Trying to quit smoking and don’t know what to do? In this interview with Dr. Nicola Lindson we discuss the various methods she has researched on smoking cessation.
Dr. Lindson first of all let me thank you for taking the time for this interview. Would you say electronic cigarettes aid towards smoking cessation?
I am currently co-leading an exciting project to carry out a living Cochrane systematic review of electronic cigarettes (e-cigarettes) for quitting tobacco smoking. This means that we look at the available evidence each month and see if there have been any new studies looking at the effectiveness or safety of e-cigarette interventions for quitting smoking.
If there has been then we incorporate these into a wider review of all of the existing evidence. So far, our review provides moderate‐certainty evidence that e-cigarettes with nicotine help more people to quit than e-cigarettes without nicotine, and nicotine replacement therapy (a well-established and effective treatment for quitting smoking).
We have not found any clear evidence of harms caused by nicotine e-cigarettes so far, but the length of the longest study in our review is two years and the overall number of studies is small; therefore, we need more long-term studies to assess the harms of e-cigarettes.
Despite these findings, many people still think that e-cigarettes are more, or equally as, harmful as tobacco cigarettes, so my colleagues and I are focusing on different ways to get the emerging messages from our review out there to the general public.
Making The Move
One of the ways we are doing this is through a podcast, where we discuss the new evidence and interview researchers about their studies.
Some of the questions my colleagues and I get asked a lot is about the amount of young people who are using e-cigarettes and whether e-cigarette use is likely to act as a gateway to tobacco use.
This is an area we don’t have clear answers on yet; however we will be carrying out a review of the existing evidence soon. In the meantime, the general consensus is that although e-cigarettes are less harmful than tobacco cigarettes they are not completely harmless.
Therefore, if you smoke tobacco cigarettes and would like to try to use e-cigarettes to quit then the evidence suggests this may be a good idea, but if you are not already smoking tobacco then there isn’t any reason to start using e-cigarettes.
Does meditation/mindfulness help towards quitting smoking?
The popularity of meditation and mindfulness practice has increased in recent years, and evidence has started to emerge looking at whether it could be an effective treatment for quitting smoking.
As a result, we are in the process of carrying out a Cochrane systematic review of the available research literature to see what the evidence shows so far. We are hoping that this will be published by the end of 2021, beginning of 2022.
We don’t expect to find a lot of studies to start with but the great thing about Cochrane Reviews is that they can be updated when new evidence becomes available and they grow as the evidence base grows.
Are antidepressants actually prescribed to help people quit?
Yes, one of the commonly licensed medications used for quitting smoking worldwide is an antidepressant called bupropion. New Zealand also licenses an antidepressant called nortriptyline for this purpose.
It isn’t clearly understood why these medications help people to quit smoking, but a review that I am an author on found that bupropion can increase people’s chances of quitting by around 50%.
However, despite its effectiveness bupropion isn’t as commonly used for quitting smoking as nicotine replacement therapy and another medication called varenicline, as the latter two treatments have less side effects and are more effective respectively.
How effective is nicotine replacement therapy?
Nicotine replacement therapy, known as NRT, has been around to help people quit smoking for more than 20 years. It can be prescribed by a doctor but, in many countries, is also available to buy from grocery stores and pharmacies.
NRT is available in a range of forms, including skin patches, chewing gum, nasal and oral sprays, inhalators, and lozenges. It works by delivering nicotine, one of the addictive parts of tobacco, without all of the other harmful chemicals that are present in tobacco smoke.
Evidence for the use of NRT to stop smoking is strong and it has been found to be both safe and effective when used to help people to stop smoking.
A Cochrane Review written by my colleagues found that NRT helped around 50% more people to quit than a placebo.
The authors conclude that this evidence is high certainty and that any new studies comparing NRT to placebo are very unlikely to change their confidence in this effect.
What is Most Effective?
Which form is more effective? Is it patches, chewing gum or electronic cigarettes?
When looking at which form of NRT to use to maximise a person’s chances of quitting, our review on this subject shows that using a skin patch and another form of NRT, such as gum or lozenge, at the same time helps 25% more people to quit than using one form of NRT on its own.
This finding is based on 14 studies including more than 11,000 people and has been judged high quality. There is much less evidence comparing NRT to e-cigarettes at the current time.
