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7 The management of nicotine addiction

*7.1 General and non-pharmacological approaches
*7.2 Nicotine replacement therapy
*7.3 Non-nicotine medications for treating nicotine addiction
*7.4 Evidence-based treatment of nicotine addiction
*7.5 Nicotine replacement treatment in pregnancy
*7.6 Cost-effectiveness of treating nicotine addiction
*References

7.1 General and non-pharmacological approaches

There are two general approaches to the management of nicotine addiction, comprising:

  1. Population interventions that can be delivered on a large scale, such as advertising campaigns, educational or self-help materials, products which can be bought over-the-counter, brief routine interventions by health care professionals, and telephone help-lines.
  2. Individual interventions based on the traditional model of intensive expert-delivered treatments, and delivered to smokers either individually or in groups.

The two approaches overlap, and there are constant efforts to adapt for wider dissemination interventions proven to be effective in the intensive treatment setting.

In general terms, the greater the degree of contact between the smoker and the treatment provider in these interventions, the greater the efficacy achieved. However, it is also true that, in general, the more intensive the intervention the greater the financial cost and the smaller the proportion of the smoking population reached by the intervention. Treatment cost-efficacy is also clearly an important issue in this area because treatments have often been regarded as overly expensive for the results they deliver. This may not necessarily be the case since intensive interventions tend to attract the more highly dependent, and therefore high-risk, smokers.1 However, even the most highly effective intervention service will have little impact on population smoking prevalence if only a minority of smokers use it, and it is the case that smokers in the UK seldom attend specialist treatment clinics. Even well run and centrally based smoking cessation clinics with large catchment areas can expect to attract only some 200-300 smokers per year. This is clearly a tiny minority of the smoking population, so the role of other interventions also needs to be assessed.

Comprehensive summaries of the existing evidence are available through the US Agency for Health Care Policy and Research guideline document2 and the more recent Cochrane Centre reviews used in the preparation of evidence-based guidelines in the UK (see Section 7.4 for details).

Wide-reach approaches

In view of the scale of smoking prevalence, there is a pressing need for interventions reaching large populations. Numerous approaches have attempted to address this need and can be difficult to classify. There is a thin line dividing minimal interventions, which can still be considered treatments aimed at managing nicotine addiction (eg brief advice by a health professional), and educational or motivational approaches, which would not be defined as treatment (eg similar advice delivered through posters or mass media).

Comprehensive community-oriented interventions. A range of interventions can be targeted at whole communities (eg posters, mass-media campaigns, telephone and self-help interventions, 'quit and win' contests, etc). Such 'all-out' broad interventions have strong intuitive validity, but a number of sensible interventions have not in fact proven to be effective in the area of smoking cessation. Many community-level strategies have never been properly tested on their own, but a state-of-the-art comprehensive community level strategy has been carefully evaluated in the Community Intervention Trial for Smoking Cessation (COMMIT), the single biggest test of a smoking cessation intervention to date.3,4 A community-level intervention comprising 58 mandated and numerous additional activities was tested in 11 matched pairs of communities in the US. The results were disappointing, showing no statistically significant effect on the target group of heavy smokers (>24 per day) or on total smoking prevalence, though there was a small effect of potential public health significance in light to moderate smokers. It has been pointed out that the same type of general and motivational interventions could well be more effective in countries less saturated with anti-smoking education.5 Also, the lack of an overall effect does not necessarily mean that all the component parts were also ineffective; some of these were reaching only small groups of smokers, and may not have been run in an optimal way.

Self-help interventions. Self-help leaflets and books are an inexpensive way of distributing cessation advice to a large potential market. Most such materials, however, repeat variations of behavioural advice developed in the 1970s prior to full appreciation of the addictive nature of smoking and the advent of pharmacological treatments. From a contemporary point of view, the face validity of some of them is good, particularly when advice on nicotine replacement therapy (NRT) is included, but in others it is rather poor. An interesting development based on computing technology is to personalise advice to individual smokers.6 In the Cochrane review of the relevant literature,7,8 comprising 41 trials of variable methodological rigour, overall there was a small but significant effect of self-help in comparison with no intervention. There was also an advantage of personalised self-help materials in comparison with generic ones, but no incremental benefit of self-help materials when added to other brief interventions. The US guidelines2 suggest that written materials may be more effective when combined with other more intensive therapies.

Telephone help-lines. When well advertised, telephone help-lines can elicit a large number of calls.9 Although there is no clear evidence on the effectiveness of brief outreach telephone counselling, a large study of up to six proactive 50-minute counselling sessions with smokers ready to quit found this intervention to be effective.10 Clear research evidence is lacking for the more usual responsive telephone counselling but, even in the absence of strong evidence of efficacy, existing responsive help-lines such as Quitline in the UK can assume another potentially important role in referring callers to locally available face-to-face treatments.

