World No Tobacco Day

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The Cochrane Reviews highlighted here are freely available while this Special Collection is featured on The Cochrane Library homepage.

World No Tobacco Day is held each year on 31 May and is organised by the World Health Organization (WHO). The WHO states that tobacco is the second major cause of deaths in the world, currently responsible for killing one in ten adults worldwide. This makes systematic reviews of methods of cessation and prevention of uptake of tobacco important. Cochrane Reviews of interventions for tobacco addiction provide guidance on their effectiveness and are essential for establishing evidence or the lack of it for different treatment or prevention techniques.

The Cochrane Tobacco Addiction Group prepares Cochrane Reviews of pharmacotherapy; self-managed behavioural or lifestyle interventions; help from healthcare professionals for general or special groups; and the effectiveness of complementary therapies. The Group also prepares Cochrane Reviews that evaluate the effects of community, institution, and school-based interventions as well as interventions by government policy on population health.  Recently we published our first overview of pharmacological interventions.[1]

First published to coincide with World No Tobacco Day 2010, revised for 2011 and 2012, this Special Collection has been updated for World No Tobacco Day 2014. It highlights a selection of new and recently updated Cochrane Reviews that address tobacco addiction in the general population. The full list of Cochrane Tobacco Addiction Group reviews can be browsed here.

References:
[1] Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329. DOI: 10.1002/14651858.CD009329.pub2.

Pharmacotherapy interventions

Pharmacological interventions for smoking cessation: an overview and network meta-analysis

Some medications have been proven to help people to quit smoking, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. This overview assesses the following questions: How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long-term abstinence (six months or longer)? How do the remaining treatments compare with placebo in achieving long-term abstinence? How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits?

Antidepressants for smoking cessation

There are at least three reasons to believe that antidepressants might help in smoking cessation. Nicotine withdrawal may produce depressive symptoms or precipitate a major depressive episode, and antidepressants may relieve these. Nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect. Finally, some antidepressants may have a specific effect on neural pathways (e.g. inhibiting monoamine oxidase) or receptors (e.g. blockade of nicotinic-cholinergic receptors) underlying nicotine addiction. This review assesses the effect of antidepressant medications including bupropion and nortriptyline to aid long-term smoking cessation.

Nicotine receptor partial agonists for smoking cessation

Nicotine receptor partial agonists, including varenicline and cytisine, may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist). Varenicline was developed as a nicotine-receptor partial agonist from cytisine, a drug widely used for smoking cessation in some eastern and central European countries. The first trial reports of varenicline were released in 2006, and further trials have now been published or are currently under way. This review assesses the efficacy and tolerability of nicotine-receptor partial agonists for smoking cessation, and considers the adverse events profile associated with their use. The April 2012 edition of Cochrane Journal Club also discusses nicotine receptor partial agonists for smoking cessation, including a podcast, PowerPoint slides, patient vignette and discussion questions.

Nicotine replacement therapy for smoking cessation

The aim of nicotine replacement therapy (NRT) is temporarily to replace much of the nicotine from cigarettes. This reduces both the motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. This review determines the effect of NRT compared to placebo in aiding smoking cessation, and considers whether there is a difference in effect for the different forms of NRT (chewing gum, transdermal patches, nasal spray, inhalers, and tablets/lozenges) in achieving abstinence from cigarettes. The review also examines whether the effect is influenced by the dosage, form, and timing of use of NRT; the intensity of additional advice and support offered to the smoker; or the clinical setting in which the smoker is recruited and treated.

Opioid antagonists for smoking cessation

The reinforcing properties of nicotine may be mediated through release of various neurotransmitters both centrally and systemically. People who smoke report positive effects such as pleasure, arousal, and relaxation as well as relief of negative affect, tension, and anxiety. Opioid (narcotic) antagonists are of particular interest to investigators as potential agents to attenuate the rewarding effects of cigarette smoking. This review aims to evaluate the efficacy of opioid antagonists in promoting long-term smoking cessation (including naloxone and the longer-acting opioid antagonist naltrexone).

Behavioural interventions

Biomedical risk assessment as an aid for smoking cessation

A possible strategy for increasing smoking cessation rates could be to provide smokers who have contact with healthcare systems with feedback on the biomedical or potential future effects of smoking, such as measurement of exhaled carbon monoxide, lung function, or genetic susceptibility to lung cancer. This review evaluates the efficacy of biomedical risk assessment provided in addition to counselling, as an aid to smoking cessation.

Competitions and incentives for smoking cessation

Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. This review aims to determine whether competitions and incentives lead to higher long-term quit rates. The review also examines the relationship between incentives and participation rates.

Internet-based interventions for smoking cessation

The Internet has become a regular part of daily life for most people in many parts of the world. It now offers an additional means of effecting changes to behaviour such as smoking. This review assesses the effectiveness of Internet-based interventions for smoking cessation and the effectiveness of tailored, interactive Internet-based interventions when compared to static sites.

Relapse prevention interventions for smoking cessation

A number of treatments can help smokers make a successful quit attempt, but many initially successful quitters relapse over time. Interventions used to help people avoid relapse usually focus on teaching the skills to cope with temptations to smoke. This review assesses whether specific interventions for relapse prevention reduce the proportion of recent quitters who return to smoking.

Help from healthcare providers

Nursing interventions for smoking cessation

Nurses may advise patients to improve their health by stopping smoking. Such advice may be brief or part of more intensive interventions. This review evaluates the effectiveness of nursing-delivered smoking cessation interventions with different intensities and within different settings and populations.

