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Systematic Review
To support the U.S. Preventive Services Task Force in updating its 2015 recommendation on tobacco cessation interventions for adults, including pregnant women. The review addressed the effectiveness and safety of pharmacotherapy, behavioral interventions, and electronic cigarettes for tobacco cessation.
Among adults, combined pharmacotherapy and behavioral interventions significantly increased smoking abstinence by 83 percent versus usual care or minimal support control groups not using medication (risk ratio [RR] 1.83 [95% confidence interval [CI], 1.68 to 1.98]). All seven FDA-approved medications for smoking cessation were found to be effective in increasing smoking quit rates compared with placebo or nondrug arms at 6 or more months followup. The pooled RR for abstinence for nicotine replacement therapy (NRT, all forms) was 1.55 (95% CI, 1.49 to 1.61), for bupropion, 1.64 (95% CI, 1.52 to 1.77), and for varenicline, 2.24 (95% CI, 2.06 to 2.43). Combined NRT versus a single form of NRT showed a statistically significantly greater cessation effect (RR 1.25 [95% CI, 1.15 to 1.36]). Pooled analysis of trials directly comparing NRT and bupropion did not suggest a difference between the two types of pharmacotherapy; however, varenicline has been shown to be superior to both NRT and bupropion in achieving abstinence at 6 months or greater, although there are fewer trials testing these differences. Although less evidence is available, certain medications such as nortriptyline and cytisine used for tobacco cessation have shown potential benefits. None of the drugs were associated with serious adverse events, including major cardiovascular adverse events or serious neuropsychiatric events.
Compared with various controls, behavioral interventions such as in-person advice and support from clinicians including physician advice, nurse advice, individual counseling with a cessation specialist, group behavioral interventions, telephone counseling, mobile phone-based interventions, interactive and tailored internet-based interventions, and the use of incentives had modest but significantly increased relative smoking cessation at 6 or more months (15% to 88% range in relative effects). There was a lack of clear benefit of motivational interviewing, decision aids, print-based, nontailored self-help materials, real-time video counseling, biofeedback (feedback on smoking exposure, smoking-related disease, or smoking-related harms), exercise, acupuncture, hypnotherapy, and system change interventions compared with controls; however, there was substantially less evidence related to each of these interventions.
Five trials were identified that addressed the effectiveness and harms of the use of electronic cigarettes among adults. No trials testing the effects of electronic cigarettes for smoking cessation among pregnant women were identified. Results were mixed on smoking cessation effectiveness at 6 to 12 months among smokers intending to quit when compared with placebo devices or NRT.
Among pregnant women, smoking cessation during late pregnancy was greater among women receiving any type of behavioral intervention, with evidence most clear for counseling versus controls (RR 1.31 [95% CI, 1.16 to 1.47]). Behavioral interventions were also associated with an increase in mean birthweight of babies as well as a decreased risk of low birth weight. One new trial was identified of NRT among pregnant women, but no new trials testing the effects of bupropion or varenicline in this population. For NRT, rates of validated cessation among women allocated to NRT (5.4% to 28.2%) compared with placebo (5.0% to 25.4%) were not statistically different (pooled RR 1.11 [95% CI, 0.79 to 1.56]). Benefits of NRT on infant health outcomes were seen in a few trials, but that evidence was limited. There was no clear evidence of harms from behavioral interventions or associated with NRT use during pregnancy, but harms also could not be ruled out given sparse reporting, low statistical power for evaluating rare harms, and limitations of observational study comparisons.
There is strong evidence that a range or pharmacological and behavioral interventions, both individually and in combination, are effective in increasing smoking cessation in adults. Moreover, behavioral interventions can help pregnant women stop smoking. Data on the effectiveness and safety of electronic cigarettes for smoking cessation among adults are limited as are data on the use of tobacco cessation pharmacotherapies among pregnant women. Future research should focus on direct comparisons between different combinations and classes of drugs, adaptations of interventions for diverse populations, and the efficacy and safety of electronic cigarettes.