Utility of Face-to-Face Counseling
Many members of ATTUD provide face-to-face individual counseling. Since funding for tobacco treatment often originates from public health funding, many funders are concerned that the increased cost of such treatment is not warranted, given the known efficacy of group and phone counseling. As in many fields, the onus for burden of proof of the utility of more intensive treatment lies with those who believe such treatment is needed. One possible rationale for more intensive treatment is that it will bring higher quit rates. However, most meta-analyses (including the Cochrane reviews) or randomized studies of more vs less intensive treatment, conclude more intensive treatment only slightly increases quit rates, if at all. In addition, non-randomized comparisons have found that specialists obtain higher quit rates than non-specialists (NTR 15:1239, 2013). Other studies sometimes find face-to-face more effective than group or individual and sometimes do not. Of course these studies suffer from selection bias; i.e., in many, but not all, studies those who choose more intensive treatment are more addicted to nicotine, have less support, etc. In addition, in these studies, the duration and content of the treatments vary by modality, making their interpretation difficult. A recent study by ATTUD member Chris Sheffer is perhaps the best comparison thus far (Am J Pub Hlth, in press, online). In this study participants received the same treatment content and of similar duration. In the short term, face-to-face did better than phone but not in the long term. However, one could still justify face-to-face counseling four ways. First, one could argue that it’s important to have multiple options for smokers to increase uptake of a treatment. Second, one could show that face-to-face individual attracted those who would not attend phone or group. No one has directly tested this (ie. by randomly assigned to treatment modes and seeing who shows up). Also, although some papers suggest a certain type of smoker is more likely to attend face-to-face (e.g. those more addicted); other studies have not replicated this. Third, similarly, one could show that there are some smokers who are unlikely to quit unless they obtain face-to-face counseling. For example, it would be reasonable to hypothesize that those with mental health problems or who have never gone more than a week without smoking or who have a toxic environment (e.g. live with a smoker and are living a stressed life) might need face-to-face. Again, no consistent predictor of the need for face-to-face has emerged. Fourth, one could propose a stepped-care model in which smokers first try minimal treatments and then those of moderate intensity and then intensive treatment. Although such models make sense in many situations, they are problematic when the problem is urgent or life-threatening or when delay to obtain optimal treatment could be harmful. This may be the case for tobacco treatment. For example, assume it takes a smoker 10 years to go from a self-quit to using a booklet to using single NRT, to phone counseling, to prescription medication and then finally to face-to-face counseling, then either a) they fail to make multiple quit attempts or b) they suffer a tobacco related disease (e.g. a heart attack) may precede their obtaining optimal treatment. Many professions have guidelines about allocation of more intensive treatments (e.g. see www.asam.org). Although many of these are based on the best available evidence, for some the evidence base is very small. I think that we need more analyses of data sets to better indicate which smokers really require face-to-face counseling and urge ATTUD members to consider such research. I think the practice of face-to-face counseling for tobacco dependence is going to continue to come under question and we desperately need data to justify such treatment.