Advice by physicians. A review of 31 randomised controlled trials from both primary and hospital care concluded that brief advice by doctors is effective, and that more intensive interventions only marginally increase the efficacy of brief advice.11 Overall, the efficacy is low (1-3% above controls), but because of wide reach this approach has the potential to influence smoking prevalence in whole populations. It should be noted that, as might be expected, brief interventions are effective primarily with light smokers.12 Brief interventions by other health care staff are also effective, to a degree similar to that achieved by clinicians.1

Despite its proven value, it seems difficult to initiate and maintain routine smoking cessation interventions in general practice with all smokers. The low success rates can be demoralising, insistent advice can strain the doctor-patient relationship, general practitioner (GP) consultations often have other pressing priorities, and the time available for extra input is short.13

Intensive interventions

Behavioural interventions. Smoking cessation clinics in the UK typically offer a combination of NRT and behavioural support delivered over a series of weekly sessions. Both individual and group behavioural treatments are effective.7,8,14 The Cochrane reviews found no difference in efficacy between individual and group treatments, so preference must be given to group approaches where practicable as they are considerably more cost-effective, though some smokers prefer the individual approach. The large Lung Health Study15 provides a persuasive confirmation of the effectiveness of intensive support combined with NRT, achieving as it did a one-year abstinence rate of 35% versus 9% with usual care (see Section 5.2 for details). Two aspects of intensive behavioural treatments deserve a separate note:

  • Relapse prevention. Well-run intensive treatments are very effective in helping even heavy and dependent smokers to stop smoking for a period of several weeks. As with other addictions, however, relapse is the major problem, eroding the success rates of 50-60% at one month to 20-30% one year later.16 This is still a respectable success rate because, without treatment, cessation rates are very low. Nevertheless, the lack of effective relapse prevention is felt acutely in clinical practice. Several relapse prevention procedures have been proposed and are widely practised, but so far none has proven clearly effective.
  • Social support. Social support is believed to be an important ingredient of intensive treatments, and of group treatments in particular. Having another person or a group of fellow smokers involved in a quit attempt seems to provide a boost to the effort to succeed. A recent trial of an attempt to translate this mechanism of intervention to general practice by 'buddying' pairs of smokers showed a significant short-term effect in comparison with a control group.17 More work is needed on designing and evaluating social support treatments applicable on a larger scale.

Hypnosis and acupuncture. Hypnosis and acupuncture hold a special place among a range of existing treatments for smokers. While most other treatments are practised only on a very limited scale, the number of commercial advertisements for acupuncture and hypnosis suggests that these two approaches are popular with smokers. The Cochrane group has reviewed nine studies of hypnosis18 and 16 trials of acupuncture,19 and concluded that evidence of specific efficacy is lacking. Some people can of course be helped by numerous different unproven procedures, via non-specific and placebo effects.

7.2 Nicotine replacement therapy

NRT is the only pharmacotherapy licensed in the UK to manage nicotine addiction. At the time of writing, there are five different NRT products on the market, some produced in different strengths and different versions. This section outlines their general features, as well as their individual characteristics, with special attention to issues of efficacy, dose-response, dependence potential, NRT combinations, and choosing the right product for individual smokers.

Mode of action

The main short-term difficulties smokers experience when trying to stop smoking seem to be attributable to acute nicotine withdrawal. The basic idea behind using nicotine replacement is to break the quitting process into two phases. In the first phase, smokers learn to cope without smoking behaviour and regular rapid boli of nicotine, while protected from the worst withdrawal effects by moderate levels of nicotine provided by NRT. Later, nicotine is gradually withdrawn completely.

NRT alleviates withdrawal discomfort.20 However, as has been pointed out, the severity of withdrawal is only a weak predictor of success in stopping smoking. Although such alleviation probably constitutes the main effect of NRT, other mechanisms may also have a role, such as the provision of a coping mechanism, or even the replacement of some of the hypothetical positive effects of nicotine.21 NRT may also make early relapses to smoking in smokers trying to quit less rewarding, and therefore less likely to trigger a full-scale relapse. A related possible mechanism could be deconditioning because the link between pharmacological reinforcement and smoking behaviour may weaken during abstinence accompanied by NRT use.

Overall efficacy

Whatever the actual mechanism, there is ample evidence that NRT is effective in helping smokers quit. It has been by far the most extensively and rigorously tested smoking cessation treatment. The most recent update of the Cochrane review (May 1999)22 summarises 49 trials of nicotine gum, 24 of transdermal nicotine patch, four of nicotine spray and four of nicotine inhalators. The overall odds ratio for abstinence with NRT compared to placebo was 1.73 (95% confidence interval 1.60-1.86). These odds were maintained regardless of the intensity of additional support or the setting in which the NRT was offered. In addition to enhancing early cessation, there is evidence that NRT also reduces early relapse.23

Dose response

Increasing nicotine dose seems to increase treatment efficacy, though the dose-response curve is shallow.24 For nicotine chewing gum, the 4 mg gum was shown to be more effective than the 2 mg gum in highly dependent smokers, though it is not known whether this also applies to less dependent smokers. A recent large-scale trial of nicotine transdermal patches (the Collaborative European Anti-Smoking Evaluation (CEASE) trial) has shown a small, but significant advantage of 25 mg over 15 mg patches in sustained one-year abstinence rates.25 Some other trials have also shown higher delivery patches to be more effective,26,27 though in one large study the effect did not reach significance,24 and in another substantial study it was absent.28

Given the apparently stronger effect of higher nicotine doses with a self-dosing oral preparation such as the gum, increasing the nicotine delivery of these products should be further examined.

