Facts of Life

Facts of Life:
Issue Briefings for Health Reporters
Vol. 10, No. 7
July 2005

Smoking Cessation: Beyond the Patch

The Issue

The Facts

Evaluating Behavioral Quit Therapies

Expert Sources

References

The Issue:

Since the government declared smoking “a hazard to your health” in 1964, the percentage of Americans who smoke cigarettes has fallen sharply. However, despite decades of no-smoking advice, tobacco still poses a significant worldwide risk. In the United States, smoking-related diseases cause nearly 20 percent of all deaths each year. Direct medical costs from smoking top $75 billion each year, and almost 14 percent of Medicaid spending is attributable to smoking-related illness. ¹

Cessation Without Medication

Smoking cessation aids such as nicotine replacement patches, pills and gum are used by millions to give up tobacco. Since 1997, physicians have prescribed the antidepressant drug bupropion to treat the cravings and withdrawal symptoms experienced by quitters. Although many studies confirm the success of these therapies ², medication is not always part of a smoker’s cessation arsenal. A recent review found that fewer than one in five smokers use nicotine replacement therapy when they attempt to kick the habit. ³

Evidence for a Behavioral Approach

As studies accumulate on behavioral approaches to smoking cessation, systematic reviews of their efficacy follow. In particular, researchers are examining the evidence for community based interventions, workplace programs and tailored cessation counseling for older smokers, pregnant women and racial and ethnic minority smokers ^{4, 5, 6}. As smoking cessation therapy enters its fourth decade, other studies focus on the long-term success of specific cessation.

The Facts:

• The 1996 U.S. Public Health Service clinical practice guidelines for smoking cessation treatment synthesized research findings from nearly 3,000 studies. Another 3,000 new smoking cessation studies were added to the guideline’s evidence base in 2000.⁷

• A review of workplace programs for smoking cessation suggests that the programs reduce the number of cigarettes smoked during the workday, but there is conflicting evidence about whether they reduce overall cigarette consumption by smokers.⁹

• Smokers employed in completely smoke-free workplaces smoke three fewer cigarettes a day on average, according to a 2002 systematic review.¹⁰

• A 2004 review found that psychologists, physicians and nurses can all deliver effective smoking cessation counseling, but the effectiveness of each provider increased nearly twofold when used with nicotine replacement therapy.¹¹

• Smokers who suffer from depression are not more likely to return to smoking after cessation treatment than smokers without depression, according to a 2003 analysis.¹²

• Smoking cessation treatment during pregnancy can reduce the risk of low birth weight and preterm birth, according to a 2004 systematic review.¹³

• A review of community-wide quit programs found that most programs have limited effects, at most producing a 3 percent decline in the number of smokers in a community.¹⁴

• Reward programs and competitions to quit smoking do not change rates of long-term smoking cessation, according to a 2005 systematic review. ¹⁵

• Selective serotonin reuptake inhibitor antidepressants like Prozac or Zoloft have not been shown to aid in long-term smoking cessation.¹⁶

• Despite being widely recommended to those who wish to quit smoking, there is not enough evidence to show that regular exercise is an effective aid in smoking cessation.¹⁷

• Several recent systematic reviews found no clear evidence that acupuncture, acupressure, laser therapy, electrostimulation or hypnotherapy are effective for smoking cessation. ^18,19

Evaluating Behavioral Quit Therapies

Clinical trials of a nicotine replacement patch or a drug that controls a smoker’s cigarette cravings can be relatively straightforward. The drug trials measure the effect of a single variable (the medication) on a simple outcome (giving up cigarettes for a specific length of time). Evaluating the effects of a behavioral intervention on smoking cessation can be considerably more difficult, according to cessation researcher Tim Lancaster, M.D., of Oxford University.

“Part of the reason for continued interest in behavioral approaches is that we know that some of them help, but don’t know much about which components of the treatment make a difference. So a lot of studies are looking at different elements of behavioral treatments to try to tease this out,” he explains.

Lancaster and his colleagues are analyzing new studies and updating previous systematic reviews of behavioral interventions for smoking cessation for the Cochrane Collaboration’s Tobacco Addiction Group. The reviews provide a glimpse at what works, what does not work and what might work among behavioral treatments.

