treatobacco.net
Efficacy of treatments
for tobacco dependence
Last updated December 2013
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Efficacy section
Chair
Lindsay Stead
The Cochrane Tobacco Addiction
Group, University of Oxford, UK
Paul Aveyard
University of Birmingham, UK
Michael Fiore
Univ. of Wisconsin Medical School, USA
Jonathan Foulds
Penn State University, Hershey,
Pennsylvania, USA
John Hughes
University of Vermont, Burlington, USA
Martin Raw
consultant,
of Nottingham, UK
Robert West
Last updated December 2013
Freelance
and University
University College London, 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 and
reflect the most recent update of the US guidelines in 2008.
Last updated December 2013
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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.
Intervention
Target population
Brief
opportunistic
advice from a
physician to stop
Smokers attending GP
surgeries or outpatient
clinics
Effect
size1
95% CI
2%
1%-3%
1
The difference in >6 month abstinence rate between intervention and control/placebo in studies
reported
West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999.
Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation.
Cochrane Database of Systematic Reviews 2013, 5.
Last updated December 2013
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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, Raw M. Thorax. 2000; 55: 987-999.
Last updated December 2013
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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, Raw M. Thorax. 2000; 55: 987-999.
USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.
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.
Last updated December 2013
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Face-to-face behavioural support
Intervention
Target population
Effect
size
95% CI
Face-to-face intensive
behavioral support
from a specialist
Moderate to heavy
smokers seeking help
7%
3%-10%
Face-to-face intensive
behavioral support
from a specialist
Smokers admitted to
hospital
4%
0%-8%
West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999.
USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.
Last updated December 2013

Effect of smokers clinic
Intervention
Target population
Intensive behavioral
support plus NRT or
bupropion
Moderate to heavy smokers
seeking help from a smokers
clinic
Effect
13-19%
Expected effect combining effect of medication with effect of behavioural support.
West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999.
Last updated December 2013
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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
1. Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. Cochrane Database of
Systematic Reviews 2013, Issue 8.
2. West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999.
Last updated December 2013
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Efficacy of various behavioural support approaches
Estimated cessation
rate (%)
20
16,8
15
12,3
13,9
13,1
10,8
10
5
0
No
intervention
(reference
group)
Self-help
Proactive
telephone
counselling
Individual
counselling
Group
counselling
USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.
Last updated December 2013
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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.
Written materials and internet sites that are tailored to the
needs of individual smokers are more likely to be helpful
than standard materials.
Intervention
Target population
Effect
size
95% CI
Written self-help
materials
Smokers seeking help with
stopping
1%
0%-2%
Internet based
interventions
Smokers seeking help with
stopping
unclear
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: 987-999.
Civljak M, Stead LF, Hartmann-Boyce J, Sheikh A, Car J. Internet-based interventions for smoking cessation.
Cochrane Database of Systematic Reviews 2013, Issue 7.
Last updated December 2013
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Other support
Telephone calls from a counsellor may be more effective
than self-help materials alone.
Intervention
Target population
Pro-active
telephone
counselling
Smokers wanting help with
stopping but not receiving
face to face support
Effect
size
95% CI
2%
1%-4%
West R, McNeill A,Raw M. Thorax. 2000; 55: 987-999.
USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008 (Table 6.16).
Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of
Systematic Reviews 2013, Issue 8.
Last updated December 2013
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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.
• Combining nicotine patch with a short acting form of NRT
increases success rates.
West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999.
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for
smoking cessation. Cochrane Database of Systematic Reviews 2012, 11.
USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.
Last updated December 2013
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NRT with limited behavioural support
Intervention
Effect size
95% CI
Nicotine gum
4%
3%-5%
Nicotine transdermal patch
6%
4%-8%
West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999.
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for
smoking cessation. Cochrane Database of Systematic Reviews 2012, 11.
Last updated December 2013

NRT with intensive support
Intervention
Effect
size
95% CI
Nicotine gum
7%
5%-8%
Nicotine transdermal patch
6%
5%-7%
12%
7%-17%
Nicotine inhalator
8%
4%-12%
Nicotine sublingual tablet
8%
6%-10%
Nicotine nasal spray
West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999.
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for
smoking cessation. Cochrane Database of Systematic Reviews 2012, 11.
Last updated December 2013
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Nicotine receptor partial agonists
Varenicline and cytisine are both effective aids to smoking cessation.
Intervention
Target population
Effect
size
95% CI
Varenicline
2.0 mg
Moderate to heavy
smokers receiving
behavioral support
15%
13%-17%
Cytisine
1.5 mg
Moderate to heavy
smokers receiving brief
behavioral support
6%
4%-9%
Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of
Systematic Reviews 2012, 4.
Last updated December 2013
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Bupropion
Bupropion is an effective aid to smoking cessation.
Intervention
Target population
Effect
size
95% CI
Bupropion
(300mg/day SR)
Moderate to heavy
smokers receiving
intensive behavioral
support
7%
6%-8%
West R, McNeill A, Raw M. Thorax. 2000; 55: 987-999.
Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane
Database of Systematic Reviews 2014, 1.
Last updated December 2013
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Comparative effectiveness of
pharmacotherapies
• A combination of direct and indirect evidence suggests
that varenicline is more effective than bupropion or a
single type of NRT, but of similar efficacy to combination
NRT
Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and
network meta-analysis. Cochrane Database of Systematic Reviews 2013, 5.
Last updated December 2013
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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, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation.
Cochrane Database of Systematic Reviews 2014, 1.
USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2008.
Last updated December 2013
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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 2008.
Last updated December 2013
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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, Rampes H, Liu JP, Stead LF, Campbell J. Acupuncture and related interventions for smoking cessation.
Cochrane Database of Systematic Reviews 2014, 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 2008.
Last updated December 2013
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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, Raw M. Smoking cessation guidelines for
health professionals: an update. Thorax. 2000; 55: 987-999.
– 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 2008.
http://www.surgeongeneral.gov/tobacco/
Parrott S, et al. Thorax. 1998; 53: S1-S38.
Cromwell J, et al. JAMA. 1997; 278: 1759-1766.
Last updated December 2013
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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.
Last updated December 2013
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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.
Last updated December 2013
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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.
Last updated December 2013
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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, 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 December 2013
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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.
Last updated December 2013
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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.
Last updated December 2013
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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.
Last updated December 2013
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