Behavioural support and pharmacotherapy improve smoking quit rates in adults

Patnode CD, Henderson JT, Thompson JH, et al. Les interventions de counseling comportemental et la pharmacothérapie pour la désaccoutumance au tabac chez les adultes, notamment les femmes enceintes: une revue des revues pour le U.S. Preventive Services Task Force. Annals of Internal Medicine. 2015;163:608-621.

Review question

What are the benefits and harms of behavioural support and pharmacotherapy for tobacco cessation in adults, including pregnant women? 

Are electronic nicotine delivery systems (ENDS) an effective and safe way to quit smoking?

Background

Tobacco use and exposure to cigarette smoke is the leading cause of disease, disability and death, and annually causes over 480 000 early deaths in the United States. The U.S. Preventative Services Task Force recommended first in 2003 and again in 2009 that doctors talk to adults about the use of tobacco and provide assistance for quitting for those who smoke.

How the review was done

A review of reviews was conducted including reviews published between 2009 and 2014 that assessed the effectiveness of behavioral approaches and pharmacotherapy on smoking cessation among adults as well as pregnant women. In addition, a search for primary studies was conducted to assess the effectiveness and safety of ENDS on smoking cessation. There were 54 reviews included in this report and 2 primary studies.

Review features:

• Behavioural approaches included: physician advice, tailored/non-tailored self-help material, phone counseling, in-person individual or group counselling, compared to no advice, usual care, medication, brief advice.
• Pharmacotherapy included: nicotine replacement therapy (NRT), bupropion or varenicline. Results were compared to placebo, one type of NRT, no NRT, no bupropion.
• ENDS included electronic cigarettes compared to NRT patches, placebo electronic cigarettes with voluntary quit line behavioural support, or electronic cigarettes with no nicotine.
• Smoking quit rates, health outcomes and adverse events were measured.

What the researchers found

General adult population:

Behavioural support

• Health outcomes – significantly fewer men died from respiratory illnesses in the group who received quitting support vs. control group at 33 year follow-up.
• Quitting outcomes – counseling by physicians and nurses, tailored self-help print materials and phone counseling increased quitting at 6 months vs. minimal intervention/usual care. Minimal and intensive advice greatly increased quit rates vs. no advice, with intensive advice being more beneficial.

Pharmaceuticals

• Health outcomes: none of the reviews reported on health outcomes
• Quitting outcomes: NRT, bupropion, and varenicline improved quitting at 6 months or longer. 
• Adverse events: no serious side effects associated with NRT and bupropion, but NRT linked to increased risk of minor cardiovascular events. Varenicline associated with increased risk of serious cardiovascular events.

Combined behavioral support and pharmaceuticals

• Combined use of behavioural support and NRT or bupropion significantly increased quitting at 6 months or longer vs. controls.

ENDS

• ENDS offered no benefit on smoking cessation among those planning to quit. 
• No significant difference in adverse side effects between ENDS group and NRT patch group.

Pregnant women:

• Behavioral support significantly improved quit rates, while NRT showed no significant benefit.  

Conclusion

Behavioural support and pharmacotherapy improve smoking quit rates in adults, both when alone or combined. Behavioural support is most effective among pregnant women, and electronic delivery systems are not effective for smoking cessation among those intending to quit.