NIHR Signal Behavioural and drug treatment together help those with lung disease stop smoking

Published on 6 December 2016

Smokers with chronic obstructive pulmonary disorder (COPD) given drug treatment alongside behavioural therapy were more than twice as likely to stop smoking by six months as those given behavioural treatment alone. There was also some evidence that high intensity behavioural treatment is more effective than usual care or lower intensity therapy.

This review identified a large number of trials investigating different smoking cessation therapies. However, due to the variation in behavioural or drug treatments used, only four high quality studies could be pooled in meta-analysis. These studies provided evidence that the three standard smoking cessation treatments – nicotine replacement therapy, bupropion and varenicline – are more effective than placebo. As different combinations of behavioural and drug treatment were used there was no evidence to support one approach over another.

There isn’t yet enough evidence to say if smokers with COPD benefit from extra or different treatments than smokers without COPD, but given the importance of stopping smoking, this suggests that for this group the more intensive the effort the better the results.

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Why was this study needed?

About 640,000 people in England have been diagnosed with COPD, and there may be another 1.3 million undiagnosed. COPD is one of the most common causes of death in England, and the fifth largest cause of emergency hospital admissions. Smoking is the main cause of COPD, thought to be responsible for about nine in 10 cases. About 35% of newly diagnosed people with COPD are still smoking.

The damage caused to the lungs is permanent, but stopping smoking is the most important way people can slow down the progression of COPD. There is evidence to support the effectiveness of stop-smoking therapies for smokers in general. However, there has been little evidence about the best way to help smokers with COPD to stop. People with COPD are likely to have been smoking for longer and may need additional help to stop. This updated Cochrane review identified evidence published since an earlier 2003 review on the topic.

What did this study do?

This systematic review included 16 randomised controlled trials with a total of 13,123 adults with COPD, aged from 48 to 66 years. Trials investigated the effectiveness of behavioural or drug treatments, or both, to help people with COPD to stop smoking for at least six months.

Four of the studies were similar enough to be pooled for meta-analysis. The rest were too different in terms of type of treatment, severity of COPD, and how smoking cessation was defined and measured. Behavioural therapies and usual care differed, making it difficult to interpret and compare the results. The most common risks of bias across trials were participants and assessors being aware of treatment given, and incomplete outcomes reported. Trials mainly came from Europe, US or Canada. One trial came from Ireland but none was UK-based.

What did it find?

  • In four trials with 1,540 participants, smokers with COPD who received drug treatment combined with intensive behavioural support were more than twice as likely to stop smoking by six months (quit rates in 17 per 100) as those who received behavioural support alone (7 per 100) risk ratio [RR] 2.53, 95% confidence interval [CI] 1.83 to 3.50. High GRADE of evidence.
  • These four trials had used the smoking cessation therapies authorised for use in the UK, and all three were effective compared with placebo:
    • Bupropion: RR 2.03, 95% CI 1.26 to 3.28 (pooled results of two studies).
    • Nicotine replacement therapy (in the form of a tablet): RR 2.60 95% CI 1.29 to 5.24 (one study).
    • Varenicline: RR 3.34, 95% CI 1.88 to 5.92 (one study).
  • High-intensity behavioural treatment had a very large effect in increasing quit rates compared to usual care in one trial including 3,562 people (RR 25.38, 95% CI 8.03 to 80.22). This was scored moderate GRADE of evidence as it was unclear on how allocation to the treatment groups was concealed from the investigators prior to randomisation, so this result should be treated with caution.
  • High-intensity behavioural treatment was also more effective than low-intensity behavioural treatment (40.5 vs 18.6%) in a single trial including 85 people (RR 2.18, 95% CI 1.05 to 4.49).

What does current guidance say on this issue?

The NICE guideline on diagnosing and managing COPD in adults says that all smokers diagnosed with COPD should be encouraged to stop and offered help to do so at every opportunity. They should be offered nicotine replacement therapy, varenicline or bupropion, as appropriate, combined with a support programme.

The NICE commissioning guide on services for people with COPD advises commissioners to ensure that stop-smoking services are integrated with services for people with COPD. They should also ensure that clinicians are trained and competent to deliver brief interventions to people needing help to stop smoking at any point in their care.

What are the implications?

This review reinforces the current guidance that people with COPD should be offered a combination of drug treatment with behavioural support to help them to stop smoking. It finds little evidence for preferring any particular form of drug treatment or behavioural therapy over any other.

