Group vs. individual therapy – which is best? Andy McEwen CRUK Health Behaviour Unit University College London

Overview  What we know about behavioural support  Development of group and one-to- one treatment in the UK  Findings from a study comparing group and one-to-one treatment  What treatment should UK smoking cessation services be offering?

What we know about behavioural support (1) “A range of methods of support from focused counselling and advice, through coping skills training to group support. In fact, most programmes tested have been eclectic, involving many different components.” (West at al, 2000)

What we know about behavioural support (2) (West et al, 2000)

What we (don’t) know about behavioural support (3)  What the ‘active ingredients’ of behavioural support are  Whether some professionals are better at providing behavioural support than others  Whether behavioural support is more effective when provided in groups or in individual sessions

Development of group and one-to- one treatment (1)  1998: ‘Smoking Kills’ white paper  1998: Smoking cessation guidelines – local services should be organised around a team of full-time staff providing group smoking cessation treatment (level 3)  1998: White paper also allowed for a large number of trained part-time Community Advisors (level 2)

Development of group and one-to- one treatment (2)  Recruitment and training an initial problem for services  Group treatment, perceived as less labour-intensive, was preferred in response to high demand for services  In 2002 virtually all services provided both one-to-one and group treatment (Bauld et al, 2005)

Development of group and one-to- one treatment (3)  In 8 out of 10 services more clients were treated one-to-one than in groups  In 5 out of 10 services virtually all treatment (90%-100% of clients) was delivered one-to-one  Since their formation 35% of services had shifted towards one-to-one support (National Evaluation Smoking Cessation Services, 2003)

Development of group and one-to- one treatment (4) Reasons for growing number of one-to- one treatments being offered by services:  Client choice  Lack of trained staff to run groups  Rural setting  Pressure from PCT’s (Bauld et al, 2005; National Evaluation Smoking Cessation Services, 2003)

Group v. one-to-one treatment (1) Research setting:  3 London boroughs with a population of about 600,000  Stop smoking service has two arms: clinic (group) and community (one-to-one) treatment

Group v. one-to-one treatment (2) Treatment regimens:  Both treatment regimens follow a service protocol with a written manual  Attendance for group or one-to-one treatment is largely down to choice and availability  55% attended group treatment; 45% attended one-to-one treatment

Group v. one-to-one treatment (4) Clinic data:

Group v. one-to-one treatment (5) Community data:

Group v. one-to-one treatment (6) Client data:  CA attracted more clients: BMEG, lower education and entitled to free prescriptions  Clients attending group treatment more likely to be taking medication for cardiac, respiratory and mental illnesses  75% of clients used NRT and 22% Zyban (31% for group clients and 14% for one-to-one clients, p<.001)

Group v. one-to-one treatment (7) Abstinence data:  4 week abstinent clients were older and married or living with a partner  Clients abstinent at weeks 3 & 4 were also older and married. Plus: white, had more education, smoked less cigarettes per day and with a lower FTND Self-reportCO-verified 4 week29%25% Week 3 & 441%37%

Group v. one-to-one treatment (8) Abstinence data:

Group v. one-to-one treatment (9) Variables entered into forced-entry logistic regressions:  Those considered to influence abstinence (treatment type, age, ethnicity, marital status and FTND)  Where there were differences between whether clients received one-to-one or group treatment (eligibility for free prescriptions, hand-rolled smoking and use of NRT and Zyban)

Group v. one-to-one treatment (10) Predictors of 4 week continuous abstinence:  Group treatment (OR: 2.3), use of Zyban (OR: 0.65) and medication for mental health problem (OR: 0.45) Predictors of abstinence at weeks 3 & 4:  Group treatment (OR: 1.6), age (OR: 1.02), education (OR: 1.5) medication for mental health problem (OR: 0.45)

Group v. one-to-one treatment (11)  More dependent smokers defined as FTND > 5  These smokers were more likely to quit in groups (27%) than in one-to- one treatment (21%) (p<.05)

Group v. one-to-one treatment (12) Limitations:  short-term outcomes  single service Conclusions:  Behavioural support effective in ‘real world’ setting  Group (clinic) treatment more effective than one-to-one (community) treatment Reasons why?

“Did you hear that? He said he had a cigarette this week!”

What treatment should UK smoking cessation services be offering? Where possible:  A combination of group and one-to- one treatment  A method for referring clients from CA (one-to-one) to clinics (groups) – especially more dependent smokers  Supervision and support for CA from full-time specialist advisors