Ex-Smokers Have Few Proven Weapons Against Relapse, Weight Gain

For former smokers like Obama, kicking the habit can prove incredibly difficult, and here is a new blow for abstainers: a large review of studies concludes that programs designed to help former smokers often fail to improve long-term quit rates.

Although interventions designed to help former smokers avoid relapse frequently focus on teaching skills for dealing with temptation, there is no evidence that this strategy works, said Peter Hajek, Ph.D., a co-author of the review.

Hajek, a professor of clinical psychology and director of the Tobacco Dependence Research Unit at the University of London, and colleagues reviewed 54 studies of more than 44,000 patients that evaluated the effectiveness of behavioral and pharmacological interventions in preventing relapse in ex-smokers.

The majority of the studies took place in the United States.

Researchers evaluated two main types of relapse interventions, both of which followed patients for at least six months after their quit date. One intervention taught smokers to identify risky situations and to develop and use alternative coping strategies.

The results of these interventions were disappointing, the authors said, since the interventions were not effective at reducing relapse rates.

“Despite the obvious intuitive validity of this approach, such skills may not be relevant, or they are difficult to teach, or perhaps people are not that good in applying them in real life,” Hajek said of the findings.

The second type of relapse intervention involved extended treatment contact through telephone or in-person counseling up to 11 months after the smokers’ initial quit date.

“This also yielded negative results, but most ex-smokers did not continue to visit clinics or phone help lines. It is possible that ongoing support that is more convenient, such as texting or messaging, or support that accompanies ongoing medication, would be more effective,” Hajek said.

Investigators also examined how pharmacological treatments designed to reduce tobacco dependence influenced a smoker’s ability to avoid cigarettes. They found that extended use of varenicline, a drug used to treat smoking addiction that manufacturers market as Chantix in the United States, showed some effectiveness in preventing relapse.

However, extended use of nicotine replacement treatments such as patches or chewing gum have not undergone proper testing, although they show promise, the authors report.

“The real problem in stopping smoking is not relapse. The real problem is getting through the first week. Forty percent of smokers who try do not even abstain for two days and 60 percent do not make it for a week,” said John Hughes, M.D., who researches tobacco dependence.

Hughes, a professor of psychology, psychiatry and family practice at the University of Vermont, researches tobacco dependence, had no affiliation with the review. He agreed with the review authors that no proven treatments exist to help smokers who abstain for a short time to remain abstinent.

“Most clinicians, myself included, believe continuing medication reduces relapse . . . so we encourage smokers to keep extra medicine in their cabinet, and if a stressor’s causing a craving, to immediately start back on medication. We also encourage them to hang out with smokers as little as possible because this makes getting a cigarette too easy,” Hughes said.

“Smokers may benefit from knowing that the longer they stay off cigarettes, the more likely they are to remain that way,” Hajek said. “The temptations weaken and once people start to see themselves as non-smokers and view smoking as something they just do not do any more, things get easy. One of the main dangers lies in thinking that a ‘one-off’ occasional cigarette cannot hurt. Ninety percent of lapses end up in full-blown relapse.”

Dealing with weight gain is also a common issue that plagues ex-smokers. Smokers gain an average of 15 pounds (about 7 kilograms) once they kick the habit.

A second Cochrane review, also co-authored by Hajek, examined 60 behavioral and pharmacological interventions, which included more than 28,000 patients, used to prevent weight gain in smokers.

Both reviews appear in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

“Only some fairly involved interventions showed signs of possible efficacy, such as a free supply of very low-calorie meals and cognitive behavioral treatments,” Hajek said. These strategies helped ex-smokers limit weight gain to between 2.8 pounds and 11.4 pounds after a year, researchers reported.

Interventions that involved the use of medications, such as bupropion (Wellbutrin, an antidepressant), fluoxetine (Prozac, also an antidepressant), nicotine replacement therapy and varenicline also limited weight gain in ex-smokers, but these effects were only small and mostly short-lived. They disappeared once the person stopped taking the medications, Hajek said.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

Hajek P, et al. Relapse prevention interventions for smoking cessation (Review). Cochrane Database of Systematic Reviews 2009, Issue 1.

Parsons AC, et al. Interventions for preventing weight gain after smoking cessation (Review). Cochrane Database of Systematic Reviews 2009, Issue 1.