Aversive smoking for smoking cessation.

BACKGROUND Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke. OBJECTIVES This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose-response effect on smoking cessation at different levels of aversive stimulation. SEARCH STRATEGY We searched the Cochrane Tobacco Addiction Group trials register for studies which evaluated any technique of aversive smoking. SELECTION CRITERIA Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment. DATA COLLECTION AND ANALYSIS We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta-analysis using a fixed effect model. MAIN RESULTS Twenty-five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose-response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 1.98 (95% confidence intervals (CI): 1.36 to 2.90). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non-significant result. Other aversion methods were not shown to be effective (odds ratio 1.15, 95% confidence interval 0.73 to 1.82). There was a borderline dose-response to the level of aversive stimulation (OR 1.66, 95% CI: 1.00 to 2.78). REVIEWERS' CONCLUSIONS The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose-response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology.

[1]  L. Green,et al.  Self-initiated, cue extinction, and covert sensitization procedures in smoking cessation , 1980, Journal of Behavioral Medicine.

[2]  J. Flaxman Quitting smoking now or later: Gradual, abrupt, immediate, and delayed quitting , 1978 .

[3]  T. Baker,et al.  Aversive smoking therapies: a conditioning analysis of therapeutic effectiveness. , 1983, Behaviour research and therapy.

[4]  G. R. Norton,et al.  The role of aversion in the rapid-smoking treatment procedure. , 1977, Addictive behaviors.

[5]  T. Baker,et al.  Effects of maintenance sessions on smoking relapse: delaying the inevitable? , 1987, Journal of consulting and clinical psychology.

[6]  E. Lichtenstein,et al.  Successful treatment of habitual smokers with warm, smoky air and rapid smoking. , 1972, Journal of consulting and clinical psychology.

[7]  R. Steffy,et al.  Aversive and cognitive factors in the modification of smoking behaviour. , 1970, Behaviour research and therapy.

[8]  L. Pederson,et al.  Incorporation of rapid smoking in a community service smoking withdrawal program. , 1980, The International journal of the addictions.

[9]  George Davey Smith,et al.  Misleading meta-analysis , 1995, BMJ.

[10]  J. Curran,et al.  Effectiveness of negative practice and self-control techniques in the reduction of smoking behavior. , 1976, Journal of consulting and clinical psychology.

[11]  R. Barkley,et al.  The effects of rapid smoking and hypnosis in the treatment of smoking behavior. , 1977, International Journal of Clinical and Experimental Hypnosis.

[12]  M. Merbaum,et al.  The relationship between aversion, group training and vomiting in the reduction of smoking behavior. , 1979, Addictive behaviors.

[13]  Ober Dc Modification of smoking behavior. , 1968 .

[14]  W. B. Walker,et al.  Low-risk aversive group treatments, physiological feedback, and booster sessions for smoking cessation , 1985 .

[15]  J. Berecz Maintenance of nonsmoking behavior through self administered wrist band aversion therapy , 1979 .

[16]  William L. Claiborn,et al.  Stimulus satiation and smoking: a revisit. , 1972, Journal of clinical psychology.

[17]  S. Hall,et al.  Preventing relapse to cigarette smoking by behavioral skill training. , 1984 .

[18]  S. Hall,et al.  Two-year efficacy and safety of rapid smoking therapy in patients with cardiac and pulmonary disease. , 1984, Journal of consulting and clinical psychology.

[19]  G. Wilde BEHAVIOUR THERAPY FOR ADDICTED CIGARETTE SMOKERS: A PRELIMINARY INVESTIGATION. , 1964, Behaviour research and therapy.

[20]  R. Sanson-Fisher,et al.  The rapid-smoking technique: therapeutic effectiveness. , 1981, Behaviour research and therapy.

[21]  B. Danaher Rapid smoking and self-control in the modification of smoking behavior. , 1977, Journal of consulting and clinical psychology.

[22]  M. Law,et al.  An analysis of the effectiveness of interventions intended to help people stop smoking. , 1995, Archives of internal medicine.

[23]  J. Berecz Modification of smoking behavior through self-administered punishment of imagined behavior: a new approach to aversion therapy. , 1972, Journal of consulting and clinical psychology.

[24]  H. Lukaski,et al.  Rapid Smoking: A Cautionary Note , 1977 .

[25]  J. Resnick Effects of stimulus satiation on the overlearned maladaptive response of cigarette smoking. , 1968, Journal of consulting and clinical psychology.

[26]  H. Eysenck Handbook of multivariate experimental psychology: Raymond B. Cattell(Ed.): Rand McNally, Chicago. $25.00 , 1968 .

[27]  T. Carmody,et al.  Utilization of adverse rapid smoking in groups: efficacy of treatment and maintenance procedures. , 1977, Journal of consulting and clinical psychology.

[28]  P. N. Tongas The Kaiser-Permanente Smoking Control Program: Its purpose and implications for an HMO. , 1979 .

[29]  E. Lichtenstein,et al.  Hot, smoky air as an aversive stimulus in the treatment of smoking. , 1969, Behaviour research and therapy.

[30]  P. Salzberg,et al.  A short duration group treatment of smoking behavior by stimulus saturation. , 1970, Behaviour research and therapy.

[31]  L. Trentadue,et al.  Comparison of satiation and rapid smoking in self-managed smoking cessation. , 1978, Addictive behaviors.

[32]  H. Lando Self-pacing in eliminating chronic smoking: Serendipity revisited? , 1976 .

