Health agencies seeking to maximise the number of people stopping smoking must consider two broad questions. The first concerns effectiveness: is one approach more effective than another in helping smokers stop; do different methods work better with different smokers? Questions of effectiveness are asked by academics and therapists with professional interest in the intrinsic merits of various approaches. The second question asks whether interventions can be applied throughout a community: has an approach the potential to meet the mass demand its successful operation would imply; what staffing levels are necessary to penetrate a target group; are these levels realistic in times of economic recession? If these questions are asked at all, they are asked by health administrators, funding agencies, politicians, and above all by the tobacco industry. The industry’s opposition can be thought of as the litmus test of a method’s likely impact. The industry has gone on record as “fully supporting sensible and effective public education”1 about smoking and only the naive could see such a statement as anything less than encouragement for orthodox smoking-control activities. The industry has never opposed stop-smoking groups and therapies, but it has actively fought mass health-promotion programs2 and legislative proposals.3 In 1982, 38 percent of men and 33 percent of women smoked in the UK4 – a formidable number of people. All cessation approaches need to be evaluated in relation to this second goal of mass application before they are assessed in terms of their effectiveness. A 5 percent success rate among 10,000 people is over 333 times more efficient than the 30 percent success rate achieved by group work involving only 50 subjects. It is this latter sort of activity, however, that occupies nearly everyone involved in smoking cessation.

Most of the people working in the field are psychologists and the literature is dominated by therapeutic approaches based on individual and small-group techniques. A randomly chosen year of the annual bibliography5 from the US Office on Smoking and Health, which abstracts all research and commentary connected with the subject, was surveyed to establish this domination. The 1981 volume contained 2,055 abstracts. One hundred and twenty-eight concerned research and descriptions of cessation techniques, but only four of these described mass-reach programs and a further four described strategies that might be adopted by general practitioners and other health workers. Of the 128 abstracts, 33 were doctoral dissertations that included such esoteric procedures as “subliminal stimulation of symbiotic fantasies”, “contingency contracting”, and “griefwork”. The study groups of the reports seldom exceeded 100 self-selected subjects. The literature on smoking cessation is biased towards therapeutic interventions modelled on psychological concepts of smoking as a behavioural or dependency problem.

​Smoking cessation groups and clinics: their contribution to reducing smoking prevalence

Raw and Heller reviewed6 the functioning of all 55 stop-smoking clinics in the UK in 1983. There are considerable difficulties in estimating the precise contribution of these clinics to a national reduction in smoking prevalence. Only 19 (36 percent) of the clinics had usable data and none had kept records of follow-up essential for determining the permanency of cessation. These 19 had a total annual throughput of 2,390 smokers and a total abstinent population after one year of 560 (mean 23 percent and a range of 14 to 43 percent). If this figure were trebled to account for success rates from the remaining 36 clinics (probably a very liberal assumption), a total emerges of approximately 1,680 people who appear to have stopped smoking following attendance at cessation clinics and groups in one year. How does this figure compare with the potential number of smokers who might be described as ripe to stop? When 1,711 British smokers were asked “How determined are you to try and give up smoking?”, 42 percent answered positively.7 If this figure were at all indicative of the proportion of smokers actively thinking of stopping, then 8.3 million (of Britain’s 19.8 million adult smokers) represents the number of potential ex-smokers. In contrast, organised stop-smoking groups and clinics benefit 0.2 percent, or one in every 5,000 smokers currently wanting to stop. Levitt reached similar conclusions about the role of clinics in the USA, where, in 1975, 2,176 reached less than 0.1 percent of smokers.8  At that rate, 200,000 clinics would be required just to keep the proportion of smokers at the present level. As can be seen from a comparison with the rate at which people are stopping smoking unaided, clinics make an utterly insignificant contribution to the overall pattern of smoking cessation. In Britain in 1982, 30 percent of men and 16 percent of women were ex-smokers, proportions that had risen from 23 percent and 10 percent respectively in 1972.9 This trend corresponds to the decline in smoking prevalence over the same decade (down from 53 to 38 percent in men and from 41 to 33 percent in women). Evidence suggests that the decline in smoking prevalence is a result of people giving up smoking rather than fewer young people taking up the habit. Marsh suggests:

How then have therapeutic, small-scale approaches come to dominate worldwide cessation efforts when simple arithmetic points to the futility of group-based approaches? One answer is that clinical psychologists have long had a professional interest in dependency problems. It was natural for them to apply their training and skills to programs of smoking cessation. Psychologists view themselves as assisting individuals. Criticism that their aggregated efforts do not reduce smoking prevalence is misplaced, since that was never their aim. Raw and Heller also found that 62 percent of clinics were run by health-education officers, whose work is normally of neither an individual nor therapeutic nature.

