Clinical Question

Which behavioral interventions help people quit smoking, and what factors influence how successful they are?

Evidence-Based Answer

A variety of behavioral interventions are effective for smoking cessation. Providing individual or group counseling (odds ratio [OR] = 1.44; 95% credibility interval [CrI], 1.22 to 1.70; number needed to treat [NNT] = 40), guaranteed financial incentives (OR = 1.46; 95% CrI, 1.15 to 1.85; NNT = 29), and text message–based counseling (OR = 1.45; 95% CrI, 1.17 to 1.80; NNT = 33) provide the greatest benefit. Population characteristics do not consistently affect the success of these interventions. All of the interventions provide additional benefit even when smoking cessation pharmacotherapy is prescribed. There are no apparent harms of behavioral interventions.¹ (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

In 2019, 20.8% of all adults in the United States (26.2% of men and 7% of women) reported tobacco use.² Worldwide, more than 7 million people die annually of tobacco-related illnesses, including cancer, cardiovascular disease, and chronic obstructive pulmonary disease.¹ Smoking cessation remains an important public health goal with the potential to save lives and reduce the burden of disease. Using the data from all relevant Cochrane reviews, the authors sought to summarize which behavioral interventions help smokers quit.

This review included 33 prior Cochrane reviews that examined behavioral interventions for smoking cessation encompassing 312 unique randomized controlled trials and a total of 250,563 participants.¹ To be included, randomized controlled trials had to compare one behavioral intervention with another or with no intervention and had to report a primary outcome of abstinence from smoking at a minimum of six months postintervention. Studies in which both groups received pharmacotherapy were included, but those in which only the intervention group received pharmacotherapy were excluded. Reviews had to include adult smokers 18 to 63 years of age in the general population, and most studies were conducted in the United States or Western Europe, with about 37% taking place in health care settings and 63% in community settings. Many (140) of the 312 studies included patients who were motivated to quit, eight studies included people who were not interested in quitting, and the remaining studies did not specify patient motivation. The median age of trial participants was 42 years, and the median percentage of women was 54%.

The authors chose 38 different components of behavioral interventions to analyze in the combined review, including the type of motivation (how or why to quit), the type of intervention (e.g., counseling, hypnotherapy, financial incentives), the mode of delivery (i.e., individual, group, web, or text message), and the clinician doing the intervention (including but not limited to physicians, nurses, and pharmacists). They also examined whether subsets of the population (e.g., socioeconomic status) or the intensity of the intervention (i.e., number of sessions or length of treatment) affected the degree to which these interventions worked.

Four interventions improved the rates of smoking cessation at six months' follow-up: phone counseling, text message–based interventions, individual or group counseling, and guaranteed financial incentives. Text message–based interventions compared automated text messages with minimal support (NNT = 33; 95% confidence interval [CI], 20 to 100). They ranged in length from one week to six months; some were tailored to the individual and others were provided with general messages. Effective counseling interventions included group counseling compared with self-help (NNT = 25; 95% CI, 14 to 33) and individual cessation counseling compared with usual care, brief advice, or self-help materials (NNT = 25; 95% CI, 20 to 33). Group counseling interventions generally ran for six to eight sessions, and individual counseling consisted of face-to-face sessions, each lasting at least 10 minutes, with a smoking cessation counselor. Guaranteed financial incentives (including cash payments or vouchers for goods and groceries) improved rates of smoking cessation (NNT = 29; 95% CI, 19 to 50) compared with no incentives. Data did not make clear the optimal frequency or duration of any of these interventions. The evidence was insufficient to confidently determine whether tailoring interventions to specific patient characteristics, such as baseline motivation or socioeconomic status, changed the likelihood of success.

The U.S. Preventive Services Task Force recommends that clinicians ask all adults about tobacco use and provide behavioral interventions and U.S. Food and Drug Administration–approved pharmacotherapy aimed at cessation (Grade A recommendation). ³ This recommendation includes a summary of evidence-based behavioral interventions to consider, including physician or nurse advice, individual counseling, group counseling, telephone counseling, and mobile phone–based interventions. Many professional societies, including the American Heart Association and American Cancer Society, prominently include behavioral interventions as potentially successful parts of a tobacco cessation plan.⁴ Several evidence-based behavioral interventions may be accessed free of charge through the Centers for Disease Control and Prevention, the American Cancer Society, and specific state departments of public health.⁵