Dependence potential

Fears have been expressed about the dependence potential of NRT since it first appeared on the market. Among smokers' clinic patients, some 25% of long-term successes who started on the nicotine gum were still using it at one year,29 as were 43% of continuing long-term successes of a similar sample who started on nasal spray.30 No cases of long-term use of the nicotine patches have been reported, suggesting that the incidence of long-term use may be related to the speed of nicotine absorption from individual products. The nasal spray study30 allowed the monitoring of the effect on relapse rate of withdrawing the medication after one year. Reassuringly, there was no difference in relapse rate between those who used the spray for one year and those who did not.31 Long-term NRT users seem closer in their characteristics to treatment failures than to 'NRT-free' long-term treatment successes, and it is likely that many of them would be smoking if NRT was not available over a protracted period of time.29 NRT does not create new dependence as users are already dependent on nicotine, of which NRT typically provides less than cigarettes and in a much safer way.32 Long-term use of NRT does not seem to be associated with any significant harmful effects.15.

Additional support

Current moves to make NRT treatments more widely available have the potential to bring about substantial public health benefits.33 There is a reservation that without 'psychological packaging', involving explanation of effects and creation of adequate expectations, smokers may not adequately engage with treatment and NRT may then be less effective. Appropriate briefing of smokers purchasing NRT, through well designed leaflets, or even via repeated mailings of tailored product and behavioural advice, should be able to offset this effect.

Currently available nicotine replacement therapy products

Nicotine chewing gum. Three brands of nicotine chewing gum are on the market, all in 2 mg and 4 mg doses, and all equivalent in their nicotine delivery. Smokers are instructed to chew each piece of gum slowly for some 30 minutes. The usual recommendation is to chew one piece per hour, supplemented by opportunistic use as required, with total usage of up to 15 pieces a day. Nicotine enters the bloodstream via the buccal mucosa, and the plateau blood nicotine level is reached after about 30 minutes. Only about 0.9 mg nicotine from one piece of 2 mg gum and 1.2 mg from 4 mg gum reaches the bloodstream.34

Nicotine transdermal patch. There are four brands of patch on the UK market. The highest doses of all preparations aim to deliver about 1 mg of nicotine per hour. Some patches are designed to be worn for only 16 hours to avoid sleep-time nicotine dosing, while 24-hour patches are aimed at prevention of urges to smoke on waking. Nicotine absorption is slow, taking hours to reach a plateau. Users have no control over the nicotine dose but, because of simple instructions and ease of use, compliance with patch use is much better than with other NRT products.35

All existing types of patch come in three different strengths, to be used in similar schedules, starting with the strongest dose and using the weaning-off doses for up to three months. Eight weeks of patch use has been shown to be as effective as longer courses of treatment, and there is no evidence that tapered use is better than abrupt withdrawal.22,25

Nicotine nasal spray. Nicotine nasal spray consists of a bottle of nicotine solution which is sprayed into a nostril by an air pump plunger via a nozzle. It provides by far the most rapid nicotine absorption among the NRT products, reaching a plateau in about 10 minutes. A single spray into one nostril delivers about 0.5 mg of nicotine, absorbed mostly through the nasal mucosa. The recommended usage is one spray in each nostril hourly up to 16 times a day. There is some evidence that the spray is especially helpful to more highly dependent smokers.30 The spray is initially unpleasant to use. Although users who persevere get used to the irritant effects, this is a serious drawback and necessitates close initial supervision and reassurance of first-time users.

Nicotine inhalator. The inhalator consists of a plastic holder resembling a cigarette holder, and cartridges containing a polythene plug impregnated with nicotine. Puffing on the inhalator brings nicotine vapour into the mouth and throat, where it is absorbed. The nicotine does not reach the lungs. About 20 puffs on the inhalator equal one puff on a cigarette, so frequent and intensive puffing for some 20 minutes is needed to obtain about 1 mg of nicotine. Users are advised to use 6-12 cartridges per day, each of them for three puffing sessions. The inhalator has some appeal in promising to replace some of the behavioural aspects of smoking, but users tend to feel self-conscious in public.35 This may change with wider awareness of the device.

Nicotine sublingual tablet. Nicotine tablets are designed to be held under the tongue until they dissolve, usually within 20-30 minutes. The nicotine absorption profile and the dose delivered from the preparation are similar to that of nicotine chewing gum and nicotine inhalator. These formulations, particularly if used heavily, may be more user friendly than the gum, though experience with these relatively new products is currently limited.

Differences between products in efficacy

There is no evidence that, overall, products with similar nicotine delivery differ in efficacy.35 The one study that directly compared 16-hour and 24-hour patches found no difference in efficacy.36 It remains a possibility that different products may differ in acceptability, the adherence of users to recommended usage, and ultimately in effects on outcome for special subgroups of clients.

