Efficacy

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Efficacy of treatments for tobacco dependence

Last updated February 2008

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Efficacy section

Chair

Lindsay Stead
Michael Fiore

John Hughes Martin Raw Robert West

The Cochrane Tobacco Addiction Group, Cochrane Collaboration, UK Department of Medicine, University of Wisconsin Medical School, USA University of Vermont, USA Freelance consultant, and University of Nottingham, UK St George’s Hospital Medical School, London, UK

Last updated February 2008

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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. • The efficacy section will be updated when the US clinical practice guideline update is published in 2008

Last updated February 2008

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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
Intervention Brief opportunistic advice from a physician to stop
1

Target Effect size1 95% CI population Smokers 2% 1-3% attending GP surgeries or outpatient clinics

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

West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004; 4.

Last updated February 2008

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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 and Raw M. Thorax 2000; 55: 987-999.

Last updated February 2008

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

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Face-to-face behavioural support
Intervention Target Effect 95% CI population size Face-to-face intensive Moderate to 7% 3%-10% behavioural support from a heavy specialist smokers seeking help with stopping Face-to-face intensive Smokers 4% 0%-8% behavioural support from a admitted to specialist hospital

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

Last updated February 2008

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Effect of smokers clinic

Intervention Intensive behavioural support plus NRT or bupropion

Population Moderate to heavy smokers seeking help from a smokers clinic

Effect 13-19%

Expected effect combining effect of medication with effect of behavioural support

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

Last updated February 2008

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Face-to-face behavioural support
• Nurses can be effective where trained and employed for the purpose1 • 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 evidence2

1. Rice VH, Stead LF. Cochrane Database Syst Rev 2004; 1. 2. West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Last updated February 2008

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Efficacy of various behavioural support approaches

20
Estimated cessation rate (%)
16,8

15
12,3 10,8

13,1

13,9

10 5 0
No intervention (reference group) Self-help Proactive telephone counselling Individual counselling Group counselling

USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2000. Last updated February 2008

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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
Intervention Written self-help materials Target population Smokers seeking help with stopping Effect 95% CI size 1% 0%-2%

Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Database Syst Rev 2005; 3. West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Last updated February 2008

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Other support
Telephone calls from a counsellor may be more effective than self-help materials alone
Intervention Pro-active telephone counselling Target population Smokers wanting help with stopping but not receiving face to face support Effect 95% CI size 2% 1%-4%

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

Last updated February 2008

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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

West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Stead et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008; 1. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2000. Last updated February 2008

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Nicotine Replacement Therapy
• There has been little research on combinations of different types of NRT • There is some evidence that adding another form of NRT to the nicotine patch increases success rates

West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Stead et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008; 1. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2000. Last updated February 2008

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NRT with limited behavioural support

Intervention Nicotine gum Nicotine transdermal patch

Effect size 4% 6%

95% CI 2%-5% 4%-8%

West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Stead et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008; 1. Last updated February 2008

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NRT with intensive support

Intervention Nicotine gum Nicotine transdermal patch Nicotine nasal spray Nicotine inhalator Nicotine sublingual tablet

Effect size 7% 7% 12% 8% 8%

95% CI 5%-8% 5%-8% 7%-17% 4%-12% 6%-10%

West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Stead et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008; 1. Last updated February 2008

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Varenicline
Varenicline is an effective aid to smoking cessation
Intervention Varenicline 2.0 mg Target population Moderate to heavy smokers receiving behavioral support Effect 95% CI size 14% 11-17%

West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Cahill K, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 2007; 4. Last updated February 2008

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Bupropion
Bupropion is an effective aid to smoking cessation
Intervention Bupropion (300mg/day SR) Target population Moderate to heavy smokers receiving intensive behavioural support Effect 95% CI size 8% 7%-9%

West R, McNeill A and Raw M. Thorax 2000; 55: 987-999. Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2007; 1. Last updated February 2008

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Bupropion
• Limited evidence from a single trial that bupropion is more effective than nicotine patch alone, and that a combination of bupropion and the patch is more effective than nicotine patch alone.

Last updated February 2008

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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

Covey LS, et al. Drugs 2000; 59: 17-31 Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2000; 4. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2000. Last updated February 2008

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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

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 2000.

Last updated February 2008

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

White AR, et al. Acupuncture for smoking cessation. Cochrane Database Syst Rev 2006; 1. Abbot NC, et al. Hypnotherapy for smoking cessation. Cochrane Database Syst Rev 2002; 1. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD: AHQR 2000. Last updated February 2008

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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 and Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55: 987-999 – Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. A Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, 2000.

Parrott S, et al. Thorax 1998; 53: S1-S38. Cromwell J, et al. JAMA 1997; 278: 1759-1766. Last updated February 2008

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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.
Last updated February 2008

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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

Last updated February 2008

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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.

Last updated February 2008

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US Public Health Service Guidelines
• 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 or bupropion 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.

Last updated February 2008

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US Public Health Service Guidelines
• 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.

Last updated February 2008

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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

Last updated February 2008

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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

Last updated February 2008

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