What Percentage of People Start Smoking Again Within a Year

• Journal List
• HHS Author Manuscripts
• PMC2577779

Addict Behav. Writer manuscript; available in PMC 2009 December 1.

Published in final edited form as:

PMCID: PMC2577779

NIHMSID: NIHMS74689

Relapse to Smoking After 1 Year of Abstinence: A Meta-analysis

John R. Hughes

¹Dept. of Psychiatry, Academy of Vermont, Burlington, VT

Erica N. Peters

^aneDept. of Psychiatry, University of Vermont, Burlington, VT

Shelly Naud

²Dept. of Medical Biostatistics, Academy of Vermont, Burlington, VT

Abstruse

Most clinical trials use half dozen mo or 1 yr follow-ups as proxies for life-time smoking cessation. Retrospective studies have estimated 2–15% of smokers relapse each year after the kickoff 1 year of abstinence, but these accept methodological problems such every bit retentivity bias. We searched for prospective studies of adult quitters that reported the number of participants abstinent at 1 twelvemonth follow-up and who remained abstemious at ≥ 2 twelvemonth follow-ups. We included studies that reported the percent who remained lapse-free, did not keep treatment subsequently 1 yr, and had ≤ x% lost to follow-up. Nosotros did non locate any population-based studies just did locate eight randomized, controlled trials, all testing nicotine medications. After deleting one trial with outlier results, a meta-analysis estimated the annual incidence of relapse after ane yr to be 10%; nonetheless, the small sample sizes resulted in a wide 95% confidence interval (v–17%) suggesting this estimate is not very accurate. We conclude a not-significant corporeality of relapse occurs after ane twelvemonth. Better quantification of this relapse rate is important to improve estimates of lifelong abstinence and reductions in morbidity and bloodshed from smoking cessation.

Keywords: Nicotine dependence, relapse, smoking, smoking abeyance, tobacco, tobacco utilise disorder

one. Introduction

The goal of tobacco control policies and smoking cessation treatment among adult smokers is to induce life-long forbearance (Burns, 2000; Usa Department of Health and Human Services, 1990). Nearly clinical trials and cohort studies use six mo or 1 yr follow-ups every bit proxy measures to estimate life-long forbearance (Pierce & Gilpin, 2003). Few trials have examined abstinence after 1 twelvemonth (Etter & Stapleton, 2006).

Whether ane yr follow-ups are good proxies for lifelong abstinence depends on how much relapse occurs after 1 yr. Relapse to smoking after a quit attempt is greatest in the first few weeks and decreases quickly over time (Hughes, Keely, & Naud, 2004). In retrospective data sets of non-handling samples, among those abstinent at i twelvemonth, 2–15% relapse each twelvemonth thereafter (Gilpin, Pierce, & Farkas, 1997; Hammond & Garfinkel, 1963; Hammond & Garfinkel, 1964; Kirscht, Brock, & Hawthorne, 1987; The states Dept Wellness and Man Services, 1990). The best retrospective gauge of relapse was from the population-based US National Health and Diet Examination Report (NHANES) Follow-upward Study done in 1982–1984 (Figure 1) (US Dept Health and Homo Services, 1990). The pct of 1 yr abstainers who relapsed in the 2d and tertiary years were 14% and 10% and this decreased to < v% in the years thereafter. Although the NHANES survey has the asset of using a large, representative sample, information technology was nerveless over twenty yrs ago and was reported only in an appendix of the 1990 Surgeon General's Written report. Possibly more importantly, retrospective reports of abstinence are often invalid, particularly when they require remember of events occurring several years previously (Gilpin & Pierce, 1994).

Retrospective reports of relapse after i twelvemonth of abstinence from the 1982–1984 US National Wellness and Nutrition Examinations Study.

A few prospective studies take examined long-term follow-up. A recent review of 12 studies of nicotine replacement (NRT) efficacy focused on whether efficacy (i.east. odds ratio) persisted later on 1 year (Etter et al., 2006). Our analyses of data from Table 3 of that commodity indicates 31% in the placebo grouping and 33% in the agile grouping relapsed between the 1 yr follow-up and the long-term follow-up; withal, these rates are difficult to translate because the long-term follow-up varied widely (from iii–8 yrs) and the data do not permit determination of the annual charge per unit of relapse. In add-on, these estimates are likely inflated because the studies counted loss-to-follow-ups as relapses and several studies had rates of loss-to-follow-upwardly of > 20%.

