Quitting Smoking: Behavioral Therapy and Medications Can Help

Smoking has long been a leading cause of premature death. Fortunately, evidence-based behavioral therapy (such as counseling) and medication (such as nicotine chewing gum) can aid in smoking cessation.

Independent researchers recently prepared an updated systematic review of the scientific evidence on the effectiveness and safety of various smoking-cessation interventions. The review, which was commissioned by the U.S. Preventive Services Task Force (USPSTF) — a volunteer panel of national experts in disease prevention and evidence-based medicine working independently of the drug and medical-device industries — informed the task force’s most recent smoking-cessation recommendations.[1]

The new evidence review concluded that behavioral therapy and pharmacotherapy (drug therapy) to quit smoking are effective for nonpregnant adults, but only behavioral interventions work for pregnant people.[2]

Smoking’s toll

In 2019, approximately 51 million American adults reported using some form of tobacco.[3] Cigarette smoking causes over 480,000 premature deaths each year,[4] and 16 million Americans suffer from serious smoking-induced illnesses such as various cancers, emphysema, asthma, cardiovascular disease, diabetes, immune disorders and reproductive problems.[5]

About two-thirds of smokers say they wish to quit, and 55% attempt to quit each year, but only about 7% succeed. Still, as of 2015, nearly 53 million adults in the U.S. reported that they had quit smoking, suggesting an overall eventual success rate of 59%.[6]

Accordingly, smoking cessation is personally quite challenging, but attainable. Moreover, it is a quintessential public health goal.

Evidence for the USPSTF

An article in the Jan. 19, 2021, issue of the Journal of the American Medical Association (JAMA) systematically reviewed the effectiveness and safety of pharmacotherapy, behavioral interventions and electronic cigarettes (e-cigarettes, vaping) for tobacco cessation.

The JAMA article summarized the results of 67 previous reviews addressing pharmacotherapy and behavioral interventions to quit smoking. Among the 67 reviews, one studied 53 randomized clinical trials (RCTs) involving more than 25,000 subjects and found that combined behavioral and pharmacotherapy significantly increased relative quit rates by 68% to 98%.

Five pharmacotherapy-focused reviews of 336 RCTs including over 159,000 subjects found the following:

• Nicotine replacement therapy (NRT) — which is available as a transdermal nicotine patch (HABITROL, NICODERM CQ), nicotine gum or lozenge (NICORETTE), and nicotine nasal spray or oral inhalant (NICOTROL) — increased the probability of quitting (for at least six months) by 49% to 61%.
• Bupropion (previously marketed under the brand name ZYBAN) increased the probability of quitting by 49% to 76%.
• Varenicline (CHANTIX) increased the probability of quitting by 106% to 143%.

Absolute increases in quitting with pharmacotherapy ranged on average from 6% for NRT to 15% for varenicline. Systematic review of these pharmacotherapy studies further revealed that combining different types of NRT products (such as patches and chewing gums) was, on average, 25% more effective than using just one nicotine product. Additionally, these studies “suggested that varenicline may be superior to NRT and bupropion.”

Public Citizen’s Health Research Group (HRG) has designated bupropion as Limited Use because it can cause adverse effects that include seizures and suicidal thoughts.[7]

Varenicline’s safety concerns include neuropsychiatric effects like seizures, panic attacks and suicidal thoughts; other adverse effects include abnormal heart rhythm, heart attack and stroke.[8] Accordingly, HRG has classified varenicline as a smoking-cessation drug of last resort: It should be used only if all other smoking-cessation methods have failed.

The JAMA article also summarized data from 20 published reviews focused on behavioral smoking-cessation therapies, which included 830 separate RCTs and over 500,000 subjects. These studies overall led the authors to conclude that there was moderate-to-high evidence of benefit from such interventions, including individual and group counseling and mobile-phone–based interactions/supports. More specifically, behavioral interventions yielded six or more months of significantly increased smoking abstinence in behavioral therapy users compared with those in control groups. For example, focused physician advice about smoking cessation increased the probability of successful quitting by 58% to 96%.

Finally, the JAMA article’s assessment of RCTs testing e-cigarettes as a smoking-cessation therapy found that there was insufficient evidence that such therapy was safe and effective. These studies overall did reveal that coughing, nausea, throat irritation and sleep disruption were the most common adverse effects associated with vaping.[9]

Despite speculation that e-cigarettes may reduce cravings for combustible cigarettes, vaping devices are not FDA-approved for smoking cessation. Moreover, the toxic effects of vaping products remain poorly understood and have been linked to escalating nicotine addiction among youths, as well as to rare cases of serious lung illness and death.[10]

Smoking cessation in pregnancy

For pregnant smokers, insufficient or no evidence was found showing that smoking cessation with NRT is beneficial, and no trials were found that tested bupropion, varenicline or e-cigarettes. However, behavioral smoking-cessation therapy trials in pregnant women did demonstrate moderate-to-strong evidence of benefit.

