Efficacy of treatments for tobacco dependence

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treatobacco.net

• Efficacy of treatments for tobacco dependence

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Efficacy section

• Chair Lindsay Stead The Cochrane Tobacco
  Addiction Group, Cochrane Collaboration, UK
• Michael Fiore Department of Medicine,
  University of Wisconsin Medical School, USA
• John Hughes University of Vermont, USA
• Martin Raw Freelance consultant, and
  University of Nottingham, UK
• Robert West St Georges Hospital Medical
  School, London, UK

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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

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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
1 The difference in gt6 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.
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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.
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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.
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Face-to-face behavioural support
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.
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Effect of smokers clinic
Expected effect combining effect of medication
with effect of behavioural support
West R, McNeill A and Raw M. Thorax 2000 55
987-999.
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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 not2
• 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.
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Efficacy of various behavioural support approaches
Estimated cessation rate ()
USDHHS. Treating Tobacco use and dependence. A
clinical practice guideline. Rockville, MD AHQR
2000.
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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
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.
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Other support
Telephone calls from a counsellor may be more
effective than self-help materials alone
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.
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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.
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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.
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NRT with limited behavioural support
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.
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NRT with intensive support
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.
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Varenicline

• Varenicline is an effective aid to smoking
  cessation

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.
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Bupropion

• Bupropion is an effective aid to smoking
  cessation

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.
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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.

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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.
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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.
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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.
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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.
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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.

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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

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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.

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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.

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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.

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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

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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