ii. Methods

Nosotros searched for prospective (i.e. cohort) studies of relapse later ane twelvemonth; these could include uncontrolled studies. We initially obtained possible studies via searching the Cochrane Tobacco Addiction database (www.cochrane.org), the database used in the 2000 USPHS Guideline (Fiore et al., 2000), and the first writer's collection of xvi other meta-analyses on smoking cessation treatments. We too searched Pub Med by searching for "(nicotin* OR tobacco OR smok*) AND (cease* OR quit* OR relaps* OR cessation) AND long" in the championship of clinical trials. A similar search substituted the phrase "1 OR ii OR iii … OR 15" for the phrase "long". These searches were limited to "clinical trials" in "humans". Similar searches were conducted with PsychInfo, EMBASE, SSCI, and the Centre for Disease Command Tobacco Data and Prevention Database. The author also asked those on the Society for Research on Nicotine and Tobacco (SRNT) and College on Issues of Drug Dependence (CPDD) list-serves and those who authored relevant abstracts at recent CPDD, SRNT, National/World Congresses on Tobacco or Wellness, and Lodge for Behavioral Medicine meetings to send publications on this topic. This search resulted in 99 articles read by the first author.

3. Inclusion Criteria

Given that we are interested in relapse, we required report of prolonged abstinence (i.e., not indicate prevalence abstinence) both at the 1 yr and afterward follow-ups. When a study was unclear or stated the number/per centum abstinent "at" a follow-up, we assumed this was point-prevalent abstinence. This requirement eliminated several large, population-based and semi-population based studies such as the Customs Intervention Trial for Smoking Cessation (COMMIT Inquiry Grouping, 1995). Nosotros also excluded studies whose treatment connected beyond one yr every bit this could influence relapse rates. This eliminated the Lung Health Report (Anthonisen et al., 1994) and the Multiple Chance Gene Intervention Trial (Hughes, Hymowitz, Ockene, Simon, & Vogt, 1981), both of which were large trials with multiple postal service-1yr follow-ups. To increase external validity, we excluded studies of "special populations"; e.g., of adolescents, pregnant smokers, elderly smokers, minority smokers and non-cigarette tobacco users. We excluded studies that had only 1.5 yr follow-ups because they would contribute little information.

Nigh studies causeless that those who could not be reached were smokers. In this scenario, high relapse rates could exist solely due to low contact rates. For example, one study reported that almost all the "relapse" was due to loss of follow-ups (Richmond & Kehoe, 2007). We chose to exclude studies that had >10% lost-to-follow-upwardly between contacts or that did not report the number lost-to-follow-upward. Some trials used survival analyses which assumes those missing are non more likely to exist smokers (Hosmer & Lemeshow, 1999). Given this is unlikely, (Hughes et al., 2003; Hall et al., 2001) we excluded these studies.

four. Results

We did non locate whatsoever natural history studies or population-based studies. We did locate eight prospective studies (reported via 12 articles) that met our inclusion criteria (Blondal, 1989; Blondal, Franzon, & Westin, 1997; Blondal, Gudmundsson, Olafsdottir, Gustavsson, & Westin, 1999; Clavel-Chapelon, Paoletti, & Benhamou, 1992; Clavel-Chapelon, Paoletti, & Benhamou, 1997; Glavas, rumboldt, & Rumboldt, 2003; Mikkelsen, Tonnesen, & Norregaard, 1994; Stapleton, Sutherland, & Russell, 1998; Sutherland et al., 1992; Tonnesen, Norregaard, & Sawe.U, 1992; Tonnesen et al., 1988; Tonnesen et al., 1992; Tonnesen, Norregaard, Simonsen, & Sawe, 1991). All of these studies were included in the Etter and Stapleton review (Etter et al., 2006); however, four of the trials in that earlier review were non included in our review because they had loftier rates of lost-to-follow-up. The first and second authors and two students read the articles and coded them for the variables in Tabular array one. The pocket-sized amount of disagreement (<10%) was settled by a give-and-take betwixt the two raters.

