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Meta-Analysis
. 2019 Feb 13;2(2):CD003999.
doi: 10.1002/14651858.CD003999.pub5.

Relapse prevention interventions for smoking cessation

Jonathan Livingstone-Banks  1 , Emma Norris, Jamie Hartmann-Boyce, Robert West, Martin Jarvis, Peter Hajek
Affiliations
Meta-Analysis

Relapse prevention interventions for smoking cessation

Jonathan Livingstone-Banks et al. Cochrane Database Syst Rev. .

Update in

  • Relapse prevention interventions for smoking cessation.
    Livingstone-Banks J, Norris E, Hartmann-Boyce J, West R, Jarvis M, Chubb E, Hajek P. Livingstone-Banks J, et al. Cochrane Database Syst Rev. 2019 Oct 28;2019(10):CD003999. doi: 10.1002/14651858.CD003999.pub6. Cochrane Database Syst Rev. 2019. PMID: 31684681 Free PMC article.

Abstract

Background: A number of treatments can help smokers make a successful quit attempt, but many initially successful quitters relapse over time. Several interventions have been proposed to help prevent relapse.

Objectives: To assess whether specific interventions for relapse prevention reduce the proportion of recent quitters who return to smoking.

Search methods: We searched the Cochrane Tobacco Addiction Group trials register, clinicaltrials.gov, and the ICTRP in February 2018 for studies mentioning relapse prevention or maintenance in their title, abstracts, or keywords.

Selection criteria: Randomised or quasi-randomised controlled trials of relapse prevention interventions with a minimum follow-up of six months. We included smokers who quit on their own, were undergoing enforced abstinence, or were participating in treatment programmes. We included studies that compared relapse prevention interventions with a no intervention control, or that compared a cessation programme with additional relapse prevention components with a cessation programme alone.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: We included 77 studies (67,285 participants), 15 of which are new to this update. We judged 21 studies to be at high risk of bias, 51 to be at unclear risk of bias, and five studies to be at low risk of bias. Forty-eight studies included abstainers, and 29 studies helped people to quit and then tested treatments to prevent relapse. Twenty-six studies focused on special populations who were abstinent because of pregnancy (18 studies), hospital admission (five studies), or military service (three studies). Most studies used behavioural interventions that tried to teach people skills to cope with the urge to smoke, or followed up with additional support. Some studies tested extended pharmacotherapy.We focused on results from those studies that randomised abstainers, as these are the best test of relapse prevention interventions. Of the 12 analyses we conducted in abstainers, three pharmacotherapy analyses showed benefits of the intervention: extended varenicline in assisted abstainers (2 studies, n = 1297, risk ratio (RR) 1.23, 95% confidence interval (CI) 1.08 to 1.41, I² = 82%; moderate certainty evidence), rimonabant in assisted abstainers (1 study, RR 1.29, 95% CI 1.08 to 1.55), and nicotine replacement therapy (NRT) in unaided abstainers (2 studies, n = 2261, RR 1.24, 95% Cl 1.04 to 1.47, I² = 56%). The remainder of analyses of pharmacotherapies in abstainers had wide confidence intervals consistent with both no effect and a statistically significant effect in favour of the intervention. These included NRT in hospital inpatients (2 studies, n = 1078, RR 1.23, 95% CI 0.94 to 1.60, I² = 0%), NRT in assisted abstainers (2 studies, n = 553, RR 1.04, 95% CI 0.77 to 1.40, I² = 0%; low certainty evidence), extended bupropion in assisted abstainers (6 studies, n = 1697, RR 1.15, 95% CI 0.98 to 1.35, I² = 0%; moderate certainty evidence), and bupropion plus NRT (2 studies, n = 243, RR 1.18, 95% CI 0.75 to 1.87, I² = 66%; low certainty evidence). Analyses of behavioural interventions in abstainers did not detect an effect. These included studies in abstinent pregnant and postpartum women at end of pregnancy (8 studies, n = 1523, RR 1.05, 95% CI 0.99 to 1.11, I² = 0%) and at postpartum follow-up (15 studies, n = 4606, RR 1.02, 95% CI 0.94 to 1.09, I² = 3%), studies in hospital inpatients (4 studies, n = 1300, RR 0.95, 95% CI 0.81 to 1.11, I² = 0%), and studies in assisted abstainers (10 studies, n = 5408, RR 0.99, 95% CI 0.87 to 1.13, I² = 56%; moderate certainty evidence) and unaided abstainers (5 studies, n = 3561, RR 1.06, 95% CI 0.96 to 1.16, I² = 1%) from the general population.

Authors' conclusions: Behavioural interventions that teach people to recognise situations that are high risk for relapse along with strategies to cope with them provided no worthwhile benefit in preventing relapse in assisted abstainers, although unexplained statistical heterogeneity means we are only moderately certain of this. In people who have successfully quit smoking using pharmacotherapy, there were mixed results regarding extending pharmacotherapy for longer than is standard. Extended treatment with varenicline helped to prevent relapse; evidence for the effect estimate was of moderate certainty, limited by unexplained statistical heterogeneity. Moderate-certainty evidence, limited by imprecision, did not detect a benefit from extended treatment with bupropion, though confidence intervals mean we could not rule out a clinically important benefit at this stage. Low-certainty evidence, limited by imprecision, did not show a benefit of extended treatment with nicotine replacement therapy in preventing relapse in assisted abstainers. More research is needed in this area, especially as the evidence for extended nicotine replacement therapy in unassisted abstainers did suggest a benefit.

