ATTUD Journal Club Postings

Results of Recent Cochrane Review on Efficacy of Different Tobacco Dependence Treatments

The Tobacco Addiction Group of Cochrane (of which I am a member) published six new or revised meta-analyses of treatments for tobacco dependence. I am a big fan of the Cohrane reviews because they are all done using the same methods, usually locate all the available trials, and use rigorous methods.

An updated review of motivational interviewing (MI) located 28 studies and found MI moderately increased cessation by 1.3 fold compared to brief advice alone.  Interestingly, shorter MI sessions did better than longer ones and even a single session increased quitting.  Contrary to my expectation, MI worked equally when in those who did or did not plan to quit at the time.

An updated review of pharmacotherapies for pregnant smokers examined 9 NRT trials and a single bupropion trial but no trials of varenicline. NRT increased cessation 1.4. There were no significantly worsened perinatal outcomes in the NRT conditions and some indication of improvement in a few such outcomes. This was despite low adherence to treatment. One conclusion suggested testing higher doses of NRT.

A meta-analysis examined 47 trials of more vs less intensity behavioral treatment when added to medication treatment. More intense treatment increased quit rates slightly by 1.2 fold. In person and phone treatment appeared equally effective.

An updated review of using incentives (money, vouchers, lottery tickets, etc.) found 21 studies. These incentives increased quitting 1.4 fold. Surprising to me, this occurred even at follow-up long after the incentives had stopped. Some of the trials had smokers make a deposit that would be earned back and these trials did not have better or worse outcomes than when the study simply provided extra monies. The incentive program was especially effective in pregnant women (a 3.6 fold increase and positive results in 8 of 9 studies).

An updated review of treatment for smokeless tobacco examined 34 trials. The two varenicline trials were positive (RR = 1.3), as were the five trials of lozenge (1.4 fold increase). The bupropion, nicotine gum and nicotine patch studies were not effective.  I cannot come up with a reason why lozenge would be effective but gum and patch would not be. The 17 studies of behavioral therapies were so varied they could not be pooled but my reading is that they are very likely to be effective.

A review located 8 studies of interventions to increase treatment adherence (most of which focused on adherence to psychosocial treatments, not medication treatments). A significant but small positive effect was found (RR = 1.1) and the quality of the trials was not great.