Nicotine replacement therapy combinations

There is a growing interest in evaluating the notion that treatment efficacy may be increased by using two or more NRT products at the same time. This could arise via increased nicotine intake and, in the case of combinations including nicotine patches, via supplementing the steady nicotine levels from the patch with occasional boosts from the faster delivery products to counteract surges in withdrawal discomfort.

The evidence supporting product combinations has so far been rather weak. The Cochrane review concluded that there is no strong evidence that NRT combinations are more effective than single products.22 Other studies have been published since the last update of the Cochrane review. For example, adding the patch to nicotine inhaler37 or nicotine nasal spray38 did not improve mid-term efficacy of the inhaler or spray alone. One study reported a combination of spray and patch to be superior to patch alone, but did not include a spray-only treatment group.39

7.3 Non-nicotine medications for treating nicotine addiction

NRT medications are effective and safe,40 but some smokers prefer not to use them because they are sceptical of the replacement rationale, or fear addiction, or believe that nicotine is harmful. In addition, many smokers have tried NRT, but have not succeeded in quitting41 and might benefit from switching to a non-nicotine medication.

The following paragraphs briefly review non-nicotine medications that have been tested. Placebo-controlled trials are emphasised. Data from non-humans and on non-cessation outcomes (relief of withdrawal symptoms or suppression of post-cessation weight gain) are not discussed. Recent reviews give more detailed information.42-45

Antidepressants

One common rationale for using antidepressants for smoking cessation has been that many smokers either have depressive symptoms or develop them post-cessation, and that these interfere with cessation.46 Another rationale is that nicotine dependence is associated with low dopamine levels which are corrected by some antidepressants.47

Bupropion. Currently, bupropion is the only non-nicotine therapy for smoking cessation marketed in the USA.47,48 At the time of writing, it is likely to become available for use in the UK in the near future. Bupropion is an atypical antidepressant with both dopaminergic and adrenergic actions. Treatment begins one week prior to cessation, and lasts 7-12 weeks. In four trials, bupropion, like NRT, doubled quit rates.48 Importantly, its efficacy does not appear to be due to its classical antidepressant effects because the drug works equally well in smokers with and without a past history of depression. Like NRT, bupropion also appears to reduce post-cessation weight gain,47 at least while it is being used. One study has reported that combined nicotine patch and bupropion produced higher quit rates than the nicotine patch alone.49 Side effects are mild and consist of nausea and insomnia. Earlier trials in depressed patients suggested that bupropion increased the risk of seizures, but more recent data with the slow-release preparation indicate that with doses of 300 mg per day or less, and with simple screening, the risk of seizures is small and no more than with other antidepressants.47-49

Nortriptyline. The other antidepressant that appears to increase cessation is nortriptyline, a tricyclic antidepressant with mostly noradrenergic properties and little dopaminergic activity. Two published trials indicate that nortriptyline increases cessation rates, an effect apparently unrelated to depressive symptoms.50,51 Side effects from nortriptyline include anticholinergic effects, nausea and sedation.

Other antidepressants. In one study, imipramine, which has mostly noradrenergic and serotonergic effects, did not improve smoking cessation,52 but a small study suggested that doxepin, which has similar neurochemical effects, increased short-term cessation.53

Cigarette smoking inhibits the enzyme monoamine oxidase (MAO)-A.53-55 This enzyme breaks down acetylcholine, so smoking increases cholinergic and adrenergic transmission. Moclobemide is an MAO inhibitor which has been used in smoking cessation to replace the MAO inhibition of smoking and, in fact, was effective in the short term in the one published study.56
Of the selective serotonin reuptake inhibitor group of antidepressants, fluoxetine has been tested in two large multicentre trials, one of which went unreported. The other study reported increased cessation with fluoxetine, but did not report abstinence rates.57 One study of venlafaxine reported negative results.58

In summary, there is clear evidence that bupropion is an effective non-nicotine therapy, and suggestive evidence that nortriptyline may also be effective. Across antidepressant studies, those with adrenergic activity appear to be more likely to be effective than those without it. Thus, although many workers have focused on dopaminergic activity to explain antidepressant efficacy for smoking cessation, it may be noradrenergic activity that is responsible for efficacy.

Clonidine

Clonidine is an a2-noradrenergic agonist that suppresses sympathetic activity; it is mostly used for hypertension, but also to reduce alcohol and opiate withdrawal.59 Both as pills and as a patch in low doses (usually 0.2-0.4 mg per day), clonidine increased smoking cessation in eight of nine trials.59 Although early studies suggested that clonidine was effective only for women, later studies have not found this. Clonidine has more significant side effects (eg sedation, postural hypotension) and more drop-outs due to side effects than NRT. For these reasons, it is mainly used as a second-line drug for those who cannot, or do not wish to, take NRT or bupropion.