[33]  R. Peto,et al.  Beta blockade during and after myocardial infarction: an overview of the randomized trials. , 1985, Progress in cardiovascular diseases.

[34]  R. Russell,et al.  A comparison of covert sensitization and “nonspecific” treatment in the modification of smoking behavior , 1974 .

[35]  Z. Amit,et al.  Comparison of three behavioral techniques in the modification of smoking behavior. , 1975, Journal of consulting and clinical psychology.

[36]  H. Lando A comparison of excessive and rapid smoking in the modification of chronic smoking behavior. , 1975, Journal of consulting and clinical psychology.

[37]  S. Hall,et al.  Smoking cessation in patients with cardiopulmonary disease: an initial study. , 1983, Addictive behaviors.

[38]  A. Marston,et al.  Comparison of behavior modification approaches to smoking reduction. , 1971, Journal of consulting and clinical psychology.

[39]  M. Russell,et al.  Temporal contiguity in electric aversion therapy for cigarette smoking. , 1976, Behaviour research and therapy.

[40]  T. Baker,et al.  Measures of affect and nicotine dependence predict differential response to smoking cessation treatments. , 1992, Journal of consulting and clinical psychology.

[41]  E. Becoña,et al.  Nicotine fading and smokeholding methods to smoking cessation. , 1993, Psychological reports.

[42]  L. Sushinsky Expectation of future treatment, stimulus satiation, and smoking. , 1972, Journal of consulting and clinical psychology.

[43]  R. Jeffery,et al.  Aversive smoking using printed instructions and audiotape adjuncts. , 1980, Addictive behaviors.

[44]  H. Lando,et al.  Influence of group cohesion on the behavioral treatment of smoking. , 1984 .

[45]  M. Wagner,et al.  Comparing behavior modification approaches to habit decrement--smoking. , 1970, Journal of consulting and clinical psychology.

[46]  T. Whitman Modification of chronic smoking behavior: A comparison of three approaches. , 1969, Behaviour research and therapy.

[47]  Rapid puffing as a treatment component of a community smoking program. , 1976, Journal of community psychology.

[48]  B. Danaher,et al.  Research on rapid smoking: interim summary and recommendations. , 1977, Addictive behaviors.

[49]  T. Whitman Aversive control of smoking behavior in a group context. , 1972, Behaviour research and therapy.

[50]  W. Garlington,et al.  Development and evaluation of treatment paradigms for the suppression of smoking behavior. , 1977, Journal of applied behavior analysis.

[51]  T. Baker,et al.  Treatments for cigarette smoking: an evaluation of the contributions of aversion and counseling procedures. , 1986, Behaviour research and therapy.

[52]  E. Lichtenstein,et al.  Long-term effects of rapid smoking treatment for dependent cigarette smokers. , 1977, Addictive behaviors.

[53]  P. Suedfeld,et al.  Restricted environmental stimulation therapy and aversive conditioning in smoking cessation: active and placebo effects. , 1986, Behaviour research and therapy.

[54]  C. Keutzer Behavior modification of smoking: the experimental investigation of diverse techniques. , 1968, Behaviour research and therapy.

[55]  P. McGovern,et al.  Nicotine fading as a nonaversive alternative in a broad-spectrum treatment for eliminating smoking. , 1985, Addictive behaviors.

[56]  O. Barbarin Comparison of symbolic and overt aversion in the self-control of smoking. , 1978, Journal of consulting and clinical psychology.

[57]  R. Steffy,et al.  Smoking modification procedures tailored to subject characteristics , 1971 .

[58]  A. Carlin,et al.  Aversive conditioning: learning or dissonance reduction? , 1968, Journal of consulting and clinical psychology.

[59]  C. Tori A smoking satiation procedure with reduced medical risk. , 1978, Journal of clinical psychology.

[60]  E Corty,et al.  Response prevention in the treatment of cigarette smoking. , 1984, Addictive behaviors.

[61]  M A Russell,et al.  Rapid smoking, cue exposure and support in the modification of smoking. , 1980, Behaviour research and therapy.

[62]  J. Conway Behavioral self-control of smoking through aversive conditioning and self-management. , 1977, Journal of consulting and clinical psychology.

[63]  G. Hackett,et al.  Partial component analysis of a comprehensive smoking program. , 1979, Addictive behaviors.

[64]  H. Lando Successful treatment of smokers with a broad-spectrum behavioral approach. , 1977, Journal of consulting and clinical psychology.

[65]  S. B. Levenberg,et al.  Smoking cessation: Long-term irrelevance of mode of treatment , 1976 .

[66]  R. Hill Prescribing aversive relapse to enhance nonsmoking treatment gains: A pilot study * , 1988 .

[67]  H. Lando Aversive conditioning and contingency management in the treatment of smoking. , 1976, Journal of consulting and clinical psychology.

[68]  H. Lando A factorial analysis of preparation, aversion, and maintenance in the elimination of smoking. , 1982, Addictive behaviors.

[69]  E. Lichtenstein,et al.  Comparison of rapid smoking, warm, smoky air, and attention placebo in the modification of smoking behavior. , 1973, Journal of consulting and clinical psychology.

[70]  C. Elliott,et al.  A multiple-component treatment approach to smoking reduction. , 1978, Journal of consulting and clinical psychology.

[71]  C. Feyerabend,et al.  Blood nicotine and carboxyhemoglobin levels after rapid-smoking aversion therapy. , 1978 .

[72]  R. Glasgow Effects of a self-control manual, rapid smoking, and amount of therapist contact on smoking reduction. , 1978, Journal of consulting and clinical psychology.