Smoking cessation: Tactics that make a big difference

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Applied Evidence

Smoking cessation: Tactics that make a big difference

J Fam Pract. 2007 October;56(10):817-824

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References

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10. An LC, Zhu SH, Nelson DB, et al. Benefits of telephone care over primary care for smoking cessation. Arch Intern Med 2006;166:536-542.

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One study¹¹ compared 2 Web programs involving 11,969 smokers. This RCT (SOR: B) looked at an interactive program based, in part, on the AHRQ treatment guidelines. This program generates personalized letters for the participants along with monthly e-mail reminders. A modified program was used as the control. The control program was developed by a maker of NRT products, and contained more information about nicotine than about tobacco dependence and cessation. This program was also shorter than the interactive program, which was designed to assist smoking cessation.

Both programs improved quit rates: 10.9% for the interactive program and 8% for the modified/control program, compared with 3.3% for no treatment at all. Although this study was based on participant reports of abstinence over the previous 7 days, and had low follow-up rates (which Internet studies tend to have), the interactive program produced 1 more quitter for every 26 participants than the modified (control) program, using an intent-to-treat analysis (14.6% vs. 10.7%, P<.001, OR=1.43, 95% CI, 1.28–1.59).

FAST TRACK

Toll-free quitlines provide patients with personal counseling—appealing to those uncomfortable discussing their smoking in a group

Another study¹² looked at the use of a more extensive Web site, combining video, audio, and text. This RCT (SOR: B) was fully automated and delivered entirely by computer. Again, using the AHRQ guidelines and other sources, researchers designed a series of 5 modules to simulate working with a live counselor. There were 13 different versions, to match the demographics of the participant. The modules ended with a “quit calendar” to pick a date within the next 30 days. The program had 20 hours of video, although no participant saw every section. The intent-to-treat analysis showed a significant difference from the treatment group at 12.3% vs the controls at 5.0% (OR=2.66, 95% CI, 1.18–5.99).

TABLE 1
Web-based support helps smokers quit

www.quitnet.com Boston University School of Public Health	Personalized quit plans
www.ffsonline.org American Lung Association	“Freedom from smoking” modules to guide smokers through quit process
www.whyquit.com Privately supported	Support for “cold turkey” quitting
www.trytostop.org Massachusetts Department of Public Health	Personalized “Quit Wizard” program

Text messages work

Text messaging may also have a place in supporting smoking cessation efforts. An interesting, although short, study¹³ looked at using text messaging to target younger smokers in New Zealand. This RCT (SOR: B) involved 1705 smokers who had cell phones with text messaging. Researchers sent participants up to 5 messages daily around their quit date, drawing from over 100 messages that could be personalized with individual names/nicknames. The quit rate was doubled 6 weeks out (28% vs 13%; relative risk=2.20; 95% CI, 1.79–2.70).

Rx in hand, support in place

When Ann left my office, she took with her a prescription for varenicline, the state’s quitline number, and the URL for an online support program. Ann was eager to try varenicline: a coworker of hers was using it and doing well. Ann had tried the nicotine patch in the past, but reported that it gave her nightmares. She’d also kept smoking while wearing it. This time, she hoped she’d finally be able to quit for good.

Weighing the drug treatment options

The AHRQ guidelines recommend several types of pharmacotherapy. First-line therapies include different forms of NRT and sustained-release bupropion (Zyban).^2,3

Nicotine replacement therapy doubles the chances of quitting

With NRT, the nicotine in cigarettes is replaced with nicotine from another source. The thought is that by reducing the withdrawal symptoms, the patient is less likely to relapse and resume smoking. Nicotine replacement is available in several forms: gum, transdermal patches, intranasal spray, inhaler, and lozenges.

A Cochrane meta-analysis of NRT¹⁴ (SOR: A) analyzed 123 studies that followed patients for at least 6 months from their quit date. The authors concluded that NRT could almost double a patient’s chances of quitting smoking. The data from various types of NRT revealed the types to be similarly efficacious (TABLE 2). In the treated groups, 17% were abstinent and only 10% were abstinent in the control groups at the various endpoints of the trials. Smokers with higher levels of nicotine dependence as indicated by smoking 10 or more cigarettes daily have higher quit rates using replacement nicotine. Generally, treatments of 8 weeks are as effective as longer courses.

The Cochrane meta-analysis also revealed that:

Duration of therapy ranges from 3 weeks to 12 months with the various forms of NRT.
There was no benefit to tapering off the NRT as compared to an abrupt withdrawal.
Patients are much more likely to relapse after NRT in the first 3 months.
Combining several forms of NRT may aid a relapsed smoker in another quit attempt. However, the re-attempt should be delayed by a few months, as back-to-back courses are unlikely to improve quit rates.