Our review of e-cigarettes found three studies that explored this and has found some evidence that people who receive e-cigarettes are more likely to quit than people who use NRT. My colleagues and I are hoping to carry out more research in the future to explore this further.
Does reduced smoking help those who just cannot stop?
The first Cochrane Review I carried out looked at whether quitting smoking all at once (abruptly) helped more people to quit smoking than reducing smoking first.
The reason that this is an interesting question is that many health professionals advise people to stop smoking abruptly; however, some people have tried this approach and failed many times or just feel that they cannot quit this way, and would prefer to quit more gradually.
So that we can offer those people evidence-based advice, it is important to investigate whether reducing to quit is at least as effective as the standard approach.
I carried out this review as part of my PhD and so it has a special place in my heart. Therefore, I was excited to update it in 2019 and find that the studies carried out to answer this question had more than doubled.
We found evidence to suggest that neither reduction‐to‐quit nor abrupt quitting interventions resulted in superior long‐term quit rates when compared with one another.
There was also some evidence to suggest that reduction‐to‐quit interventions may be more effective when pharmacotherapy is used as an aid; in particular fast‐acting types of NRT, such as gum or lozenge, and varenicline.
What are the consequences of going cold turkey i.e. quitting smoking without using any treatment?
Evidence suggests that many smokers try to quit without assistance, such as counselling and medication. However, not many of these people are successful. That is because quitting smoking is a very difficult thing to do.
My colleagues and I have found high quality evidence that receiving counselling to stop smoking increases a person’s chances of quitting long-term and medications, such as a combination of NRT products and varenicline, have also been found to be effective, with increasing evidence for the effectiveness of e-cigarettes.
Seen as smoking is uniquely deadly and one in every two people who smoke will die through smoking-related causes the consequences of going cold turkey could be severe.
At the beginning of the year my colleague, Jamie Hartmann-Boyce, and I wrote an article on eight evidence-based ways to quit smoking that was informed by our Cochrane Reviews.
We hope this will help people to find a way to quit smoking successfully this year.
Mental Health and Smoking
Based on your research what would you say is the link between mental health and smoking?
My colleagues and I published a systematic review in 2014, which found that quitting smoking was associated with improved mental health. This is an important finding as anecdotally many people think that smoking relieves their stress and worry about the impact quitting may have on their mental health.
Clinicians may also worry about this and so it may affect the advice that they give to patients about quitting smoking. Knowing that quitting is associated with an improvement in anxiety and depression could provide a compelling motivation for people to make a quit attempt, and also contribute toward treatment for mental health problems.
Therefore, this paper had a big impact and contributed to a range of healthcare guidance. The review was originally published in a journal called the BMJ; however, we are in the process of updating it and publishing it as a Cochrane Review that we plan to publish in the first half of 2021.
Finding The Reason
Please tell us about your motivation into your area of specialisation?
My motivation for doing research into smoking cessation treatments is quite simply that I want to be able to help people to improve their health. When I was a child I witnessed one of my close relatives give up smoking and I realised how hard they found it.
Although I didn’t know there and then that this is what I wanted to do, when I studied for my degree in Psychology, I immediately became interested in the area of Addiction and specifically tobacco smoking.
I particularly like working on systematic reviews in this area as it allows us to gather all of the existing evidence together and draw conclusions from it. These conclusions can then go on to influence clinical practice and healthcare guidance and ultimately help people to quit smoking.
Keeping that in mind is extremely rewarding and provides me with lots of motivation to keep doing what I am doing.
Our readers are mainly the youth from different parts of the world who look up to achievers such as yourself. A word of advice for them?
Don’t worry if you don’t know what you want to do as a career from a young age. I certainly didn’t, and when leaving school, and even University, I didn’t even have a clear idea of what a healthcare researcher did.
However, I focused on the subjects I enjoyed, and have always been open to the opportunities that come my way.
Sometimes those opportunities have been a bit scary (like talking to 500 people at a conference, or moving to a new city) and I’ve had to give myself a bit of a pep talk, but I’m always glad that I took them.
Dr. Nicola Lindson is employed with the Nuffield Department of Primary Care Health Sciences, University of Oxford, UK. She is a University Research Lecturer and Cochrane Managing Editor. Cochrane is a global non-profit organisation that systematically reviews and critically appraises healthcare research to help people to make evidence-based decisions. Nicola’s research is well recognised internationally. She is focused on tobacco addiction, smoking cessation and harm reduction.
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