plasma TCN monitoring


NotesDrug arms collapsed as no evidence for a treatment group interaction reported. 1 + 2 vs 3 + 4 in comparison 1.1.2 vs S-H control, although the I Quit Kit is only a brief pamphlet.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesNo information on losses to follow up, all participants included in analyses

Hollis 1993

MethodsCountry; USA
Recruitment: Patients visiting outpatient internal medicine and family practice offices in a group practice health maintenance organisation.


Participants2707 smokers who received provider (physician, physician assistant or nurse practitioner) advice to quit
Therapists: Project nurse or health counsellor


InterventionsIf subjects refused to see a counsellor they were mailed information appropriate to their assignment.
1. Advice - In addition to provider advice, given brief pamphlet by health counsellor
2. Self quit - Cessation advice, CO assessment, 10 min video, stop smoking kit, and choice of S-H manuals. Encouraged to set quit date. 1 follow-up telephone call and series of mailings.
3. Group referral. Cessation advice, CO assessment. Video encouraged use of intensive (9 meetings over 2m) group programme, and waiver of fee. Effort made to schedule attendance.
4. Combination. Participants shown video explaining both S-H and group approaches, and encouraged to choose one.


Outcomes1 yr 2-PP abstinence (7 days at 3 and 12m)
Validation: Saliva cotinine at 1 yr. Most conservative outcome is used in which self-reported non-smokers who did not provide saliva samples are recorded as smokers.


Notes3 vs 2 in comparison 1.1.2 vs S-H programme. 3 vs 1 in 1.3.1 vs brief advice control.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?No'Two random digits contained in the patient's health record nunber were used to assign patients'

Allocation concealment?NoAll patients who received initial provider advice were considered participants, and providers who delivered initial message stated to be blind to assignment, so possibility of selection bias may be low

Incomplete outcome data addressed?
All outcomes
Unclear14% lost to follow up at 12m. Response rates not significantly different across conditions, all participants included in analysis

Huber 2003

MethodsCountry: Germany
Recruitment: Community volunteers


Participants174 smokers
55% female, av age 38, av cpd 28
Therapists: experienced counsellors, each took 2 groups in each condition


Interventions1. 5 x90 min weekly meetings. Included contracting, reinforcement, relaxation, skills training, nicotine gum
2. Same schedule of meetings, 45 min only, focus on sharing experiences. Nicotine gum
3. As 1, no nicotine gum. Not included in meta-analysis


OutcomesPP abstinence at 12m
Validation: CO ≤4ppm


NotesIncluded in 2009 update. No non-group control, in comparison 2.1.2


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes31 people attending 2 or fewer meetings not included in analysis. Said to be evenly distributed. Later drop-outs included as smokers.

Jorenby 1995

MethodsCountry: USA (2 sites)
Recruitment: Community volunteers
Group size; not specified


Participants504 smokers (≥15 cpd); ˜53% female, av age 44, av cpd 26-29
Therapists: Trained smoking cessation counsellors


InterventionsCompared 22 mg vs 44 mg nicotine patch and 3 types of adjuvant treatment. Patch groups collapsed. All participants had 8 weekly assessments by research staff
1. Minimal: Given S-H pamphlet by physician during screening visit for trial entry, and instructed not to smoke whilst wearing patch. No further contact with counsellors.
2. Individual: Given S-H pamplet at screening visit along with motivational message. Also met nurse counsellor x3 following quit date. Nurse helped generate problem-solving strategies and provided praise and encouragement.
3. Group: Given S-H pamplet at screening visit along with motivational message. Received 8x 1hr weekly group sessions. Skills training, problem-solving skills.


Outcomes7 day PP abstinence at 26w
Validation: CO <10ppm.


NotesNo sig diff in dose-related outcome and no dose-counselling interaction at 26w reported, so patch arm collapsed in analysis. 3 vs 1 in comparison 1.4, group + NRT vs NRT with minimal support. 3 vs 2 in 1.2.1, group vs individual (different programme).


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Yes'randomly ordered within blocks of 30 assignments'

Allocation concealment?UnclearAllocation by research assistant, concealment not described

Incomplete outcome data addressed?
All outcomes
Unclear78 (3.7%) excluded from ITT analysis due to death or too ill for follow up. 426 (20%) lost to follow up included in ITT analysis; higher loss in treatment than control.

