BMJ  2003;327:1395-1396 (13 December), doi:10.1136/bmj.327.7428.1395

Commentary

Putting the research into practice

¹ Tobacco Research and Treatment Center, Harvard Medical School, Boston, MA 02114, USA nrigotti{at}partners.org

Tobacco use is common and is the leading preventable cause of death in the United States and the United Kingdom. Smoking cessation benefits virtually every smoker, regardless of age, disease state, or years of smoking.¹ Smoking persists because of physical dependence on nicotine and psychological dependence on cigarettes as part of the daily routine, and as a way of coping with stress.² Smokers, even those with tobacco related disease, are often ambivalent about quitting, discouraged by failed attempts to stop, and unaware of effective treatments. Tobacco use is best regarded by doctors as a chronic condition requiring long term management rather than just one-time advice to quit.^{2 3}

Selecting treatments

Pharmacotherapy and counselling are each effective for treating tobacco use, but combining the two produces the best success.^3-5 Smoking cessation counselling uses cognitive behavioural therapy combined with education about nicotine dependence and withdrawal symptoms. Generally, a trained counsellor provides a series of sessions, in person or by telephone, over at least four weeks.³

The first line drugs for smoking cessation are nicotine replacement and buproprion SR (sustained release), an atypical antidepressant.^{3 4} Each roughly doubles cessation rates compared to a placebo.^3-5 Nortriptyline, a tricyclic antidepressant, is effective but considered second line because it has less evidence of efficacy.³ No other antidepressant, no anti-anxiety drug, and no alternative therapy, such as hypnosis or acupuncture, has clearly shown efficacy for smoking cessation.³

Brief smoking cessation counselling by a doctor or other healthcare professional in the course of daily practice is more effective than just advising a smoker to quit. The recommended strategy is to (a) identify every patient's smoking status; (b) advise all smokers to quit; (c) assess each smoker's readiness to quit; (d) provide brief counselling and assistance (medication, and referral to a specialised telephone or in-person counselling programme); and (e) monitor progress of treatment.^{3 4}

Pitfalls in using the evidence

Few studies have compared the effective drugs with each other. One study found that bupropion was superior to the nicotine patch.⁶ Another found that nicotine replacement products were equally effective.⁷ In the absence of clear empirical guidance, clinical guidelines and expert opinion regard first line drugs as roughly equivalent and recommend basing the choice of treatment on a smoker's preference and past experience, unless one drug is contraindicated.^2-4 Although the various nicotine replacement products and bupriopion can be combined safely, the usual strategy is to start with one drug and add a second if the smoker has difficulty maintaining abstinence.

Current treatment methods assume that a smoker is ready to attempt cessation, but many smokers are not. These smokers often frustrate doctors, and an effective strategy for them is unclear. Motivational enhancement strategies, initially designed for alcohol abuse, have been adapted to treat smokers and are recommended, but their efficacy has not been shown.⁸

When to refer

Primary care physicians can treat many smokers successfully, and they should initiate and monitor treatment with all smokers. Smokers with characteristics that predict a low chance of success can benefit from referral.² Smokers with little confidence in their ability to quit or little social support for non-smoking (for example, a spouse who smokes) need referral to a formal smoking counselling program. Many smokers who have repeatedly failed to quit have never used behavioural treatment and benefit from referral to a formal programme, as well as intensive pharmacotherapy. Smokers with active alcohol misuse, substance misuse, depression, or other psychiatric disorder cannot succeed in quitting without concomitant treatment of these conditions.

---

Competing interests: NAR has received funding for research from GlaxoSmithKline, which manufactures smoking cessation products.

References

1. US Department of Health and Human Services. The health benefits of smoking cessation: a report of the surgeon general. Rockville, MD: US Department of Health and Human Services, 1990. (DHHS publication No (CDC) 90-8416.)
2. Rigotti NA. Treatment of tobacco use and dependence. N Engl J Med 2002;346: 506-12.[Free Full Text]
3. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Treating tobacco use and dependence: a clinical practice guideline. Rockville, MD: US Department of Health and Human Services, 2000. www.surgeongeneral.gov/tobacco (accessed 6 Nov 2001).
4. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000;55: 987-99.[Abstract/Free Full Text]
5. Lancaster T, Stead L, Silagy C, Sowden A for the Cochrane Tobacco Addiction Review Group. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321: 355-8.[Free Full Text]
6. Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999;340: 685-91.[Abstract/Free Full Text]
7. Hajek P, West R, Foulds J, Nilsson F, Burrows S, Meadow A. Randomized comparative trial of nicotine polacrilex, a transdermal patch, nasal spray, and an inhaler. Arch Intern Med 1999;159: 2033-8.[Abstract/Free Full Text]
8. Burke BL, Arkowitztt, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled trials. J Consul Clin Psychol 2003;71: 843-61.[CrossRef][ISI][Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Article

What the educators are saying

Maureen Kelly and Peter Cantillon
BMJ 2003 327: 1393. [Full Text] [PDF]