Session 6: Nicotine Replacement Therapy in Combination with Behavioral and Psychological Support

Current evidence indicates that use of nicotine replacement therapy in combination with behavioral and psychological support:

     is more successful than such pharmacologic therapy alone in achieving smoking cessation, 

but the use of nicotine replacement therapy should not be conditioned on concomitant behavioral and psychological therapy.

       Although transdermal nicotine therapy may be of value even in patients who do not participate in formal smoking cessation programs, many patients receiving such therapy have been otherwise healthy, nicotine-dependent smokers who were described as motivated to quit smoking and who often were treated by experienced researchers in specialized clinics and/or had frequent contact with clinicians. 

The success of nicotine gum for smoking cessation in general medical practice, where intensive behavioral support generally is not feasible and/or patient motivation may be less than optimal, has been relatively poor,  and it has been suggested that abstinence rates reported from studies of transdermal nicotine therapy in specialized clinics may not accurately reflect the efficacy that can be expected in the general community.

Current data suggest that rates of smoking cessation in patients receiving transdermal nicotine therapy are higher and less variable, at least in the short term, when concomitant behavioral support is provided.

Therefore, the manufacturers and most clinicians recommend that transdermal systems of nicotine preferably be used as part of a comprehensive program of multiple treatment strategies, including behavioral modification, to assist in the cessation of smoking. The quality, intensity, and frequency of such behavioral support appear to influence the outcome of attempts to quit smoking, although the minimum and/or essential components of a successful smoking-cessation program have not been clearly defined to date. The efficacy of intranasal or orally inhaled nicotine replacement therapy as an adjunct to smoking cessation also has been demonstrated in patients who underwent concomitant psychosocial interventions (e.g., group support, individualized counseling), and therefore a comprehensive program of behavioral modification is recommended when this method of nicotine therapy is employed. 

Different strategies of concomitant behavioral support influence the rate of abstinence from smoking achieved with transdermal nicotine, although evidence against differential outcome also exists.

 An analysis of pooled data from several well-designed, controlled studies showed that the rate of abstinence from smoking was greater with counseling that was of high rather than of low intensity, as indicated by ratings on an index that reflected the importance of counseling as a goal at meetings with patients, frequency of meetings during the first 4 weeks of treatment with transdermal nicotine, number of meetings held during the first 12 weeks of abstinence from smoking, and length of meetings.

Analysis of individual criteria revealed higher rates of abstinence from smoking when counseling was a primary goal of meetings with patients, when patients were met with at least weekly during the first 4 weeks of treatment with transdermal nicotine, and when at least 7 meetings were held during the first 12 weeks of abstinence. In addition, rates of abstinence from smoking were higher with group counseling than with individual counseling.

 

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