First published on 1 April 2020 and updated on an ongoing basis; last updated on 8 June 2021 (changes detailed below); all the reviews in this Special Collection are free to access
This Special Collection is one of a series of collections on COVID-19. It is also available in Simplified Chinese, Traditional Chinese, Croation, Czech, Farsi, French, German, Japanese, Korean, Bahasa Malaysia, Portuguese Russian, Spanish, and Thai.
Tobacco smoking and second-hand smoke are known to be risk factors for acute respiratory infections.[1] There are mixed findings on the association between smoking and COVID-19, and a rapid review of existing studies has found that evidence of a relationship between the two is inconclusive.[2]
However, the World Health Organization is urging people to stop smoking tobacco to minimize the risks associated with the current coronavirus pandemic in both people who smoke and those exposed to second-hand smoke.[3]
For many people quitting isn’t easy; however, there are a number of reviews evaluating interventions to help people to stop smoking. Evidence suggests that people who smoke should use a combination of ‘stop smoking medicines’ and behavioural support to give them the best chances of success.[4] Options for these may be more limited than usual at the current time, however there are still evidence-based ways available to help people succeed. Cochrane Tobacco Addiction has collated this Special Collection of the best available evidence to address this need during the current COVID-19 pandemic. Many reviews in the collection have associated Cochrane Clinical Answers.
This Special Collection includes Cochrane Reviews on the following topics: medication; behavioural support; and gradual quitting. Interventions that mimic the act of smoking, notably e-cigarettes, have been excluded from this collection as the risks associated with their use in relation to the current pandemic are not clear. Cochrane Tobacco Addiction are working to remain up to date on all the relevant information, to provide support to people attempting to stop smoking during this difficult time.
Updated 8 June 2021: added links to translation into Traditional Chinese, Croatian and Korean
Medication
Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. NRT is a safe, effective medication that can easily be bought over the counter in supermarkets and pharmacies. It comes in the form of patches, gum, lozenges, and sprays. The evidence suggests that people are best able to quit if they use a combination of NRT (i.e. using a patch and a fast acting form of NRT, such as gum or lozenge, at the same time), and that using NRT in this way is just as likely to help people quit as the stop smoking medications that a doctor can provide.[5]
Nicotine replacement therapy versus control for smoking cessation
This review determines the effectiveness and safety of NRT, including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long‐term smoking cessation, compared with placebo or 'no NRT' interventions. Associated Cochrane Clinical Answer: How do single over‐the‐counter nicotine replacement therapy (NRT) agents compare with placebo/no NRT agents for smoking cessation?
Although there is clear evidence that NRT used after smoking cessation is effective, it is unclear whether higher doses, longer durations of treatment, or using NRT before cessation add to its effectiveness. This review determines the effectiveness and safety of different forms, deliveries, doses, durations, and schedules of NRT, for achieving long‐term smoking cessation, compared with one another. Associated Cochrane Clinical Answer: How does combination nicotine replacement therapy (NRT) compare with monotherapy for people trying to quit smoking?
Behavioural support
Behavioural support for quitting smoking delivered via printed materials (such as those provided from trusted services like the NHS in the UK or the CDC in the United States), telephone, internet programmes, and text-messaging programmes have all been found to have a positive effect on quit rates. Many countries have quitlines that people who smoke can call for support (although these may not all be staffed during the pandemic), as well as online programmes and information. It is important to seek out trusted sources for information, such as those provided by governments or healthcare services or providers.
The four Cochrane Reviews in this section provide evidence for these remote methods of support.
Internet‐based interventions for smoking cessation
Although many people attempt to give up smoking on their own, advice from a health professional increases the chances of quitting. The Internet with its wide reach is a potential platform to help people quit smoking. This review aims to determine the effectiveness of Internet‐based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults. Associated Cochrane Clinical Answer: How do tailored and non‐tailored internet‐based interventions for smoking cessation in adults compare with active and inactive controls and with each other?
