Efficacy of treatments for tobacco dependence

Last updated December 2013

Efficacy of treatments for tobacco dependence

treatobacco.net


Efficacy section

Chair Lindsay Stead The Cochrane Tobacco Addiction Group, University of Oxford, UK

Paul Aveyard University of Birmingham, UK

Michael Fiore Univ. of Wisconsin Medical School, USA

Jonathan Foulds Penn State University, Hershey, Pennsylvania, USA

John Hughes University of Vermont, Burlington, USA

Martin Raw Freelance consultant,and University of Nottingham, UK

Robert West University College London, London, UK


Efficacy of treatment

• The purpose of the efficacy database is to provide information on effective treatments for tobacco dependence.

• The key findings are based on the results of systematic reviews of the evidence from randomised controlled trials of treatment interventions.

• Highlighting interventions that have been shown to produce a sustained increase in quit rates 6 months or more after treatment.

• Recommendations are based on clinical practice guidelines and reflect the most recent update of the US guidelines in 2008.


Brief opportunistic advice

Brief advice from a primary care physician during a routine consultation is effective in increasing the number of smokers stopping for at least 6 months.

West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2013, 5.

1 The difference in >6 month abstinence rate between intervention and control/placebo in studies reported

Intervention Target population Effect size1

95% CI

Brief opportunistic advice from a physician to stop

Smokers attending GP surgeries or outpatient clinics

2% 1%-3%


West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999.

Brief opportunistic advice

• May trigger a quit attempt in 40% of cases.• Reduced effect with repeated exposure.• Minimal effect on heavy smokers in absence of

NRT/bupropion or behavioural support.• GPs prefer to give to patients with smoking-related

diseases but no greater in effect in this group compared to no intervention.


West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2005; 2. Stead LF, Lancaster T. Group behaviour therapy for smoking cessation. Cochrane Database Syst Rev. 2005; 2.

Face-to-face behavioural support

• Behavioural support with multiple sessions of individual or group counselling aids smoking cessation. The following components assist quitting:– problem solving;– skills training;– intra-treatment social support.

• Dose-response relationship between the amount of therapist-client contact and successful cessation.



West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.

Intervention Target population Effect size

95% CI

Face-to-face intensive behavioral support from a specialist

Moderate to heavy smokers seeking help

7% 3%-10%

Face-to-face intensive behavioral support from a specialist

Smokers admitted to hospital

4% 0%-8%


Effect of smokers clinic

West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999.

Expected effect combining effect of medication with effect of behavioural support.

Intervention Target population Effect

Intensive behavioral support plus NRT or bupropion

Moderate to heavy smokers seeking help from a smokers clinic

13-19%


1. Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8.2. West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999.


• Nurses can be effective where trained and employed for the purpose.1

• Specialist counselling for pregnant smokers is effective but brief midwife delivered advice probably is not.2

• There has been limited research on support for adolescent smokers, and no clear evidence.2


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15

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Self-help Proactivetelephone

counselling

Individualcounselling

Groupcounselling

USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.

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Efficacy of various behavioural support approaches


Self-help interventions

Generic self-help interventions provided without personal support have a small effect on quit rates. Their impact is smaller and less certain than face-to-face interventions.Written materials and internet sites that are tailored to the needs of individual smokers are more likely to be helpful than standard materials.

Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Database Syst Rev. 2005; 3. West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999.Civljak M, Stead LF, Hartmann-Boyce J, Sheikh A, Car J. Internet-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 7.


95% CI

Written self-help materials

Smokers seeking help with stopping

1% 0%-2%

Internet based interventions

Smokers seeking help with stopping

unclear


Other support

Telephone calls from a counsellor may be more effective than self-help materials alone.

West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008 (Table 6.16).Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8.


95% CI

Pro-active telephone counselling

Smokers wanting help with stopping but not receiving face to face support

2% 1%-4%


West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999. Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, 11.USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.

Nicotine Replacement Therapy

• NRT is effective in aiding smoking cessation.• Effectiveness of NRT does not depend on the amount of

face-to-face behavioural support.• All forms of NRT appear to be similarly effective. • Choice of type may be based on susceptibility to side

effects, patient preference and availability.• There is evidence that heavy smokers are more

successful on 4mg than 2mg nicotine gum.• Combining nicotine patch with a short acting form of NRT

increases success rates.


NRT with limited behavioural support

West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999. Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, 11.

Intervention Effect size 95% CI

Nicotine gum 4% 3%-5%

Nicotine transdermal patch 6% 4%-8%


NRT with intensive support

West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999. Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, 11.

Intervention Effect size

95% CI

Nicotine gum 7% 5%-8%

Nicotine transdermal patch 6% 5%-7%

Nicotine nasal spray 12% 7%-17%

Nicotine inhalator 8% 4%-12%

Nicotine sublingual tablet 8% 6%-10%


Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2012, 4.

Nicotine receptor partial agonists

Varenicline and cytisine are both effective aids to smoking cessation.