Mecamylamine

Mecamylamine is a nicotine antagonist originally used to decrease cholinergic activity, and thus reduce blood pressure.60,61 It does not specifically bind at the nicotinic receptor but blocks the associated ion channel; this may be why, in humans, it blocks the effects of nicotine but does not precipitate withdrawal symptoms.60,61 Early trials with moderate-level doses of mecamylamine alone produced unacceptable side effects. Based on a theoretical analysis, two trials have tested a combination of nicotine patch with low doses of mecamylamine (5-10 mg per day), and both found that this combination was superior to placebo.62 In the later study, mecamylamine alone was helpful early on, but not at later follow-up. However, the preliminary report of an even more recent multicentre trial failed to confirm efficacy.63 Although some gastrointestinal effects, particularly constipation, were significant, side effects with the lower doses and with the counteracting effects of nicotine were not a major cause of drop-out.

Buspirone

Buspirone is a serotonin agonist which acts as a non-sedating, non-addicting anxiolytic. Buspirone has been tested as an aid to stopping smoking because anxiety is commonly associated with cessation. The first study found a significant effect on short-term cessation in normal (non-anxious) smokers.64 A second study found that buspirone increased quit rates among smokers with above average pre-cessation anxiety levels,65 while a third found buspirone to be ineffective in both low- and high-anxiety smokers.66 Ondansetron, a serotonin antagonist, failed to improve cessation in one study.67

Lobeline

Lobeline is a nicotine-related alkaloid with some, but limited, activity at nicotinic receptors,68 and is found in several over-the-counter smoking cessation aids. Both older studies69 and two more recent studies70,71 have failed to find that lobeline increases quit rates.

Naltrexone

Naltrexone (a long-acting formulation of naloxone) blocks opioid release, and is used to treat both opioid and alcohol dependence. Two randomised trials reported positive short-term results,71,72 but a recent trial failed to confirm efficacy.73

Silver acetate

Silver acetate, found in some over-the-counter preparations, interacts with cigarette smoke to produce an aversive metallic taste. Both older74 and newer75 studies with silver acetate have failed to find evidence of efficacy.

Sensory replacement

Although often overlooked, sensory effects of smoking are important to its reinforcing effects, and their absence during cessation may be a cause for relapse.76 Three clinical trials of inhalers with chemicals to mimic the sensory feel of cigarettes have been tested:

  • an ascorbic acid aerosol increased short-term cessation77
  • a citric acid inhaler increased very short-term cessation but only in heavy smokers,78 and
  • a citric acid inhaler plus nicotine patch increased short-term cessation over a placebo inhaler plus nicotine patch.79

Sensory replacement therapy could be useful for the many smokers who report missing the sensory aspects of smoking, for the minority of smokers for whom nicotine dependence is not an important barrier to cessation or as an adjunct to NRT or non-nicotine therapies. Thus, further testing appears warranted.

Summary

Bupropion and clonidine are the only proven non-nicotine therapies for smoking cessation (see Table 7.1). Of these, bupropion is preferred because of its better side effect profile. Nortriptyline, moclobemide, mecamylamine and sensory replacement have shown preliminary promise.

Bupropion has been widely used in the USA and appears to be popular.41 This could be because it is the first non-nicotine therapy to become widely available to smokers, or because many smokers have failed NRT and are looking for new treatments. In either case, it suggests that there is a future for non-nicotine therapies for smoking cessation, and that smoking cessation services need to be able to adapt to deliver bupropion and other new developments that are shown to be effective and cost-effective.

Table 7.1. Non-nicotine therapies for smoking cessation.

Proven therapies:

Bupropion

Clonidine

Possible therapies: 

Nortriptyline

Noradrenergic antidepressants

MAOIs

Mecamylamine + NRT

Sensory replacement

Therapies that have been tested but found to be ineffective, or that at the present time lack sufficient evidence: 

Anorectics

Benzodiazepines

Beta-blockers

Buspirone

Caffeine/ephedrine

Cimetidine

Dextrose

Lobeline

Naltrexone

Odansetron

Phenylpropanolamine

Silver acetate

Stimulants

SSRI antidepressants

 

 

MAOI = monoamine oxidase inhibitor; NRT = nicotine replacement therapy; 

SSRI = selective serotonin reuptake inhibitor.

 

7.4 Evidence-based treatment of nicotine addiction

Nicotine addiction occupies a strange position in the health care system of Britain, and probably of most countries. Treatment of nicotine addiction has been shown to be both effective80 and cost-effective;81 despite this, at the time of writing it is still not universally available as part of the NHS. This situation is particularly inconsistent, given that the NHS provides treatment for addicts to illicit drugs and to alcohol. A 1995 Health Education Authority (HEA) survey, Health in England,82 found that only about 29% of smokers who had seen their GP in the previous year said they had been given advice on smoking. A 1996 HEA survey83 reported that only 39% of pregnant smokers said they had received advice about smoking. The limited evidence available on the delivery of treatment through the NHS shows that it is variable84 and depends on the enthusiasm and commitment of individuals.

