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 CLINICAL INQUIRIES

Evidence Based Answers from the Family Physicians Inquiries Network

What are the most effective
ways you can help patients
stop smoking?

Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas

University of Texas Southwestern Medical Center Library, Dallas

  Evidence summary

Brief counseling works

Good evidence suggests that physician-administered smoking cessation counseling lasting less than 3 minutes improves quit rates.¹ A Cochrane analysis of pooled data from 17 randomized trials that compared brief advice to no advice or usual care showed a small but significant increase in the odds of smoking cessation (odds ratio [OR]=1.74; 95% confidence interval [CI], 1.48-2.05).² The absolute difference in cessation rate was about 2.5% (number needed to treat [NNT]=40).

Another systematic review of 188 RCTs concluded that an estimated 2% (95% CI, 1%-3%; P<.001) of all smokers stopped smoking and did not relapse for as long as a year after receiving advice and encouragement to quit smoking from their physician in a single routine consultation.³

NRT is effective and safe for heart patients

NRT reduces withdrawal symptoms associated with stopping smoking by partially replacing nicotine in the blood. Abstinence rates are superior to placebo based on a Cochrane review (OR=1.77; 95% CI, 1.66-1.88; NNT=20; 95% CI, 17-23).⁴ The Cochrane review also concluded that all commercially available forms of NRT are effective for smoking cessation. Also, recent studies have established no association between NRT and further cardiac events.¹

Antidepressants are good treatment options

Bupropion acts by increasing brain levels of dopamine and norepinephrine and is a nicotine antagonist. A large double-blind, placebo controlled trial compared the relative efficacy of sustained-release bupropion (n=244), nicotine patch (n=244), bupropion plus nicotine patch (n=245), and placebo (n=160).⁵ At 1 year, the bupropion groups had higher self-reported point-prevalence abstinence rates (abstinence during the previous 7 days) than the placebo and nicotine-patch-alone groups (bupropion 30%, placebo 16%, nicotine-patch-alone 16%; absolute risk reduction [ARR]=0.14, NNT=7, P<.001).

Continuous abstinence (abstinence from quit date) was also higher for the bupropion groups compared with placebo (bupropion 18%, placebo 6%; ARR=0.12; NNT=8; P<.001). Adding nicotine replacement to bupropion therapy increased 1-year smoking cessation rates by 5% over bupropion alone but was not statistically significant.

A Cochrane review assessing the efficacy of antidepressants for smoking cessation showed that, when used as monotherapy, bupropion (31 trials; OR=1.94; 95% CI, 1.72-2.19) and nortriptyline (4 trials; OR=2.34; 95% CI, 1.61-3.41) both doubled the odds of smoking cessation.⁶

Another option: Varenicline

Varenicline, a partial agonist at the α4β2 nicotinic acetylcholine receptor, aids smoking cessation by relieving nicotine withdrawal symptoms. A Cochrane meta-analysis concluded that varenicline resulted in significantly greater continuous abstinence at 12 months than placebo (OR=3.22; 95% CI, 2.43-4.27; NNT=8; 95% CI, 5-11).⁷

Recommendations

The US Preventive Service Task Force (USPSTF) strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions as needed.⁸ The USPSTF’s Clinical Practice Guideline for treating tobacco dependence recommends following a 5-step (5 A’s) intervention for smoking cessation in patients willing to quit.¹

1. Ask the patient about smoking status at every visit.

2. Advise the patient to stop smoking.

3. Assess the patient’s willingness to quit.

4. Assist the patient by setting a date to quit smoking, providing self-help materials, and recommending the use of pharmacologic agents.

5. Arrange for follow-up visits.

References

1. Fiore MC. US public health service clinical practice guideline: treating tobacco use and dependence. Respir Care. 2000;45:1200–1262.
2. Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2004;(4):CD000165.
3. Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med. 1995;155:1933–1941.
4. Silagy C, Lancaster T, Stead L, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2004;(3):CD000146.
5. Jorenby DE, Leischo SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med. 1999;340:685–691.
6. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007(1);CD000031.
7. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2007;(1):CD006103.
8.  US Preventive Services Task Force. Counseling to Prevent Tobacco Use and Tobacco-Related Diseases: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2003.

The Journal of Family Practice ©2008 Quadrant HealthCom Inc.