Review: Nicotine gum and varenicline, but not behavioral interventions, reduce relapse in persons who have stopped smoking
Authors: Charles J. Bentz
Journal: Annals of Internal Medicine (2009)

ACP Journal Club21 July 2009Review: Nicotine gum and varenicline, but not behavioral interventions, reduce relapse in persons who have stopped smokingCharles J. Bentz, MD, FACPCharles J. Bentz, MD, FACPLegacy Health System Tobacco Cessation Program, Portland, Oregon, USA (C.J.B.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-2-200907210-02011 SectionsAboutVisual AbstractAbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationHajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev. 2009;(1):CD003999. https://pubmed.ncbi.nlm.nih.gov/19160228Clinical Impact RatingsGIM/FP/GP: Pulmonology: AbstractQuestionIn persons who stop smoking, which interventions prevent relapse?Review scopeIncluded studies evaluated behavioral and pharmacologic interventions for relapse prevention (RP) in persons who had stopped smoking on their own or with treatment and those who had enforced abstinence (e.g., because of pregnancy, hospitalization, or military training). Studies randomized current smokers or those who had stopped smoking before randomization (abstainers). Exclusion criteria for studies of current smokers were exercise or aversive smoking interventions, hospitalized populations, or lack of explicit focus on RP unless there was extended telephone follow-up after initial cessation. Outcome was proportion of persons not smoking at ≥ 6 months.Review methodsCochrane Tobacco Addiction Group trial register (Aug 2008) was searched for randomized controlled trials (RCTs) or quasi-RCTs with ≥ 6 months of follow-up. 54 trials met the selection criteria: 36 randomized abstainers, 17 randomized current smokers, and 1 randomized both.Main resultsAbstainers. The main results are shown in the Table. Nicotine gum was effective (Table), and 1 trial of persons (n = 1210) who stopped smoking with treatment found that extended use of varenicline was better than placebo for continued smoking cessation at 12 months (44% vs 37%, relative benefit [RB] increase 18%, 95% CI 3 to 36, number needed to treat 16, 95% CI 8 to 91). Current smokers. Adding behavioral RP components to cessation interventions did not improve smoking cessation at longest follow-up (10 trials with time-matched interventions, n = 872, 24% vs 27%, RB reduction 9%, CI −13 to 27).ConclusionVarenicline and nicotine gum reduce relapse in persons who have stopped smoking; behavioral interventions do not reduce risk for relapse.Source of funding: NHS Research & Development Programme, UK.For correspondence: Dr. L.F. Stead, University of Oxford, Oxford, England, UK. E-mail lindsay.[email protected]ox.ac.uk.Relapse prevention (RP) vs placebo or control for continued cessation in persons who had stopped smoking at randomization*Initial cessationComparisonNumber of trials (n)Weighted event ratesAt longest follow-upRBI/RBR (95% CI)NNT (CI)Enforced (pregnancy)Behavioral RP vs control11 (3273)36% vs 33%RBI 7% (−2 to 18)NSEnforced (in hospital)Behavioral RP vs control3 (667)38% vs 40%RBR 6% (−13 to 22)NSWithout treatmentBehavioral RP vs control5 (3561)29% vs 27%RBI 8% (−2 to 19)NSWith treatmentBehavioral RP vs control5 (1462)34% vs 34%RBI 0% (−13 to 15)NSAt ≥ 12 mo after quit dateWithout treatmentNicotine gum vs control2 (2261)21% vs 17%RBI 24% (4 to 47)25 (13 to 146)With treatmentNRT vs placebo2 (553)24% vs 23%RBI 4% (−23 to 40)NSWith treatmentBupropion vs placebo5 (1587)27% vs 23%RBI 17% (−1 to 39)NSWith treatmentBupropion + NRT vs placebo2 (243)25% vs 22%RBI 18% (−25 to 87)NS*NRT = nicotine replacement therapy; NS = not significant; other abbreviations defined in Glossary. RBI, RBR, NNT, and CI calculated from data in article using a fixed-effect model.CommentaryGetting smokers to quit is one thing: Keeping them from starting again is another. The review by Hajek and colleagues found that medications (varenicline and nicotine gum) helped prevent relapse but that behavioral interventions focused on identifying and resolving tempting situations were not effective.The latter finding seems surprising. Many interventions that are proven to help patients quit smoking include this type of “skills training,” so why didn’t this review find benefit? One reason is that many published studies on tobacco cessation do not separate efforts aimed at initial cessation from those directed at preventing relapse. The result is that Hajek and colleagues were left with a selection of trials that primarily assessed brief behavioral interventions. Also, few of these clinical trials evaluated intensive programs, which are known to be effective and for which there is a proven dose response between the amount of contact and successful quitting (1). Moreover, most of the studies in this review evaluated brief “skills training” interventions; other approaches to relapse prevention, such as those based upon improving self-efficacy (a construct within social cognitive theory), were not evaluated.It is likely that the negative results of this review simply reflect how a reductionist viewpoint of the standard RCT limits our ability to understand the complexity of the changing contextual variables in treating addiction (2).The review found that long-term medication is helpful and underscored that tobacco dependence is a chronic relapsing condition. All physicians need to focus on improving clinical systems that promote cessation attempts. It is also clear that purchasers and payers of health care need to provide comprehensive benefits for effective pharmacotherapy.Charles J. Bentz, MD, FACPLegacy Health System Tobacco Cessation ProgramPortland, Oregon, USAReferences1 Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. AHCPR supported clinical practice guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. May 2008. www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163 (accessed 30 Apr 09). Google Scholar2 Tucker JA, Roth DL. Extending the evidence hierarchy to enhance evidence-based practice for substance use disorders. Addiction. 2006;101:918-32. [PMID: 16771885] Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Legacy Health System Tobacco Cessation Program, Portland, Oregon, USA (C.J.B.)This article was published at Annals.org on 7 July 2009. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByYoung male daily smokers are nicotine dependent and experience several unsuccessful quit attempts 21 July 2009Volume 151, Issue 2Page: JC1-11KeywordsHospitalizationsNicotineNicotine replacement therapyPopulation statisticsPregnancyPulmonary medicineResearch funding ePublished: 21 July 2009 Issue Published: 21 July 2009 CopyrightCopyright © 2009 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...