Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Self-help interventions alone minimally increase smoking cessation

ACP J Club. 1999 Mar-April;130:41. doi:10.7326/ACPJC-1999-130-2-041


Source Citation

Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Review, latest version 26 Aug 1998. In: The Cochrane Library. Oxford: Update Software.


Abstract

Question

How effective are self-help smoking cessation interventions?

Data sources

Studies were identified by searching the Tobacco Addiction Review Group Register (which includes studies identified from MEDLINE, PsycLIT, Dissertation Abstracts Online, Applied Social Sciences Index and Abstracts, Social Citations Index, and Social Science Citations Index) using the terms self-help, manual, and booklet; and bibliographies of previous reviews.

Study selection

Randomized or quasi-randomized controlled trials were selected if they had ≥ 6 months of follow-up and if ≥ 1 treatment arms involved a self-help intervention without repeated face-to-face contact with a therapist. Self-help interventions had to involve a structured program for quitting. Studies of pregnant women were excluded.

Data extraction

Data were extracted on the study population, method of randomization, type of intervention, follow-up, and validation of self-reported cessation.

Main results

Meta-analysis of 10 trials of self-help compared with no self-help found no clear differences for smoking cessation at longest follow-up (P = 0.06) (Table). When 3 trials, in which the control group received some form of leaflet, were excluded from the analysis, the self-help group had slightly higher smoking cessation rates (P < 0.04) (Table). Adding self-help to advice or to nicotine replacement therapy did not increase smoking cessation. Several studies assessed enhancements to self-help interventions. Meta-analysis of 6 studies showed that personalized self-help materials increased smoking cessation compared with standard materials (6.2% vs 4.3%, relative benefit increase [RBI] 49%, 95% CI 12 to 98). Meta-analysis of 6 studies showed that self-help materials with telephone follow-up increased smoking cessation (11.4% vs 7.9%, RBI 55%, CI 30 to 85).

Conclusions

Self-help interventions alone minimally increase smoking cessation rates. Self-help materials added to nicotine replacement therapy or to advice do not confer additional benefits. Self-help interventions that are personalized to individual smokers or supplemented with telephone follow-up improve smoking cessation.

Sources of funding: National Health Service and Imperial Cancer Research Fund.

For correspondence: Mrs. Lindsay Stead, ICRF General Practice Research Group, Division of Public Health and Primary Health Care, Institute of Health Sciences, Old Road, Headington, Oxford OX3 7LF, UK. FAX 44 1865 227137.


Table. Self-help vs no self-help for smoking cessation at longest follow-up (range 6 to 24 mo)*

Number of studies Weighted event rates RBI (95% CI) NNT (CI)
Self-help No self-help
10 5.1% 4.5% 8% (-8 to 27) Not significant
7† 4.3% 3.5% 27% (2 to 58) 123 (64 to 1771)

*Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article.
†Control group received no written materials.


Commentary

Lancaster and Stead did a concise review of the randomized controlled trials of smoking cessation self-help materials. They conclude that self-help materials have limited benefit but may still play a role in smoking cessation programs.

Self-help materials are a low-intensity intervention and should not be expected to be very effective. For smoking cessation, self-help materials are somewhat beneficial when tailored to a person's readiness to quit or when used in conjunction with telephone follow-up. Self-help materials have no benefit if mailed or added to the advice of a health care professional in the clinical setting.

What role do self-help materials play in the primary care clinic? For patients who are not ready to quit, the materials can motivate them to attempt to quit between clinic visits. For patients who are ready to quit, the materials can reinforce the clinician's advice and provide details of the cessation instructions. Although some experts recommend that all persons who smoke receive nicotine replacement therapy (1), self-help materials may be sufficient for motivated persons who are light smokers and are much less expensive than medication therapy (2).

In a busy clinic, advice from health professionals may not be systematically given, so I still recommend using self-help materials to fill in the gaps of clinical advice. The bottom line of this review is that clinicians should not expect self-help materials to be very successful on their own.

Eric C. Westman, MD, MHS
Duke University and Durham Veterans Affairs Medical CenterDurham, North Carolina, USA


References

1. The Agency for Health Care Policy and Research smoking cessation clinical practice guideline. JAMA. 1996;275:1270-80.

2. Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Review, latest version 21 May 1998. In: The Cochrane Library. Oxford: Update Software.