Review: Simple support and nicotine replacement improve quit rates for smokers
ACP J Club. 1996 Mar-April;124:46. doi:10.7326/ACPJC-1996-124-2-046
Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med. 1995 Oct 9;155:1933-41. [PubMed ID: 7575046]
To study the efficacy of interventions designed to help persons stop smoking.
Randomized controlled trials were identified using MEDLINE and Index Medicus, bibliographies of relevant studies and review articles, and contact with experts.
Studies were selected if follow-up lasted at least 6 months. 120 studies (188 trials) were included.
Data were extracted on type of intervention, type of health care provider, number of patients studied, and patients' specific health status (such as pregnancy and high risk for ischemic heart disease). Intention-to-treat analysis was used for each trial. The result for each intervention was expressed as the summary difference between percentages of treated and control patients who had quit smoking at 6 to 12 months.
After one episode of advice and encouragement from a physician (17 trials), the summary difference of smokers who stopped smoking was 2% (95% CI 1% to 3%), a modest but highly cost-effective result ($1500 US per life saved). The summary difference of more frequent encouragement (10 trials) was 5% (CI 1% to 8%); this was greater, but the data from the various trials were variable. The summary difference of advice and encouragement was greater in situations of special risk: pregnancy (10 trials), 8% (CI 4% to 11%); after myocardial infarction (1 trial), 36% (CI 23% to 48%); and in men who had high risk for ischemic heart disease (4 trials), 21% (CI 10% to 31%). Nonspecific behavior modification therapy was no more effective than simple advice (30 trials): 2% (CI 0% to 4%). Nicotine replacement was effective: 2-mg nicotine gum in consecutive patients (15 trials), 3% (CI 2% to 5%); 2-mg nicotine gum in self-referred patients, who were probably more motivated (13 trials), 11% (CI 7% to 15%); nicotine patch in consecutive patients (4 trials), 4% (CI 2% to 6%); and nicotine patch in self-referred patients (10 trials), 13% (CI 10% to 16%). The summary difference for nicotine replacement was greater in nicotine-dependent smokers. The effects of using nurses in health promotion clinics, clonidine, aversion with rapid or satiation smoking, and hypnosis were unclear. Supportive group sessions, aversion with silver acetate gum or spray, sensory deprivation, tranquilizers, and acupuncture were ineffective. Gradual stopping was no better than sudden cessation.
Advice for persons to stop smoking is effective, especially in certain high-risk populations. Additional interventions add to the rates of smoking cessation but may not be as cost-effective as simple interventions.
Source of funding: Department of Health, London, England.
For article reprint: Not available.
Many millions of people around the world continue to smoke cigarettes. Many methods to assist patients to quit smoking exist, but their efficacy and cost-effectiveness vary greatly. Law and Tang did an exhaustive review of the published literature and appropriately focused on randomized controlled trials that followed patients for at least 6 months. The article provides summary estimates for all these trials and also provides estimates for trials in which biochemical verification was done.
For clinicians, an important finding is that some smokers will quit as a result of brief, unsolicited advice from their physicians. Additional interventions building on brief physician advice, including follow-up appointments, letters, and telephone calls, are warranted and can add to the effectiveness. In high-risk situations, such as pregnancy and ischemic heart disease, the efficacy of interventions is quite high, and these populations must be targeted. No strong data support the use of behavior modification therapy. Finally, the availability of effective agents will vary from country to country (e.g., only nicotine gum and transdermal nicotine patches are approved for use by the U.S. Food and Drug Administration). The nicotine patch is easier to use and, in trials done in typical physician practices, was more effective than the gum. New forms of nicotine replacement such as nasal spray, inhalers, and other effective non-nicotine pharmacologic agents will continue to be offered in the next few years. Ineffective treatments include acupuncture, sensory deprivation, and aversion therapy.
This thorough article can be an excellent resource for clinicians, and the references cited will be highly useful to clinical investigators. Clinicians should assist patients in smoking cessation by using modalities that are proved to be efficacious. Above all, physicians must provide brief advice to all smokers during each encounter.
Jasjit S. Ahluwalia, MD, MPH, MS
Emory University School of MedicineAtlanta, Georgia, USA