95% CI

Varenicline2.0 mg

Moderate to heavy smokers receiving behavioral support

15% 13%-17%

Cytisine1.5 mg

Moderate to heavy smokers receiving brief behavioral support

6% 4%-9%


West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2014, 1.

Bupropion

Bupropion is an effective aid to smoking cessation.


95% CI

Bupropion (300mg/day SR)

Moderate to heavy smokers receiving intensive behavioral support

7% 6%-8%


Comparative effectiveness of pharmacotherapies

• A combination of direct and indirect evidence suggests that varenicline is more effective than bupropion or a single type of NRT, but of similar efficacy to combination NRT

Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database of Systematic Reviews 2013, 5.


Covey LS, et al. Drugs. 2000; 59: 17-31 Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2014, 1.USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.

Other pharmacological treatments

• Nortriptyline - There is evidence for effectiveness of this tricyclic antidepressant but because of the side effect profile it should be considered only as a second line therapy after bupropion and NRT.

• Clonidine has been found to be effective but its usefulness is limited by side effects.


Hughes JR, et al. Anxiolytics for smoking cessation Cochrane Database Syst Rev. 2000; 4. Stead LF, Hughes JR. Lobeline for smoking cessation Cochrane Database Syst Rev. 2002; 1. Nicotine Addiction in Britain: Royal College of Physicians, 2000. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.

Other pharmacological treatments

• Other treatments have been evaluated but results are inconclusive:

– appetite suppressants– benzodiazepines– beta-blockers– buspirone– caffeine/ephedrine– cimetidine– dextrose tablets (food supplement)– lobeline– moclobemide (monoamine oxidase inhibitor)– SSRIs


White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews 2014, 1.Barnes J, Dong CY, McRobbie H, Walker N, Mehta M, Stead LF. Hypnotherapy for smoking cessation. Cochrane Database Syst Rev. 2010;10.USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD: AHQR 2008.

Acupuncture and Hypnotherapy

• Acupuncture and hypnotherapy have not been shown to aid smoking cessation over and above any placebo effect.


Parrott S, et al. Thorax. 1998; 53: S1-S38. Cromwell J, et al. JAMA. 1997; 278: 1759-1766.

Guidelines

• There is strong evidence that smoking cessation interventions are highly cost-effective.

• English and US guidelines in place to offer recommendations on smoking cessation:– West R, McNeill A, Raw M. Smoking cessation guidelines for

health professionals: an update. Thorax. 2000; 55: 987-999.– Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and

Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

http://www.surgeongeneral.gov/tobacco/

http://www.surgeongeneral.gov/tobacco/


English Health Development Agency Guidelines

• Up-to-date and readily accessible records of patients’ smoking status should be maintained by primary care physicians and hospitals.

• Primary care physicians should advise patients to stop and where appropriate refer to specialist services at least once a year.

• Hospital staff should advise patients to stop and refer at the earliest opportunity.

• Smokers of 10 or more cigarettes per day should normally be encouraged to use nicotine replacement therapy or bupropion as a cessation aid.


English Health Development Agency Guidelines

• Smokers should be given accurate and balanced information on the effectiveness and safety of these drugs.

• A structured programme of behavioural support should be available to all smokers who want it and for reasons of cost-effectiveness should involve group treatment unless practical or other considerations dictate otherwise.


US Public Health Service Guidelines

• Clinic screening systems such as expanding the vital signs to include tobacco use status, or the use of other reminder systems such as chart stickers or computer prompts are essential for the consistent assessment, documentation and intervention with tobacco use.

• All patients should be screened for tobacco use and assessed for their interest in quitting.

• All physicians and clinicians should strongly advise every patient who smokes to quit.



• All healthcare personnel and clinicians should repeatedly and consistently deliver smoking cessation interventions to their patients.

• Patients should be encouraged to use nicotine replacement therapy, bupropion or varenicline for smoking cessation (see safety database for more information about use in special populations).

• To be most effective, interventions should include either individual, group or telephone counselling/contact.



• Intensive interventions are more effective than brief interventions and should be used when resources permit, but every smoker should be offered at least a minimal or brief intervention.

• Smoking cessation interventions should help smokers recognize and cope with problems encountered in quitting (problem solving/ skills training), should provide social support as part of treatment, and should encourage smokers to seek support from family and friends.

• Where feasible, smokers attempting to quit with self-help material alone should be provided with access to support through a telephone hotline/helpline.


Areas for further research

• The elements of behavioural interventions that enhance effectiveness.

• Effectiveness of combining:– different NRT formulations;– NRT and non-nicotine pharmacotherapies.

• Long-term use of NRT or other pharmacotherapies to prevent relapse or reduce harm.

• Interventions for adolescent smokers.


Areas for further research

• Improving access to effective interventions.• Organisation of healthcare systems for delivery of

appropriate interventions.• Optimal sequence of treatment combinations for

repeated attempts to quit.• Treatment of smokers with co-morbidities.

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Efficacy of treatments for tobacco dependence

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