Discover Portal

Someone smoking

NIHR Signal Adding behavioural support to drug treatment helps more people quit smoking

Published on 20 August 2019

doi: 10.3310/signal-000808

Among people using drug treatment to stop smoking, adding telephone or face-to-face behavioural support boosts their chances of success. Adding support increases the proportion of people quitting from around 17% on average to about 20%. This is a small but worthwhile increase given the health risks associated with smoking.

These were the findings of an updated Cochrane review, which included 83 studies. All 29,536 participants were using nicotine replacement therapy or another drug to help them stop smoking.

The review compared adding behavioural support, most often four or more counselling sessions, with less or no support, or a different type of support. The extra support increased success rates after six months or longer, but there was little evidence on what form of support was best.

Overall, the quality of the studies was good, and the message that behavioural support is beneficial is conclusive. Commissioners should consider their local context and outcomes when selecting appropriate support packages.

Share your views on the research.

Why was this study needed?

For people who smoke, giving up is the most effective thing they can do to reduce their risk of serious health conditions and early death. Public Health England has estimated that the annual financial burden of smoking on the NHS is £2.6 billion.

Behavioural support and drug therapies, including nicotine replacement therapy, bupropion and varenicline, can help people stop smoking. Behavioural support can range from the more intensive, such as a series of one-to-one counselling sessions, to group therapy, telephone helplines or brief advice.

Other Cochrane reviews have assessed the evidence on behavioural and pharmaceutical interventions individually. However, as they do not assess how much benefit is gained from adding different levels of behavioural support to drug therapy, this review aimed to fill the gap in research.

What did this study do?

This was an update of a Cochrane systematic review, which included 83 studies, with 29,536 participants followed for six months or more. The studies were mainly from the USA, with three from the UK. They were conducted mainly in healthcare and community settings.

Included studies compared receiving more behavioural support with receiving less or no support, or a different type of support. The support was all person-to-person, but could be delivered by telephone or face-to-face. There was variation in the number of contacts and duration of contact. In 76 studies, the control group received some form of support. All participants were offered or provided with drug treatments, mostly nicotine replacement therapy.

Overall the quality of evidence was good, and we can trust the conclusions of this review.

What did it find?

  • Pooling 65 studies with a total of 23,331 participants found that on average providing additional behavioural support increased the proportion of people not smoking at follow up, the quit rate, from about 17% to about 20% (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.08 to 1.22; high quality evidence). This was considered a clinically relevant difference, given the health risks associated with smoking.
  • The relative increase in quit rates remained similar when comparing more versus less behavioural support and when comparing support versus no support.
  • There was little variation in results between studies, and the results have remained consistent over the successive updates to the review, suggesting that the findings are robust.
  • Subgroup analyses suggested that both telephone support and face-to-face support improved quit rates (8 studies using telephone counselling, 6,670 participants, RR 1.25, 95% CI 1.15 to 1.37; 57 studies using face-to-face support, 16,661 participants, RR 1.11, 95% CI 1.03 to 1.19). As no direct comparison between telephone and face-to-face support was made, the slight difference in improvement could have been due to other differences between these studies.
  • Few studies compared different behavioural support interventions, and their findings did not conclusively show whether some were better than others.

What does current guidance say on this issue?

In its 2018 guidance on stop smoking interventions and services, NICE recommends that all adults who smoke are offered evidence-based interventions to help them quit, which includes behavioural support and nicotine replacement therapy, among others. NICE notes that behavioural support typically involves weekly meetings (one-on-one or in a group) for at least the first four weeks of a quit attempt.

NICE notes that those providing support should receive appropriate training, such as that provided by the National Centre for Smoking Cessation and Training. Their training ensures that stop smoking practitioners have the knowledge and skills to deliver effective behavioural support.

What are the implications?

Both drug therapies and behavioural support are offered by the NHS to those trying to quit smoking. This review provides a clear message that providing these approaches together gives the best results.

There is a wide range of approaches to behavioural support. In the absence of definitive evidence on which are best, commissioners may wish to consider their local population, available services and the outcomes of ongoing stop smoking programmes in their area when tailoring approaches to achieve the best outcomes.

The National Centre for Smoking Cessation and Training provides a toolkit for commissioners to undertake a local needs analysis exercise.

Citation and Funding

Hartmann-Boyce J, Hong B, Livingstone-Banks J et al. Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation. Cochrane Database Syst Rev. 2019;(6):CD009670.

Cochrane UK and the Tobacco Addiction Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

Cancer Research UK. Stop smoking services stubbed out across England. Oxford: Cancer Research UK; 2019.

