Clinical Review

Smoking cessation: Tactics that make a difference

OBG Manag. 2008 March;20(3):35-44

References

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Web-based programs offer reminders

Like quitlines, Web-based programs offer smokers immediate feedback to help them quit. Many of the programs include links to quitting resources, stories from former smokers and cancer patients, live advice from counselors, and message boards (TABLE 1). Web-based programs have been shown to help improve quit rates.

One study compared two Web programs involving 11,969 smokers.¹¹ This RCT looked at an interactive program based, in part, on the AHRQ treatment guidelines. This program generates personalized letters for the participants along with monthly e-mail reminders. A modified program, developed by a maker of NRT products, served as the control; it contained more information about nicotine than about tobacco dependence and cessation. This program was also shorter than the interactive program, which was designed to assist smoking cessation.

Both programs improved quit rates: 10.9% for the interactive program and 8% for the modified/control program, compared with 3.3% for no treatment at all. Although this study was based on participant reports of abstinence over the previous 7 days, and had low followup rates (which Internet studies tend to have), the interactive program produced one more quitter for every 26 participants than the modified (control) program did, according to an intent-to-treat analysis (14.6% vs 10.7%, P<.001 or="1.43;" ci>

Another RCT looked at the use of a more extensive Web site, combining video, audio, and text.¹² This program was fully automated and delivered entirely by computer. Again, using the AHRQ guidelines and other sources, researchers designed a series of five modules to simulate work with a live counselor. There were 13 different versions to match the demographics of the participant. The modules ended with a “quit calendar” for use by the participant to pick a date within the next 30 days. The program included 20 hours of video, although no participant saw every section. The intent-to-treat analysis showed a significant difference between groups: 12.3% in the treatment group versus 5% in the control group (OR=2.66; 95% CI, 1.18–5.99).

TABLE 1

Web-based support helps smokers quit

www.quitnet.com Boston University School of Public Health	Personalized quit plans
www.ffsonline.org American Lung Association	“Freedom from smoking” modules to guide smokers through quit process
www.whyquit.com Privately supported	Support for “cold turkey” quitting
www.trytostop.org Massachusetts Department of Public Health	Personalized “Quit Wizard” program

Text messages work

A short but interesting study used text messaging to target younger smokers in New Zealand.¹³ This RCT involved 1,705 smokers who had cell phones with text messaging. Researchers sent participants up to five messages daily around their quit date, drawing from over 100 messages that could be personalized with individual names/nicknames. The quit rate doubled 6 weeks out (28% vs 13%; relative risk=2.2; 95% CI, 1.79–2.70).

CASE…continued Support in place

Ann leaves the office with her prescription for varenicline and OCs, the state’s quitline number, and the URL for an online support program. She is eager to try varenicline: A coworker of hers is using it and doing well. Ann has tried the nicotine patch in the past, but says that it gave her nightmares. (She kept smoking while wearing it.) This time, she hopes she’ll finally be able to quit for good.

Weighing the drug treatment options

The AHRQ guidelines recommend several types of pharmacotherapy. First-line therapies include different forms of NRT and sustained-release bupropion (Zyban).^2,3

Nicotine replacement therapy doubles the chance of quitting

With NRT, the nicotine in cigarettes is replaced with nicotine from another source to reduce withdrawal symptoms so that the patient is less likely to relapse. Nicotine replacement is available in several forms: gum, transdermal patches, intra-nasal spray, inhaler, and lozenges.

A Cochrane meta-analysis of NRT analyzed 123 studies that followed patients for at least 6 months after their quit date.¹⁴ The authors concluded that NRT could almost double a patient’s chance of quitting smoking. The data from various types of NRT revealed the types to be similarly effective (TABLE 2). In the treated groups, 17% were abstinent, compared with only 10% in the control groups at the various endpoints of the trials. Smokers who had higher levels of nicotine dependence, as indicated by smoking 10 or more cigarettes daily, had higher quit rates using replacement nicotine. Generally, treatment for 8 weeks was as effective as a longer course.

The Cochrane meta-analysis also revealed that:

Duration of therapy ranges from 3 weeks to 12 months with the various forms of NRT.
There was no benefit to tapering off the NRT, compared with abrupt withdrawal.
Patients are much more likely to relapse after NRT in the first 3 months.
Combining several forms of NRT may aid a relapsed smoker in another quit attempt. However, the reattempt should be delayed by a few months, as back-to-back courses are unlikely to improve quit rates.