With more than 100,000 emergency admissions to hospital in England for exacerbations of COPD and more than 750,000 'bed days' each year used by those in hospital, managing this important lung condition is already a priority for commissioners. Increasing the ‘intensity’ of smoking cessation programmes offered to this priority group looks like it could double quit rates and would be cost saving in the long term. It will likely remain a priority.

Citation and Funding

van Eerd EA, van der Meer RM, van Schayck OC, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;(8):CD010744.

Cochrane UK and the Cochrane Airways Group are supported by NIHR infrastructure funding.

Bibliography

NHS Choices. Chronic obstructive pulmonary disease (COPD). London: Department of Health; 2016.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Services for people with chronic obstructive pulmonary disease (COPD): a commissioning guide. London: National Institute for Health and Care Excellence; 2011.

Shabab L, Jarvis MJ, Britton J, and West R.  Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax. 2006;61:1043–47.

Why was this study needed?

About 640,000 people in England have been diagnosed with COPD, and there may be another 1.3 million undiagnosed. COPD is one of the most common causes of death in England, and the fifth largest cause of emergency hospital admissions. Smoking is the main cause of COPD, thought to be responsible for about nine in 10 cases. About 35% of newly diagnosed people with COPD are still smoking.

The damage caused to the lungs is permanent, but stopping smoking is the most important way people can slow down the progression of COPD. There is evidence to support the effectiveness of stop-smoking therapies for smokers in general. However, there has been little evidence about the best way to help smokers with COPD to stop. People with COPD are likely to have been smoking for longer and may need additional help to stop. This updated Cochrane review identified evidence published since an earlier 2003 review on the topic.

What did this study do?

This systematic review included 16 randomised controlled trials with a total of 13,123 adults with COPD, aged from 48 to 66 years. Trials investigated the effectiveness of behavioural or drug treatments, or both, to help people with COPD to stop smoking for at least six months.

Four of the studies were similar enough to be pooled for meta-analysis. The rest were too different in terms of type of treatment, severity of COPD, and how smoking cessation was defined and measured. Behavioural therapies and usual care differed, making it difficult to interpret and compare the results. The most common risks of bias across trials were participants and assessors being aware of treatment given, and incomplete outcomes reported. Trials mainly came from Europe, US or Canada. One trial came from Ireland but none was UK-based.

What did it find?

  • In four trials with 1,540 participants, smokers with COPD who received drug treatment combined with intensive behavioural support were more than twice as likely to stop smoking by six months (quit rates in 17 per 100) as those who received behavioural support alone (7 per 100) risk ratio [RR] 2.53, 95% confidence interval [CI] 1.83 to 3.50. High GRADE of evidence.
  • These four trials had used the smoking cessation therapies authorised for use in the UK, and all three were effective compared with placebo:
    • Bupropion: RR 2.03, 95% CI 1.26 to 3.28 (pooled results of two studies).
    • Nicotine replacement therapy (in the form of a tablet): RR 2.60 95% CI 1.29 to 5.24 (one study).
    • Varenicline: RR 3.34, 95% CI 1.88 to 5.92 (one study).
  • High-intensity behavioural treatment had a very large effect in increasing quit rates compared to usual care in one trial including 3,562 people (RR 25.38, 95% CI 8.03 to 80.22). This was scored moderate GRADE of evidence as it was unclear on how allocation to the treatment groups was concealed from the investigators prior to randomisation, so this result should be treated with caution.
  • High-intensity behavioural treatment was also more effective than low-intensity behavioural treatment (40.5 vs 18.6%) in a single trial including 85 people (RR 2.18, 95% CI 1.05 to 4.49).

What does current guidance say on this issue?

The NICE guideline on diagnosing and managing COPD in adults says that all smokers diagnosed with COPD should be encouraged to stop and offered help to do so at every opportunity. They should be offered nicotine replacement therapy, varenicline or bupropion, as appropriate, combined with a support programme.

The NICE commissioning guide on services for people with COPD advises commissioners to ensure that stop-smoking services are integrated with services for people with COPD. They should also ensure that clinicians are trained and competent to deliver brief interventions to people needing help to stop smoking at any point in their care.

What are the implications?

This review reinforces the current guidance that people with COPD should be offered a combination of drug treatment with behavioural support to help them to stop smoking. It finds little evidence for preferring any particular form of drug treatment or behavioural therapy over any other.

With more than 100,000 emergency admissions to hospital in England for exacerbations of COPD and more than 750,000 'bed days' each year used by those in hospital, managing this important lung condition is already a priority for commissioners. Increasing the ‘intensity’ of smoking cessation programmes offered to this priority group looks like it could double quit rates and would be cost saving in the long term. It will likely remain a priority.

