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Taylor AH, Thompson TP, Streeter A, Chynoweth J, Snowsill T, Ingram W, Ussher M, Aveyard P, Murray RL, Harris T, Green C, Horrell J, Callaghan L, Greaves CJ, Price L, Cartwright L, Wilks J, Campbell S, Preece D, Creanor S. Motivational support intervention to reduce smoking and increase physical activity in smokers not ready to quit: the TARS RCT. Health Technol Assess 2023; 27:1-277. [PMID: 37022933 PMCID: PMC10150295 DOI: 10.3310/kltg1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Background Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear. Objectives The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective. Design This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation. Setting and participants Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458). Intervention The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity. Main outcome measures The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed. Results The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval -£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236). Conclusions There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective. Limitations Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence. Future work Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence. Trial registration This trial is registered as ISRCTN47776579. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adrian H Taylor
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Tom P Thompson
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Adam Streeter
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Jade Chynoweth
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Tristan Snowsill
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Wendy Ingram
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Michael Ussher
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rachael L Murray
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tess Harris
- Population Health Research Institute, St George's, University of London, London, UK
| | - Colin Green
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jane Horrell
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Lynne Callaghan
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Lisa Price
- Sport and Health Sciences, University of Exeter, Exeter, UK
| | - Lucy Cartwright
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Jonny Wilks
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Sarah Campbell
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Dan Preece
- Public Health, Plymouth City Council, Plymouth, UK
| | - Siobhan Creanor
- Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
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Hartmann-Boyce J, Livingstone-Banks J, Ordóñez-Mena JM, Fanshawe TR, Lindson N, Freeman SC, Sutton AJ, Theodoulou A, Aveyard P. Behavioural interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2021; 1:CD013229. [PMID: 33411338 PMCID: PMC11354481 DOI: 10.1002/14651858.cd013229.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Smoking is a leading cause of disease and death worldwide. In people who smoke, quitting smoking can reverse much of the damage. Many people use behavioural interventions to help them quit smoking; these interventions can vary substantially in their content and effectiveness. OBJECTIVES To summarise the evidence from Cochrane Reviews that assessed the effect of behavioural interventions designed to support smoking cessation attempts and to conduct a network meta-analysis to determine how modes of delivery; person delivering the intervention; and the nature, focus, and intensity of behavioural interventions for smoking cessation influence the likelihood of achieving abstinence six months after attempting to stop smoking; and whether the effects of behavioural interventions depend upon other characteristics, including population, setting, and the provision of pharmacotherapy. To summarise the availability and principal findings of economic evaluations of behavioural interventions for smoking cessation, in terms of comparative costs and cost-effectiveness, in the form of a brief economic commentary. METHODS This work comprises two main elements. 1. We conducted a Cochrane Overview of reviews following standard Cochrane methods. We identified Cochrane Reviews of behavioural interventions (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials) for smoking cessation by searching the Cochrane Library in July 2020. We evaluated the methodological quality of reviews using AMSTAR 2 and synthesised data from the reviews narratively. 