Estimating the true effectiveness of smoking cessation interventions under variable comparator conditions: A systematic review and meta-regression

Background and aims: Behavioural smoking cessation trials have used comparators that vary considerably between trials. Although some previous meta-analyses made attempts to account for variability in comparators, these relied on subsets of trials and incomplete data on comparators. This study aimed to estimate the relative effectiveness of (individual) smoking cessation interventions while accounting for variability in comparators using comprehensive data on experimental and comparator interventions. Methods: A systematic review and meta-regression was conducted including 172 randomised controlled trials with at least 6 months follow-up and biochemically verified smoking cessation. Authors were contacted to obtain unpublished information. This information was coded in terms of active content and attributes of the study population and methods. Meta-regression was used to create a model predicting smoking cessation outcomes. This model was used to re-estimate intervention effects, as if all interventions have been evaluated against the same comparators. Outcome measures included log odds of smoking cessation for the meta-regression models and smoking cessation differences and ratios to compare relative effectiveness. Results: The meta-regression model predicted smoking cessation rates well (pseudo R2 = 0.44). Standardising the comparator had substantial impact on conclusions regarding the (relative) effectiveness of trials and types of intervention. Compared with a ‘no support comparator’, self-help was 1.33 times (95% CI = 1.16–1.49), brief physician advice 1.61 times (95% CI = 1.31–1.90), nurse individual counselling 1.76 times (95% CI = 1.62–1.90), psychologist individual counselling 2.04 times (95% CI = 1.95–2.15) and group psychologist interventions 2.06 times (95% CI = 1.92–2.20) more effective. Notably, more elaborate experimental interventions (e.g. psychologist counselling) were typically compared with more elaborate comparators, masking their effectiveness. Conclusions: Comparator variability and underreporting of comparators obscures the interpretation, comparison and generalisability of behavioural smoking cessation trials. Comparator variability should, therefore, be taken into account when interpreting and synthesising evidence from trials. Otherwise, policymakers, practitioners and researchers may draw incorrect conclusions about the (cost) effectiveness of smoking cessation interventions and their constituent components

Changing behaviour

Individual change in behaviour has the potential to decrease the burden of chronic disease due to smoking, diet and low physical activity. Smoking quit rates can be increased by simple advice from a physician or trained counsellor, overall and in people at high risk of smoking related disease, with low intensity advice as effective as high intensity advice. Advice from a nurse, telephone counselling, individualised self help materials and taking exercise may also be beneficial. Training health professionals increases the frequency of offering antismoking interventions but may not increase their effectiveness. Nicotine replacement therapy, bupropion and nortriptyline may improve short term quit rates as part of smoking cessation strategies. Moclobemide, selective serotonin reuptake inhibitors, anxiolytics and acupuncture have not been shown to be beneficial. Smoking cessation programmes increase quit rates in pregnant women, but nicotine patches may not be beneficial compared with placebo. Physical activity in sedentary people may be increased by counselling, with input from exercise specialists possibly being more effective than physicians, in women over 80 years and in younger adults. Advice on eating a low cholesterol diet leads to a mean 0.2 to 0.3 mmol/L decrease in blood cholesterol concentration in the long term, but no consistent effect of this on morbidity or mortality has been shown. Intensive interventions to reduce sodium intake lead to small decreases in blood pressure, but may not reduce morbidity or mortality. Advice to lose weight leads to greater weight loss than no advice, and cognitive behavioural therapy may be more effective than dietary advice

Smoking cessation : role of health care providers

It is evident that tobacco use can lead to nicotine dependence and serious health problems. It is equally evident that cessation can significantly reduce the risk of suffering from smoking related diseases. Total cessation is the only intervention with the potential to reduce tobacco-related mortality in the short- and medium-term, whilst a reduction in consumption has a limited effect. Some smokers quit without using evidence-based cessation treatments. However, there are treatments that have been proven to be effective for smokers who want help to quit. Simple advice from a physician has been shown to increase abstinence rates significantly compared to no advice.peer-reviewe