Lando 1985

MethodsCountry: USA
Recruitment: Media advertising
Group size: 8-12


Participants130 smokers (65 in relevant arms)
51% female, av age 38, av cpd 30


InterventionsAll received orientation + 2 weekly + 6 consecutive sessions in w3, then quit day
1. Nicotine fading + 7 maintenance sessions over 6w
2. Nicotine fading. No post-quit maintenance
3. Oversmoking + maintenance (not used in review)
4. Nicotine fading + oversmoking + maintenance (not used in review)


OutcomesAbstinence at 12m (PP)
Validation: CO and informants


NotesNo non-group control. 2 vs 1 in comparison 2.1 for effect of extended contact


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not stated

Allocation concealment?UnclearNo details given

Lando 1990

MethodsCountry: USA, 3 sites
Recruitment: Community volunteers
Group size av 10-11


Participants1041 smokers; 57% female, av age 43, av cpd 29
Therapists: trained facilitators


Interventions1. ACS FreshStart. Orientation + 4 x 1 hr sessions over 2w. No TQD set
2. ALA Freedom from Smoking. Orientation + 7 x 90-120 min sessions over 7w. TQD at 3rd session.
3. Laboratory-derived programme. 16 x 45-60 min sessions over 9w. Nicotine fading procedure and smoke-holding used during preparation phase.


OutcomesSustained abstinence (slips allowed) at 1 yr. (PP and quit attempts also reported)
Validation: attempted for 43% sample. serum TCN < 80-100 ng/ml. Borderline cases required cotinine <15 ng/ml


NotesNo non-group control. Results not displayed in graphs. Quit rates: 1. 12% (N = 331). 2. 19% (N =363). 3. 22% (N= 347)
P = 0.014 corrected for design effect. No facilitator effect found.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'randomly assigned ... as a function of orientation session attended' 70 orientation sessions held and 97 treatment groups formed

Allocation concealment?UnclearNo details given, but participants only given general information about type of programme.

Incomplete outcome data addressed?
All outcomes
Yes6% loss to follow up at 1 yr. All except 3 deaths included

Lando 1991

MethodsCountry: USA
Recruitment: Community volunteers
Group size; 4-16, typically 6-11


Participants353 smokers; 52: female, av age 42, av cpd 30
Therapists: Trained facilitators, mainly graduates, including some who had quit through clinic programme.


InterventionsBoth interventions included 16 x 45-60 min sessions over a 9w period. Nicotine fading schedule prior to quit date at 3w.
1. Enriched cohesiveness intervention: included written commitments and exercises designed to facilitate positive group interaction
2. Standard group treatment


Outcomes1 yr sustained (relapse-free) abstinence
Validation: randomly selected subsample of those claiming abstinence tested for saliva TCN, but not clear whether reported data includes a correction for false reporting.


NotesNo non-group control. In comparison 2.3.2 evaluating group cohesion. Originally a factorial design comparing satiation and nicotine fading in addition to cohesiveness manipulation, but satiation arm abandoned. Only data for nicotine fading procedure arms reported in paper. P values reported in the paper were corrected for the design effects of clustering.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclearrandomly assigned by information group attended. 32 information meetings and 41 treatment groups

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes6.5% loss to follow up included in analyses.

Leung 1991

MethodsCountry: Hong Kong
Recruitment: Community volunteers


Participants95 (63 in relevant arms); 26% female, av age ˜37, av cpd ˜26


Interventions1. Behavioural programme including self monitoring, management techniques, coping skills. 10 x 1½ hr sessions over 2w.
2. Auricular acupuncture. Same no. of sessions. Not used in review
3. Waiting list control


OutcomesAbstinence (not defined) at 6m
Validation by cohabitant and work colleague report.


Notes1 vs 3, comparison 1.5


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes9 people lost to follow up reincluded in analyses for MA

McDowell 1985

MethodsCountry: Canada
Recruitment: Volunteers visiting family practices for scheduled appointments
Groups size; 10-15


Participants366 smokers in 9 group family practices; 60% female; av age 36, av cpd 24
Therapists: depended on intervention


Interventions1. Physician advice by one of 12 family physicians. 15 min counselling session with U.S. 'NCI Helping Smokers Quit Kit' and one postal follow up.
2. Operation Kick-It programme. 9 sessions. Therapists: public health nurse or health educator
3. Cognitive Behavior Modification programme. 9 sessions. Therapists: 1 of 2 M.Ed psychologists
4. Self-monitoring control followed up at 2, 6 and 12m.


