Peer Program Helps Childhood Cancer Survivors to Quit SmokingKey Words
Smoking cessation, peer counseling, childhood cancer survivors (Definitions of many terms related to cancer can be found in the Cancer.gov Dictionary.)
Summary
A large randomized clinical trial found that a peer-counseling approach to smoking cessation doubled the quit rate among childhood cancer survivors compared to a self-help approach, and at a relatively low cost compared to other interventions known to be successful.
Source
Journal of Clinical Oncology, published online August 22, 2005; in print September 20, 2005 (see the journal abstract).
Background
Smoking raises the risk of cancer, but that risk has even more dire implications for those who have already battled cancer in their childhoods. Childhood cancer survivors have often suffered organ damage as a result of their disease and treatment, and so smoking is a particularly dangerous pastime for them.
There are now more than 250,000 survivors of childhood cancer alive in the United States. While they smoke at a somewhat lower rate than age- and sex-matched groups from the general population, public health experts would like to find a way of encouraging childhood cancer survivors not to smoke at all.
Randomized clinical trials have clearly shown that certain approaches to helping smokers quit are better than no intervention at all. Counseling by a health professional improves a smoker’s chances of quitting, as do nicotine replacement therapies (gum, patches) and drugs that combat depression. Some evidence also exists that peer counseling might be effective, too.
The Study
The Partnership for Health (PFH) smoking cessation clinical trial is an outgrowth of the Childhood Cancer Survivors Study (CCSS), in which more than 14,000 childhood cancer survivors agreed to be followed over time so that researchers can learn how cancer may affect their lives in the long term.
CCSS participants were eligible to join the PFH trial if they were over the age of 18, were not being treated for cancer, and were active smokers. Researchers enrolled 796 participants from 22 different sites who met these conditions, and randomly assigned them to either a self-help group or a peer-counseling program.
Those in the self-help group received a letter from the trial’s doctors explaining that if they quit smoking, they’d lower their chances of getting a secondary cancer. Smokers in this group also received a manual with more tips and information about quitting, including discussion about the benefits of over-the-counter nicotine replacement therapies. Participants were allowed to purchase and use such therapies if they wished, but they had to obtain them on their own.
Those in the other group were assigned a peer counselor, someone who was also a childhood cancer survivor and who had been trained in “motivational interviewing” – an approach that emphasizes the smoker’s choice, personal responsibility for change, and self-confidence. The counselors called their assignees up to six times within a seven-month period. Prior to the first call, participants received a written report with “how to quit” information tailored to their personal interests and cancer histories, as captured in the questionnaire they’d originally filled out to join the larger CCSS study.
During the telephone calls, counselors adjusted their comments to meet each participant’s particular level of readiness to quit and their interest in other health topics and goals. Extra materials might also be sent, again targeted to the individual. If participants indicated a willingness to try a nicotine replacement therapy, such therapies were provided at no cost. Overall, the peer-counseling program was based on principles from a number of theories about behavior change, with an emphasis on the role of strong social support.
Participants in both groups filled out surveys at eight months and again at 12 months after their interventions began. To increase the likelihood that participants would report the truth about their smoking behavior, researchers told them their saliva would be collected and tested, though this was not done (a technique called the bogus pipeline procedure).
The trial team was led by Karen M. Emmons, Ph.D., of the Harvard School of Public Health and the Dana-Farber Cancer Institute in Boston, Mass.
Results
Some of the 796 participants failed to get their smoking cessation materials and not all filled out their eight-month and 12-month surveys. But enough did to allow for key statistically significant findings.
Most importantly, the quit rate was significantly higher in the peer-counseling group than in the self-help group. At eight months, 16.8 percent of the peer-counseling group had quit compared to just 8.5 percent in the self-help group; at 12 months, those rates were 15 percent and 9 percent, respectively. This means that the peer-counseling participants were twice as likely to quit.
While neither group was more likely than the other to attempt quitting, the peer-counseling program was clearly better at helping would-be quitters to succeed. The more peer-counseling calls participants received, the more likely they would quit.
The self-help intervention cost about $1.25 per participant, while the peer-counseling approach cost about $300 per participant. As a comparison, interventions consisting of counseling from a doctor and nicotine replacement therapies have been found to cost as much as $7,000 per would-be quitter.
Limitations
Researchers with the trial noted that it was difficult to locate and track potential participants, given that the PFH trial was launched six years after their entry into the CCSS study. Such difficulties, they wrote, “had an impact on the response rate.”
In addition, the PFH participants were mostly white, “despite substantial efforts to recruit minority group members.” This means the findings may not be generally applicable to the whole U.S. population.
Another caveat to consider, according to Erik M. Auguston, Ph.D., M.P.H., of the National Cancer Institute’s Tobacco Control Research Branch, is that “use of [nicotine replacement therapy] varied between the groups, so we can't definitively say if the peer counseling was responsible for the improved outcome. However, it may also be that having a peer actively involved in your cessation attempt contributes to using additional, effective tools like NRT.”
Comments
While a 15 percent quit rate at 12 months may not seem high, wrote the researchers, “it is important to note that this study was conducted among nonvolunteers, that is, individuals who did not proactively seek out smoking cessation. In fact, many participants were not interested in quitting smoking” at the start of the trial. “PFH provides a road map for the development of a national model for smoking cessation interventions for cancer survivors.”
Added NCI’s Augustson, “success rates may be even higher in a treatment-seeking population” – that is, among smokers who are actively seeking help with quitting. “As the number of survivors of child cancers continues to rise due to more effective diagnosis and treatment, smoking in this group will become an increasingly important public health problem. Thus, findings effective treatment programs will take on an even greater value.”
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