2. We used the included reviews to identify randomised controlled trials of behavioural interventions for smoking cessation compared with other behavioural interventions or no intervention for smoking cessation. To be included, studies had to include adult smokers and measure smoking abstinence at six months or longer. Screening, data extraction, and risk of bias assessment followed standard Cochrane methods. We synthesised data using Bayesian component network meta-analysis (CNMA), examining the effects of 38 different components compared to minimal intervention. Components included behavioural and motivational elements, intervention providers, delivery modes, nature, focus, and intensity of the behavioural intervention. We used component network meta-regression (CNMR) to evaluate the influence of population characteristics, provision of pharmacotherapy, and intervention intensity on the component effects. We evaluated certainty of the evidence using GRADE domains. We assumed an additive effect for individual components. MAIN RESULTS We included 33 Cochrane Reviews, from which 312 randomised controlled trials, representing 250,563 participants and 845 distinct study arms, met the criteria for inclusion in our component network meta-analysis. This represented 437 different combinations of components. Of the 33 reviews, confidence in review findings was high in four reviews and moderate in nine reviews, as measured by the AMSTAR 2 critical appraisal tool. The remaining 20 reviews were low or critically low due to one or more critical weaknesses, most commonly inadequate investigation or discussion (or both) of the impact of publication bias. Of note, the critical weaknesses identified did not affect the searching, screening, or data extraction elements of the review process, which have direct bearing on our CNMA. Of the included studies, 125/312 were at low risk of bias overall, 50 were at high risk of bias, and the remainder were at unclear risk. Analyses from the contributing reviews and from our CNMA showed behavioural interventions for smoking cessation can increase quit rates, but effectiveness varies on characteristics of the support provided. There was high-certainty evidence of benefit for the provision of counselling (odds ratio (OR) 1.44, 95% credibility interval (CrI) 1.22 to 1.70, 194 studies, n = 72,273) and guaranteed financial incentives (OR 1.46, 95% CrI 1.15 to 1.85, 19 studies, n = 8877). Evidence of benefit remained when removing studies at high risk of bias. These findings were consistent with pair-wise meta-analyses from contributing reviews. There was moderate-certainty evidence of benefit for interventions delivered via text message (downgraded due to unexplained statistical heterogeneity in pair-wise comparison), and for the following components where point estimates suggested benefit but CrIs incorporated no clinically significant difference: individual tailoring; intervention content including motivational components; intervention content focused on how to quit. The remaining intervention components had low-to very low-certainty evidence, with the main issues being imprecision and risk of bias. There was no evidence to suggest an increase in harms in groups receiving behavioural support for smoking cessation. Intervention effects were not changed by adjusting for population characteristics, but data were limited. Increasing intensity of behavioural support, as measured through the number of contacts, duration of each contact, and programme length, had point estimates associated with modestly increased chances of quitting, but CrIs included no difference. The effect of behavioural support for smoking cessation appeared slightly less pronounced when people were already receiving smoking cessation pharmacotherapies. AUTHORS' CONCLUSIONS Behavioural support for smoking cessation can increase quit rates at six months or longer, with no evidence that support increases harms. This is the case whether or not smoking cessation pharmacotherapy is also provided, but the effect is slightly more pronounced in the absence of pharmacotherapy. Evidence of benefit is strongest for the provision of any form of counselling, and guaranteed financial incentives. Evidence suggested possible benefit but the need of further studies to evaluate: individual tailoring; delivery via text message, email, and audio recording; delivery by lay health advisor; and intervention content with motivational components and a focus on how to quit. We identified 23 economic evaluations; evidence did not consistently suggest one type of behavioural intervention for smoking cessation was more cost-effective than another. Future reviews should fully consider publication bias. Tools to investigate publication bias and to evaluate certainty in CNMA are needed.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - José M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Cinciripini PM, Karam-Hage M, Kypriotakis G, Robinson JD, Rabius V, Beneventi D, Minnix JA, Blalock JA. Association of a Comprehensive Smoking Cessation Program With Smoking Abstinence Among Patients With Cancer. JAMA Netw Open 2019; 2:e1912251. [PMID: 31560387 PMCID: PMC6777393 DOI: 10.1001/jamanetworkopen.2019.12251] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients with cancer who smoke after diagnosis risk experiencing reductions in treatment effectiveness, survival rates, and quality of life, and increases in complications, cancer recurrence, and second primary cancers. Smoking cessation can significantly affect these outcomes, but to date comprehensive treatment is not widely implemented in the oncologic setting. OBJECTIVES To describe a potential model tobacco treatment program (TTP) implemented in a cancer setting, report on its long-term outcomes, and highlight its importance to quality patient care. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort of smokers was treated in the TTP at a comprehensive cancer center from January 1, 2006, to August 31, 2015. Data analysis was performed from November 2017 to December 2018. Participants included 3245 patients (2343 with current cancer; 309 with previous cancer; 593 with no cancer history) drawn from a population of 5061 smokers referred for treatment in the TTP. Reasons for exclusion included follow-up for a noncancerous disease, no medical consultation, smoked less than 1 cigarette per day; or died before the 9-month follow-up. EXPOSURES Treatment consisted of an in-person medical consultation, 6 to 8 in-person and telephone follow-up counseling sessions, and 10 to 12 weeks of pharmacotherapy. MAIN OUTCOMES AND MEASURES Primary outcome was 9-month 7-day point-prevalence abstinence evaluated using time-specific (3-, 6-, and 9-month follow-ups) and longitudinal covariate-adjusted and unadjusted regression models with multiple imputation, intention-to-treat, and respondent-only approaches to missing data. The Fagerström Test for Cigarette Dependence was used as a measure of dependence (possible range, 0-10; higher numbers indicate greater dependence). RESULTS Of the 3245 smokers, 1588 (48.9%) were men, 322 (9.9%) were of black race/ethnicity, 172 (5.3%) were of Hispanic race/ethnicity, and 2498 (76.0%) were of white race/ethnicity. Mean (SD) age was 54 (11.4) years; Fagerström Test for Cigarette Dependence score, 4.41 (2.2), number of cigarettes smoked per day, 17.1 (10.7); years smoked, 33 (13.2); and 1393 patients (42.9%) had at least 1 psychiatric comorbidity. Overall self-reported abstinence was 45.1% at 3 months, 45.8% at 6 months, and 43.7% at 9 months in the multiply imputed sample. Results across all models were consistent, suggesting that, in comparison with smokers with no cancer history, abstinence rates within this TTP program did not differ appreciably whether smokers had current cancer, were a cancer survivor, or had smoking-related cancers, with the exception of patients with head and neck cancer; the rates were higher at 9 months (relative risk, 1.31; 95% CI, 1.11-1.56; P = .001) and in longitudinal models (relative risk, 1.24; 95% CI, 1.08-1.42; P = .002). CONCLUSIONS AND RELEVANCE In this study, mean smoking abstinence rates did not differ significantly between patients with cancer and those without cancer. These findings suggest that providing comprehensive tobacco treatment in the oncologic setting can result in sustained high abstinence rates for all patients with cancer and survivors and should be included as standard of care to ensure the best possible cancer treatment outcomes.
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Affiliation(s)
- Paul M. Cinciripini
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Maher Karam-Hage
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - George Kypriotakis
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Jason D. Robinson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Vance Rabius
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Diane Beneventi
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Jennifer A. Minnix
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Janice A. Blalock
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
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4
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Feldman I, Helgason AR, Johansson P, Tegelberg Å, Nohlert E. Cost-effectiveness of a high-intensity versus a low-intensity smoking cessation intervention in a dental setting: long-term follow-up. BMJ Open 2019; 9:e030934. [PMID: 31420398 PMCID: PMC6701567 DOI: 10.1136/bmjopen-2019-030934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The aim of this study was to conduct a cost-effectiveness analysis (CEA) of a high-intensity and a low-intensity smoking cessation treatment programme (HIT and LIT) using long-term follow-up effectiveness data and to validate the cost-effectiveness results based on short-term follow-up. DESIGN AND OUTCOME MEASURES Intervention effectiveness was estimated in a randomised controlled trial as numbers of abstinent participants after 1 and 5-8 years of follow-up. The economic evaluation was performed from a societal perspective using a Markov model by estimating future disease-related costs (in Euro (€) 2018) and health effects (in quality-adjusted life-years (QALYs)). Programmes were explicitly compared in an incremental analysis, and the results were presented as an incremental cost-effectiveness ratio. SETTING The study was conducted in dental clinics in Sweden. PARTICIPANTS 294 smokers aged 19-71 years were included in the study. INTERVENTIONS Behaviour therapy, coaching and pharmacological advice (HIT) was compared with one counselling session introducing a conventional self-help programme (LIT). RESULTS The more costly HIT led to higher number of 6-month continuous abstinent participants after 1 year and higher number of sustained abstinent participants after 5-8 years, which translates into larger societal costs avoided and health gains than LIT. The incremental cost/QALY of HIT compared with LIT amounted to €918 and €3786 using short-term and long-term effectiveness, respectively, which is considered very cost-effective in Sweden. CONCLUSION CEA favours the more costly HIT if decision makers are willing to spend at least €4000/QALY for tobacco cessation treatment.