OutcomesAbstinence (over 1w diary period) at 12m
Validation: participants warned that saliva TCN might be tested, but only a few sampled. No results reported.


Notes2 & 3 vs 1 in comparison 1.3.1 vs physician or nurse advice/counselling, and in 1.5 vs minimal intervention control.
3 vs 2 in 2.1.1


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details, allocation took place once potential participants returned questionnaires

Incomplete outcome data addressed?
All outcomes
Yes8% lost to follow up, slightly higher for controls. All reincluded for this analysis

Minthorn-Biggs 2000

MethodsCountry: Canada
Recruitment: Community volunteers
Group size; not stated


Participants75 smokers; 68% female, av age 41, av cpd 25
Therapists: Study author or Lung Association facilitator


Interventions1. Canadian Lung Association Countdown programme. 7 weekly sessions
2. Social interaction programme. 12 sessions over 6w + 4 weekly. Skills training
3. No-treatment control


OutcomesAbstinence at 6m (12m rates only available for groups 1 and 2)
Validation: none


Notes1+2 vs 3 in comparison 1.5 vs no treatment. 3 vs 2 in 2.1.2, effect of additional skills training. No control for therapist effects


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesDrop-outs included in analyses

Nevid 1997

MethodsCountry: USA
Recruitment: Community volunteers, via media and healthcare settings
Group size: 3-12, single-sex groups, same-sex therapists


Participants93 Hispanic smokers (excludes 56 people, 35 Gr, 21 S-H who were randomized but did not attend any session and were not included in further analysis); 48% female, av age 44, av cpd 21
Therapists: bilingual Hispanic psychologists and social workers


Interventions1. Group therapy. 8 x 2 hrs. Included videos using culturally specific components. Motivation, nicotine fading, quitting techniques, RP, 'buddy' support. TQD 5th week
2. S-H with 1 group session for motivation and instructions and telephone contact. ALA Freedom from Smoking in 20 days in English & Spanish, also Guia para Dejar de Fumar
Both conditions received same maintenance programme; ALA S-H manual A Lifetime of Freedom from Smoking and 2 telephone calls a month for 6m.


OutcomesAbstinence at 12m (sustained from post-treatment). PP rates also reported
Validation. Saliva cotinine


NotesComparison 1.1.2 vs different S-H. Low take-up rates. 33% of eligible attended orientation session, only 62% of enrollees attended any further session. Using 12m PP rates would give 3/39 vs 4/54 quit.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'pairwise random assignment ... a random numbers table was used to generate a sequence of odd and even numbers, which was then used as the basis for randomly assigning members of each pair of consecutively enrolled participants within each gender to either [the treatment or control]'

Allocation concealment?UnclearSeems unlikely from description that schedule was concealed

Incomplete outcome data addressed?
All outcomes
YesPost-randomization drop-outs are excluded. There was differential attendance

Omenn 1988

MethodsCountry: USA
Recruitment: Single worksite (13,000 workers, 9 employers)
Group size: typically 15-20


Participants159 smokers; 66% male, av age 43, av cpd 25, with preference for group programme or no preference. (Smokers with preference for S-H were not allocated to group programmes.)
Led by instructors trained in both programmes.


Interventions1. Multiple Component programme. 3 sessions over 3w. Didactic format
2. RP programme. 8 sessions over 8w. Interactive format, choice of immediate or phased quit
3. Minimal Treatment programme. S-H materials only. ACS 22-page Quitter's Guide 7-day plan.


OutcomesAbstinence at 12m (single PP)
Validation: saliva cotinine ≤35ng/ml


Notes1+2 vs 3 in comparison 1.1.2 vs different S-H. No difference in outcome at 12m between 2 group programmes. Self-reported quit rates similar across all 3 conditions but more missing saliva samples in S-H so validated rates lower.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'nurses at aid stations using randomized assignment lists generated by research centre, within preference for format'

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesAt least 89% followed up in each arm

Otero 2006

MethodsCountry: Brazil
Recruitment: Community volunteers
Group size 12


Participants1199 smokers (includes 254 non-attenders); 63% female, av.age 42, 46% smoked >20 cpd
Therapists: trained doctors, nurses or psychologists


InterventionsFactorial design with NRT 21mg or 14mg patch for 8w incl tapering and 5 levels of behavioural support collapsed into 3 for analysis
1. SIngle 20 min session - classified as brief intervention control in meta-analysis
2. Cognitive behavioural, 1 or 2 weekly x1 hr sessions
3. As 2, with 3 or 4 weekly sessions.
Maintenance or recycling sessions provided to all groups at 3, 6, 12m.