The barriers to action amongst GPs include lack of time, perceived lack of skills, and the perception that success rates are low.2,85,86 The last of these may be particularly important in engaging the interest of GPs. Appreciating the difference between success rates and the numbers reached may help: intensive treatments that achieve high cessation rates but reach limited numbers will usually produce fewer ex-smokers than less intensive approaches which reach many smokers. Thus, brief advice from GPs (defined as up to 3 minutes) (see Table 7.2) may encourage 'only' about 2% more smokers to stop compared with normal care control, but this apparently low figure applied nationally to all GPs would be enormously worthwhile and cost-effective. With an average of about 9,000 patients and 2,600 smokers (29%) in a five-partner practice, brief advice could help more than 50 (2% of 2,600) additional smokers each year in that practice to stop. Nationally, this would produce about 300,000 additional ex-smokers. With NRT added to usual care (see Table 7.2), the result would be about 156 (6% of 2,600) extra ex-smokers per practice, or almost one million nationally. These apparently low absolute figures are worthwhile and extremely cost-effective compared to many other things doctors do,81 and this message needs to be conveyed clearly to health professionals.

Table 7.2. Estimates of the effect of smoking cessation interventions
on smoking abstinence rates at six months (source: Ref 80).

Intervention element

Data source

Increase in %
of smokers abstinent for 6 months or longer

Very brief advice to stop (3 min) by clinician, versus no advice

AHCPR2

2

Brief advice to stop (up to 10 min) by clinician, versus no advice

AHCPR2

3

Adding NRT to brief advice versus brief advice alone or brief advice plus placebo

Cochrane22

6

Intensive support (eg smokers' clinic) versus no intervention

AHCPR2

8

Intensive support plus NRT versus intensive support or intensive support plus placebo

Cochrane22

8

Cessation advice and support for hospital patients versus no support

AHCPR2

5

Cessation advice and support for pregnant smokers versus usual care or no intervention

AHCPR2

7

Note: to estimate the overall effect of a particular package of treatment (eg intensive behavioural support plus nicotine replacement therapy (NRT)), broadly speaking, the effects of the elements can be added together. Thus, intensive support plus NRT can increase long-term abstinence rates by some 16% (8% intensive support plus 8% NRT) over control.
AHCPR = US Agency for Health Care Policy and Research

The relative lack of progress in the last 20 years clearly indicates that education and persuasion are not enough. Until structural factors are addressed, including renegotiating the core contracts of relevant health professionals to include smoking cessation treatment, the situation will probably not change. In effect, a change is needed in the culture of the NHS towards the delivery of effective preventive interventions. Such a change will not come easily, and will require the support of government as well as of health professionals.

This may be beginning to happen in England. In December 1998, the government launched a White Paper on tobacco control,86 the first ever in the UK, which for the first time set out a framework for an NHS smoking cessation treatment service. Funding was allocated to develop these services, initially in relatively deprived areas called health action zones (HAZ) for one year, with the promise of money for two additional years and more national coverage if all goes well in the first year. The treatment services envisaged are essentially those described in the evidence-based guidelines published in Britain at about the same time as the White Paper.80,81 The recommendations of the guidelines are summarised in Tables 7.2 and 7.3. Key features of the guidelines are that they:

  • are evidence-based
  • are endorsed by the professions, and
  • now have some financial support from central government to begin establishing treatment services.

It remains to be seen whether the changes recommended in the guidelines will be widely adopted into the fabric of the health service.

7.5 Nicotine replacement treatment in pregnancy

There is little information available on the use and relative risks of NRT in pregnancy, so it is difficult to formulate policy on the use of NRT in this indication.80,85,86 However, cigarette smoking, in general, delivers more nicotine and results in higher levels of organ exposure than NRT, and also exposes the individual to many other toxins (see Section 2.6). It therefore seems likely that, whilst smoking cessation through non-pharmacological means remains the ideal, nicotine replacement is likely to be appreciably safer to the mother and fetus than continued smoking. NRT is therefore theoretically justified in pregnant women in whom non-pharmacological interventions have failed. However, because of concerns about excessive exposure to nicotine over time, it may be prudent to use shorter-acting NRT products such as gum or lozenges rather than patches. It also makes sense to attempt to dose NRT so as not to exceed the levels of nicotine in the body derived from cigarette smoking for an individual pregnant smoker.

Table 7.3. Recommendations for health professionals.80

Recommendations for all health professionals

  • Assess the smoking status of patients at every opportunity; advise all smokers to stop; assist those interested in doing so; refer to specialist cessation service if necessary; recommend smokers who want to stop to use NRT; provide accurate information and advice on NRT.
  • Smoking and smoking cessation should be part of the core curriculum of the basic training of all health professionals.

Recommendations for the primary care team

  • Assess the smoking status of patients at every opportunity; advise all smokers to stop; assist those interested in doing so; offer follow-up; refer to specialist cessation service if necessary; recommend smokers who want to stop to use NRT; provide accurate information and advice on NRT.

