Tobacco use is the leading cause of preventable disease in the United States.1 Almost 70% of individuals who smoke would like to quit but lack the knowledge and resources to succeed. Lack of these resources, coupled with the highly addictive properties of nicotine, increases the likelihood of relapse among individuals who quit smoking. Equipping patients with evidence-based tools, namely the combination of pharmacologic and non-pharmacologic modalities, increases the probability of achieving smoking abstinence.
Non-pharmacological behavioral interventions for smoking cessation
The 2020 Surgeon General Smoking Cessation Report examined several behavioral smoking cessation treatment strategies with varying levels of support for their use.1 They include behavioral therapy, cognitive behavioral therapy (CBT), motivational interviewing (MI), acceptance and commitment therapy (ACT), contingency management, and monetary incentives.
Behavioral therapies for smoking cessation focus on increasing individuals’ control over their behavior by adopting various approaches to effectively handle triggers, cravings, and withdrawal symptoms.1 Lancaster and Stead (2017) published a meta-analysis of 49 randomized and quasi-randomized trials, with approximately 19,000 participants, evaluating whether individual counseling from a smoking cessation specialist would help adults who smoke successfully quit at a 6-month follow-up.2 Thirty-three trials in the meta-analysis compared individual counseling to minimal behavioral intervention. The intervention group consisted of individual counseling with at least one face-to-face session, while the comparison group was offered usual care, brief advice, or self-help materials. Researchers found high-quality evidence supporting individually delivered smoking cessation counseling as a more successful quit strategy than minimal contact in the absence of pharmacotherapy (relative risk [RR], 1.57; 95% confidence interval [CI], 1.40 to 1.77; adjusted N=11,100; 27 studies). They also found moderate evidence to support adding counseling to nicotine replacement therapy (NRT) (RR, 1.24; 95% CI, 1.01 to 1.51; adjusted N=2662; 6 studies) with a slight benefit of more intensive counseling compared to brief counseling (RR, 1.29; 95% CI, 1.09 to 1.53; adjusted N=2920; 11 studies). The authors concluded that there was a 40% to 80% increased chance of quitting after 6 months when individuals received counseling compared to nominal support.
Cognitive behavioral therapy is a psychotherapeutic intervention that teaches individuals techniques to modify negative thoughts, emotions, and behaviors by encouraging self-monitoring, goal-setting, and strengthening problem-solving skills to change the content of their thoughts.3 The use of CBT is helpful for sustained cessation and for those who desire to quit smoking by changing their behaviors and thoughts related to tobacco. In a 2017 systematic review of 21 randomized controlled trials including 4946 adults, the Norwegian Institute of Public Health assessed the effectiveness of cognitive therapies for smoking cessation in adults compared to usual care, other therapies, or no intervention. The primary outcome was smoking abstinence. Thirteen of the studies followed up with participants at least 6 months after the end of the intervention. The researchers found that cognitive therapies had similar effects on smoking abstinence rates compared to usual care or minimal interventions 6 to 12 months later (RR, 1.29; 95% CI, 0.90 to 1.85; adjusted N=585; 3 studies). They also found that cognitive therapies with NRT resulted in better abstinence rates than other interventions with NRT up to 12 months later (RR, 1.53; 95% CI, 1.06 to 2.19; adjusted N=1309; 8 studies). Additionally, cognitive therapies had higher smoking abstinence rates than other interventions 12 months later (RR, 2.05; 95% CI, 1.09 to 3.85; adjusted N=850; 6 studies). However, for each of these pooled results, the quality of evidence was low. The researchers reported moderate-quality evidence demonstrating that cognitive therapies used with medication improved smoking abstinence rates more than medication alone (RR, 1.39; 95% CI, 1.10 to 1.76; adjusted N=673 participants; 5 studies). The authors concluded that adding cognitive therapies to medication, NRT, or other interventions may improve smoking cessation rates.