Mobile phone text messaging and app‐based interventions for smoking cessation
Mobile phone‐based smoking cessation support (mCessation) offers the opportunity to provide behavioural support to those who cannot or do not want face‐to‐face support. In addition, mCessation can be automated and therefore provided affordably even in resource‐poor settings. This review assesses whether mobile phone‐based smoking cessation interventions increase smoking cessation rates in people who smoke. Associated Cochrane Clinical Answer: Is randomized controlled trial evidence available to support the use of mobile phone–based interventions for smoking cessation?
Print‐based self‐help interventions for smoking cessation
Many people who smoke give up smoking on their own, but materials that provide a structured programme for them to follow may increase the number who quit successfully. This review aims to determine the effectiveness of different forms of print‐based self‐help materials that provide a structured programme for people who smoke to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print‐based self‐help, such as computer‐generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups. Associated Cochrane Clinical Answer: How do tailored and non‐tailored self‐help interventions compare with no self‐help or each other for smoking cessation?
Telephone counselling for smoking cessation
Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines. This review evaluates the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline. Associated Cochrane Cliniical Answer: What are the effects of telephone counseling for smoking cessation?
Gradual quitting
The COVID-19 pandemic is unprecedented and stressful, and it may not seem achievable to make big behavioural changes during this time. For people who cannot attempt stopping smoking immediately, an option is to reduce the number of cigarettes smoked before quitting. There is evidence to suggest that people who reduce their smoking before stopping altogether may be just as likely to successfully stop as those who quit abruptly.
However, it is always beneficial to quit sooner rather than later to reduce the health risks associated with smoking tobacco as much as possible, as there is no clear evidence that reducing cigarettes smoked without quitting completely has any beneficial effect on health. Therefore, people who do wish to cut-down their smoking before quitting should ideally ensure that the reduction period is as brief as possible, i.e. days or weeks rather than months. For a short-term plan it may be worth setting a quit day and specific reduction targets (e.g. reduce by a third of usual cigarettes over week 1, two-thirds over week 2, and to zero over week 3), as there is no evidence from a Cochrane Review that this is any less effective than other approaches to gradual cessation. Using a fast-acting form of NRT, such as gum or lozenge to replace cigarettes improves the chances of success, and it is safe to use this while still smoking.
Smoking reduction interventions for smoking cessation
The standard way most people are advised to stop smoking is by quitting abruptly on a designated quit day. However, many people who smoke have tried to quit many times and may like to try an alternative method. Reducing smoking behaviour before quitting could be an alternative approach to cessation. However, it is important to ensure that abrupt quitting is not more effective than reducing to quit, and to determine whether there are ways to optimize reduction methods to increase the chances of cessation. This review assesses the effect of reduction‐to‐quit interventions on long‐term smoking cessation. Associated Cochrane Clinical Answer: How do different smoking reduction interventions compare in terms of long‐term (≥ 6 months) smoking cessation?
References
1. Centers for Disease Control and Prevention. Health effects of secondhand smoke, 27 February 2020. www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects
2. Simons D, Shahab L, Brown J, Perski O. (2020). The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review. Qeios. https://doi.org/10.32388/UJR2AW
3. World Health Organization. Tobacco Free initiative: Tobacco and waterpipe use increases the risk of suffering from COVID-19. www.emro.who.int/tfi/know-the-truth/tobacco-and-waterpipe-users-are-at-increased-risk-of-covid-19-infection.html (accessed 19 March 2020).
4. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews. 2016;(3):CD008286. https://doi.org/10.1002/14651858.CD008286.pub3
5. Cahill K, Stevens S, Perera R, Lancaster; T. Pharmacological interventions for smoking cessation: an overview and network meta‐analysis. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329. https://doi.org/10.1002/14651858.CD009329.pub2
Acknowledgements
This Special Collection was developed by Jamie Hartmann-Boyce and Nicola Lindson (Cochrane Tobacco Addiction Group), working with Toby Lasserson (Deputy Editor in Chief) and Monaz Mehta (Editor) in the Cochrane Editorial Methods Department.
Translation
This Special Collection was translated into [language] by [name of Cochrane Group and optionally translators] on [date of the latest translation update].
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Contact
Cochrane Editorial and Methods Department (emd@cochrane.org)