Adding Behavioral Therapy to Medication for Smoking Cessation

To the Editor: The article by Dr Hughes and colleagues¹ summarizing the recent advances in the pharmacotherapy of smoking was a much-needed update to the medical literature and provided valuable information for clinical physicians. However, an aspect that needs clarification is the most efficacious implementation strategy for adjunctive counseling used in a tobacco cessation program. Hughes et al suggest that behavioral therapy strategies with patients by telephone can be used rather than traditional face-to-face counseling. The Agency for Health Care Policy and Research meta-analytic review of tobacco cessation programs clearly stated that there is a dose-response relationship between the duration and length of counseling, and suggested a 20 min/wk session for at least 4 weeks. Lichtenstein et al² suggest that telephone counseling can be effective but do not suggest it is as effective as face-to-face counseling. To our knowledge, there is no published empirical evidence directly comparing the 2 modalities for smoking cessation.

In our experience, face-to-face behavioral therapy or supportive therapy provided in a group format allows 1 clinician to effectively treat as many as 15 patients in a typical hour session. These patients also benefit from group support and treatment uniformity. It is our view that telephone counseling should be considered as an adjunct to a well-defined behavioral modification program rather than the primary psychotherapeutic intervention. We often use such a strategy in our clinic when patients are unable to attend group sessions but we emphasize group attendance. Further research comparing the relative efficacy of telephone counseling with face-to-face behavioral modification in tobacco cessation programs would be an interesting area for research.