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Affiliation(s)
- Inna Feldman
- Department of Public Health and Caring Science, Uppsala Universitet, Uppsala, Sweden
| | - Asgeir Runar Helgason
- Department of Public Health Sciences, Social Medicine, Karolinska Institutet, Stockholm, Sweden
- Reykjavik University and Icelandic Cancer Society, Reykjavik University, Reykjavik, Iceland
| | | | - Åke Tegelberg
- Centre for Clinical Research, Uppsala University, Hospital of Vastmanland, Västerås, Sweden
- Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Eva Nohlert
- Centre for Clinical Research, Uppsala University and Region Vastmanland, Västerås, Sweden
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5
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Virtanen SE, Galanti MR, Johansson PM, Feldman I. Economic evaluation of a brief counselling for smoking cessation in dentistry: a case study comparing two health economic models. BMJ Open 2017; 7:e016375. [PMID: 28729321 PMCID: PMC5541608 DOI: 10.1136/bmjopen-2017-016375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study aimed to compare the cost-effectiveness estimates of a brief counselling of smoking cessation in dentistry by using two different health economic models. DESIGN AND OUTCOME MEASURES Intervention effectiveness was estimated in a cluster randomised controlled trial. The number of quitters was estimated based on 7-day abstinence and on smoking reduction at follow-up. Health economic evaluation was performed using two models: (1) a population-based model employing potential impact fractions and (2) a Markov model estimating the cost-effectiveness of the intervention for the actual participants. The evaluation was performed from healthcare and societal perspectives, and health gains were expressed in quality-adjusted life-years (QALYs). SETTING Dental clinics in Sweden. PARTICIPANTS 205 Swedish smokers aged 20-75 years. INTERVENTIONS A brief, structured behavioural intervention was compared with 'usual care'. RESULTS The cost per quitter was US$552 in the intervention and US$522 in the 'usual care' condition. The net saving estimated with the population-based model was US$17.3 million for intervention and US$49.9 million for 'usual care', with health gains of 1428 QALYs and 2369 QALYs, respectively, for the whole Swedish population during 10 years. The intervention was thus dominated by 'usual care'. The reverse was true when using the Markov model, showing net societal savings of US$71 000 for the intervention and US$57000 for 'usual care', with gains of 5.42 QALYs and 4.74 QALYs, respectively, for lifelong quitters. CONCLUSION The comparison of intervention and 'usual care' derived from small-scale studies may be highly sensitive to the choice of the model used to calculate cost-effectiveness. TRIAL REGISTRATION The cluster randomised trial is registered in the ISRCTN register of controlled trials with identification number ISRCTN50627997.
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Affiliation(s)
- Suvi Erika Virtanen
- Department of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden
| | - Maria R Galanti
- Department of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden
| | | | - Inna Feldman
- Department of Public Health and Caring Science, Uppsala Universitet, Uppsala, Sweden
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Berg ML, Cheung KL, Hiligsmann M, Evers S, de Kinderen RJA, Kulchaitanaroaj P, Pokhrel S. Model-based economic evaluations in smoking cessation and their transferability to new contexts: a systematic review. Addiction 2017; 112:946-967. [PMID: 28060453 PMCID: PMC5434798 DOI: 10.1111/add.13748] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 06/06/2016] [Accepted: 12/30/2016] [Indexed: 12/04/2022]
Abstract
AIMS To identify different types of models used in economic evaluations of smoking cessation, analyse the quality of the included models examining their attributes and ascertain their transferability to a new context. METHODS A systematic review of the literature on the economic evaluation of smoking cessation interventions published between 1996 and April 2015, identified via Medline, EMBASE, National Health Service (NHS) Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA). The checklist-based quality of the included studies and transferability scores was based on the European Network of Health Economic Evaluation Databases (EURONHEED) criteria. Studies that were not in smoking cessation, not original research, not a model-based economic evaluation, that did not consider adult population and not from a high-income country were excluded. FINDINGS Among the 64 economic evaluations included in the review, the state-transition Markov model was the most frequently used method (n = 30/64), with quality adjusted life years (QALY) being the most frequently used outcome measure in a life-time horizon. A small number of the included studies (13 of 64) were eligible for EURONHEED transferability checklist. The overall transferability scores ranged from 0.50 to 0.97, with an average score of 0.75. The average score per section was 0.69 (range = 0.35-0.92). The relative transferability of the studies could not be established due to a limitation present in the EURONHEED method. CONCLUSION All existing economic evaluations in smoking cessation lack in one or more key study attributes necessary to be fully transferable to a new context.