Rural smokers : a prevention opportunity

Background: Smoking is the largest single cause of preventable death and disease in Australia. This study describes smoking prevalence and the characteristics of rural smokers to guide general practitioners in targeting particular groups.Methods: Cross sectional surveys in the Greater Green Triangle region of southeast Australia using a random population sample (n=1563, participation rate 48.7%) aged 25&ndash;74 years. Smoking information was assessed by a self administered questionnaire.Results: Complete smoking data were available for 1494 participants. Overall age adjusted current smoking prevalence was 14.9% (95% CI: 13.1&ndash;16.7). In both genders, current smoking prevalence decreased with age. Those aged 25&ndash;44 years were more likely to want to stop smoking and to have attempted cessation, but less likely to have received cessation advice than older smokers.Discussion: This study provides baseline smoking data for rural health monitoring and identifies intervention opportunities. General practice is suited to implement interventions for smoking prevention and cessation at every patient encounter, particularly in younger individuals.<br /

Are there valid proxy measures of clinical behaviour?

Background: Accurate measures of health professionals' clinical practice are critically important to guide health policy decisions, as well as for professional self-evaluation and for research-based investigation of clinical practice and process of care. It is often not feasible or ethical to measure behaviour through direct observation, and rigorous behavioural measures are difficult and costly to use. The aim of this review was to identify the current evidence relating to the relationships between proxy measures and direct measures of clinical behaviour. In particular, the accuracy of medical record review, clinician self-reported and patient-reported behaviour was assessed relative to directly observed behaviour. Methods: We searched: PsycINFO; MEDLINE; EMBASE; CINAHL; Cochrane Central Register of Controlled Trials; science/social science citation index; Current contents (social & behavioural med/clinical med); ISI conference proceedings; and Index to Theses. Inclusion criteria: empirical, quantitative studies; and examining clinical behaviours. An independent, direct measure of behaviour (by standardised patient, other trained observer or by video/audio recording) was considered the 'gold standard' for comparison. Proxy measures of behaviour included: retrospective self-report; patient-report; or chart-review. All titles, abstracts, and full text articles retrieved by electronic searching were screened for inclusion and abstracted independently by two reviewers. Disagreements were resolved by discussion with a third reviewer where necessary. Results: Fifteen reports originating from 11 studies met the inclusion criteria. The method of direct measurement was by standardised patient in six reports, trained observer in three reports, and audio/video recording in six reports. Multiple proxy measures of behaviour were compared in five of 15 reports. Only four of 15 reports used appropriate statistical methods to compare measures. Some direct measures failed to meet our validity criteria. The accuracy of patient report and chart review as proxy measures varied considerably across a wide range of clinical actions. The evidence for clinician self-report was inconclusive. Conclusion: Valid measures of clinical behaviour are of fundamental importance to accurately identify gaps in care delivery, improve quality of care, and ultimately to improve patient care. However, the evidence base for three commonly used proxy measures of clinicians' behaviour is very limited. Further research is needed to better establish the methods of development, application, and analysis for a range of both direct and proxy measures of behaviour

Implementation of a quality improvement project on smoking cessation reduces smoking in a high risk trauma patient population.

BackgroundCigarette smoking causes about one of every five deaths in the U.S. each year. In 2013 the prevalence of smoking in our institution's trauma population was 26.7 %, well above the national adult average of 18.1 % according to the CDC website. As a quality improvement project we implemented a multimodality smoking cessation program in a high-risk trauma population.MethodsAll smokers with independent mental capacity admitted to our level I trauma center from 6/1/2014 until 3/31/2015 were counseled by a physician on the benefits of smoking cessation. Those who wished to quit smoking were given further counseling by a pulmonary rehabilitation nurse and offered nicotine replacement therapy (e.g. nicotine patch). A planned 30 day or later follow-up was performed to ascertain the primary endpoint of the total number of patients who quit smoking, with a secondary endpoint of reduction in the frequency of smoking, defined as at least a half pack per day reduction from their pre-intervention state.ResultsDuring the 9 month study period, 1066 trauma patients were admitted with 241 (22.6 %) identified as smokers. A total of 31 patients with a mean Injury Severity Score (ISS) of 14.2 (range 1-38), mean age of 47.6 (21-71) and mean years of smoking of 27.1 (2-55), wished to stop smoking. Seven of the 31 patients, (22.5 %, 95 % confidence interval [CI] of 10-41 %) achieved self-reported smoking cessation at or beyond 30 days post discharge. An additional eight patients (25.8 %, 95 % CI 12-45 %) reported significant reduction in smoking.ConclusionsTrauma patients represent a high risk smoking population. The implementation of a smoking cessation program led to a smoking cessation rate of 22.5 % and smoking reduction in 25.8 % of all identified smokers who participated in the program. This is a relatively simple, inexpensive intervention with potentially far reaching and beneficial long-term health implications. A larger, multi-center prospective study appears warranted.Level of evidenceTherapeutic Study, Level V evidence