Citation and Funding

van Eerd EA, van der Meer RM, van Schayck OC, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;(8):CD010744.

Cochrane UK and the Cochrane Airways Group are supported by NIHR infrastructure funding.

Bibliography

NHS Choices. Chronic obstructive pulmonary disease (COPD). London: Department of Health; 2016.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Services for people with chronic obstructive pulmonary disease (COPD): a commissioning guide. London: National Institute for Health and Care Excellence; 2011.

Shabab L, Jarvis MJ, Britton J, and West R.  Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax. 2006;61:1043–47.

Smoking cessation for people with chronic obstructive pulmonary disease

Published on 23 August 2016

van Eerd, E. A.,van der Meer, R. M.,van Schayck, O. C.,Kotz, D.

Cochrane Database Syst Rev Volume 8 , 2016

BACKGROUND: Smoking cessation is the most important treatment for smokers with chronic obstructive pulmonary disease (COPD), but little is known about the effectiveness of different smoking cessation interventions for this particular group of smokers. OBJECTIVES: To evaluate the effectiveness of behavioural or pharmacological smoking cessation interventions, or both, in smokers with COPD. SEARCH METHODS: We searched all records in the Cochrane Airways Group Specialised Register of Trials. In addition to this electronic search, we searched clinical trial registries for planned, ongoing, and unpublished trials. We searched all databases from their inception. We checked the reference lists of all included studies and of other systematic reviews in relevant topic areas. We searched for errata or retractions from eligible trials on PubMed. We conducted our most recent search in March 2016. SELECTION CRITERIA: We included randomised controlled trials assessing the effectiveness of any behavioural or pharmacological treatment, or both, in smokers with COPD reporting at least six months of follow-up abstinence rates. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data and performed the methodological quality assessment for each study. We resolved any disagreements by consensus. MAIN RESULTS: We included 16 studies (involving 13,123 participants) in this systematic review, two of which were of high quality. These two studies showed that nicotine sublingual tablet and varenicline increased the quit rate over placebo (risk ratio (RR) 2.60 (95% confidence interval (CI) 1.29 to 5.24) and RR 3.34 (95% CI 1.88 to 5.92)). Pooled results of two studies also showed a positive effect of bupropion compared with placebo (RR 2.03 (95% CI 1.26 to 3.28)). When pooling these four studies, we found high-quality evidence for the effectiveness of pharmacotherapy plus high-intensity behavioural treatment compared with placebo plus high-intensity behavioural treatment (RR 2.53 (95% CI 1.83 to 3.50)). Furthermore, we found some evidence that high-intensity behavioural treatment increased abstinence rates when compared with usual care (RR 25.38 (95% CI 8.03 to 80.22)) or low-intensity behavioural treatment (RR 2.18 (95% CI 1.05 to 4.49)). Finally, the results showed effectiveness of various combinations of psychosocial and pharmacological interventions. AUTHORS' CONCLUSIONS: We found high-quality evidence in a meta-analysis including four (1,540 participants) of the 16 included studies that a combination of behavioural treatment and pharmacotherapy is effective in helping smokers with COPD to quit smoking. Furthermore, we conclude that there is no convincing evidence for preferring any particular form of behavioural or pharmacological treatment.

Chronic obstructive pulmonary disease (COPD) is a broad term encompassing two main lung conditions, chronic bronchitis and emphysema, which make breathing difficult. Management centres on stopping smoking, giving drugs to open the airways and reduce inflammation, and antibiotics to manage infective flare-ups.

Nicotine replacement therapy to reduce cravings is available in several forms, including tablets, lozenges and patches. Varenicline is a drug that stimulates nicotine receptors in the body. Bupropion is an antidepressant drug currently only licensed in the UK for smoking cessation. Both varenicline and buproprion may be associated with rare adverse effects and should be used with caution in younger people and those with previous mental health problems.

Expert commentary

Stopping smoking is the only treatment to improve the long-term prognosis as well as improving symptoms of COPD. This should make it foremost in the treating-clinicians’ minds, but we regard smoking cessation as ‘up to the patient’ and simply advise patients to stop. This review shows that treatments, like smoking cessation medications, work as well in people with COPD as in the general population. More importantly, it shows that high intensity sustained support is massively more effective than usual care and low intensity support is effective too. These results should prompt clinicians to actively support their patients to stop smoking.

Paul Aveyard, Professor of Behavioural Medicine, University of Oxford