Table i

Prospective Studies of Relapse Afterwards 1 Year

Study	Follow-ups (yrs)	Percentlost to f/u	Groups	Percent using active tx at 1 yr f/u	Fraction relapsed betwixt ane yr and last f/u	Per centum relapsed/twelvemonth by tx group	Percent relapsed/yr in entire study
Blondal 89	two	0%	Gum	2%	1/30	3%	4%
			Placebo		ane/22	5%
Blondal, 97	2	<1%	NNS	45%	5/twenty	25%	21%
			PIacebo		2/13	xv%
Tonneson, 88	two	<1%	4mg Gum/High Dependence	half dozen%	3/12	25%	35%
			2mg Gum/High Dependence		2/4	50%
			2mg Mucilage/Low Dependence		6/23	26%
			Placebo/Low Dependence		7/12	58%
Tonneson, 91	3	0%	Patch	0%	9/24	xix%	17%
Tonneson, 92			Placebo		2/7	fourteen%
Mikkelsen 94
Sutherland, 92	3.5	x%	NNS	43%	v/33	half dozen%	11%
Stapleton, 98			PIacebo		8/fourteen	23%
Clavel, 92	4	iii%	Placebo + Sham	0%	seven/25	9%	thirteen%
Clavel, 97			Placebo + Acupuncture		4/18	7%
			Mucilage + Sham		x/23	fourteen%
			Gum + Acupuncture		sixteen/thirty	17%
Glavas 03	5	0%	Patch	0%	3/13	6%	5%
			Placebo		1/9	3%
Blondal, 99	six	0%	Patch + NNS	thirteen%	13/32	eight%	7%
			Patch + Placebo		3/thirteen	5%

All eight studies were randomized controlled trials (RCTs) of NRT that had follow-ups ranging from ii–vi yrs postal service-quit date. The incidence of lost-to-follow-ups was essentially zip in seven studies. All but 1 study (Blondal, 1989) clearly stated they "confirmed" self-report via carbon monoxide levels. Only one written report (Tonnesen et al., 1991) had more than one follow-upwards. The eight studies reported on xx groups; i.eastward., on 12 treatment groups and 8 placebo groups. The sample sizes were minor; the number of one year quitters ranged from 4–33/report group and 31–96/written report. In six of the studies, few or none were using NRT at i year follow-upwardly. In two studies, almost half of participants were using NRT at the one-twelvemonth; however, neither of these studies allowed NRT use beyond 1 year (Table 1). Since the results of these two trials did not appear to differ from the other six, we included them. Studies varied on when the follow-up occurred; thus, to compare relapse incidence across studies, we converted results to the incidence of relapse/extra twelvemonth subsequently the ane year follow-up (nb--this comparison assumes relapse incidence does not decrease with longer follow-ups-- an issue nosotros address in the word).

Across both report groups and studies, the annual incidence of relapse was typically <20% (Table 1). All just one of the studies reported relapse rates of <25%. One report (Tonnesen et al., 1988) appeared to be an outlier equally information technology reported the four highest relapse rates in the data set (i.e. 25–l%). We attempted to collate the results by inbound annual relapse rates for each of the 20 study groups into a meta-analysis (Einarson, 1997). Several incidence rates were nigh zero. To prevent these from having an inflated weight and bias the results, we used an arcsine transformation. Nevertheless, the chi-square test for homogeneity suggested the results were heterogeneous across study groups (p=.01) precluding an accurate meta-analytic judge (Einarson, 1997). We deleted the one outlier study (Tonnesen et al., 1988) and the results remained heterogeneous. We thought some of the heterogeneity could be due to the pocket-sized sample sizes; thus, we increased the sample size by making the study, not the experimental group, the unit of measurement of assay. Since this required combining those who had previously been in active and placebo groups, we tested whether the incidence of relapse later on 1 yr differed in these two treatments and it did not. The results across studies remained heterogeneous (p = .01). Finally, nosotros repeated this report-based meta-assay and deleted the outlier study. Although in that location remained some variability (see Effigy ii), the results were statistically homogenous (p=.11) with a relapse rate of 10%/yr; withal, the 95% CI was broad (5–17%) suggesting little accuracy.

Prospective incidence of relapse after forbearance at 1 yr in trials that met inclusion criteria.

v. Discussion

Our major finding is the paucity of valid, generalizable, detailed estimates of the incidence of relapse after 1 yr. The validity of most studies that report long term follow-ups is compromised by their use of signal prevalence outcomes, past high rates of lost-to-follow-ups, or by continued handling afterwards i yr. We did locate eight long-term studies that avoided these problems and study their results; even so, the internal validity of these studies was express past their small number and sample sizes, and their external validity was limited by their use of treatment seekers, which are a minority of smokers.

After deleting i study as an outlier, our meta-assay estimated the incidence of relapse to exist 10%/yr. This judge is like to the x–fourteen% relapse incidence reported in the second and third years of the NHANES survey (United states Dept Health and Human Services, 1990) and to the 2–fifteen% rates reported in other large retrospective studies (Gilpin et al., 1997; Hammond et al., 1963; Hammond et al., 1964; Kirscht et al., 1987; US Dept Health and Human Services, 1990). Although this 10% incidence of relapse may appear small, if it continues yr afterwards year, and then, for instance, after five yrs, 41% of 1 yr quitters would accept relapsed. Our included studies did not accept multiple follow-ups to examination whether the incidence of relapse decreases over time. In the previously mentioned NHANES study and in ii other large studies that did non meet our inclusion criteria (Anthonisen et al., 1994; Hughes et al., 1981; U.s.a. Dept Health and Human being Services, 1990), the incidence of relapse appeared to exist less in later years, which would decrease concerns about the cumulative effect of late relapses. For the reasons listed to a higher place, we believe our estimate of 10% almanac relapse rates should be considered preliminary.