Martin S, Lomas JR and Claxton K. Is an ounce of prevention worth a pound of cure? Estimates of the impact of English public health grant on mortality and morbidity. York: Centre for Health Economics; 2019.

NCSCT. Introducing the NCSCT. Dorchester. National Centre for Smoking Cessation and Training; 2019.

NCSCT. Stop smoking services – needs analysis: a toolkit for commissioners. Dorchester. National Centre for Smoking Cessation and Training; 2012.

NHS website. NHS stop smoking services help you quit. London. Department of Health and Social Care; 2018.

NICE. Stop smoking interventions and services. NG92. London: National Institute for Health and Care Excellence; 2018.

Pirie K, Peto R, Reeves GK, Green J, Beral V, Million Women Study Collaborators. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-41.

Public Health England. Cost of smoking to the NHS in England: 2015. London. Public Health England; 2017.

Why was this study needed?

For people who smoke, giving up is the most effective thing they can do to reduce their risk of serious health conditions and early death. Public Health England has estimated that the annual financial burden of smoking on the NHS is £2.6 billion.

Behavioural support and drug therapies, including nicotine replacement therapy, bupropion and varenicline, can help people stop smoking. Behavioural support can range from the more intensive, such as a series of one-to-one counselling sessions, to group therapy, telephone helplines or brief advice.

Other Cochrane reviews have assessed the evidence on behavioural and pharmaceutical interventions individually. However, as they do not assess how much benefit is gained from adding different levels of behavioural support to drug therapy, this review aimed to fill the gap in research.

What did this study do?

This was an update of a Cochrane systematic review, which included 83 studies, with 29,536 participants followed for six months or more. The studies were mainly from the USA, with three from the UK. They were conducted mainly in healthcare and community settings.

Included studies compared receiving more behavioural support with receiving less or no support, or a different type of support. The support was all person-to-person, but could be delivered by telephone or face-to-face. There was variation in the number of contacts and duration of contact. In 76 studies, the control group received some form of support. All participants were offered or provided with drug treatments, mostly nicotine replacement therapy.

Overall the quality of evidence was good, and we can trust the conclusions of this review.

What did it find?

  • Pooling 65 studies with a total of 23,331 participants found that on average providing additional behavioural support increased the proportion of people not smoking at follow up, the quit rate, from about 17% to about 20% (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.08 to 1.22; high quality evidence). This was considered a clinically relevant difference, given the health risks associated with smoking.
  • The relative increase in quit rates remained similar when comparing more versus less behavioural support and when comparing support versus no support.
  • There was little variation in results between studies, and the results have remained consistent over the successive updates to the review, suggesting that the findings are robust.
  • Subgroup analyses suggested that both telephone support and face-to-face support improved quit rates (8 studies using telephone counselling, 6,670 participants, RR 1.25, 95% CI 1.15 to 1.37; 57 studies using face-to-face support, 16,661 participants, RR 1.11, 95% CI 1.03 to 1.19). As no direct comparison between telephone and face-to-face support was made, the slight difference in improvement could have been due to other differences between these studies.
  • Few studies compared different behavioural support interventions, and their findings did not conclusively show whether some were better than others.

What does current guidance say on this issue?

In its 2018 guidance on stop smoking interventions and services, NICE recommends that all adults who smoke are offered evidence-based interventions to help them quit, which includes behavioural support and nicotine replacement therapy, among others. NICE notes that behavioural support typically involves weekly meetings (one-on-one or in a group) for at least the first four weeks of a quit attempt.

NICE notes that those providing support should receive appropriate training, such as that provided by the National Centre for Smoking Cessation and Training. Their training ensures that stop smoking practitioners have the knowledge and skills to deliver effective behavioural support.

What are the implications?

Both drug therapies and behavioural support are offered by the NHS to those trying to quit smoking. This review provides a clear message that providing these approaches together gives the best results.

There is a wide range of approaches to behavioural support. In the absence of definitive evidence on which are best, commissioners may wish to consider their local population, available services and the outcomes of ongoing stop smoking programmes in their area when tailoring approaches to achieve the best outcomes.

The National Centre for Smoking Cessation and Training provides a toolkit for commissioners to undertake a local needs analysis exercise.

Citation and Funding

Hartmann-Boyce J, Hong B, Livingstone-Banks J et al. Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation. Cochrane Database Syst Rev. 2019;(6):CD009670.

Cochrane UK and the Tobacco Addiction Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

Cancer Research UK. Stop smoking services stubbed out across England. Oxford: Cancer Research UK; 2019.

Martin S, Lomas JR and Claxton K. Is an ounce of prevention worth a pound of cure? Estimates of the impact of English public health grant on mortality and morbidity. York: Centre for Health Economics; 2019.