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Affiliation(s)
- Marrit L. Berg
- Department of Health Services Research, CAPHRI Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | - Kei Long Cheung
- Department of Health Services Research, CAPHRI Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | - Mickaël Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | - Silvia Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands,Trimbos Institute, Netherlands Institute of Mental Health and AddictionUtrechtThe Netherlands
| | - Reina J. A. de Kinderen
- Department of Health Services Research, CAPHRI Care and Public Health Research InstituteMaastricht UniversityMaastrichtThe Netherlands,Trimbos Institute, Netherlands Institute of Mental Health and AddictionUtrechtThe Netherlands
| | | | - Subhash Pokhrel
- Health Economics Research GroupBrunel University LondonUxbridgeUK
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7
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Abstract
BACKGROUND Individual counselling from a smoking cessation specialist may help smokers to make a successful attempt to stop smoking. OBJECTIVES The review addresses the following hypotheses:1. Individual counselling is more effective than no treatment or brief advice in promoting smoking cessation.2. Individual counselling is more effective than self-help materials in promoting smoking cessation.3. A more intensive counselling intervention is more effective than a less intensive intervention. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialized Register for studies with counsel* in any field in May 2016. SELECTION CRITERIA Randomized or quasi-randomized trials with at least one treatment arm consisting of face-to-face individual counselling from a healthcare worker not involved in routine clinical care. The outcome was smoking cessation at follow-up at least six months after the start of counselling. DATA COLLECTION AND ANALYSIS Both authors extracted data in duplicate. We recorded characteristics of the intervention and the target population, method of randomization and completeness of follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. In analysis, we assumed that participants lost to follow-up continued to smoke. We expressed effects as a risk ratio (RR) for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study using the Cochrane 'Risk of bias' tool and the GRADE approach. MAIN RESULTS We identified 49 trials with around 19,000 participants. Thirty-three trials compared individual counselling to a minimal behavioural intervention. There was high-quality evidence that individual counselling was more effective than a minimal contact control (brief advice, usual care, or provision of self-help materials) when pharmacotherapy was not offered to any participants (RR 1.57, 95% confidence interval (CI) 1.40 to 1.77; 27 studies, 11,100 participants; I2 = 50%). There was moderate-quality evidence (downgraded due to imprecision) of a benefit of counselling when all participants received pharmacotherapy (nicotine replacement therapy) (RR 1.24, 95% CI 1.01 to 1.51; 6 studies, 2662 participants; I2 = 0%). There was moderate-quality evidence (downgraded due to imprecision) for a small benefit of more intensive counselling compared to brief counselling (RR 1.29, 95% CI 1.09 to 1.53; 11 studies, 2920 participants; I2 = 48%). None of the five other trials that compared different counselling models of similar intensity detected significant differences. AUTHORS' CONCLUSIONS There is high-quality evidence that individually-delivered smoking cessation counselling can assist smokers to quit. There is moderate-quality evidence of a smaller relative benefit when counselling is used in addition to pharmacotherapy, and of more intensive counselling compared to a brief counselling intervention.