OutcomesAbstinence at 12m (7 day PP)
Validation: none


NotesNew for 2009 update. 2&3 vs 1 without patch in comparison 1.3.1. 2&3 vs 1 with patch in 1.4. 3 vs 2 (patch conditions collapsed) in 2.1.2.
29% of no-patch group participants asked for nicotine patch after the 3m follow up


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?YesRandomized, stratified by age & sex, by independent specialist

Allocation concealment?YesTrial administrators blind

Incomplete outcome data addressed?
All outcomes
YesNon-participants and losses to follow up included in ITT analysis

Patten 2002

MethodsCountry: USA
Recruitment: Volunteers attending Alcoholics Anonymous
Group size approx 8


Participants48 smokers with history of alcohol dependence but 3m of drug and alcohol abstinence; 47% female, av age 42, av cpd 28
Therapists: different clinical psychologist and doctoral student pair for each condition


Interventions1. Behavioural counselling, 12 x 2hr weekly, TQD w8. Includes nicotine fading, skills training, homework, discussion
2. As 1 + Cognitive Behavioural Mood Management skills training. Same length


OutcomesAbstinence at 12m, sustained at 1, 3m.
Validation: CO <10ppm (PP rates and informant or CO-validated rates also reported)


NotesNo non-group control. Comparison 2.3, effect of additional mood management component


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearMethod not described; cluster-randomized on basis of order of recruitment

Allocation concealment?UnclearUnclear

Incomplete outcome data addressed?
All outcomes
YesAll participants included in ITT analysis

Pederson 1981

MethodsCountry: USA
Recruitment: Volunteers for a S-H smoking cessation programme


Participants40 smokers; 60% female, av.age 39 years, av cpd 28


Interventions1. Pomerleau & Pomerleau manual, an introductory session, followed by 1 hr group meetings at 2 and 6w.
2. Danaher & Lichtenstein manual and same schedule of meetings as 1.
3. Waiting list control


OutcomesAbstinence at 6m for at least 3m
Validation: none


Notes1&2 vs 3 in comparison 1.5. Described by the authors as a S-H programme but the 3 meetings met criteria for a group programme.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described. Participants switched between the 2 manuals because of scheduling constraints.

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesAll participants included in ITT analysis

Pisinger 2005

MethodsCountry: Denmark
Recruitment: proactive invitation to sample from a population register


Participants2408 daily smokers identified by questionnaire from the total sample; 40% female, av age 46, 57% in precontemplation
Therapists: Doctors or nurses trained in counselling


Interventions1. 'Low intensity': single 15-45 min session of individual lifestyle counselling using motivational interviewing
2. 'High intensity': as 1 plus offer of participation in 6 session group course over 5m. Option to consider and be invited again in 3m
Untreated population control not included in this review


OutcomesPP abstinence at 5 yrs (follow up at 1 & 3 yrs also)
Validation: serum cotinine


NotesComparison 1.3.1. 5 yr outcomes reported in Pisinger 2008.


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?Unclear'random sample.' More participants were randomized allocated to the high intensity intervention

Allocation concealment?Yes‘the sample was a priori randomized’

Incomplete outcome data addressed?
All outcomes
UnclearDeaths and emigrations excluded. 20% did not attend or return questionnaires at 5 yrs, included in ITT analysis

Rabkin 1984

MethodsCountry: Canada
Recruitment: Media advertisements
Group size; 10


Participants168 community volunteers (67 in relevant arms)
av age 40, av cpd 24
Therapist: 'trained in group behaviour techniques'


Interventions1. Behaviour modification. Multicomponent, 5 x 45-90 min meetings over 3w
2. Health Education. Single group meeting with didactic lectures by a health professional, film, discussion. Individual session with a therapist 1w later including a counselling element
3. Hypnosis
4. Waiting list control, with no long term follow up


OutcomesSelf-reported abstinence via questionnaire at 6m follow up
No validation at 6m, Blood TSN at 3w


Notes1 vs 2 in comparison 1.3.2 vs other method. 2 does not meet criteria of >1 group session, and includes a session of individual counselling. 3&4 not used in this review


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesProportion of drop-outs similar, included in ITT analysis

Rice 1994

MethodsCountry: USA
Recruitment: Health professional and self referral.


