Effectiveness of interventions to aid smoking cessation Robert West University College London September 2008

Disclosure I undertake research and consultancy for manufacturers of smoking cessation medications and am a trustee of QUIT

Aims To review the effectiveness of aids to cessation –Behavioural support –Medications To make recommendations for practice

Behavioural support Advice, encouragement and activities designed to: –maximise motivation to maintain abstinence e.g. using anticipated praise and shame; fostering sense of achievement –minimise motivation to smoke e.g. advising on stress reduction, avoiding high-risk situations –improve medication adherence e.g. explaining mechanism of action –enhance self-regulatory skills and capacity e.g. teaching strategies for resisting urges in smokers seeking help with stopping

Review summaries + Good evidence for clinically significant effect +?Evidence suggestive of a clinically significant effect ? Insufficient evidence to draw a general conclusion -?Evidence suggestion of no clinically significant effect -Good evidence for no clinically significant effect

Basis for summaries Main reviews –Cochrane –NICE –Systematic review from Pubmed (for internet interventions) See also –

Behavioural support Modes of delivery Type of provider Target population Intervention components

Modes of delivery ConclusionIssues One-to-one face-to-face vs written materials +No clear effect of intensity Group face to-face vs written materials +Not clearly different from one-to-one Telephone vs written materials +Mostly lacking biochem verification Telephone plus face-to-face vs face-to-face only +No biochemical verification Tailored internet vs untailored +?No biochemical verification; depends on particular system Written materials vs nothing+?Small overall effect and heterogeneous

Types of provider ConclusionIssues Nurses+Mixes different intervention types; advice and support during health checks not found to be effective Pharmacists+?Limited data

Target populations ConclusionIssues Patients before surgery+Short-term effect Hospitalised patients+Only in those also offered medication and support after discharge Pregnant smokers+Appears to require dedicated specialist Smokers in the workplace+Similar to support given in other contexts

11 Intervention components ConclusionIssues Promoting physical exercise ?Limited data Hypnotherapy?No evidence for specific effect but heterogeneity Use of biomarkers?Limited data: new studies not included Relapse prevention-?Limited data Aversive smoking+?Poor quality studies Enhancing partner support-?Limited data Competitions and incentives -Short-term benefits only

Conclusions: behavioural support Clear evidence that behavioural support can be effective –delivered through a variety of modalities –by a variety of providers –with variety of target populations –but no clear evidence on how to improve on basic behavioural support Need to build on this with innovative approaches and evaluation methods Requires: –detailed information about intervention elements –taxonomy of intervention elements and link with theories

Medications Tablets and drug delivery devices that: –minimise the desire or need to smoke –block the rewarding effect of nicotine if a lapse occurs

Nicotine Replacement Therpay ConclusionIssues NRT vs placebo+Many smokers have already tried and failed on NRT Start patch 2wks before TQD vs start on TQD +Requires longer lead in Combine patch + acute NRT vs single forms +Increased cost NRT for Reduce to Quit vs placebo +Not clear how this translates into clinical practice

Other medications ConclusionIssues Bupropion vs placebo+Contraindications Bupropion vs NRT?Conflicting results Bupropion + NRT vs either alone ?Conflicting results Varenicline vs placebo+New drug, more expensive Varenicline vs bupropion+New drug, more expensive Varenicline vs NRT+New drug, more expensive

Conclusions: Medication Varenicline and ‘optimised NRT’ appear to have the greatest efficacy No clear benefit of bupropion over NRT

Recommendations Treatment of choice –Optimised NRT (patch started before quit date then combination of patch plus acute form) or –Varenicline plus –specialist face-to-face behavioural support plus –telephone support Otherwise consider –Standard NRT –Bupropion –Internet –Telephone support alone

Major areas of uncertainty NRT for pregnant smokers Medication and behavioural support for psychiatric patients New models of delivery –rolling groups –drop-in centres –etc. Relapse prevention methods Content of behavioural support Behavioural support in primary care