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Affiliation(s)
- Tim Lancaster
- King’s College LondonGKT School of Medical EducationLondonUK
| | - Lindsay F Stead
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
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8
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Preet R, Khan N, Blomstedt Y, Nilsson M, Stewart Williams J. Assessing dental professionals' understanding of tobacco prevention and control: a qualitative study in Västerbotten County, Sweden. BDJ Open 2016; 2:16009. [PMID: 29607070 PMCID: PMC5831015 DOI: 10.1038/bdjopen.2016.9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/16/2016] [Accepted: 11/01/2016] [Indexed: 11/09/2022] Open
Abstract
Aim: To assess dental professionals’ understanding of tobacco prevention and control. Materials and methods: In Sweden dental hygienists receive training in tobacco prevention and control. The study setting is Västerbotton County in the north of Sweden where a number of successful tobacco control initiatives have been established. A purposeful sample comprising five male and four female dental professionals and trainees was selected. Data were collected through in-depth semi-structured individual interviews and analysed using content analysis. Results: Informants acknowledged limited adherence to tobacco prevention. They were not confident of their knowledge of tobacco and non-communicable disease prevention and had limited awareness of global oral health policies. Reasons for poor adherence included professional fragmentation, lack of training, and the absence of reimbursement for time spent on prevention activities. Discussion: The success of efforts to reduce smoking in Västerbotton County is attributed to the network of local public health initiatives with very limited involvement by local dental professionals. Conclusions: The findings highlight the need to more actively engage the dental workforce in tobacco control and prevention. Moreover, it is important to recognise that dental professionals can be public health advocates for tobacco control and prevention at global, national and local levels.
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Affiliation(s)
- Raman Preet
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Nausheen Khan
- Laboratory of Muscle Biology, Anatomy, Integrative Medical Biology, Umeå University, Umeå, Sweden
| | - Yulia Blomstedt
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Maria Nilsson
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Jennifer Stewart Williams
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden.,Priority Research Centre for Generational Health and Ageing, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
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9
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Brandon TH, Simmons VN, Sutton SK, Unrod M, Harrell PT, Meade CD, Craig BM, Lee JH, Meltzer LR. Extended Self-Help for Smoking Cessation: A Randomized Controlled Trial. Am J Prev Med 2016; 51:54-62. [PMID: 26868284 PMCID: PMC4914420 DOI: 10.1016/j.amepre.2015.12.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 12/09/2015] [Accepted: 12/24/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Far too few smokers receive recommended interventions at their healthcare visits, highlighting the importance of identifying effective, low-cost smoking interventions that can be readily delivered. Self-help interventions (e.g., written materials) would meet this need, but they have shown low efficacy. The purpose of this RCT was to determine the efficacy of a self-help intervention with increased duration and intensity. DESIGN Randomized parallel trial design involving enrollment between April 2010 and August 2011 with follow-up data for 24 months. SETTING/PARTICIPANTS U.S. national sample of daily smokers (N=1,874). INTERVENTION Participants were randomized to one of three arms of a parallel trial design: Traditional Self-Help (TSH, n=638), Standard Repeated Mailings (SRM, n=614), or Intensive Repeated Mailings (IRM, n=622). TSH received an existing self-help booklet for quitting smoking. SRM received eight different cessation booklets mailed over a 12-month period. IRM received monthly mailings of ten booklets and additional material designed to enhance social support over 18 months. MAIN OUTCOME MEASURES The primary outcome was 7-day point-prevalence abstinence collected at 6, 12, 18, and 24 months. RESULTS Data were analyzed between 2013 and 2015. A dose-response effect was found across all four follow-up points. For example, by 24 months, IRM produced the highest abstinence rate (30.0%), followed by SRM (24.4%) and TSH (18.9%). The difference in 24-month abstinence rates between IRM and TSH was 11.0% (95% CI=5.7%, 16.3%). Cost analyses indicated that, compared with TSH, the incremental cost per quitter who received SRM and IRM was $560 and $361, respectively. CONCLUSIONS Self-help interventions with increased intensity and duration resulted in significantly improved abstinence rates that extended 6 months beyond the end of the intervention. Despite the greater intensity, the interventions were highly cost effective, suggesting that widespread dissemination in healthcare settings could greatly enhance quitting. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01352195.
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Affiliation(s)
- Thomas H Brandon
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Vani N Simmons
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Steven K Sutton
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marina Unrod
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Paul T Harrell
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia
| | - Cathy D Meade
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Benjamin M Craig
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ji-Hyun Lee
- Division of Epidemiology and Biostatistics, University of New Mexico Cancer Center, Albuquerque, New Mexico
| | - Lauren R Meltzer
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Feirman SP, Donaldson E, Glasser AM, Pearson JL, Niaura R, Rose SW, Abrams DB, Villanti AC. Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review. Nicotine Tob Res 2016; 18:229-42. [PMID: 25977409 DOI: 10.1093/ntr/ntv104] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/05/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models. METHODS We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies. RESULTS The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies. CONCLUSIONS This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.