In summary, our written report suggests (a) the almanac charge per unit of relapse later on i year is likely substantial, especially when it cumulates over years, (b) annual relapse rates are likely to be near 10%, and (c) hereafter estimates need to report prolonged abstinence outcomes, and invest fourth dimension and attempt to insure low rates of lost-to-follow-up. Improving the accuracy of the charge per unit of post 1 yr relapse is specially of import to make up one's mind how adequate 6 mo or ane twelvemonth abstinence rates are as proxies for life-long forbearance. Information technology is also important to improve calculations of the benefits of cessation or handling on morbidity and bloodshed reduction (U.s.a. Section of Health and Human Services, 1990). We would encourage those conducting either treatment or accomplice studies to go on to follow abstinent smokers after 1 yr, and to report these outcomes.

Acknowledgements

This analysis was supported by NIDA Senior Scientist Award DA-00490(JRH) and Institutional Training Grant DA-07242(ENP)

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early on version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before information technology is published in its terminal citable form. Please notation that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

• Anthonisen NR, Connett JE, Kiley JP, Altose Doctor, Bailey WC, Buist Equally, Conway WA, Jr, Enright PL, Kanner RE, O'Hara P, Owens GR, Scanlon PD, Tashkin DP, Wise RA. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the charge per unit of decline of FEV. Periodical of the American Medical Association. 1994;272:1497–1505. [PubMed] [Google Scholar]
• Blondal T. Controlled trial of nicotine polacrilex gum with supportive measures. Archives of Internal Medicine. 1989;149:1818–1821. [PubMed] [Google Scholar]
• Blondal T, Franzon One thousand, Westin A. A double-blind randomized trial of nicotine nasal spray as an aid in smoking cessation. European Respiratory Periodical. 1997;x:1585–1590. [PubMed] [Google Scholar]
• Blondal T, Gudmundsson LJ, Olafsdottir I, Gustavsson Yard, Westin A. Nicotine nasal spray with nicotine patch for smoking cessation: Randomised trial with half-dozen yr follow up. British Medical Journal. 1999;318:285–289. [PMC free article] [PubMed] [Google Scholar]
• Burns D. Population impact of smoking cessation: Proceedings of a conference on what works to influence abeyance in the general population; Bethesda, Physician: National Cancer Institute; 2000. [Google Scholar]
• Clavel-Chapelon F, Paoletti C, Benhamou S. A randomised 2X2 factorial design to evaluate different smoking cessation methods. Revue d'Epidemiologie et de Sante Publique. 1992;40:187–190. [PubMed] [Google Scholar]
• Clavel-Chapelon F, Paoletti C, Benhamou S. Smoking cessation rates 4 years afterward treatment by nicotine gum and acupuncture. Preventive Medicine. 1997;26:25–28. [PubMed] [Google Scholar]
• COMMIT Research Group. Community Intervention Trial for Smoking Cessation (COMMIT): I. Cohort results from a iv-year community intervention. American Journal of Public Wellness. 1995;85:183–192. [PMC free article] [PubMed] [Google Scholar]
• Einarson T. Pharmacoeconomic applications of meta-analysis for single groups using antifungal onychomycosis lacquers as an instance. Clinical Therapeutics. 1997;xix:559–569. [PubMed] [Google Scholar]
• Etter J, Stapleton J. Nicotine replacement therapy for long-term smoking cessation: a meta-analysis. Tobacco Control. 2006;15:280–285. [PMC free article] [PubMed] [Google Scholar]
• Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, Heyman RB, Jaen CR, Kottke T, Lando HS, Mecklenburg RE, Mullen PD, Nett LM, Robinson L, Stizer ML, Tommasello Ac, Villejo Fifty, Wewers ME. Treating Tobacco Apply and Dependence. Clinical Practice Guideline. Rockville, MD: U.Due south. Public Health Service; 2000. [Google Scholar]
• Gilpin E, Pierce JP. Measuring smoking cessation: Problems with recall in the 1990 California Tobacco Survey. Cancer Epidemiology, Biomarkers & Prevention. 1994;3:613–617. [PubMed] [Google Scholar]
