Cut Down to Quit with Nicotine Replacement Therapies (NRT) in Smoking Cessation: Systematic Review of Effectiveness and Economic Analysis

Department of Public Health and Epidemiology, University of Birmingham, UK.
Health technology assessment (Winchester, England) (Impact Factor: 5.03). 03/2008; 12(2):iii-iv, ix-xi, 1-135. DOI: 10.3310/hta12020
Source: PubMed


To examine the effectiveness and cost-effectiveness of nicotine replacement therapy (NRT) for 'cut down to quit' (CDTQ) smoking.
Major electronic databases were searched up to July 2006.
Data from studies meeting the criteria were reviewed and analysed. A decision analytical model was constructed to estimate the cost-effectiveness of CDTQ from the NHS perspective.
No systematic reviews of the effectiveness of CDTQ and no randomised controlled trials (RCTs) specifically addressing CDTQ were identified. Seven randomised placebo-controlled trials satisfied the inclusion criteria; six of these were industry sponsored. However, sustained smoking cessation was only reported as a secondary outcome in these trials and required commencement of cessation within the first 6 weeks of treatment. Meta-analyses of the study level results demonstrated statistically significant superiority of NRT compared with placebo. Individual patient data from unpublished reports of five RCTs were used to calculate sustained abstinence of at least 6 months starting at any time during the treatment period (generally 12 months). From this the meta-analysis indicated statistically significant superiority of NRT versus placebo [relative risk 2.06, 95% confidence interval (CI) 1.34 to 3.15]. The proportions achieving this outcome across all five RCTs were 6.75% of participants in receipt of NRT and 3.29% of those receiving placebo. The number-needed-to-treat was 29. This measure of sustained abstinence was used for economic modelling. No existing economic analyses of CDTQ were identified. A de novo decision analytic model was constructed to estimate the cost-effectiveness of making CDTQ with NRT available for smokers unwilling or unable to attempt an abrupt quit. The outcome measure was expected quality-adjusted life-years (QALYs). The model results suggest that CDTQ with NRT delivers incremental cost-effectiveness ratios (ICERs) ranging from around 1500 pounds/QALY to 7700 pounds/QALY depending on the age at which smoking cessation was achieved and the modes of CDTQ delivery. Assuming applicability to a single population, CDTQ was not cost-effective compared with abrupt quitting. If CDTQ with NRT were to be offered on the NHS as a matter of policy, the base-case results suggest that it would only be effective and cost-effective if a substantial majority of the people attempting CDTQ with NRT were those who would otherwise make no attempt to quit. This result is robust to considerable variation in the forms of CDTQ with NRT offered, and to the assumptions about QALY gained per quit success.
Meta-analysis of RCT evidence of quit rates in NRT-supported smoking reduction studies indicates that NRT is an effective intervention in achieving sustained smoking abstinence for smokers who declare unwillingness or inability to attempt an abrupt quit. The 12-month sustained abstinence success rate in this population (approximately 5.3% with NRT versus approximately 2.6% with placebo) is considerably less than that documented for an abrupt quit NRT regime in smokers willing to attempt an abrupt quit with NRT (which according to other systematic reviews is around 16% with NRT versus 10% with placebo). Most of the evidence of effectiveness of CDTQ came from trials that required considerable patient-investigator contact. Therefore, for CDTQ with NRT to generate similar abstinence rates for this recalcitrant population in a real-world setting would probably require a similar mode of delivery. The modelling undertaken, which was based on reasonable assumptions about costs, benefits and success rates, suggests that CDTQ is highly cost-effective compared with no quit attempt. CDTQ remains cost-effective if dilution from abrupt quitting forms a small proportion of CDTQ attempts. In an alternative analysis in which smokers who switch from an abrupt quit to CDTQ retain the success rate of abrupt quitters, all forms of CDTQ appear cost-effective. Randomised trials in recalcitrant smokers allowing head-to-head comparison of CDTQ delivered with various modalities would be informative.