Participants406 smokers with a cardiovascular health problem
Therapists: Clinical nurse specialist who had undergone a 1w teaching workshop for Smokeless (a multicomponent intervention in 6 booklets including elements of skills training, behavioural rehearsal, aversive puffing).


InterventionsAll except control received Smokeless
1. Individual Intervention: Met with nurse for 4 x 1hr sessions in w1 and single maintenance session in w2.
2. Group Intervention: Met in groups of 5-7 on same schedule
3. Written intervention: Given Smokeless materials in labelled envelopes to open on same schedule. Prompted by call from project secretary.
4. No Intervention: Advice from nurse to quit smoking


OutcomesPP abstinence at 1 yr
Saliva TCN tested but not used to correct self report


NotesThe published data was based on 255 subjects willing to participate in the treatment allocated. Numbers randomized to treatment provided by author.
2 vs 3 in comparison 1.1 vs self help; 2 vs 1 in 1.2.1 vs individual therapy, 2 vs 4 in 1.3.1


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described. Stratified by sex, smoking history and history of cardiovascular incident

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes34% chose not to participate after randomization, with differences between groups. Reincluded in ITT analyses. 12 deaths not included

Romand 2005

MethodsCountry: France, 6 towns
Recruitment: Community volunteers, motivated to quit


Participants228 smokers
54% female, av age 42, av cpd 20
Therapists: 2 professionals per group, e.g. trained psychologist and qualified health adviser


Interventions1. Five Day Plan (FDP); 5 sessions on consecutive nights, & supplementary sessions 1-2w later
2. Control; 1 hr of general information on tobacco-related health problems


OutcomesAbstinence at 12m, lapse-free (PP also reported)
Validation: CO <10ppm


NotesNew for 2009 update. In comparison 1.3.2
Using the less stringent definition of abstinence would reduce the effect, 16% vs 11% quit. A small number of control group participants attended other FDP courses or used pharmacotherapy


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, stratified by town, 'balanced every four individuals'

Allocation concealment?UnclearNo details given. The discrepancy in group sizes suggests the possibility of selection bias, but may be due to the stratification & chance

Incomplete outcome data addressed?
All outcomes
Yes17% & 15% lost at 12m, included as smokers in ITT analysis

Sawicki 1993

MethodsCountry: Germany
Recruitment: From a university diabetic outpatients clinic


ParticipantsDiabetic smokers prepared to participate in a stop-smoking programme; 40% female, av age 37, av cpd 21


Interventions1. Extensive behaviour therapy including self control. 10 x 90 min weekly sessions. Led by a psychotherapist
2. Physician advice, 15 min unstructured session.
NRT offered in the case of severe addiction.


OutcomesAbstinence at 6m
Validation: serum cotinine <20 ng/ml


NotesComparison 1.3.1


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes25/44 participated in group programme and 31/45 received physician advice. Non-participants followed up and included in ITT analysis

Schmitz 2007

MethodsCountry: USA
Recruitment: Community volunteers


Participants154 women smokers >20 cigs/day
Av.age 48, av.cigs/day 21
Therapists: Masters level therapists, 2 per group


InterventionsFactorial trial of bupropion versus placebo (collapsed in analysis) and 2 group therapies.
1. CBT based on relapse prevention model, 7 weekly 60 min meetings, TQD morning of 1st session, 10 days after start of meds
2. Supportive therapy (ST), same schedule, emphasis on group support


OutcomesAbstinence at 12m (7 day PP)
Validation: CO≤10ppm, saliva cotinine <15ng/ml


NotesNew for 2009 update
No non-group control. There was no main effect of either type of treatment so pharmacotherapy arms collapsed. There was an interaction between behavioural support condition and pharmacotherapy; People receiving bupropion benefitted more from CBT whilst people on placebo had higher quit rates with ST. 2 vs 1 in comparison 2.3.1


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?YesUrn procedure, balancing on a range of outcome-related variables

Allocation concealment?Yes‘Investigators and research staff blind to randomization codes’

