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Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation
Open accessAbstract
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, I² = 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, I² = 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.
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“Although medications are effective by themselves, their effi cacy might be improved when combined with behavioral treat ments that alter learned smoking- associated behaviors 186 .”
From Substance use disorders: a comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention (2023) · cites this paper as [186]
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“A meta- analysis of 65 randomized controlled trials (RCTs) reported 6- month cessation rates of 20% when behavioral support was added to medications, compared to 17% when medications were used by themselves 186 .”
From Substance use disorders: a comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention (2023) · cites this paper as [186]
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Metadata
- Authors
- Hartmann-Boyce, J., Hong, B., Livingstone-Banks, J., Wheat, H., & Fanshawe, T. R.
- Affiliations
- University of Oxford; Nuffield Department of Primary Care Health Sciences; Radcliffe Observatory Quarter Woodstock Road Oxford UK OX2 6GG
- Birmingham Dental Hospital (GB)
- University of Oxford (GB)
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2019-06-05
- Volume
- 2019
- Issue
- 6
- Pages
- CD009670-CD009670
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC6549450
- OpenAlex
- W2948298121
- Cited by
- 186
- References
- 252
- Citations by year
- 2026: 10 · 2025: 20 · 2024: 21 · 2023: 34 · 2022: 36 · 2021: 36 · 2020: 22 · 2019: 5
- FWCI
- 2.91
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- other-oa
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion, other-oa)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Open Research Exeter (University of Exeter) (publishedVersion)
- Figshare (submittedVersion)
- PEARL (University of Plymouth) (submittedVersion)
- Funders
- National Institute for Health and Care Research (16/114/20, SRP/16/114/20, ACF-2017-09-014)
- Department of Health and Social Care
- Evidence Synthesis Programme
- NIHR Oxford Biomedical Research Centre
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Social Sciences › Psychology › Applied Psychology › Behavioral Health and Interventions
- Keywords
- smoking cessation, behavioral support, pharmacotherapy, nicotine replacement therapy, bupropion, nortriptyline, varenicline, smoking abstinence, telephone support, face-to-face support, support intensity, nicotine dependence, relapse, risk of bias, tobacco control, harm reduction funding
- MeSH terms
- Varenicline, Behavior Therapy, Combined Modality Therapy, Female, Humans, Nortriptyline, Pregnancy, Smoking, Tobacco Use Disorder, Smoking Cessation, Bupropion, Nicotinic Agonists, Tobacco Use Cessation Devices
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