USPSTF: Rely on Behavioral, Drug-Based Therapy for Smoking Cessation

Behavioral interventions and approved drug-based therapies for smoking cessation got the green light from the U.S. Preventive Services Task Force (USPSTF), although e-cigarettes as a quit-smoking tool failed to make the grade, according to an updated recommendation.

With an “A” grade, “The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and [FDA-approved] pharmacotherapy for cessation to nonpregnant adults who use tobacco,” wrote Alex H. Krist, MD, MPH, of Virginia Commonwealth University in Richmond, and co-authors.

The task force also supported clinicians asking all pregnant persons about tobacco use, advising them to quit, and providing “behavioral interventions for cessation to pregnant persons who use tobacco,” also with an “A” grade, they wrote in JAMA.

However, the task force concluded that the evidence was insufficient to recommend pharmacotherapy interventions for tobacco cessation in pregnancy, as was the evidence for electronic cigarettes (also known as vaping) in all adults, Krist’s group said.

The current recommendation is an update of the task force’s guideline on smoking cessation from 2015, but with new data on e-cigarettes, and joins a 2020 recommendation on the prevention and cessation of tobacco products by children and adolescents.

In a JAMA Patient Page, Jill Jin, MD, MPH, of Northwestern Medicine in Chicago, highlighted that “Potential harms of behavioral interventions are slim to none,” although “Potential harms of pharmacotherapy may include some serious side effects, but the risk of these is small.” Reported adverse events (AEs) have included dizziness and dry mouth with bupropion SR and constipation and nausea with varenicline.

In an accompanying editorial, Brenna VanFrank, MD, MSPH, and Letitia Presley-Cantrell, PhD, both of the CDC in Atlanta, noted that the updated recommendation is in line with those from the U.S. Surgeon General and the CDC, as well as multiple clinical guidelines, such as the American College of Cardiology, the American Pharmacists Association, the American Academy of Family Physicians, and the American Thoracic Society.

But even with these “prominent endorsements of efficacy and safety [of behavioral interventions and pharmacotherapy], less than 5% of US adults who try to quit smoking use this combination of treatments,” they pointed out.

VanFrank and Presley-Cantrell wrote that “Systems-level changes can make it easier for clinicians to give their patients the treatment they need,” such as the use of team-based approaches to care — “In treating tobacco use and dependence, primary care clinicians should not be expected to do the work alone,” they said — chronic disease management models to manage the burden of screening and treatment delivery, and working with “community-based healthcare providers to extend “treatment with cessation services like quitlines, web interventions, and text interventions.

Krist and co-authors suggested that clinicians implement the recommendation by asking all adults, regardless of pregnancy status, about tobacco use, and using the Agency for Healthcare Research and Quality’s “5 As” system or the “Ask, Advise, Refer” approach, as well as treating smoking status as a vital sign.

The current recommendation is based on an evidence review by Carrie D. Patnode, PhD, MPH, of the Center for Health Research at Kaiser Permanente Northwest in Portland, Ore., and co-authors, who looked at 67 reviews of pharmacotherapy and behavioral interventions; nine trials on e-cigarettes for smoking cessation; and seven trials of nicotine replacement therapy (NRT) use in pregnancy.

They reported that the following were all tied to increased quit rates versus minimal support or placebo at ≥6 months:

• Combined pharmaco- and behavioral therapy: pooled risk ratio 1.83 (95% CI 1.68 to 1.98).
• NRT: RR 1.55 (95% CI 1.49 to 1.61).
• Bupropion: RR 1.64 (95% CI 1.52 to 1.77).
• Varenicline: RR 2.24 (95% CI 2.06 to 2.43).
• Advice from clinicians: RR 1.76 (95% CI 1.58 to 1.96).

Patnode’s group also found no serious AEs, such as major cardiovascular or neuropsychiatric events, with drug-based interventions versus placebo or non-drug approaches.

In terms of pregnant women, behavioral interventions were linked with greater smoking cessation during late pregnancy (RR 1.35, 95% CI 1.23 to 1.48) versus no intervention. Also, the rates of validated cessation among pregnant women on NRT versus placebo were not significantly different (pooled RR 1.11, 95% CI 0.79 to 1.56).

As for pharmacotherapy in this population, Patnode and co-authors found that “There was no evidence of perinatal harms related to NRT use among pregnant women, but data for assessing rare harms were very limited,” and that “Evidence from 5 large cohort studies did not find differences in stillbirth, birth outcomes, or any congenital anomaly for infants born to mothers with exposure to NRT, bupropion, or varenicline versus those unexposed to medications but whose mothers smoked.”

Finally, the authors highlighted a lack of evidence for the use of e-cigarettes as an intervention to quit tobacco-based smoking. “No studies on the use of e-cigarettes as tobacco cessation interventions reported health outcomes, and few trials reported on the potential adverse events of e-cigarette use when used in attempts to quit smoking,” they wrote. “This is particularly concerning given the apparent longer-term use of e-cigarettes for cessation compared to pharmacotherapy in addition to the recent outbreak of e-cigarette, or vaping, product use-associated lung injury.”

The main limitation to the review was that the majority of the data came from 2015 and before, so “there may be evidence on specific population and intervention subsets that has been published after each review’s last search date. If this occurred, the respective bodies of evidence may not reflect these newer studies,” although Patnode’s group suggested that, “Given the consistency of the effects within each group over time… it appears unlikely that any new trials… would have substantial bearing on the overall results of this overview of reviews.”

The recommendation is on the same page as those from other professional societies, including the American College of Obstetrics and Gynecologists (ACOG), which calls for pregnant smokers to undergo brief behavioral counseling, be introduced to evidence-based smoking cessation aids, and attempt NRT “only after a detailed discussion with the patient of the known risks of continued smoking, the possible risks of NRT, and need for close supervision.” However, ACOG is not in favor of the use of e-cigarettes in pregnant and postpartum individuals as a cessation tool, Krist and co-authors noted.

The task force called for more research on “the effectiveness of e-cigarettes for smoking cessation, as well as potential short- and long-term harms of e-cigarette use, and to understand whether there are effective pharmacotherapy options for pregnant person.”

1. The U.S. Preventive Services Task Force (USPSTF) recommends clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA–approved pharmacotherapy for cessation, but states that there is insufficient evidence to support electronic cigarettes as a cessation tool.

2. The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation, but evidence is insufficient to support pharmacotherapy in this population.

Shalmali Pal, Contributing Writer, BreakingMED™

Cat ID: 151

Topic ID: 88,151,730,192,151,489,925