ATTUD Journal Club Postings

Efficacy of Adding Counseling to Medications for Smoking Cessation: When is Counseling Justified

A recent Cochrane review (“Behavioral Interventions as adjuncts to pharmacotherapy for smoking cessation”, Issue 12, 2012) reviewed 38 studies found individual in-person or phone counseling of at least 4 sessions were 1.3 times higher than that with medications alone (mostly NRT) with some evidence of greater quit rates with greater intensity of treatment. In comparison, in separate Cochrane reviews, in the absence of medications, individual counseling increased quitting by a factor of 1.7, individual phone counseling by a factor of 1.4 and group counseling by a factor of 1.3. There were an insufficient number of trials to test phone vs in-person counseling.

This is good evidence that smokers taking medications do still benefit from counseling.  Unfortunately, there was no test of whether counseling was especially beneficial to those with more prior failures at quitting or severe nicotine dependence or with psychiatric comorbidity. I think it is imperative for our field to show that for some smokers, brief advice or medications is not sufficient and that individual counseling is especially effective. If hardening is occurring (and there is evidence for this among those seeking treatment (Drug Alcohol Depend 11:117, 2011), then if we can show that for “hard-core” smokers, counseling is especially helpful, we can justify treatment to health agencies. Also, I think there are some smokers whose situation is such that counseling would be especially helpful; e.g., having a spouse who smokes and undermines quitting. I know this is controversial to say, but I think, that given the proven efficacy and low cost of OTC meds, it’s hard to justify the costs of 5-10 individual in-person sessions to health care agencies. And, of course, my naïve notion is that I can a priori identify some smokers who do not have a good chance of quitting if they only use OTC meds. But, although matching patients to different intensities of treatment makes sense it is hard to empirically demonstrate.  Part of me wants to say, that given the huge benefits of smoking cessation, this is one time to not worry about possible overtreatment. But I don’t think my health care colleagues would agree.

Look forward to hearing comments on this.