Medications (including all types of nicotine replacement therapy, bupropion and varenicline) have been shown to help people quit smoking, and people seeking help to quit smoking will frequently be offered medication (pharmacotherapy). Behavioural support also helps people to quit. Behavioural support may include brief advice or more intensive counselling, and may be provided face-to-face individually or in groups, or by telephone, including 'quitlines'. It has been unclear how much additional benefit is gained from adding support, or providing more intensive support for people who are using medication for a quit attempt.
We looked for trials that enrolled smokers and provided or offered medication to all participants, then randomized them to receive different amounts of behavioural support. People in the control group could get just written information, or some personal support. The trials had to test the addition of more intensive support, involving additional face-to-face or by-telephone contact, or longer sessions. To assess whether the intervention helped people to quit, the trials had to assess the number of people not smoking after at least six months. We did not include studies that only recruited pregnant women, or adolescents.
We searched for trial reports in May 2015. Forty-seven trials were eligible, with over 18,000 participants. Participants usually wanted to make a quit attempt, although a small number of studies offered support to people who had not indicated that they were trying to quit. Combining results from 47 trials suggests that increasing the amount of behavioural support for people using a smoking cessation medication increases the chances of quitting smoking for the long term by about 10% to 25%. Providing some support via personal contact, face-to-face or by telephone, is beneficial, and people making a quit attempt using medication will increase their chances of success if they also have access to behavioural support.
Quality of the evidence
We judged the overall quality of evidence to be high, with further research unlikely to change the results.
Providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking has a small but important effect. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 25%, based on a pooled estimate from 47 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support.
Effective pharmacotherapies are available to help people who are trying to stop smoking, but quitting can still be difficult and providing higher levels of behavioural support may increase success rates further.
To evaluate the effect of increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition.
We searched the Cochrane Tobacco Addiction Group Specialised Register in May 2015 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline that evaluated the addition of personal support or compared two or more intensities of behavioural support.
Randomized or quasi-randomized controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount of behavioural support. The intervention condition had to involve person-to-person contact. The control condition could receive less intensive personal contact, or just written information. We did not include studies that used a contact-matched control to evaluate differences between types or components of support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.
One author prescreened search results and two authors agreed inclusion or exclusion of potentially relevant trials. One author extracted data and another checked them.
The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.
Forty-seven studies met the inclusion criteria with over 18,000 participants in the relevant arms. There was little evidence of statistical heterogeneity (I² = 18%) so we pooled all studies in the main analysis. There was evidence of a small but statistically significant benefit from more intensive support (RR 1.17, 95% CI 1.11 to 1.24) for abstinence at longest follow-up. All but four of the included studies provided four or more sessions of support to the intervention group. Most trials used NRT. We did not detect significant effects for studies where the pharmacotherapy was nortriptyline (two trials) or varenicline (one trial), but this reflects the absence of evidence.
In subgroup analyses, studies that provided at least four sessions of personal contact for the intervention and no personal contact for the control had slightly larger estimated effects (RR 1.25, 95% CI 1.08 to 1.45; 6 trials, 3762 participants), although a formal test for subgroup differences was not significant. Studies where all intervention counselling was via telephone (RR 1.28, 95% CI 1.17 to 1.41; 6 trials, 5311 participants) also had slightly larger effects, and the test for subgroup differences was significant, but this subgroup analysis was not prespecified. In this update, the benefit of providing additional behavioural support was similar for the subgroup of trials in which all participants, including controls, had at least 30 minutes of personal contact (RR 1.18, 95% CI 1.06 to 1.32; 21 trials, 5166 participants); previously the evidence of benefit in this subgroup had been weaker. This subgroup was not prespecified and a test for subgroup differences was not significant. We judged the quality of the evidence to be high, using the GRADE approach. We judged a small number of trials to be at high risk of bias on one or more domains, but findings were not sensitive to their exclusion.