To help smokers quit, combining treatments is essential

Many smokers who say they have tried everything to quit have not used behavioral treatments.

Nancy Rigotti, MD
Director, Center for Tobacco Research and Treatment, Massachusetts General Hospital

BOSTON– Despite advances in public health, smoking remains one of the most common, preventable, and costly health problems in the United States and around the world. In the United States, more deaths – about 480,000 each year – are attributable to smoking than to any other preventable cause. The 34 million American adults who smoke today could gain an average of a decade in life if they quit, and most smokers want to quit. Yet fewer than one in three people trying to quit use evidence-based treatment to help them succeed.

In a new clinical review in JAMAresearchers from Massachusetts General Hospital (MGH) and the University of Oxford are synthesizing the most recent data on this topic and providing advice to doctors and the public on the most effective treatments to help smokers quit.

The review confirms that smoking cessation medications and FDA-approved behavioral support programs are each effective in helping smokers quit, but they are most effective when used together. “Many people who are trying to quit smoking underestimate how helpful it is to get support and encouragement from a coach or counselor along the way,” says Nancy Rigotti, MD, author Principal and Director of the Tobacco Research and Treatment Center (TRTC) at the MGH. “Many smokers who say they’ve 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 to access evidence-based behavioral support. These include free quit smoking phone lines, text messaging, and programs on the Internet.

By analyzing reviews in the Cochrane Database of Systematic Reviews and other sources such as recommendations from the US Task Force on Preventive Services, Rigotti and colleagues found that new methods of administering approved withdrawal medications by the FDA may 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 to relieve nicotine withdrawal throughout the day, but also use a nicotine lozenge, gum or inhaler as needed if the urge to smoke occurs during the day,” says Rigotti.

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

The review summarizes a three-step, evidence-based strategy that physicians and other clinicians can use to integrate smoking cessation treatment into routine medical practice in all settings: ask patients about tobacco use, give clear advice to stop and offer treatment by prescribing medication. and connecting patients directly to behavioral treatment resources. “Having a brief conversation with each 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 at the Mongan Institute and Division of General Internal Medicine. The review’s fellow authors are Gina Kruse, MD, MPH, assistant professor of medicine at Harvard Medical School and TRTC researcher, and Jamie Hartmann-Boyce, DPhil, and Jonathan Livingstone-Banks, PhD, of the University of Oxford.

An audio interview with Rigotti is available on the JAMA website here.

About Massachusetts General Hospital
Massachusetts General Hospital, founded in 1811, is Harvard Medical School’s first and largest teaching hospital. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and includes more than 9,500 researchers working in more than 30 institutes, centers and departments. In August 2021, Mass General was named #5 in the US News and World Report list of “America’s Best Hospitals”.

About Oxford UniversityThe University of Oxford was ranked number 1 in the Times Higher Education World University Rankings for the fifth consecutive year, and at the heart of this success is our groundbreaking research and innovation. Oxford is world renowned for its research excellence and is home to some of the most talented people in the world. Our work helps the lives of millions of people by solving real-world problems through an extensive network of partnerships and collaborations. The breadth and interdisciplinary nature of our research sparks imaginative and inventive ideas and solutions.

Oxford University Division of Medical Sciences is one of the largest biomedical research centers in Europe, with more than 2,500 people involved in research and more than 2,800 students. The university is ranked among the best in the world for medicine and life sciences, and is home to the UK’s top medical school. It has one of the largest clinical trial portfolios in the UK and great expertise in bringing discoveries from the lab to the clinic. Partnerships with local NHS Trusts allow patients to benefit from close links between medical research and healthcare delivery.

Within the division, the Nuffield Department of Primary Care Health Sciences is the largest and highest ranked university-based primary care center in the UK and conducts world-class research and training to rethink the way healthcare is delivered in general practice and other care settings primaries. The main research focus of the department is the prevention, early diagnosis and management of common diseases, bringing together academics from many different backgrounds to work together to produce benefits for the NHS, for populations and for patients.

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