Behavioral and pharmacologic interventions may increase smoking cessation

1. From a systematic review, behavioral counseling, bupropion, nicotine replacement therapy and varenicline resulted in increased rates of smoking cessation, with varenicline demonstrating the greatest effect.

2. For pregnant smokers, behavioral interventions for smoking cessation were associated with higher birth weight and less preterm birth in addition to increased rates of cessation.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Tobacco smoking and exposure is a major risk factor for morbidity and mortality in the U.S. and is responsible for nearly half a million premature deaths annually. From this “review of reviews” conducted by the USPSTF, which aggregated eligible systematic reviews of RCTs on smoking cessation interventions, they found that, compared to no advice, smokers who received any cessation advice from physicians were more likely to have quit smoking at 6 months or more. Buproprion and nicotine replacement therapy (NRT) demonstrate similar effectiveness to cessation advice from a physician, whereas varenicline was three-fold more effective than the other interventions. There were no differences between gum, patch and lozenge, however combining multiple forms was more effective than using a single form. Combined behavioral and pharmacotherapy was more effective than pharmacotherapy alone. The evidence on the use of electronic cigarettes for cessation of conventional cigarette use were few in number, mostly fair-quality and had inconsistent findings suggesting a possible benefit to cessation. Behavioral interventions for pregnant smokers were associated with increased rates of cessation, higher birth weigh, and fewer preterm births than controls. NRT and bupropion were not associated with causing serious harm, whereas varenicline may be associated with increased serious adverse events. This study was limited by the variability between the methods used to assign quality ratings to studies as the authors of this study did not assign their own quality ratings to individual studies. Overall, this study illustrated the effectiveness of behavioral and pharmacologic interventions on increasing smoking cessation.

Click to read the study published today in the Annals of Internal Medicine

Relevant Reading: Final Recommendation Statement Tobacco Use in Adults and Pregnant Women: Counseling and Interventions, April 2009

In-Depth [systematic review]: This study screened 114 full-text systematic reviews for eligibility and 54 met eligibility criteria. The study did not replicate the data abstraction and quality ratings already assigned in prior systematic reviews. Compared to control or placebo, significantly increased rates of smoking cessation at 6 months or more was seen with cessation advice from a physician (RR 1.76, 95%CI 1.58-1.96), NRT (RR 1.60, 95%CI 1.53-1.68), bupropion (RR 1.62, 95%CI 1.49-1.76) and varenicline (RR 2.27, 95%CI 2.02-2.55). Combined pharmacotherapy and behavioral counseling was associated with 82% increased smoking cessation at 6 months, compared to placebo, and was 16% more effective than pharmacotherapy alone. Intensive advice defined as >20 minutes long, resources more than a brochure or advice given at >1 follow up visit was 37% more effective than minimal physician advice. There were no differences between gum, patch and lozenge NRT, however combining multiple forms was 34% more effective than using only one form of NRT.

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