Staying smoke-free after quitting smoking: what helps?

In this blog for people who have just stopped smoking Robert Walton, a general practitioner, helps you work out how best to stay smoke-free, looking at the latest Cochrane evidence on relapse prevention.

So you’ve managed to stop smoking – very well done indeed!  Stopping smoking brings a huge benefit in health not just for yourself but also for the rest of your family.

About half of the people who continue to smoke will die because of their habit, but if you stop by the age of 50 you halve that risk. And as you might expect, people who stop by the age of 30 are even better off – they avoid almost all the increased risk to their health arising from smoking in their younger years (https://www.bmj.com/content/328/7455/1519.full.print).

For children of smokers the risk of respiratory illness and ear infections is increased (https://www.ncbi.nlm.nih.gov/pubmed/10092699) and secondhand smoke is a major cause of premature death in people who don’t smoke themselves but who share a house with a smoker (http://ash.org.uk/information-and-resources/secondhand-smoke/ash-research-report-secondhand-smoke/).

But as the old joke goes ‘Stopping smoking is easy – I’ve done it a hundred times!’.  A recent Cochrane Review of 77 research studies with 67,285 people taking part showed that for every hundred people who stopped smoking about seventy went back to cigarettes over the next 15 months.  So almost all the benefits in health that the people might have gained were lost.

Smoking rates are falling dramatically in the United Kingdom and have dropped by almost a quarter over the last five years. But the latest figures from 2017 show there are 7.4 million people still smoking and it is therefore vitally important to find better ways of helping these people to stop smoking for good.

What does the Cochrane evidence tell us?

This Cochrane Review found several different ways of preventing relapse had been tried in a range of different studies and most looked at the effects of ‘behavioural interventions’. For this kind of treatment people are taught different ways of identifying the triggers that make them smoke and are helped to work out ways of avoiding them.  Rather disappointingly there was no evidence that these interventions made any difference to the numbers people who were going back to cigarettes. Although the effects of the interventions varied considerably from study to study so it is possible that some behavioural methods are better than others, although no firm conclusions could be drawn.

The remainder of the studies looked at people who had stopped smoking using a particular drug therapy to see whether extending the treatment could help to prevent the drift back to tobacco.  There was some evidence that extending treatment with varenicline beyond the usual three months duration probably helps to stop people from going back to tobacco.  However the evidence was very limited for extending the duration of treatment with other drugs available in the United Kingdom such as bupropion and nicotine replacement therapy.

The fact that varenicline may help to prevent relapse could potentially link in with the way that the drug works. Varenicline attaches itself to the same receptors in the brain that nicotine uses and so gives some of the same effects.  But varenicline then occupies these receptors, so blocking the action of nicotine and meaning that the pleasurable effects of nicotine are blunted. It is easy to see how this mechanism might help to prevent relapse.

Quitting in pregnancy and beyond

One area where scientific evidence is completely lacking is how best to help women who have managed to stop smoking during their pregnancy to stay clear of tobacco after the birth. Relapse rates are high in these circumstances and this was one of several areas highlighted in a recent NIHR call for research proposals to limit the harm arising from use of tobacco.

Where does this leave you?

Many smokers will not be keen to swap one drug for another, but the best evidence available to date suggests that extending treatment with varenicline which is suggested as an option by NICE will probably help you to remain smoke-free.

Join in the conversation on Twitter with @rtwalton123 @CochraneUK or leave a comment on the blog.

References may be found here.

Declaration of interest:

Dr. Walton reports grants from NIHR Health Technology Asessment, grants from NIHR Programme Grants for Applied Research, other from TTS Pharma,  outside the submitted work;  In addition, Dr. Walton has a patent WALTON R, MCKINNEY E, MARSHALL S, MURPHY M, WELSH K, others. GENETIC INDICATORS OF TOBACCO CONSUMPTION. Patent number: 2001038567. Filed date: 24 Nov 2000. Publication date: 01 Jun 2001  with royalties paid to gNostics.

 


Robert Walton

About Robert Walton

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Robert Walton is a Cochrane UK Senior Fellow in General Practice. Robert qualified in medicine in London in 1983, having taken an intercalated degree in human pharmacology and immunology. He trained at St Georges Hospital, London and became a member of the Royal College of Physicians in 1986. His work applying computerised decision support to prescribing drugs in the Department of Public Health and Primary care in Oxford led to a doctoral thesis in 1998. Robert was elected a Fellow of the Royal College of General Practitioners in 1999 and the RoyalCollege of Physicians in 2001. He became a Senior Investigator in the National Institute for Health Research (NIHR) in 2016. Robert is Clinical Professor of Primary Medical Care at Queen Mary and joint lead of the NIHR Research Design Service east London team, his research interests are in primary care, genetics, clinical trials and personalised medicine. Robert leads a five-year NIHR funded programme developing a novel training intervention to promote smoking cessation in pharmacies in east London which involves a substantive systematic review and meta analysis on behaviour change interventions in community pharmacies and will lead to a large scale cluster-randomised clinical trial. His research team is also developing a smartphone game to promote smoking cessation and researching a personalised/stratified medicine approach to tobacco dependence using computerised decision support. He sits on the NIHR Programme Grants for Applied Research sub panel A and works as an evaluator for the European Union Horizon 2020 programme (Global Alliance for Chronic Diseases, New Therapies for Rare Diseases). He contributes to UK national guidance, serving on the National Institute for Health and Care Excellence (NICE) Outcome Indicator and Technology Appraisals Committees. He has worked as a general practitioner in Oxford since 1988.

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