• Gilpin EA, Pierce JP, Farkas AJ. Elapsing of smoking abstinence and success in quitting. Journal of the National Cancer Institute. 1997;89:572–576. [PubMed] [Google Scholar]
• Glavas D, Rumboldt 1000, Rumboldt Z. Smoking cessation with nicotine replacement therapy among wellness intendance workers: randomized double-blind study. Croation Medical Journal. 2003;44:219–224. [PubMed] [Google Scholar]
• Hall SM, Delucchi M, Velicer WF, Kahler CW, Ranger-Moore J, Hedeker D, Tsoh J, Niaura R. Statistical analysis of randomized trials in tobacco treatment: Longitudinal designs with dichotomous outcome. Nicotine and Tobacco Research. 2001;3:193–203. [PubMed] [Google Scholar]
• Hammond EC, Garfinkel L. The influence of health on smoking habits. National Cancer Institute Monograph. 1963;nineteen:269–285. [PubMed] [Google Scholar]
• Hammond EC, Garfinkel 50. Changes in cigarette smoking. Journal of the National Cancer Institute. 1964;33:49–64. [PubMed] [Google Scholar]
• Hosmer DW, Lemeshow S. Applied Survival Assay: Regression Modeling of Time to Effect Data. 1st Edition. New York, NY: John Wiley & Sons; 1999. [Google Scholar]
• Hughes GH, Hymowitz N, Ockene JK, Simon N, Vogt TM. The multiple risk cistron intervention trial (MRFIT) Preventive Medicine. 1981;10:476–500. [PubMed] [Google Scholar]
• Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence amidst untreated smokers. Addiction. 2004;99:29–38. [PubMed] [Google Scholar]
• Hughes JR, Keely J, Niaura R, Ossip-Klein D, Richmond R, Swan G. Measures of forbearance from tobacco in clinical trials: Bug and recommendations. Nicotine and Tobacco Enquiry. 2003;5:13–25. [PubMed] [Google Scholar]
• Kirscht JP, Brock BM, Hawthorne VM. Cigarette smoking and changes in smoking among a cohort of Michigan adults. American Journal of Public Health. 1987;77:501–502. [PMC free article] [PubMed] [Google Scholar]
• Mikkelsen KL, Tonnesen P, Norregaard J. Three-year outcome of ii-and three-year sustained abstainers from a smoking cessation study with nicotine patches. Journal of Smoking-Related Disease. 1994;5:95–100. [Google Scholar]
• Pierce J, Gilpin E. A minimum vi-month prolonged abstinence should be required for evaluating smoking cessation trials. Nicotine and Tobacco Inquiry. 2003;5:151–153. [PubMed] [Google Scholar]
• Richmond R, Kehoe Fifty. Ten-twelvemonth survival outcome of the nicotine transdermal patch with cognitive behavioural therapy. Australian and New Zealand Journal of Public Wellness. 2007;31:282–285. [PubMed] [Google Scholar]
• Stapleton JA, Sutherland G, Russell MAH. How much does relapse subsequently one year erode effectiveness of smoking cessation treatments? Long term follow upward of randomised trial of nicotine nasal spray. British Medical Periodical. 1998;316:830–831. [PMC free article] [PubMed] [Google Scholar]
• Sutherland G, Stapleton JA, Russell MAH, Jarvis MJ, Hajek P, Belcher Thou, Feyerabend C. Randomised controlled trial of nasal nicotine spray in smoking cessation. Lancet. 1992;340:324–329. [PubMed] [Google Scholar]
• Tonnesen P, Fryd V, Hansen M, Helsted J, Gunnersen A, Forchammer H, et al. Issue of nicotine chewing gum in combination with group counseling in the abeyance of smoking. New England Journal of Medicine. 1988;318:15–27. [PubMed] [Google Scholar]
• Tonnesen P, Norregaard J, Sawe U. Two-year event in a smoking abeyance trial with a nicotine patch. Journal of Smoking Related Disease. 1992;3:241–245. [Google Scholar]
• Tonnesen P, Norregaard J, Simonsen Thou, Sawe U. A double-blind trial of a 16-hr transdermal nicotine patch in smoking cessation. New England Journal of Medicine. 1991;325:311–315. [PubMed] [Google Scholar]
• United states of america Department of Health and Man Services. The Wellness Benefits of Smoking Cessation. A Report of the US Surgeon General. Rockville, MD: Office on Smoking & Health; 1990.
• US Dept Wellness and Human being Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Washington: U.S: Authorities Printing Function; 1990. National trends in smoking abeyance.

kesslerfarre1969.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2577779/#:~:text=Retrospective%20studies%20have%20estimated%202,problems%20such%20as%20memory%20bias.

Share this post