Recommendations for smoking cessation specialists

  • Intensive smoking cessation support should, where possible, be conducted in groups, include coping skills training and social support, and should offer around 5 sessions of about 1 hour over about 1 month, and follow-up.
  • Intensive smoking cessation support should include the offer of or encouragement to use NRT, and clear advice and instruction on how to use it.

Nicotine replacement therapy

  • Smokers should be encouraged to use NRT as a cessation aid. It is effective and safe if used correctly.
  • Health professionals who deliver smoking cessation interventions should give smokers accurate information and advice on NRT.
  • Consideration should be given to ways of increasing the availability of NRT to low income smokers, including at reduced cost or free of charge.

Recommendations for specific smoker populations

  • Hospital staff should assess the smoking status of patients on admission, advise smokers to stop, and assist those interested in doing so; patients should be advised of the hospital's smoke-free status before admission.
  • Hospital patients who smoke should be offered help in stopping smoking, including the provision of NRT.
  • Pregnant smokers should be given firm and clear advice to stop smoking throughout pregnancy, and given assistance when it is requested.
  • Cessation interventions shown to be effective with adults should be considered for use with young people, with the content modified as necessary.

Recommendations for health commissioners

  • To produce cost-effective significant health gain in the population, smoking cessation interventions should be commissioned.
  • Review current practice, identify needs, and provide core funding to integrate smoking cessation into health services; plan a cessation strategy with public health specialists; seek advice from smoking cessation specialists.
  • These plans should include a specialist cessation service.
  • Training should be a core part of a smoking cessation programme in all health authorities; protected time and funding should be built into this programme.
  • Core fund smoking cessation training, or make sure that smoking cessation is prioritised within existing training budgets.
  • Make provision to ensure that NRT is available to hospital patients who need it, in conjunction with professional advice and cessation support.
  • Require all services, departments and clinics to introduce systems to maintain an up-to-date record of the smoking status of all patients in their (paper or electronic) notes; it should be regarded as a vital sign.
  • Ensure that all health care premises and their immediate surrounds are smoke-free.
  • Work with clinicians to put systems in place to audit smoking cessation interventions throughout the health care system.
NRT = nicotine replacement therapy

Research into the use of NRT in pregnancy presents a number of ethical problems but is urgently needed, particularly in relation to heavy smokers in whom non-pharmacological behavioural therapies have failed.

7.6 Cost-effectiveness of treating nicotine addiction

There is clear evidence, summarised above, that a range of interventions for the treatment of nicotine addiction are effective. However, health resources are scarce, and there are many competing demands on NHS funds, so it is also important to consider the cost-effectiveness of treatments for nicotine addiction. Such studies combine data on the costs of treatments with evidence of effectiveness.

Synthesising evidence on cost-effectiveness is problematic. Relatively little resource information has been obtained concurrently with clinical trials, and most has been estimated retrospectively. Also, even if better resource data were available, the costs of different means of delivering interventions vary across countries and over time, complicating comparisons of results across studies, plus the fact that existing studies have included different costs and consequences. Cheung and Tsevat87 criticised many published studies for excluding the consequences of changing smoking rates on health service use. The costs and consequences considered depend on the perspective taken. This is an important issue for NRT in the UK. Currently, most NRT therapy is bought from pharmacies by individuals attempting to quit, and the cost of these products falls therefore to the individual rather than to the health service. From a narrow health service perspective, these therapies currently appear to have low direct health service costs. However, from a wider societal viewpoint, the costs to individuals, whether for products or for the time involved in other therapies, would be included as part of the overall analysis.

Another important issue which influences the results from cost-effectiveness analysis is the comparison of the alternative interventions being considered. Most studies have suggested that both NRT therapies and brief advice yield value for money compared to other health care interventions when applied to the whole population of smokers. These results suggest that investing any additional resources in smoking cessation - or indeed switching from some other health care interventions into smoking cessation interventions - would be worthwhile.

There is less agreement about the most efficient means of spending any allocated budget for smoking cessation. A review of cost-effectiveness studies up to 1997 suggested that it could be concluded that the least intensive interventions, such as brief advice or the use of self-help manuals, yielded more favourable cost-effective ratios than some more intensive therapies.88 For the UK, this conclusion depends crucially on the perspective taken,89 since in this analysis NRT compared favourably with advice alone when only the NHS costs were considered.

Cromwell et al1 investigated the cost-effectiveness of American guidelines covering a range of smoking interventions, and concluded that the more intensive the intervention, the lower the cost per quality adjusted life-year (QALY) saved. However, this study included more intensive interventions than had been previously considered, consisting of five individual or seven group counselling sessions with or without NRT. Five main types of interventions were considered both without NRT and with either patches or gum, making 15 intervention types in all:

  • minimal counselling
  • brief counselling
  • full counselling
  • individual intensive counselling, and
  • group intensive counselling.

The cost-effectiveness figures were calculated, first assuming that 75% of American smokers wanting to quit had one of these interventions compared to no interventions being available. The interventions with patches were found to be more cost-effective than the equivalent intervention without NRT and with NRT gum, apart from intensive group counselling where the figures were almost equivalent for patches and no NRT. It is not clear why these findings differ from previous findings.