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Affiliation(s)
- Shari P Feirman
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elisabeth Donaldson
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Allison M Glasser
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC
| | - Jennifer L Pearson
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ray Niaura
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Shyanika W Rose
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC
| | - David B Abrams
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Andrea C Villanti
- The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
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11
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López-Núñez C, Alonso-Pérez F, Pedrosa I, Secades-Villa R. Cost-effectiveness of a voucher-based intervention for smoking cessation. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2015; 42:296-305. [PMID: 26484869 DOI: 10.3109/00952990.2015.1081913] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Contingency management (CM) has been shown to be effective in reducing smoking consumption, but has traditionally been criticized for its costs. OBJECTIVES This study assessed the cost-effectiveness of using a voucher-based CM protocol added to a cognitive behavioral treatment (CBT) for smoking cessation among treatment-seeking patients from the general population. METHODS A total of 92 patients were randomly assigned to CBT or CBT plus CM for abstinence. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the increase in costs by the increase in effects (continuous abstinence, longest duration of abstinence at 6-month follow-up and cotinine results during the treatment). An acceptability curve illustrated the statistical uncertainty surrounding the cost-effectiveness estimate. We also determined the optimum cost per participant for predicting the smoking status at 6-month follow-up. RESULTS The average cost per participant in the CBT condition was €138.73 (US$ 150.23) as opposed to €411.61 (US$ 445.73) in the CBT plus CM condition (p < 0.01). The incremental cost of using voucher-based CM to increase the number of participants that maintained abstinence at 6-month follow-up by one extra participant was €68.22 (US$ 73.88), and to lengthen the longest duration of abstinence by 1 week was €53.92 (US$ 58.39). The incremental cost to obtain an extra cotinine-negative result was €181.90 (US$ 196.98). CONCLUSION Compared with CBT alone, the voucher-based protocol required additional costs but achieved significantly better outcomes. These results will allow stakeholders to make policy decisions about CM implementation for smoking cessation in the broader community.
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Affiliation(s)
| | | | - Ignacio Pedrosa
- a Department of Psychology , University of Oviedo , Oviedo , Spain
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12
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Lämås K, Sundin K, Jacobsson C, Saveman BI, Östlund U. Possibilities for evaluating cost-effectiveness of family system nursing: An example based on Family Health Conversations with families in which a middle-aged family member had suffered stroke. ACTA ACUST UNITED AC 2015. [DOI: 10.1177/0107408315610076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Family Health Conversations (FamHC) increase health and well-being, but knowledge about their cost-effectiveness, and how to best calculate this, is lacking. In this feasibility study we evaluated the cost-effectiveness of using FamHC with families in which a middle-aged family member had suffered stroke. Seven families participated in a FamHC intervention and seven families received ordinary care. Health-related quality of life (HRQoL) was estimated with SF-6D and EQ-5D over a six-month period. The cost-effectiveness of the intervention was calculated. Families receiving FamHC intervention had significantly increased HRQoL at follow up. Cost per quality adjusted life year differed depending on the instrument and analysis method used in the calculation. However, all calculations showed that FamHC were cost-effective. We conclude that FamHC significantly increase HRQoL and suggest that they are cost-effective. Both instruments seemed to be able to capture changes. Considering the participants’ experience of answering the two instruments, we advocate the use of EQ-5D.