Physician advice for smoking cessation

Physicians may advise patients to improve their health by stopping smoking. This advice may be brief or part of more intensive interventions. This review evaluates the effectiveness of advice from physicians in promoting smoking cessation; compares minimal interventions by physicians with more intensive interventions; assesses the effectiveness of various adjunctive aids to advice in promoting smoking cessation (such as demonstration of expired carbon monoxide or pulmonary function tests, self-help manuals); and determines the effect of anti-smoking advice on disease-specific and all-cause mortality.

Telephone counselling for smoking cessation

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines. This review evaluates the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit.

Training health professionals in smoking cessation

There is good evidence that brief interventions from health professionals can increase smoking cessation attempts. A number of trials have examined whether skills training for health professionals can lead them to have greater success in helping their patients who smoke. This review evaluates the effectiveness of training health care professionals in the delivery of smoking cessation interventions to their patients, and assesses the additional effects of training characteristics such as intervention content, delivery method, and intensity.

Government policy

Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of second-hand smoke. They also offer the potential to influence social norms and smoking behaviour of the populations they affect. This review assesses the extent to which legislation-based smoking bans or restrictions: reduce exposure to second-hand smoke; help people who smoke to reduce tobacco consumption or reduce smoking prevalence; and affect the health of those in areas which have a ban or restriction in place.

Interventions based on lifestyle management

Exercise interventions for smoking cessation

Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain. This review determines whether exercise-based interventions alone or combined with a smoking cessation programme are more effective than a smoking cessation intervention alone.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

Children's exposure to other people's cigarette smoke (environmental tobacco smoke) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to environmental tobacco smoke. Preventing exposure to cigarette smoke in infancy and childhood has significant potential to improve children's health worldwide. This review evaluates the effectiveness of interventions aiming to reduce exposure of children to environmental tobacco smoke.

Family-based programmes for preventing smoking by children and adolescents

There is evidence that children's decisions to smoke are influenced by family and friends. This review assesses the effectiveness of interventions to help family members to strengthen non-smoking attitudes and promote non-smoking by children and other family members, addressing: the effect of the interventions on the smoking status of children who reported no tobacco use at baseline; the effect on the smoking behaviour of parents and other family members; and the effect on immediate variables including changes in attitudes.

Interventions for preventing weight gain after smoking cessation

Most people who stop smoking gain weight. There are some interventions that have been designed to reduce weight gain when stopping smoking. Some smoking cessation interventions may also limit weight gain although their effect on weight has not been reviewed. This review examines: interventions designed specifically to aid smoking cessation and limit post-cessation weight gain; and interventions designed to aid smoking cessation that may also plausibly have an effect on weight.

Mobile phone-based interventions for smoking cessation

Innovative effective smoking cessation interventions are required to appeal to those who are not accessing traditional cessation services. Mobile phones are widely used and are now well integrated into the daily lives of many, particularly young adults. Mobile phones are a potential medium for the delivery of health programmes such as smoking cessation. This review evaluates whether mobile phone-based interventions are effective at helping people who smoke, to quit.

Interventions for specific groups and environments

Tobacco cessation interventions for young people
Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This review evaluates the effectiveness of strategies that help young people to stop smoking tobacco.

Community interventions for preventing smoking in young people

Decisions to smoke are often made within a broad social context and therefore community interventions using coordinated, multi-component programmes may be effective in influencing the smoking behaviour of young people. This review evaluates the effectiveness of multi-component community based interventions in influencing smoking behaviour, which includes preventing the uptake of smoking in young people.

Interventions for preoperative smoking cessation

Smokers have a substantially increased risk of intra- and postoperative complications. Preoperative smoking interventions may be effective in decreasing this risk. In addition, the preoperative period may be a well-chosen time to offer smoking cessation interventions due to increased patient motivation. This review assesses the effect of preoperative smoking intervention on smoking cessation in the postoperative period and longer term. It also evaluates the effect of smoking cessation on the incidence of postoperative complications.

Interventions for smoking cessation and reduction in individuals with schizophrenia

Patients with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit or reduce smoking. This review evaluates the benefits and harms of different treatments for nicotine dependence in schizophrenia.

Mass media interventions for smoking cessation in adults

Mass media tobacco control campaigns can reach large numbers of people. While much of the literature is focused on the effects of tobacco control advertising on young people, there are also a number of evaluations of campaigns targeting adult smokers. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy. This review aims to assess the effectiveness of mass media interventions in reducing smoking among adults.

School-based programmes for preventing smoking

Smoking rates in adolescents are rising in some countries. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated. This review evaluates the use of behavioural interventions in schools to prevent children (aged 5 to 12 years) and adolescents (aged 13 to 18 years) starting smoking.

Smoking cessation interventions for smokers with current or past depression

Individuals with current or past depression are often smokers who are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, and more likely to relapse to smoking after quitting than the general population, which contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit smoking. Therefore this review aims to evaluate the effectiveness of smoking cessation interventions, with and without specific mood management components, in smokers with current or past depression.

Tobacco cessation interventions for young people

Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This review evaluates the effectiveness of strategies that help young people to stop smoking tobacco, including both behavioural and pharmacological interventions.

Workplace interventions for smoking cessation

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation. This review aims to categorize workplace interventions for smoking cessation, and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption.

Acknowledgements: Thanks to Monaz Mehta for drafting the introductory text, selecting the reviews and for comments and edits.

Image Credit: LEA PATERSON/SCIENCE PHOTO LIBRARY, C014/0101

Date published: 14 June 2010; updated 9 May 2012, 30 May 2012 and 30 May 2014 with updated Cochrane Reviews

Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org)

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