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Evidence for Everyday Health Choices

Smoking and coronavirus (COVID-19): time to quit

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Sarah Chapman and Selena Ryan-Vig share evidence from a new Cochrane Special Collection, COVID-19: Effective options for quitting smoking during the pandemic.

It’s a harsh reality that if you’re a smoker you’re more likely to get acute respiratory infections and have a higher risk of those infections becoming severe. The increased risks may come from the damage smoking does to your lungs and the transmission of a virus from hand to mouth while you’re smoking. Exposure to second-hand smoke also increases the risk of getting acute respiratory infections. Given that we are now facing an unprecedented threat from the coronavirus (COVID-19), an acute respiratory infection, there has never been a better time to stop smoking, and the World Health Organization is urging people to do so.

Evidence-based support to quit smoking

But quitting is hard for many, and perhaps particularly so at a time of great stress and when many of our routines have been so suddenly disrupted. What’s more, right now we can’t access face-to-face, in-person support for help with things like stopping smoking. However, there are other options for quitting smoking, with evidence to support them.

Cochrane Tobacco Addiction has put together a Special Collection of reviews which provide the best available evidence to inform your decisions on ways you might try to quit smoking. The Cochrane Reviews focus on interventions that are feasible under public health measures that restrict face to face contact with health practitioners.

We also have some blogshots (mini infographics) here, giving you the key information from some of these Cochrane Reviews, and some blogs, which you’ll find listed below.

With the publication of this new Special Collection this week, Cochrane author, Nicola Lindson from the Nuffield Department of Primary Care Health Sciences, University of Oxford, UK, said “If one method doesn’t work, don’t be discouraged – evidence shows some people need to try to quit many times before successfully doing so. Just because you haven’t been able to quit smoking before, doesn’t mean you won’t be able to now.”

If you can, this is a great time to do it.

Nicotine replacement therapy versus control for smoking cessation

Nicotine replacement therapy (NRT) in all licensed forms (gum, lozenges, patches, sprays, inhalers and tablets/lozenges) increases the chances of successfully quitting smoking (high-certainty evidence). Side effects from using NRT were related to the type of product, including skin irritation from patches and irritation to the inside of the mouth from gum and tablets. These reactions were usually not severe enough to prompt people to stop taking the treatment. Chest pains and palpitations were rare and serious adverse events were extremely rare. Cochrane Review (published May 2018); 136 studies with 64,640 people who smoke cigarettes included in the main analysis, comparing NRT with placebo or no NRT.

Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation

There is high-certainty evidence that using combination NRT (fast-acting form + patch) rather than a single form of NRT increases the chances of successfully quitting smoking, whether that single form is a patch or a fast-acting version (e.g. gum). Higher-dose nicotine gum works better than lower-dose gum (high-certainty evidence) and higher dose nicotine skin patches probably work better than lower dose patches (moderate-certainty evidence). Starting NRT before quit day is probably better than starting it at the same time as giving up smoking (moderate-certainty evidence). There is only low- and very low-certainty evidence on safety of NRT, which was not looked at in most of the studies. Where studies did look at safety, very few people experienced negative effects of NRT and they were mild effects such as skin irritation from patches. Cochrane Review (published April 2019); 63 studies with 41,509 people (mostly adults) who smoked at least 15 cigarettes a day and wanted to quit. Studies lasted for at least six months and compared the effects of different forms, doses, durations and schedules of NRT for people trying to quit smoking.

Mobile phone text messaging and app-based interventions for smoking cessation

Text messaging programmes designed to help people quit smoking probably improve the chance of successfully quitting compared with minimal support (moderate-certainty evidence). They also probably improve the chance of quitting smoking when added to other quit-smoking interventions compared with those interventions alone (moderate-certainty evidence). The effect of programmes delivered through smartphone apps, compared with less intensive support, is uncertain (very low-certainty evidence). The review did not include information about possible harms of the interventions. Cochrane Review (published October 2019); 26 studies with over 33,000 people who smoke. Studies compared quit rates in people who received support from text messages or smartphone apps, either alone or with other quit-smoking support interventions, with those who did not.