For instance, counseling at a variety of levels seems to improve quit rates among smokers. Lancaster says that individual, face-to-face counseling has the most support from the scientific literature, but telephone counseling and group therapy can also boost quit rates.²⁰ However, there is not enough evidence yet to know whether group therapy is as effective as individual therapy, the Cochrane researchers conclude.

The reviewers did not find any evidence that alternative therapies such as acupuncture or hypnotherapy have a significant effect on smoking quit rates. There is also no evidence that supportive partners, long thought to encourage smokers in their quit efforts, actually help to increase quit rates, according to another review ²¹.

The jury is still out on the effectiveness of other cessation interventions, including self-help materials such as pamphlets that provide quit tips ²², monitoring of quit efforts by community pharmacists ²³, exercise therapy and “speed smoking” ²⁴, in which smokers must puff on cigarettes every few seconds until they feel sick. For most of these strategies, there are too few studies to evaluate whether they can boost cessation rates, the Cochrane researchers found.

Despite increasing numbers of studies on behavioral strategies, Lancaster acknowledges that drug treatments will continue to loom large in smoking cessation therapy.

“We know that there are some biomedical treatments on the horizon, such as nicotine vaccines and a drug called rimonabant, but we are unable to review them until the primary research is released,” Lancaster says.

Expert Sources:

References

1. Centers for Disease Control and Prevention, Chronic Disease Prevention. Reducing tobacco use. Last accessed June 13, 2005 at http://www.cdc.gov/nccdphp/bb_tobacco/.

2. C Silagy et al. (2004) Nicotine replacement therapy for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 3.

3. K.M. Cummings and A. Hyland (2005) Impact of nicotine replacement therapy on smoking behavior. Annual Review of Public Health, 26, 583-599.

4. J.O. Andrews et al. (2004) Management of tobacco dependence in older adults: using evidence-based strategies. Journal of Gerontological Nursing, 30, 13-24.

5. J. Lumley et al. (2004) Interventions for promoting smoking cessation during pregnancy. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

6. D. Lawrence et al. (2003) Smoking cessation interventions in U.S. racial/ethnic minority populations: an assessment of the literature. Preventive Medicine, 36, 204-216.

7. U.S. Public Health Service (2000) Treating Tobacco Use and Dependence. Last accessed June 13, 2005 at http://www.surgeongeneral.gov/tobacco/smokesum.htm.

8. LF Stead et al. (2005) Telephone counselling for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

9. M. Moher et al. (2005) Workplace interventions for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

10. C.M. Fichtenberg and S.A. Glantz (2002) Effect of smoke-free workplaces on smoking behaviour: systematic review. British Medical Journal, 325, 188-193.

11. W.A. Mojica et al. (2004) Smoking-cessation interventions by type of provider: a meta-analysis. American Journal of Preventive Medicine, 26, 391-401.

12. B. Hitsman et al. (2003) History of depression and smoking cessation outcome: a meta-analysis. Journal of Consulting and Clinical Psychology, 71, 657-663.

13. J. Lumley et al. (2004) Interventions for promoting smoking cessation during pregnancy. (Review) The Cochrane Database of Systematic Reviews, Issue 4.

14. R.H. Secker-Walker et al. (2005) Community interventions for reducing smoking among adults. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

15. K. Hey and R. Perera (2005) Competitions and incentives for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

16. J.R. Hughes et al. (2005) Antidepressants for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

17. M. Ussher (2005) Exercise interventions for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

18. A.R. White et al. (2005) Acupuncture for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

19. N.C. Abbot et al. (2005) Hypnotherapy for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

20. T. Lancaster and L.F. Stead (2005) Individual behavioural counselling for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

21. E-W. Park et al. (2005) Enhancing partner support to improve smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

22. T. Lancaster and L.F. Stead (2005) Self-help interventions for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

23. H.K. Sinclair et al. (2005) Community pharmacy personnel interventions for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

24. P. Hajek and L.F. Stead (2005) Aversive smoking for smoking cessation. (Review) The Cochrane Database of Systematic Reviews, Issue 2.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Lisa Esposito
Editor, Health Behavior News Service
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
Washington, DC 20009
p. 202.387.2829 / f. 202.387-2857
press@cfah.org
http://www.cfah.org

© Copyright 2005, Center for the Advancement of Health

PDF Version