NCSCT. Introducing the NCSCT. Dorchester. National Centre for Smoking Cessation and Training; 2019.

NCSCT. Stop smoking services – needs analysis: a toolkit for commissioners. Dorchester. National Centre for Smoking Cessation and Training; 2012.

NHS website. NHS stop smoking services help you quit. London. Department of Health and Social Care; 2018.

NICE. Stop smoking interventions and services. NG92. London: National Institute for Health and Care Excellence; 2018.

Pirie K, Peto R, Reeves GK, Green J, Beral V, Million Women Study Collaborators. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-41.

Public Health England. Cost of smoking to the NHS in England: 2015. London. Public Health England; 2017.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

Published on 6 June 2019

Hartmann-Boyce, J.,Hong, B.,Livingstone-Banks, J.,Wheat, H.,Fanshawe, T. R.

Cochrane Database Syst Rev Volume 6 , 2019

BACKGROUND: Pharmacotherapies for smoking cessation increase the likelihood of achieving abstinence in a quit attempt. It is plausible that providing support, or, if support is offered, offering more intensive support or support including particular components may increase abstinence further. OBJECTIVES: To evaluate the effect of adding or increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition. We also looked at studies which directly compare behavioural interventions matched for contact time, where pharmacotherapy is provided to both groups (e.g. tests of different components or approaches to behavioural support as an adjunct to pharmacotherapy). SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP in June 2018 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline, that evaluated the addition of personal support or compared two or more intensities of behavioural support. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount or type of behavioural support. The intervention condition had to involve person-to-person contact (defined as face-to-face or telephone). The control condition could receive less intensive personal contact, a different type of personal contact, written information, or no behavioural support at all. We excluded trials recruiting only pregnant women and trials which did not set out to assess smoking cessation at six months or longer. DATA COLLECTION AND ANALYSIS: For this update, screening and data extraction followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates, if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a random-effects model. MAIN RESULTS: Eighty-three studies, 36 of which were new to this update, met the inclusion criteria, representing 29,536 participants. Overall, we judged 16 studies to be at low risk of bias and 21 studies to be at high risk of bias. All other studies were judged to be at unclear risk of bias. Results were not sensitive to the exclusion of studies at high risk of bias. We pooled all studies comparing more versus less support in the main analysis. Findings demonstrated a benefit of behavioural support in addition to pharmacotherapy. When all studies of additional behavioural therapy were pooled, there was evidence of a statistically significant benefit from additional support (RR 1.15, 95% CI 1.08 to 1.22, I(2) = 8%, 65 studies, n = 23,331) for abstinence at longest follow-up, and this effect was not different when we compared subgroups by type of pharmacotherapy or intensity of contact. This effect was similar in the subgroup of eight studies in which the control group received no behavioural support (RR 1.20, 95% CI 1.02 to 1.43, I(2) = 20%, n = 4,018). Seventeen studies compared interventions matched for contact time but that differed in terms of the behavioural components or approaches employed. Of the 15 comparisons, all had small numbers of participants and events. Only one detected a statistically significant effect, favouring a health education approach (which the authors described as standard counselling containing information and advice) over motivational interviewing approach (RR 0.56, 95% CI 0.33 to 0.94, n = 378). AUTHORS' CONCLUSIONS: There is high-certainty evidence that providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking increases quit rates. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 20%, based on a pooled estimate from 65 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support. More research is needed to assess the effectiveness of specific components that comprise behavioural support.

Expert commentary

Stopping smoking is still the best way to improve health and reduce health inequalities, and policy-makers and providers are always looking for ways to increase the effectiveness of any quit attempt.

This review confirms that behavioural support in addition to pharmacotherapy increases the relative effectiveness of a quit attempt by 10 to 20%. Yet previous reviews have been unable to elicit the most important component of the approach, be it therapist, intensity of intervention or theoretical underpinning of the approach.

Decision-makers will want to see which population groups benefit most from this additional support.

Rupert Suckling, Director of Public Health, Doncaster Council

The commentator declares no conflicting interests

Expert commentary

The findings of this review are clear: stopping smoking with behavioural support is good and more support is better. In the UK, behavioural support is provided through the NHS stop smoking services. Cuts in public health spending mean that 44% of local areas have abolished their specialist stop smoking service.

This leaves people with tobacco addiction and struggling to quit, at risk of not overcoming the disorder - a disorder that will lead to premature death in half of those that do not overcome it.

Public health spending generally provides a greater gain in life expectancy per pound spent than clinical interventions, so this review suggests that reversing this policy is a national priority.

Paul AveyardProfessor of Behavioural Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford

The commentator is the editor of the Cochrane Tobacco Addiction Group, the output of which includes this review