Print-based self-help interventions for smoking cessation

Compared with receiving no help at all, written self‐help materials probably help more people to stop smoking for at least six months (moderate-certainty evidence). There was no information about whether print-based self-help interventions have any harms. Cochrane Review (published January 2019); 75 studies were found and 11 of these, with over 13,000 people, provided data for the main comparison. This compared print‐based self‐help with receiving no materials. Participants were not selected for having a particular interest in quitting smoking.

Telephone counselling for smoking cessation

Multiple sessions of telephone counselling for smokers who call quitlines probably increase the chances of quitting smoking compared with provision of self-help materials or brief counselling in a single call (moderate-certainty evidence). Receiving telephone calls from counsellors or other healthcare providers probably also increases the chances of quitting for people who do not call quitlines (moderate-certainty evidence). There was no information about harms. Cochrane Review (published May 2019); 104 studies with 111,653 smokers, mostly adults from the general population but some pregnant women, teenagers and people with long term conditions. Studies explored the effectiveness of different types of telephone counselling, including for people who called ‘quitlines’ and others who received calls from counsellors or other healthcare providers.

Smoking reduction interventions for smoking cessation

It is uncertain how cutting down before quitting smoking compares with no treatment (very low-certainty evidence). People who cut down first are probably equally likely to successfully quit as those who try to quit all at once (moderate-certainty evidence). People may be more likely to quit by cutting down first when they use a stop‐smoking medicine as well (low-certainty evidence). However this is probably only true when using varenicline or a type of fast‐acting nicotine replacement therapy (NRT) such as nicotine gum or lozenge (moderate-certainty evidence) and may not be true when using a nicotine patch, combination NRT or bupropion as an aid (low- or very low‐quality evidence). There is not enough information about whether cutting down before quitting has negative effects such as cravings, difficulty sleeping, low mood or irritability.  Cochrane Review (published September 2019); 51 studies with over 22,000 people who smoked tobacco. Studies compared: 1) cutting down with no treatment; 2) cutting down with quitting all at once; 3) cutting down while using a stop-smoking medicine with cutting down alone.

There is also a review on Internet-based interventions for smoking cessation.

Evidently Cochrane blogs on quitting smoking

Chapman S. “Nicotine replacement therapy: new evidence on help to quit smoking”. 18 April 2019.

Livingstone-Banks J. “Affordable ways to support people who want to stop smoking”. 31 May 2019.

Roberts D. “Texting 2 Quit: using mobile phones to support people quit smoking”. 18 May 2016, revised 30 October 2019.

Walton R and Lindson N. “What is the best way to stop smoking – should I stop suddenly or cut down first?” 25 October 2019.

The Cochrane Special Collection, COVID-19: Effective options for quitting smoking during the pandemic is one of several Special Collections relevant to COVID-19, other recently published collections include evidence relevant to critical care and infection control; and prevention measures.

You can also find Cochrane resources and news on Coronavirus (COVID-19). This page will be continually updated with information relating to the pandemic and the various related activities that Cochrane is undertaking in response.

Take-home points

Smoking increases the risk of getting acute respiratory infections and of being more severely affected, as does exposure to second-hand smoke. The Cochrane Special Collection, COVID-19: Effective options for quitting smoking during the pandemic, pulls together evidence including Cochrane Reviews on nicotine replacement, behavioural support such as telephone, internet and text messaging programmes, and gradual quitting. The Cochrane Reviews in the Special Collection focus on interventions that are feasible under public health measures that restrict face to face contact with health practitioners.

Join in the conversation on Twitter with @CochraneUK and @CochraneTAG or leave a comment on the blog. Please note, we will not publish comments that link to commercial sites or appear to endorse commercial products.

References may be found here.

Sarah Chapman and Selena Ryan-Vig have nothing to disclose.

Sarah Chapman

About Sarah Chapman

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Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients. A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

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