Download full-text


Available from: Martin Connock,
65 Reads
  • Source
    • "Long-term approach to abstinence CDTQ over 6 m or harm reduction over extended period [30] [32], eventually achieving abstinence [33]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Patient-centred tobacco management approaches tobacco smoking as a chronic disease and can be offered to all smokers irrespective of their attitude to quitting. Maintaining a long-term relationship with smokers enables the adoption of flexible solutions and shared goals. It is argued that patient-centred tobacco management potentially heightens the chances of eventual abstinence for smokers who are unable, or not yet ready to quit. [Gould, GS. Patient-centred tobacco management. Drug Alcohol Rev 2013].
    Drug and Alcohol Review 11/2013; 33(1). DOI:10.1111/dar.12082 · 1.55 Impact Factor
  • Source
    • "To answer these questions, a cost-effectiveness model was developed involving a decision tree structure and using 12-month continuous abstinence to represent the effect of a smoking cessation (Chen et al., 2012). This structure closely followed previous model-based evaluations of smoking cessation aids (Wang et al., 2008; Woolacott et al., 2002). To inform the model, a systematic review was carried out to identify all the available evidence to inform estimates of efficacy defined in terms of 12-month continuous abstinence. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Health technology assessment requires the synthesis of evidence from multiple sources to assess the cost-effectiveness of competing interventions. However, the format of the available reported evidence is often complex. We present a case-study of electronic aids to smoking cessation, which raises various methodological challenges. The evidence base evaluated highly complex and diverse interventions, reporting one or both of two different, but related, outcome measures. Furthermore, there were differences between studies in the number and timing of follow-up times reported, whereas 12-month continuous abstinence is required in the cost-effectiveness analysis. We develop a categorization system to evaluate the interventions, and we use network meta-analysis of time-to-relapse model parameters to estimate coherent intervention effects for any pair of categories. We compare the fit of alternative time-to-relapse models and explore the effect of joint models for both outcome measures, which can be used to estimate treatment effects when a given outcome is not reported, so that all the available evidence can be combined.
    Journal of the Royal Statistical Society Series A (Statistics in Society) 08/2013; 177(1). DOI:10.1111/rssa.12018 · 1.64 Impact Factor
  • Source
    • "One of the biggest obstacles to quitting is a fear of gaining weight (Jeffery et al., 2000). Nicotine replacement therapies (NRTs), including skin patches, chewing gum, nasal spray, inhalers, and lozenges/tablets are somewhat successful at helping people quit smoking (Kralikova et al., 2009; Stead et al., 2008; Wang et al., 2008), but are relatively unsuccessful at preventing longterm weight gain in ex-smokers (Klesges et al., 1989). Likewise, the effects of bupropion or naltrexone on weight loss are limited and do not seem to extend past the treatment phase, with subjects eventually gaining as much weight as untreated ex-smokers (Farley et al., 2012; Filozof et al., 2004; Toll et al., 2010). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Increased appetite and weight gain after cessation is a deterrent for quitting smoking. Pharmacotherapies that can reduce this weight gain in ex-smokers would be invaluable, and yet are not well studied in this context. To examine the effects of extended daily exposure to intravenous cytisine, an alpha4beta2 nAChR partial agonist used for smoking cessation in some European countries, on body weight and patterns of food intake in rats. In the first experiment, programmed infusions of cytisine were administered over 15 h per day. Food intake, meal patterns, and weight change were examined relative to a vehicle-infused group during treatment, and in a post-cytisine phase. The second experiment examined the effects of cytisine on food intake, meal patterns, and weight change when substituted for nicotine in a self-administration protocol. Rats self-administered nicotine and cytisine during alternating four day periods, and changes in body weight, drug infusions, and meal patterns were compared between drugs and during an extinction phase. In the first experiment, cytisine-treated rats ate less and gained less weight than those that received the vehicle. This occurred primarily by a reduced frequency of meals. In the 12 day post-cytisine phase, animals maintained a lower body weight relative to controls throughout. In the second experiment, total pellet intake increased during cytisine substitution relative to nicotine and animals self-administered cytisine significantly less than nicotine. However, cytisine substitution maintained decreases in food intake and weight gain compared to baseline via decreases in total pellet intake and meal size. Cytisine administration results in decreased weight gain and changes in meal patterns dependent upon mode and pattern of administration and a previous history of nicotine administration.
    Pharmacology Biochemistry and Behavior 07/2013; 110. DOI:10.1016/j.pbb.2013.07.012 · 2.78 Impact Factor
Show more