More realistically, the authors calculated a scenario in which patient preferences for different interventions were used. This resulted in an estimate of $1,915 cost per QALY across the whole smoking population. This figure compares favourably with the cost per QALY from the more unrealistic scenario of everyone being offered only one type of intensive intervention. Clearly, the overall financial costs of the combined intervention package would be lower.

More intensive interventions were also costed in an analysis of data for Britain.81 In this model, a more stepped approach was assumed, with some smokers receiving brief advice alone and others - possibly those who had failed previously - being offered the more intensive interventions. Different stepped programmes were assessed, comprising:

  • brief advice alone
  • brief advice plus self-help material
  • brief advice, self-help and NRT (for a proportion of smokers), and
  • brief advice, self-help, NRT and specialist cessation interventions.

Given the current low level of such intensive services, it was assumed that only 2% of smokers would wish to use such interventions. Summary results from that study are shown in Table 7.4. From an NHS perspective, the different programmes, assumed to be directed at 50% of current smokers in any year, yield comparable cost-effectiveness figures when compared to the existing level of services. The costs to the NHS from implementing the programme with the intensive elements, based on the smoking cessation guidelines for health professionals,80 were estimated at £331,000 per health authority.

Table 7.4. Cost-effectiveness of smoking cessation programmes, England and
Wales, 1996 prices (source: Ref 81).

 

Cost per life year saved (£) 

 

 

NHS perspective

Societal perspective

Brief advice

174

212

Brief advice + self-help

221

259

Brief advice + self-help + NRT

269

606

Brief advice + self-help + NRT +
specialist cessation service

255

873

 

 

 

Notes:

  • All interventions compared to current smoking cessation practice assuming additional resources to reach 50% of smokers per year.
  • Numbers receiving different interventions based on expert opinion and available data.
  • All health gains discounted at 1.5%.

NRT = nicotine replacement therapy.

Stapleton et al90 also present some recent UK estimates based on resource data concurrently collected in a randomised controlled trial. The study was based on interventions provided within primary care, and presents the figures for the incremental (extra) costs and life-years saved of counselling with nicotine patch treatment over GP counselling alone. All interventions were directed at the more dependent smokers, and NRT was provided free. The authors used the trial results to simulate a situation in which NRT was available through prescriptions, implying that the NHS would bear more of the costs of these types of interventions than currently. However, the costs of counselling and prescribing NRT were based on the optimal cost-effectiveness assumption that such services would be provided only if participants remained abstinent. For abstinent smokers, repeat prescriptions for NRT were made available for up to 12 weeks. From an NHS perspective, the results suggest that the cost per life-year gained ranged from £345 for those aged 35-44 to £785 for those aged 55-65.

Currently, however, NRT products are not generally available on prescription in the UK. Most estimates of cost-effectiveness have taken figures from trials where the products were provided free of charge. There is evidence to suggest that the take-up of NRT products will vary depending on the charges. For example, Curry et al91 found a positive relationship between take-up of NRT and insurance cover in the USA, with more cover increasing the cost-effectiveness of interventions. More evidence should become available from the areas where NRT has been made available free for one week as part of the HAZ initiative arising from the recent White Paper.86

Most economic studies of smoking cessation have been based on the whole population of smokers, although some (such as the study by Stapleton et al90) have presented results differentiated by age. Special subgroups may yield even higher gains. There are no UK studies, for example, on the cost-effectiveness of interventions with pregnant women, but data from the US suggests that such interventions lead to immediate cost savings for health authorities, quite apart from the health gains for mothers and their children.89 Similar savings may be apparent for other high-risk groups. Lightwood and Glantz92 calculated the health cost savings from reducing the incidence of acute myocardial infarction (MI) and strokes in the USA. Krumholz et al93 estimated a cost of $220 per life-year saved from a smoking cessation programme directed at those recovering from an MI, but that figure excludes any estimate of health care cost savings.

Conclusions

In conclusion, all the available evidence suggests that treatment for nicotine addiction can be obtained at a very low cost per life-year gained compared to most other health care interventions.94,95 Investment in treatment for smokers would yield considerable health gains at low cost. All the costs per life-year saved presented in this section are well below the informal figure of £6,000 per incremental life-year gained which was previously used as an initial yardstick by the Department of Health when considering whether the NHS should adopt new therapies or techniques. It is likely that few of the general health care interventions in current and future use in Britain will have a lower cost per life-year saved or QALY than the most pessimistic estimates of the cost-effectiveness of smoking cessation intervention.

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Contents

Contributors, Foreword and Key Points
1  Tobacco smoking in Britain: an overview
2 Physical and pharmacological effects of nicotine
3 Psychological effects of nicotine and smoking in man
4 Is nicotine a drug of addiction?
5 The natural history of smoking: the smoker's career
6 Regulation of nicotine intake for smokers, and implications for health
7 The management of nicotine addiction
8 Regulatory approaches to tobacco products in Britain
9 Summary and recommendations

 

 

 

 

 

 

 

 

 

 



This page last updated on May 8, 2001