Motivational interviewing is a counseling method that centers around helping individuals confront and conquer their ambivalence for a specific behavior to find the motivation to change it.1 This technique is often used in those not yet ready to stop smoking. Lindson-Hawley and colleagues (2015) conducted a meta-analysis review of 28 studies comprised of over 16,000 adult participants to compare MI to brief advice or standard of care for smoking cessation.4 Compared to the standard of care, MI resulted in a small but statistically significant increase in the chances of quitting (RR, 1.26; 95% CI, 1.16 to 1.36; adjusted N=16,803; 28 studies). A subgroup analysis found that MI delivered by primary care physicians (PCPs) led to more instances of smoking cessation than when delivered by nurses or counselors (RR, 3.49; 95% CI, 1.53 to 7.94; adjusted N=736; 2 studies). The authors concluded that MI provided by PCPs and trained counselors could help individuals stop smoking. Though the authors concluded that the overall quality of the evidence was moderate, some of the individual studies included were of low-quality and had a potential for bias.
Lindson and colleagues (2019) completed an updated meta-analysis involving 37 studies and over 15,000 participants that evaluated the efficacy of MI for smoking cessation against multiple comparators: no intervention, in addition to another type of intervention, and with other forms of treatment alone.5 The researchers also compared higher intensity MI to lower intensity MI. They found limited useful evidence due to bias and imprecision in the comparison of MI to no smoking cessation intervention (RR, 0.84; 95% CI, 0.63 to 1.12; adjusted N=684), MI in addition to another form of smoking cessation intervention (RR, 1.07; 95% 0.85 to 1.36; adjusted N=4167), and MI compared to other forms of smoking cessation treatment alone (RR, 1.24; 95% CI, 0.91 to 1.69; N=5192). The researchers also found a slight benefit of higher intensity MI compared to lower intensity MI (RR, 1.23; 95% CI, 1.11 to 1.37; adjusted N=5620); however, the certainty of this evidence was low after removing the studies that had a risk for bias (RR, 1.00; 95% CI, 0.65 to 1.54; N=482). The authors concluded that there is insufficient evidence to determine the effects of MI compared to no intervention, as an addition to other behavioral interventions, or compared to other behavioral interventions, due to concerns of bias, imprecision, and inconsistency in the trials analyzed.
Unlike CBT, ACT does not attempt to replace one’s thoughts with an alternative thought to propel behavior change.6 Instead, ACT focuses on action-oriented changes through an individual’s willingness to experience triggering urges and emotions while attempting to quit smoking. When individuals accept that they can face those triggers rather than avoid them and may experience withdrawal symptoms and negative emotions while trying to stop smoking, they can then focus on committing to the necessary behavior changes. This intervention can modify behavior in general; however, there have been a limited number of trials with modest sample sizes specifically in smoking cessation.1 The Surgeon General Report concluded that available trials support the use of ACT for improving smoking quit rates when used via different delivery approaches and in various settings but noted that additional research is needed to determine which delivery methods are most effective.
Contingency and monetary incentives focus on using rewards to acknowledge and encourage behavioral change. These incentives are often used to help reduce health care costs associated with smoking.7 In recent years, researchers have explored whether incentives work, how long they work, and how they compare to penalties. In a meta-analysis of 21 trials with over 8400 mixed population adult smokers, Cahill and colleagues (2015) explored whether incentive and contingency management programs resulted in higher long-term quit rates for smokers compared to controls at 6 months or more. The studies offered various incentives such as lottery tickets, prize draws, cash, and vouchers for groceries and goods. Results showed that incentives did lead to higher long-term quit rates (OR, 1.42; 95% CI, 1.19 to 1.69; adjusted N=7715; 17 trials; 20 comparisons). Cahill and colleagues also examined 8 trials which included 1600 pregnant women who smoked. They found that incentives increased the likelihood of smoking cessation in pregnant women up to 24 weeks post-partum (OR, 3.60; 95% CI, 2.39 to 5.43; adjusted N=1295; moderate-quality studies). Overall, the authors concluded that incentives may boost cessation rates while they are available; however, more research is needed to determine the long-term effects on smoking cessation once the incentive is removed.
Behavioral therapy, CBT, MI, ACT, contingency management, and monetary incentives are non-pharmacologic behavioral interventions that can aid in smoking cessation.1 According to the Surgeon General Report, clinical evidence supports the use of each of these behavioral interventions for smoking cessation; however, additional trials are needed to determine their overall impact on patient care.
Posted on June 24, 2022
Last updated on June 24, 2022
Category: Smoking Cessation