Specifically, according to the JAMA article, one review composed of 26 RCTs and more than 12,000 pregnant women observed that birth weights were, on average, 2 ounces higher for infants of new mothers who received behavioral therapy for smoking cessation during pregnancy than for those born to women who received usual care or other control interventions — a difference that was statistically significant. Additionally, this review observed that the relative risk of low birth weight on average decreased by 17% for infants of women in the behavioral-therapy groups.

Regarding the effects of behavioral therapy on smoking cessation in pregnant persons, the JAMA article identified one review composed of 97 RCTs and more than 26,000 subjects that directly addressed this question. These studies overall revealed that the relative amount of successful quitting in pregnant women treated with psychosocial interventions significantly increased on average by 35% across all trials.

USPSTF recommendations[11]

Based on the systematic review of the evidence, the USPSTF in January 2021 made the following conclusions with high certainty:

• The net benefit of behavioral interventions and FDA-approved pharmacotherapy for tobacco-smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial.
• The net benefit of behavioral interventions for tobacco-smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial.

In contrast, the USPSTF concluded there was insufficient evidence on pharmacotherapy interventions for tobacco-smoking cessation in pregnant persons and on the use of e-cigarettes for tobacco-smoking cessation in adults, including pregnant persons.

The USPSTF therefore strongly recommended the following:

• Health care professionals should ask all adults about tobacco use, advise them to stop using tobacco and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco.
• Health care professionals should ask all pregnant persons about tobacco use, advise them to stop using tobacco and provide behavioral interventions for cessation to pregnant persons who use tobacco.

What You Can Do

If you smoke, you should try to quit. If you have tried to quit in the past and relapsed, do not worry! Most smokers have to make several attempts to stop before finally succeeding.

If you are a nonpregnant smoker, talk to your doctor about a smoking-cessation strategy that combines proven behavioral-therapy interventions with one or more NRT products. Follow the NRT labeling instructions carefully to avoid doubling up on your nicotine dose, especially if you use more than one form (such as gum and a patch).

Bupropion should be used only if behavioral therapies and NRT treatments fail repeatedly. Varenicline should be used only as a last resort. Use of bupropion or varenicline should occur under a doctor’s supervision and should be coupled with behavioral therapy.

If you are pregnant, use only behavioral therapies to quit smoking. Pharmaceutical therapies, including NRT, should be avoided until after your baby is born.

References

[1] US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(3):265-279.

[2] Patnode CD, Henderson JT, Coppola EL, et al. Interventions for tobacco cessation in adults, including pregnant persons; updated evidence report and systematic review. JAMA. 2021;325(3):280-298.

[3] Cornelius ME, Wang TW, Jamal A, et al. Tobacco product use Among adults — United States, 2019. MMWR Morb Mortal Wkly Rep. 2020; 69(46):1736-1742. [4] Centers for Disease Control and Prevention. Tobacco-related mortality. April 28, 2020. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm. Accessed June 14, 2021.

[5] Centers for Disease Control and Prevention. Office on Smoking and Health. Let’s Make the Next Generation Tobacco-Free: Your Guide to the 50th Anniversary Surgeon General’s Report on Smoking and Health. July 2015. https://www.hhs.gov/sites/default/files/consequences-smoking-consumer-guide.pdf. Accessed June 14, 2021.

[6] Babb S, Marlarcher A, Schauer G, et al. Quitting smoking among adults — United States, 2000–2015. MMWR Morb Mortal Wkly Rep. 2017;65(52):1457-1464.

[7] Bupropion (ZYBAN) for smoking cessation. August 2018. https://www.worstpills.org/newsletters/view/1216. Accessed June 15, 2021.

[8] Review of varenicline (CHANTIX) for smoking cessation. November 2018. https://www.worstpills.org/newsletters/view/1230. Accessed June 15, 2021.

[9] Patnode CD, Henderson JT, Coppola EL, et al. Interventions for tobacco cessation in adults, including pregnant persons; updated evidence report and systematic review. JAMA. 2021;325(3):280-298.

[10] National Institute of Drug Abuse. National Institutes of Health. Vaping devices (electronic cigarettes) DrugFacts. January 2020. https://www.drugabuse.gov/publications/drugfacts/vaping-devices-electronic-cigarettes. Accessed June 14, 2021.

[11] US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(3):265-279.