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Helping former smokers stay on the wagon: insufficient evidence regarding relapse prevention interventions for smoking cessation Critical Summary Prepared by: Jennifer Hill DDS, PhD; Shabnam Sabounchei DDS 

OVERVIEW

  • Systematic Review Conclusion:

    People often smoke again after quitting, yet there is insufficient evidence for interventions to help abstainers avoid relapse.

  • Critical Summary Assessment:

    This thorough review of 54 quasi- and randomized clinical trials of limited quality did not illuminate an effective relapse prevention strategy.

  • Evidence Quality Rating:

    Limited

A Critical Summary of:

Relapse prevention interventions for smoking cessation

Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Cochrane Database of Systematic Reviews. 2009;(1):CD003999

  • Clinical Questions:

    In smokers who have recently quit smoking, is any intervention more effective than another at preventing relapse?

  • Review Methods:

    This is an update of an earlier review. The authors searched the Cochrane Tobacco Addiction Group trials register in August 2008, which included four databases. They included quasi- and randomized controlled trials of relapse prevention interventions with a minimum follow-up of six months. They included smokers who quit on their own, or were undergoing forced abstinence, or who participated in treatment programs. Trials that compared relapse prevention to control, or compared a cessation program with a relapse prevention component to a cessation program alone were included. One author screened the studies. A second author checked the studies. A third author resolved disagreements.

  • Main Results:

    Fifty-four studies (46,647 subjects) met the inclusion criteria. The review considered 36 studies that randomized abstainers separately from studies that randomized smokers before quitting. In the studies of randomized abstainers, relapse prevention methods did not benefit women who quit smoking due to pregnancy, nor for smokers who underwent enforced abstinence. They also failed to detect significant effects of behavioral interventions in groups of smokers who quit on their own or used a formal program. Among trials randomizing smokers prior to quitting and evaluating the effect of additional relapse prevention, the authors found no evidence of benefit from behavioral interventions. Overall, providing training in skills thought to be needed for relapse avoidance did not reduce relapse. Extended treatment with varenicline significantly reduced relapse in one trial.

  • Conclusion:

    There is insufficient evidence to support the use of any specific behavioral intervention for helping short-term quitters to avoid a smoking relapse. This conclusion also applies to interventions that focus on coping with tempting situations, as most studies were concerned with these. Extended treatment with varenicline (Chamtix/Champix®) may prevent relapse.

  • Source of funding:

    University of Oxford Department of Primary Health Care, National School for Health Research School for Primary Care Research, Queen Mary’s School of Medicine and Dentistry and NHS Research and Development Program, UK

Commentary:

  • Importance and Context:

    Cigarette smoking is the major cause of preventable morbidity and mortality in the developed world. Although many smokers are able to quit, many resume smoking (relapse). This review compared the effectiveness of various methods to prevent relapse of smoking among quitters.

  • Strengths and Weaknesses of the Systematic Review:

    In this review, the authors searched four electronic data bases. They did not provide information regarding grey literature, reference lists or hand searches of journals. Heterogeneity of the studies made analysis difficult. The authors did not assess potential of publication bias, either. They strengthened their updated review by conducting sensitivity analysis on pooled results and improving how they summarized effects of treatment by use of risk ratios instead of odds ratios. Because self-reporting of cessation among smokers is notoriously unreliable, the authors used, where available, biochemically-validated cessation in preference to self-report.

  • Strengths and Weaknesses of the Evidence:

    Although 54 studies were included, most were of limited quality. All studies stated that allocation was random. However, few reported the method of sequence generation and allocation in sufficient detail to be considered free of bias. Because many trials were small, study power was limited for detecting significant differences. In order to compare trials within similar populations, interventions and outcome measures, several sub-group analyses were conducted. This resulted in fewer studies in each group. Most studies that randomized recent abstainers focused on less intensive interventions (brief or written instructions) rather than on more intensive ones (i.e. face-to-face contact designed to teach clients to identify tempting situations and apply a range of coping skills and cognitive strategies). Because of differences in populations, length of follow-up and definitions of smoking cessation, abstinence rates across interventions could not be compared.

  • Implications for Dental Practice:

    The evidence does not support the use of any specific behavioral intervention for helping ex-smokers to stay smoke-free. Regarding pharmacotherapies, extended treatment with varenicline (Chamtix/Champix) may prevent relapse.

  • Critical Summary Publication Date: 8/19/2010

These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association ©

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