Incomplete outcome data addressed?
All outcomes
Yes14 'enrollment failures' who did not receive any treatment are excluded from analyses. Other non-completers and losses to follow up included in ITT analysis

Slovinec 2005

MethodsCountry: Canada
Recruitment: Community volunteers


Participants332 women smokers of at least 10 cigs/day
Av age 40, av cigs/day 20


Interventions1. 'Usual Care' 3 x15 min physician visits, 2w before & 4 & 8w after TQD. Nicotine patch, S-H materials.
2. As 1, plus Stress Management Training. 8 x 2 hr, 2 &1w before TQD, 1,2,3,4,5,7w after. CBT targeted smoking-specific and life stressors


OutcomesAbstinence at 12m (7 day PP)
Validation: CO ≤9ppm for sample at 12m, all quitters at 2m. No disconfirmation out of 16 samples but 3 not reached (2UC, 1SM)


NotesNew for 2009 update. Comparison 1.3


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?YesRandom number table

Allocation concealment?Unclear‘Treatment allocation was concealed until completion of baseline testing at which time participants were informed of their group assignment’; unclear that study staff blind until enrollment. 'Study physicians were blind to treatment allocation'

Incomplete outcome data addressed?
All outcomes
Yes27% UC and 21% SM lost at 12m follow up, included in ITT analysis

Ward 2001

MethodsCountry: Jamaica
Recruitment: Community volunteers


Participants75 smokers (+35 assigned to a waiting list control, not included in review); 57% female, av age approx 39
Treated in 4 groups, Therapist: not described


Interventions1. Group therapy with emphasis on self efficacy and stages of change, and use of NRT. 3 x 2 hr weekly + follow up at 7w. Chose own quit date.
2. as 1 plus cognitive counter-conditioning component. Group developed negative images of smoking to be used when smoking. Same schedule


OutcomesAbstinence at 12m (PP)
Validation: saliva cotinine. Cut off not specified.


NotesNo non-group control. In comparison 2.1.1


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
Yes19 drop-outs included in ITT analysis

Wilson 2008

MethodsCountry: Northern Ireland, UK
Recruitment: Respiratory outpatient dept


Participants91 smokers with COPD
52% female, av age 61, av cigs/day 19
Therapists: trained respiratory nurses


Interventions1. Usual care; brief advice from physician including assessment of Stage of Change and advice on NRT
2. As 1, plus 5 weekly 60 min group sessions, offer of NRT in w2
3. Same schedule of individual sessions


OutcomesSustained abstinence at 12m ('intermittent cessation' also reported)
Validation: CO ≤10ppm & saliva cotinine ≤10ng/ml


NotesNew for 2009 update
No sustained abstainers in any group, 2 UC and 3 group participants achieved intermittent cessation
2 vs 3 in 1.2.1 vs individual counselling, 2 vs 1 in comparison 1.3.1 vs usual care. Only 24% attended 3 or more group meetings, 37% 3 or more individual sessions


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?YesRandomized, sequential sealed envelopes

Allocation concealment?Yes'All study personnel blind to randomisation sequence'

Incomplete outcome data addressed?
All outcomes
YesGreater loss to follow up in individual and usual care. All included in ITT analysis

Zelman 1992

MethodsCountry: USA
Recruitment: Community volunteers
Group size: 3-6


Participants116 smokers (excludes 10 early drop-outs evenly spread across groups); 54% female, av age approx 50
Therapists: clinical psychologists, 2 per group


InterventionsBehavioural counselling with nicotine gum or rapid smoking conditions collapsed here
1. Coping Skills Training. 6 x 60+ min over 2w. TQD night before 1st session. Develop strategies, reframing, contracting, thought-stopping
2. Informational and supportive counselling. Discussion, sharing of ideas and feelings. Same schedule of sessions and TQD as 1.


OutcomesSustained abstinence at 12m (no lapses >3 days)
Validation: Collateral report at 12m (CO used up to 3m follow up, blood cotinine at 6m)


NotesNo non-group control. 1 vs 2 in comparison 2.1.1


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?UnclearRandomized, method not described

Allocation concealment?UnclearNo details given

Incomplete outcome data addressed?
All outcomes
YesAuthors report that exclusion of early drop-outs does not change results.

