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CPD: Key questions on smoking cessation

CPD: Key questions on smoking cessation

Learning Objectives

This module will update you on smoking cessation, including:

  • Quit rates for different smoking cessation therapies
  • Which combinations of therapies GPs should consider using
  • The latest evidence and advice on e-cigarettes
  • The role of anti-smoking clinics

This module was initiated and funded by Pfizer


Professor Keir Lewis is a professor of respiratory medicine at Swansea University and a consultant physician in Hywel Dda University Health Board

What is the current consensus on quit rates for the various smoking cessation treatments available? And how is ‘success’ defined?

Smoking remains the ‘greatest single cause of preventable illness and premature death in the UK’1 and one of the most important causes of the health inequality between the rich and poor. There are many services and combinations of treatments available from the NHS, councils, community and the private sector.

Table 1 lists the most common approaches and their relative success rates when combining treatments, adapted from meta analyses of various large scale randomised controlled trials and guideline summaries.2

Type Quit rate at one year   Odds ratio quitting (95% CI)
Usual care 4-5% 1.0
NRT alone (over the counter) 5% 1.0 (0.7,2.8)
Behavioural therapy (BT) alone 10% 2.12 (1.38, 3.39)
Short-acting NRT + BT 15-18% 3.65 (2.31,6.01)
Long-acting NRT (patch) +BT 15% 3.73 (2.30,6.28)
Short+Long NRT+BT 20-25% 3.91 (2.6,6.0)
Bupropion + BT 20-25% 3.94 (2.48,6.55)
Varenicline +BT 30-35% 6.17 (3.54,11.19)

Table 1

These analyses come from specialised trials that often do not reflect real life combined treatments. The reviewers also noted a lot of heterogeneity in trial design (especially definitions of behavioural therapy) and many trials were only included if they had strict definitions of smoking status and stricter inclusion criteria e.g. limited or no morbidities. Despite these caveats, real world service evaluations and audits consistently show that the combination of pharmacotherapy and behavioural therapy is the most effective way to help people quit.

When comparing ‘success’ most researchers (and commissioners in the real world) adopt the ‘Russell Standard’.3

Here, definitions are clearly laid out:

  • A treated smoker (TS) is someone who has attended at least one session face to face and agreed a quit date
  • Smokers are contacted at four weeks and self-reported quits (postal questionnaire/telephone) are recorded (SR4WQ)
  • Ideally, self-reports should also be validated biologically (4WQ), by measuring exhaled carbon monoxide (eCO). Typically, levels of <10 parts per million (ppm) suggest no direct smoking within the previous 24 hours.

Assumptions on quit status at four weeks may not represent long-term success. The figures on number of quit attempts, cut downs and losses to follow up are not used in the key performance indicators, but are useful to help interpret them.

Other ways of validating smoking status, such as measuring salivary, urinary or hair cotinine levels, are currently too expensive to be used in direct point-of-care clinical testing.

Research trials (see table above), hospital and specialist services like to follow people for one year as relapse rates after that are much lower and this period accounts for important anniversaries, celebrations and life events that trigger relapse. It can provide information on the success of relapse prevention efforts and is also more convincing for stakeholders. However, it is recognised that not all services can devote the resources needed to undertake 12 month validation.

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