Last updated November 2011 Efficacy of treatments for tobacco dependence treatobacco.net

Last updated November 2011 Efficacy section ChairLindsay SteadThe Cochrane Tobacco Addiction Group, University of Oxford, UK Paul AveyardUniversity of Birmingham, UK Michael FioreUniv. of Wisconsin Medical School, USA Jonathan FouldsPenn State University, Hershey, Pennsylvania, USA John HughesUniversity of Vermont, Burlington, USA Martin RawFreelance consultant,and University of Nottingham, UK Robert WestUniversity College London, London, UK

Last updated November 2011 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 and reflect the most recent update of the US guidelines in 2008.

Last updated November 2011 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. West R, McNeill A, Raw M. Thorax. 2000; 55: Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008; 2. 1 The difference in >6 month abstinence rate between intervention and control/placebo in studies reported

Last updated November 2011 West R, McNeill A, Raw M. Thorax. 2000; 55: 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.

Last updated November 2011 West R, McNeill A, Raw M. Thorax. 2000; 55: USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 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. 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.

Last updated November 2011 Face-to-face behavioural support West R, McNeill A,Raw M. Thorax. 2000; 55: USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.

Last updated November 2011 Effect of smokers clinic West R, McNeill A,Raw M. Thorax. 2000; 55: Expected effect combining effect of medication with effect of behavioural support.

Last updated November Rice VH, Stead LF. Cochrane Database Syst Rev. 2008; West R, McNeill A,Raw M. Thorax. 2000; 55: Face-to-face behavioural support Nurses can be effective where trained and employed for the purpose. 1 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 evidence. 2

Last updated November 2011 USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR Estimated cessation rate (%) Efficacy of various behavioural support approaches

Last updated November 2011 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,Raw M. Thorax. 2000; 55:

Last updated November 2011 Other support Telephone calls from a counsellor may be more effective than self-help materials alone. West R, McNeill A,Raw M. Thorax. 2000; 55: USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008 (Table 6.16).

Last updated November 2011 West R, McNeill A, Raw M. Thorax. 2000; 55: 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 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. Combining nicotine patch with a short acting form of NRT increases success rates.

Last updated November 2011 NRT with limited behavioural support West R, McNeill A, Raw M. Thorax. 2000; 55: Stead et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2008; 1.

Last updated November 2011 NRT with intensive support West R, McNeill A, Raw M. Thorax. 2000; 55: Stead et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2008; 1.

Last updated November 2011 Cahill K, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2011; 1. Nicotine receptor partial agonists Varenicline and cytisine are both effective aids to smoking cessation.

Last updated November 2011 West R, McNeill A, Raw M. Thorax. 2000; 55: Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007; 1. Bupropion Bupropion is an effective aid to smoking cessation.

Last updated November 2011 Bupropion Limited evidence from a single trial suggests 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 November 2011 Covey LS, et al. Drugs. 2000; 59: Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007; 1. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 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.

Last updated November 2011 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, USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 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

Last updated November 2011 White AR, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev. 2011; 1. Barnes J, Dong CY, McRobbie H, Walker N, Mehta M, Stead LF. Hypnotherapy for smoking cessation. Cochrane Database Syst Rev. 2010;10. USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD: AHQR Acupuncture and Hypnotherapy Acupuncture and hypnotherapy have not been shown to aid smoking cessation over and above any placebo effect.

Last updated November 2011 Parrott S, et al. Thorax. 1998; 53: S1-S38. Cromwell J, et al. JAMA. 1997; 278: 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, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax. 2000; 55: –Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May

Last updated November 2011 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 November 2011 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 November 2011 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 November 2011 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, bupropion or varenicline 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 November 2011 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 November 2011 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 November 2011 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.