Zheng 2007

MethodsCountry: China
Recruitment: Community volunteers
Group size: 13-15


Participants232 smokers (no minimum daily amount specified); 94% male, av age 56 in I, 53 in C (P<0.05)
Therapists: health education professionals


Interventions1. Social cognitive group intervention, 5 x 2 hr twice weekly sessions
2. Waiting list control


OutcomesSustained abstinence at 6m
Validation urine cotinine <25 ng/ml


NotesNew for 2009 update


Risk of bias

ItemAuthors' judgementDescription

Adequate sequence generation?NoParticipants took paper marked 1 or 2 from a box

Allocation concealment?NoPossibility that allocation could be changed

Incomplete outcome data addressed?
All outcomes
Yes2 lost to follow up in I, 11 in C, included in ITT analysis

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Becona 1997Compared a standard group programme to relapse prevention intervention. Now included in Hajek 2009.

Bernstein 1970No long-term follow up.

Bertera 1990Not randomized.

Brown 1984Small study of nicotine fading and relapse prevention. No non-group control.

Campbell 1995Not randomized.

Carlson 2003Not controlled.

Cinciripini 1994The minimal contact self-help control condition included 8 weekly visits to the research centre to fill out questionnaires and review progress. Although participants did not receive a formal intervention they were encouraged to discuss their progress and were directed to the appropriate section of the self-help materials (I Quit Kit).
Allocation to treatment alternated for successive sequences of 5 subjects.

Cinciripini 1995All interventions received same basic group programme. 4 arms differed in pre-cessation programme of scheduled smoking.

Colletti 1979Primary outcome was reduction in smoking rate. Quit rates not given by treatment group. 42 participants randomized to 3 maintenance strategies following same cessation programme.

Colletti 1980Primary outcome was reduction in smoking rate. Quit rates not given at maximum follow up, reported not to be significantly different. 29 participants randomized to 2 maintenance procedures, 1 involving 4w additional therapis contact.

Davis 1986Compared a standard group programme to relapse prevention intervention. Now included in Hajek 2009.

Decker 1989Not randomized - run sequentially. Compared an identical programme delivered at group meetings or by weekly mailings.

Elliott 1978Primarily a study of aversive smoking.

Frikart 2003Not controlled.

Glasgow 1978No abstinence data reported at 3m or 6m follow up.

Green 2003Not controlled

Hall 1984Compared a standard group programme to relapse prevention intervention. Now included in Hajek 2009.

Hall 1985Compared a standard group programme to relapse prevention intervention. Now included in Hajek 2009.

Hall 1987Compared a standard group programme to relapse prevention intervention. Now included in Hajek 2009

Hamilton 1979No follow up of control group at 6m. Treatment arms investigated addition of social support.

Hamilton 1998Only 3m follow up. Randomization not reported in abstract.

Hilleman 2004Not randomized; historical control.

Katz 1977Only 3m follow up. Abstinence rates not reported by group. Compared 3 different group programmes.

Killen 1984Evaluated effect of relapse prevention components. Now included in Hajek 2009.

Kisely 2003Not randomized.

Klesges 1999Not group therapy: intervention was a single 50 min group session using a computer-interactive format.

Lando 1982A small trial manipulating multiple factors.

Larson 1999Only 35 participants split among 3 programme variants. Randomization and length of follow up not reported in abstract.

Lowe 1980Evaluates the effect of adding covert sensitization training to a group programme. Covered by review of aversion therapy (Hajek 2001).

Martin 1997Compared group programmes with and without an exercise component. No non-group control. Included in Cochrane review of exercise for smoking cessation (Ussher 2008).

McEwen 2006Not randomized and only 4-week follow up.

McGovern 1991Compared 2 methods of nicotine fading; all participants received the same group programme (Early version of review included within miscellaneous comparison section).

McIntyre 1986Compared an additional spouse support element with a basic programme. No non-group control.

Mogielnicki 1986Assignment to a group programme or a mailed self-help programme was sequential. There appeared to be limited follow up of participants receiving mailed programmes.

Nyborg 1986Couples were allocated to treatment and success rates were reported by couple.

Perkins 2001Primarily a study of CBT for weight control.

Pirie 1992Compared additional weight control element with a standard programme, also effect of nicotine gum in a factorial design. No non-group control.

Powell 1981Compared a standard group programme to relapse prevention intervention. Now included in Hajek 2009.

