In helping smokers quit, combining treatments is key

Despite public health advances, tobacco use remains one of the most common, preventable and costly health problems in the United States and worldwide. In the U.S., more deaths—an estimated 480,000 each year—are attributable to cigarette smoking than to any other preventable cause. The 34 million U.S. adults who smoke today could gain on average a decade of life expectancy if they quit smoking, and most smokers want to quit. Yet fewer than one in three individuals trying to quit smoking uses an evidence-based treatment to help them succeed.

In a new clinical review in JAMA, researchers at Massachusetts General Hospital (MGH) and the University of Oxford synthesize up-to-date evidence on this topic and provide guidance to physicians and the public about the most effective treatments to help smokers quit.

The review confirms that FDA-approved smoking cessation medications and behavioral support programs each are effective to help smokers quit, but they are more effective when used together. "Many people trying to quit smoking underestimate how valuable it is to get support and encouragement from a coach or counselor along the way," says Nancy Rigotti, MD, lead author and director of the Tobacco Research and Treatment Center (TRTC) at MGH. "Many smokers who say that they have tried everything to help them quit haven't used behavioral treatments."

According to co-author Gina Kruse, MD, MPH, of the TRTC: "Smokers now have many options to choose from in order to access evidence-based behavioral support. These include free telephone quitlines and text messaging and internet-based programs."

Analyzing reviews in the Cochrane Database of Systematic Reviews and other sources such as the U.S. Preventive Services Task Force recommendations, Rigotti and colleagues found that newer ways of administering FDA-approved cessation medications can increase their effectiveness. For example, nicotine replacement therapy (NRT) is more effective when two types of products are used together rather than individually. "To use combination NRT, smokers apply a nicotine patch for all-day nicotine withdrawal relief, but then also use a nicotine lozenge, gum, or inhaler as needed if cigarette cravings break through during the day," says Rigotti.

In addition to NRT, two other FDA-approved smoking cessation medications are effective: Bupropion, which reduces withdrawal symptoms, and varenicline, which does the same and dampens the rewarding effects of smoking. The review offers evidence-based guidance for choosing among the various smoking cessation medications, finding that the two most effective choices are varenicline or combination NRT. However, a single NRT product or bupropion are also effective. The review also supports combining different types of these medication categories when one alone is not successful. Overall, using medication when trying to quit approximately doubles a person's chance of success.

The review summarizes a three-step evidence-based strategy that physicians and other clinicians can use to integrate tobacco cessation treatment into routine medical practice in all settings: To ask patients about tobacco use, issue clear advice to quit, and offer treatment by prescribing medications and connecting patients directly to behavioral treatment resources. "Having a brief conversation with every patient who smokes is one of the most impactful actions a clinician can take," says Rigotti. "It's important to let patients know that it's never too early or too late to benefit from quitting smoking."

Rigotti is a professor of Medicine at Harvard Medical School and director of the MGH Tobacco Research and Treatment Center (TRTC), based in the Mongan Institute and Division of General Internal Medicine. Other authors of the review are Gina Kruse, MD, MPH, assistant professor of Medicine at Harvard Medical School and TRTC investigator, and Jamie Hartmann-Boyce, DPhil, and Jonathan Livingstone-Banks, Ph.D., of the University of Oxford.

An audio interview with Rigotti can be found on the JAMA website here.