Public demand for clinics

People who work in smoking control receive enquiries every day from smokers wanting to join a stop-smoking group. The frequency of these inquiries has led health workers to establish groups in response to demand. Potential ex-smokers hold media-fanned preconceptions about what they need and what they will experience, particularly in connection with group work. The reflex action of health workers to provide these groups clouds perspective: how representative of smokers are these people, and is the time and labour investment appropriate as a long-term strategy? There are many benefits associated with cessation clinics that have nothing to do with reducing smoking prevalence, but which are nonetheless real. Stopping smoking is seen as a cure, and if smoking needs to be cured, then the magical, laying-on-of-hands accoutrements of curing must parallel those of medicine in general. Clinics and groups are tangible entities, located in buildings with staff who have concrete, comprehensible tasks, unlike most health-education work, which sounds vague and has imperceptible effects in the short term. Public expectation that stopping smoking involves some sort of supervised therapeutic process has probably been amplified by media interest in the more exotic forms of cessation. The mystique and paraphernalia of popular notions of psychology, acupuncture and hypnotism are infinitely more newsworthy than the fact that most people stop smoking unspectacularly and alone. There is the expectation that stopping is extremely difficult and that one should place oneself passively in the hands of a healer.

Lehrer has described a quasi-sick role in group attenders, suggesting that their motivation includes a need to define themselves as ill, as much as a desire to stop smoking.11 Smoking-cessation groups are often used as a pretext for unburdening wider psychosocial difficulties. Apologists for the clinics report attenders to be hardcore heavy smokers, whose habit is so entrenched that it is unlikely to be broken unaided. However, there is no evidence of such a difference between clinic attendees and those who stop smoking on their own in terms of smoking habit, smoking history, number of attempts to stop or personality.12 A second view current in the professional community is that stopping smoking is so difficult that not to provide assistance to people wishing to give up is victim-blaming at best and sadistic at worst. The argument runs that mass-media campaigns that persuade and frighten people into wanting to stop smoking must include some sort of program of help. Clinics are often described as support services for clients, with no objective of reducing smoking prevalence in the community. However, among people who stopped smoking unaided, the picture is somewhat different. Only 19 percent of British ex-smokers report stopping as very difficult, 27 percent as fairly difficult, while a majority of 53 percent remember stopping as not at all difficult. Fifteen percent reported stopping as harder than expected, 38 percent as expected, and 41 percent as easier than expected.13 It should be remembered that these figures are obtained from successful ex-smokers. Those who found it impossible are not included. This unsuccessful group remains substantial and cannot realistically be treated in therapeutic settings.

A case against providing support for smoking cessation

It seems likely that there will always be a small proportion of dissonant smokers (who may appear quite large in number) who genuinely seem unable to quit unaided, and who seek help from groups and therapists. Ideally, this tail-end of the smoking population should be catered for in ways that are effective, non-exploitative and above all not disproportionately demanding of scarce capital and staff. Since health-service resources exist in a far from ideal world, priorities for the allocation of staff funding must be determined in the light of reducing total smoking prevalence. Provision of cessation clinics and groups perpetuates the idea that smoking has to be cured, so inhibiting the growth of confidence in self-directed cessation. A spirit of comprehensiveness sometimes motivates the establishment of a two-tiered system of help: self-help materials and a group or clinic. Self-help then becomes a second-rate option: why just get a kit when you can get the full treatment? The provision and publicity of group treatment can only cast a shadow over self-help. Most smokers attracted to self-help campaigns will have tried several times to stop smoking. People who view the prospect of stopping as easy will be unlikely to seek out any form of assistance. Those who do probably view themselves as failures. The task facing campaign planners is to instil confidence in such people. If intensive therapy, with its aura of psychology and cure, is on offer, how much more difficult does it become to help people to motivate themselves?

There is one vitally important exception to the argument that labour-intensive cessation programs are a waste of time: the daily contact of thousands of smokers with their doctors. Russell’s study of general practitioners’ advice to smoking patients suggested that a GP could expect about 25 long-term successes a year. If all GPs in the UK participated, the yield would exceed half a million ex-smokers a year, a target that could not be matched by increasing the present 50 or so clinics to 10,000! Obvious potential exists for involving dentists, health visitors, physiotherapists and nurses in similar schemes. A cardinal emphasis throughout this paper has been that if smoking prevalence is to decline significantly throughout a population, then efforts must be made to induce mass numbers of people not to smoke. Techniques pursued face-to-face or in small groups may occasionally produce impressive success rates, but they are insufficiently broad-based to achieve impressive numbers. The most widely acclaimed smoking cessation programs remain in the worst traditions of inconsequential research if they are incapable of becoming incorporated into a delivery system involving significant numbers of the smoking community.