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Affiliation(s)
| | | | | | | | - Ulrika Östlund
- Centre for Research and Development, Uppsala University/Region Gävleborg, Sweden
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13
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van Boven JFM, Vemer P. Higher Adherence During Reimbursement of Pharmacological Smoking Cessation Treatments. Nicotine Tob Res 2015; 18:56-63. [PMID: 25782457 DOI: 10.1093/ntr/ntv064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 03/07/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION In the Netherlands, pharmacologic Smoking Cessation Treatments (pSCTs) were reimbursed in 2011. In 2012 the reimbursement was discontinued. As of 2013, pSCTs were again reimbursed, provided they are accompanied by behavioral counseling. The aim of this article is to assess the impact of changes in reimbursement policy on use of-and adherence to-pSCTs. METHODS A retrospective dispensing database analysis was performed on real-world observational data (2010-2013) from the Netherlands. Data on use and adherence was collected, in patients who were dispensed bupropion or varenicline in community pharmacies for the first time. Using the InterActionDataBase (iadb.nl), adherence per patient that initiated varenicline or bupropion was calculated by adding up all dispenses between initiation of the therapy and the 120 days thereafter. Good adherence was defined as using minimal 80% of the recommended duration and intensity of use. RESULTS The prevalence of patients initiating pSCTs was stable at 0.4 per 1000 inhabitants per quarter during 2010. In 2011, the prevalence was on average 0.7, with peaks in the first (0.8 per 1000) and fourth (1.0 per 1000) quarters of 2011. In 2012, the prevalence was stable again at 0.3. In 2013, prevalence was on average 0.4, with a small peak in the first quarter. Adherence was 15.4% in 2010 versus 20.1% in 2011 (P = .002). In 2012, adherence was 13.9%, compared with 18.9% in 2013 (P = .008). CONCLUSIONS Not only the likelihood of initiating pSCTs, but also the extent of adherence to these treatments, although generally low, seems higher during reimbursement.
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Affiliation(s)
- Job F M van Boven
- Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands;
| | - Pepijn Vemer
- Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands; Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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14
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Lewis K. Using your bullets most wisely for the smoking gun. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:387-8. [PMID: 24301858 PMCID: PMC6442868 DOI: 10.4104/pcrj.2013.00098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Keir Lewis
- Associate Professor, College of Medicine, Institute of Sciences, Swansea University, Swansea, Wales, UK; Honorary Consultant Chest Physician, Hywel Dda Health Board, Llanelli, Wales, UK
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15
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Nohlert E, Öhrvik J, Tegelberg Å, Tillgren P, Helgason ÁR. Long-term follow-up of a high- and a low-intensity smoking cessation intervention in a dental setting--a randomized trial. BMC Public Health 2013; 13:592. [PMID: 23777201 PMCID: PMC3693879 DOI: 10.1186/1471-2458-13-592] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 06/11/2013] [Indexed: 11/16/2022] Open
Abstract
Background Achieving lifelong tobacco abstinence is an important public health goal. Most studies use 1-year follow-ups, but little is known about how good these are as proxies for long-term and life-long abstinence. Also, intervention intensity is an important issue for development of efficient and cost-effective cessation treatment protocols. The study aims were to assess the long-term effectiveness of a high- and a low-intensity treatment (HIT and LIT) for smoking cessation and to analyze to what extent 12-month abstinence predicted long-term abstinence. Methods 300 smokers attending dental or general health care were randomly assigned to HIT or LIT at the public dental clinic. Main outcome measures were self-reported point prevalence, continuous abstinence (≥6 months), and sustained abstinence. The study was a follow-up after 5–8 years of a previously performed 12-month follow-up, both by postal questionnaires. Results Response rate was 85% (n=241) of those still alive and living in Sweden. Abstinence rates were 8% higher in both programs at the long-term than at the 12-month follow-up. The difference of 7% between HIT and LIT had not change, being 31% vs. 24% for point prevalence and 26% vs. 19% for 6-month continuous abstinence, respectively. Significantly more participants in HIT (12%) than in LIT (5%) had been sustained abstinent (p=0.03). Logistic regression analyses showed that abstinence at 12-month follow-up was a strong predictor for abstinence at long-term follow-up. Conclusions Abstinence at 12-month follow-up is a good predictor for long-term abstinence. The difference in outcome between HIT and LIT for smoking cessation remains at least 5–8 years after the intervention. Trial registration number NCT00670514
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Affiliation(s)
- Eva Nohlert
- Centre for Clinical Research, Uppsala University, Västerås, Sweden.
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