Razavi 1999Primarily a study of relapse prevention, see Cochrane review of interventions for relapse prevention (Hajek 2009).

Reid 2008Group counselling was counfounded with nicotine replacement therapy.

Schauffler 2001Participants were randomized to be eligible for OTC NRT and a group behavioural cessation programme as part of their HMO benefit. NRT and group therapy were therefore confounded. Cessation rates were significantly higher in intervention group; 18% vs 13% at 12m. However only 1.2% participated in a behavioural programme.

Schwartz 1968Success was defined as a reduction in smoking of > 85%, not complete abstinence, and no period of continuous reduction was required at follow up. The study compared combinations of group vs individual vs no counselling and tranquillizer (equanil) vs placebo vs no prescription. It is included in the review of anxiolytics (Hughes 2000)

Smith 2001Compares 2 group interventions initiated after a cessation attempt as an adjunct to NRT and individual support. Now included in Hajek 2009.

Stevens 1989Compared a standard group programme to relapse prevention intervention. Now included in Hajek 2009

Supnick 1984Compared 4 maintenance strategies after initial therapy. No. of abstainers not reported by group at 6m follow up. The differences in content and outcome for the 4 strategies were small.

Thompson 1988A complete factorial design included combinations of physician advice, self-help materials and referral to American Health Foundation Smoking cessation classes. Not primarily a trial of group therapy. Take-up of group programme was very low.

Thorndike 2006Short follow-up (1 month). Compared CBT to time matched health education and scheduled reduced smoking.

Tiffany 1986Primarily a trial of different forms of rapid smoking, included in aversion review (Hajek 2001). No non-group control.

Vellisco 2001Not randomized. Patients were allocated to an information only or a psychological counselling group in order of attendance.

Yu 2006Short follow up (3m). (Assessed from abstract)

 
Comparison 1. Group format behavioural programmes vs Other format

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Smoking cessation. Group programme vs self-help programme134375Risk Ratio (M-H, Fixed, 95% CI)1.98 [1.60, 2.46]

    1.1 Group vs self-help (same programme content)
82391Risk Ratio (M-H, Fixed, 95% CI)2.64 [1.95, 3.56]

    1.2 Group vs self-help (different programmes)
51984Risk Ratio (M-H, Fixed, 95% CI)1.42 [1.04, 1.94]

 2 Smoking cessation. Group programme vs individual therapy5788Risk Ratio (M-H, Fixed, 95% CI)1.01 [0.77, 1.32]

    2.1 Group vs individual (similar intensity & content)
3347Risk Ratio (M-H, Fixed, 95% CI)1.25 [0.72, 2.17]

    2.2 Group vs individual (different intensity/ content)
2441Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.69, 1.28]

 3 Smoking cessation. Group programme vs brief intervention13Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Physician or nurse advice
11Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 Health Education
2Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 4 Smoking cessation. Group plus NRT vs NRT alone31051Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.88, 1.31]

 5 Smoking cessation. Group versus 'no intervention' controls81040Risk Ratio (M-H, Fixed, 95% CI)2.71 [1.84, 3.97]

 
Comparison 2. Comparisons between different group programmes [Outcome Long term cessation for all comparisons]

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 "Skills training"81524Risk Ratio (M-H, Fixed, 95% CI)1.15 [0.97, 1.37]

    1.1 Substitution of components (controlling for programme length)
4481Risk Ratio (M-H, Fixed, 95% CI)1.23 [0.89, 1.72]

    1.2 Addition of components (not controlled for programme length)
41043Risk Ratio (M-H, Fixed, 95% CI)1.12 [0.92, 1.37]

 2 Mood management61300Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.82, 1.30]

    2.1 Same contact time
4952Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.77, 1.38]

    2.2 Longer contact time
2348Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.73, 1.52]

   2.3 Mood Management versus motivational interviewing
00Risk Ratio (M-H, Fixed, 95% CI)Not estimable

 3 Manipulation of group dynamics4702Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.87, 1.46]

 4 Other miscellaneous comparisons2111Risk Ratio (M-H, Fixed, 95% CI)1.14 [0.48, 2.72]

    4.1 Programme for people with schizophrenia vs standard programme
145Risk Ratio (M-H, Fixed, 95% CI)1.65 [0.37, 7.25]

    4.2 Total abstinence vs controlled smoking programme emphasis
166Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.32, 2.78]