Flowers Hospital: Nearing Perfection on Core Measures

Describes elements of a strategy for achieving high process-of-care performance by continuously monitoring patients in four clinical areas and ensuring they receive the right care -- including concurrent reviews and quality improvement teams

Economic evaluation of smoking cessation in Ontario's regional cancer programs.

Quitting smoking after a diagnosis of cancer results in greater response to treatment and decreased risk of disease recurrence and second primary cancers. The objective of this study was to evaluate the potential cost-effectiveness of two smoking cessation approaches: the current basic smoking cessation program consisting of screening for tobacco use, advice, and referral; and a best practice smoking cessation program that includes the current basic program with the addition of pharmacological therapy, counseling, and follow-up. A Markov model was constructed that followed 65-year-old smokers with cancer over a lifetime horizon. Transition probabilities and mortality estimates were obtained from the published literature. Costs were obtained from standard costing sources in Ontario and reports. Probabilistic and deterministic sensitivity analyses were conducted to address parameter uncertainties. For smokers with cancer, the best practice smoking cessation program was more effective and more costly than the basic smoking cessation program. The incremental cost-effectiveness ratio of the best practice smoking cessation program compared to the basic smoking cessation program was $3367 per QALY gained and$5050 per LY gained for males, and $2050 per QALY gained and$4100 per LY gained for females. Results were most sensitive to the hazard ratio of mortality for former and current smokers, the probability of quitting smoking through participation in the program and smoking-attributable costs. The study results suggested that a best practice smoking cessation program could be a cost-effective option. These findings can support and guide implementation of smoking cessation programs

Smoking Cessation Interventions After Lung Cancer Screening Guideline Change

Introduction: Recent guideline changes for lung cancer screening with low-dose computed tomography recommend smoking cessation interventions be done in parallel with screening. The purpose of this study is to determine the post-guideline rates of smoking cessation interventions among patients eligible and ineligible for lung cancer screening.Methods: Using electronic health records collected from a large ambulatory care system in northern California between 2010 and 2017, authors identified new patients who were current smokers aged 55–80 years visiting a primary care provider, and grouped patients into lung cancer screening–eligible heavy smokers, screening-ineligible moderate smokers, and screening-ineligible light smokers. Screening-eligible smokers versus screening-ineligible smokers were compared in receipt of smoking cessation interventions before (2010–2013) and after (2014–2017) the guideline change, overall and by intervention type (formal counseling, informal counseling, pharmacotherapy) using hierarchical generalized linear models. Analyses were conducted in 2018–2019.Results: After the guideline change, the likelihood of receiving any smoking cessation intervention (OR=1.44, 95% CI=1.28, 1.61, p&lt;0.05), informal counseling (OR=1.29, 95% CI=1.15, 1.46, p&lt;0.05), and pharmacotherapy (OR=1.24, 95% CI=1.02, 1.50, p&lt;0.05) during a new patient visit significantly increased, with the increase not varying by level of smoking. For formal counseling, the post-guideline increase was greater for screening-eligible heavy smokers (OR=3.15, 95% CI=1.18, 8.36, p&lt;0.05) and moderate smokers (OR=3.58, 95% CI=1.29, 9.95, p&lt;0.05) relative to light smokers.Conclusions: Smoking cessation interventions increased after new lung cancer screening guidelines. Given the sizable adverse impacts of smoking on morbidity and mortality, small increases in implementation of smoking cessation interventions could have substantial public health benefits