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Conflict of interest statement

JLB: none known

EN: none known

JHB: none known

RW has received payments for lectures, research and consultancy from companies that manufacture smoking cessation medications (Pfizer, GSK, J&J). He is an unpaid advisor on the Smoke Free smartphone application and to the National Centre for Smoking Cessation and Training.

MJ: none known

PH was involved in three of the studies included in the review, and has provided consultancy for and received a research grant from Pfizer, a manufacturer of smoking cessation medications.

Figures

Figure 1
Figure 1
Study flow diagram for 2018 update
Figure 2
Figure 2
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Behavioural interventions for abstinent pregnant/postpartum women, Outcome 1 Not smoking at delivery/last follow‐up prior to delivery.
Analysis 1.2
Analysis 1.2
Comparison 1 Behavioural interventions for abstinent pregnant/postpartum women, Outcome 2 Not smoking at longest follow‐up after delivery.
Analysis 2.1
Analysis 2.1
Comparison 2 Interventions for abstinent hospitalised smokers, Outcome 1 Behavioural interventions, cessation at longest follow‐up.
Analysis 2.2
Analysis 2.2
Comparison 2 Interventions for abstinent hospitalised smokers, Outcome 2 Pharmacotherapy interventions, cessation at longest follow‐up.
Analysis 3.1
Analysis 3.1
Comparison 3 Behavioural interventions for unaided abstainers, Outcome 1 Cessation at longest follow‐up.
Analysis 4.1
Analysis 4.1
Comparison 4 Behavioural interventions for assisted abstainers, Outcome 1 Cessation at longest follow‐up.
Analysis 5.1
Analysis 5.1
Comparison 5 Pharmacotherapy for unaided abstainers, Outcome 1 Cessation 12 months after quit date.
Analysis 6.1
Analysis 6.1
Comparison 6 Pharmacotherapy for assisted abstainers, Outcome 1 Nicotine replacement therapy versus placebo. Cessation 12 months + after quit date.
Analysis 6.2
Analysis 6.2
Comparison 6 Pharmacotherapy for assisted abstainers, Outcome 2 Bupropion vs. placebo. Cessation 12 months + after quit date.
Analysis 6.3
Analysis 6.3
Comparison 6 Pharmacotherapy for assisted abstainers, Outcome 3 Combination NRT & bupropion vs placebo. Cessation at longest follow‐up.
Analysis 6.4
Analysis 6.4
Comparison 6 Pharmacotherapy for assisted abstainers, Outcome 4 Varenicline vs placebo. Cessation 12 months + after quit date.
Analysis 6.5
Analysis 6.5
Comparison 6 Pharmacotherapy for assisted abstainers, Outcome 5 Rimonabant vs placebo. Cessation 12 months + after quit date.
Analysis 7.1
Analysis 7.1
Comparison 7 Behavioural interventions for smokers. RP vs. cessation, matched for programme length, Outcome 1 Group or individual format therapy (+/‐ adjunct pharmacotherapy), cessation at longest follow‐up.
Analysis 7.2
Analysis 7.2
Comparison 7 Behavioural interventions for smokers. RP vs. cessation, matched for programme length, Outcome 2 Self‐help format, cessation at longest follow‐up.
Analysis 8.1
Analysis 8.1
Comparison 8 Behavioural interventions for smokers. RP vs. cessation, different intensity programmes, Outcome 1 Cessation at longest follow‐up.
Analysis 9.1
Analysis 9.1
Comparison 9 Interventions for smokers, tests of adjuncts to cessation programmes, Outcome 1 Behavioural interventions, cessation at longest follow‐up.
Analysis 9.2
Analysis 9.2
Comparison 9 Interventions for smokers, tests of adjuncts to cessation programmes, Outcome 2 Combined behavioural and pharma interventions, cessation at longest follow‐up.
Analysis 10.1
Analysis 10.1
Comparison 10 Interventions for smokers, test of extended pharmacotherapy, Outcome 1 Smoking cessation at 12 months.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to studies excluded from this review

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References to ongoing studies

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Additional references

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    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. [DOI: 10.1002/14651858.CD009329.pub2] - DOI - PMC - PubMed
    1. Cahill K, Lindson‐Hawley N, Thomas KH, Fanshaw TR, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 5. [DOI: 10.1002/14651858.CD006103.pub7] - DOI - PMC - PubMed
    1. Coleman T, Agboola S, Leonardi‐Bee J, Taylor M, McEwen A, McNeill A. Relapse prevention in UK Stop Smoking Services: current practice, systematic reviews of effectiveness and cost‐effectiveness analysis. Health Technology Assessment 2010;14(49):1‐152. - PubMed
    1. Edwards CC, Woodruff SI, Conway TL. Operation Stay Quit: preventing smoking relapse among US Navy women. American Journal of Health Behavior 1999;23(5):352‐5.

References to other published versions of this review

    1. Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 1. [DOI: 10.1002/14651858.CD003999.pub2] - DOI - PubMed
    1. Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD003999.pub3] - DOI - PubMed
    1. Hajek P, Stead LF, West R, Jarvis M, Hartmann‐Boyce J, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8. [DOI: 10.1002/14651858.CD003999.pub4] - DOI - PubMed

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