A randomized controlled trial of stage-matched intervention for smoking cessation in cardiac out-patients

A general health promotion approach to helping smokers with non-communicable diseases quit smoking: A pilot randomized controlled trial

Background

Despite evidence showing that continued smoking in patients with non-communicable diseases can reduce treatment efficacy and increase the risk of disease progression and multimorbidity, many smoker patients either have no intention to quit or have had failed attempts at quitting.

Objective

To examine the feasibility of a general health promotion approach that uses instant messaging to deliver brief motivational interviewing to help smokers with non-communicable diseases quit smoking.

Methods

In total, 60 participants who had medical follow-up in a special out-patient clinic were randomized into two groups, 30 in the intervention group received brief motivational interviewing to assist them with their chosen behavioral changes, and 30 in the control group received only a smoking cessation booklet. The outcome measures included self-reported 7-day point prevalence of smoking abstinence and any behavioral change reported by the participants at 6 and 12 months. Biochemical validation was performed for those who verbally reported a 7-day point prevalence of smoking abstinence at 12 months.

Results

The majority (95%) of smokers who attended the out-patient clinic owned a smartphone. The response rate was 73.2%. Retention rates at 6-month and 12-month follow-up were 83.3 and 71.7%, respectively. The process evaluation indicated that participants were satisfied with the content of the brief MI messages and appreciated the use of instant messaging as a way to provide them with professional advice and support for managing their health-related lifestyles. The intervention group had a higher biochemically validated abstinence rate than the control group at 12 months (16.7 vs. 6.7 P = 0.23) although the difference was not statistically significant (Adjusted odd ratio 2.4, 95% confidence interval, 0.43-13.75; P = 0.32.), In addition, the proportion of participants reporting a behavioral change was higher in the intervention group at 6 and 12 months.

Conclusion

This study suggested the potential efficacy and feasibility of a general health promotion approach that uses instant messaging to deliver brief motivational interviewing to help smokers with non-communicable diseases quit smoking. The findings can be used to create a new smoking cessation service model that implements a flexible, proactive and personalized approach to help smokers quit smoking.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT03983330.

A Descriptive Study on Multiple Health-Risk Behaviors among Chinese Adults in Hong Kong

This study investigated the prevalence and clustering patterns of multiple health-risk behaviors and their associations with non-communicable diseases among Chinese adults in Hong Kong. A large sample survey was conducted in all 18 districts of Hong Kong between 21 June and 31 August 2021. A total of 5737 adults completed the survey. Overall, 4605 (80.3%) had at least one health-risk behavior and 2696 (47.0%) had two or more health-risk behaviors. Multiple health-risk behaviors were more prevalent among men. The prevalence of smoking and alcohol consumption among Hong Kong Chinese women was considerably lower than in most Western countries. In contrast to previous findings, this study revealed that a high proportion of adults with high educational attainment or household income had multiple health-risk behaviors. In addition, this study revealed that the health-risk behaviors in Chinese adults co-occurred in clusters, with smoking and alcohol consumption co-occurring with other health-risk behaviors. Those who smoked or consumed alcohol had the highest proportion of multiple health-risk behaviors and the highest proportion of non-communicable diseases. The findings of this study add further evidence that health-risk behaviors co-occur in clusters and can contribute to non-communicable diseases.

Effectiveness of smoking cessation interventions for smokers with chronic diseases: A systematic review

AIMS

To systematically summarize seminal studies on the design and effectiveness of smoking cessation interventions targeted at patients with chronic diseases through a critical appraisal of the literature.

DESIGN

A systematic review.

DATA SOURCES

This review included literature identified through a search of six databases up to June 2020.

REVIEW METHODS

This review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions. The literature search was limited to English-language articles on the effectiveness of smoking cessation interventions for smokers who were aged ≥18 years and diagnosed with chronic diseases. Data were extracted using the Cochrane Data collection form for intervention reviews of randomized controlled trials and non-randomized controlled trials. The articles were subjected to a quality assessment.

RESULTS

Ten relevant articles were identified. The designs of the interventions were highly heterogeneous, and only six articles reported a significant increase in smoking abstinence among patients with chronic diseases. In the target population, an intervention delivered by healthcare professionals on an intensive schedule was shown to more effectively induce smoking cessation, compared with minimal counselling. However, methodological flaws were identified in most of the included studies.

CONCLUSION

The findings of this review suggest that additional efforts are needed to design smoking cessation interventions for patients with chronic diseases and that further examination of the effectiveness and feasibility of these interventions is warranted.

IMPACT

What problem did the study address? This review evaluated the effectiveness of smoking cessation interventions targeted at patients with chronic diseases. What were the main findings? An intervention with an intensive schedule that was delivered by healthcare professionals was shown to more effectively induce smoking cessation in patients with chronic diseases, compared with minimal counselling. More attention and resources should be directed towards smokers with no intention to quit, especially those with chronic diseases. There is an urgent need for generic smoking cessation interventions that use novel approaches to address the unique needs of this population and to integrate such evidence-based interventions into routine care. Where and on whom will the research have impact? The findings of this review may guide nurses, who play a prominent role in raising the issue of smoking cessation with patients, to design appropriate smoking cessation interventions for patients with chronic diseases. The resulting improvements in patients' health would not only benefit patients themselves but also reduce the burden of chronic diseases on healthcare systems.

Nurse-managed education: the effectiveness of secondary prevention after acute coronary syndromes and the prevalence and predictors of dropout from a cardiac rehabilitation programme

Introduction

Education programmes are now very often used to limit the consequences associated with a steady increase in the incidence of cardiovascular disease. It is important to assess the effectiveness of these programmes and the reasons why people drop out.

Aim

To evaluate the effects of intensive education of patients undergoing acute invasive cardiology procedures compared to the control group (patients educated in a classical way).

Material and methods

Randomized trial. Measurements of body weight and body composition: during hospital stay, at 45 and 180 days after acute coronary syndrome. We used a self-prepared questionnaire, LOR-T and a TANITA BC1000 body composition analyser.

Results

The sample consisted of 73 patients aged 48 to 89 years. Men constituted 58.9% of the participants. 43.8% of the respondents appeared for a follow-up visit after 45 days, and after 180 days 32.8% came. Body weight, body mass index (BMI), and health condition of the patients did not change significantly during the study. 67.1% of respondents dropped out from the nurse-managed cardiac education programme. People who were in better health, smoking, without comorbidities, having a heart attack, living far from the place of education more often dropped out from follow-up visits.

Conclusions

Patient education proved ineffective. Body weight, BMI, and health condition of the subjects, both at the time of inclusion and during the long-term evaluation, were very unfavourable.

Effectiveness of a Brief Self-determination Theory-Based Smoking Cessation Intervention for Smokers at Emergency Departments in Hong Kong: A Randomized Clinical Trial

IMPORTANCE

Clinicians have an opportunity to provide smoking cessation interventions to smokers who present to emergency departments (EDs). The effectiveness of a brief intervention based on self-determination theory for smoking cessation is uncertain.

OBJECTIVE

To examine the effectiveness of a brief intervention based on self-determination theory for smoking cessation (immediate or progressive) among Chinese smokers presenting at EDs in Hong Kong.

DESIGN, SETTING, AND PARTICIPANTS

This single-blind, multicenter intent-to-treat randomized clinical trial was conducted at the EDs of 4 major acute care hospitals in different districts of Hong Kong. In total, 1571 smokers 18 years or older who presented at 4 major EDs between July 4, 2015, and March 17, 2017, were randomized into an intervention group (n = 787) and a control group (n = 784).

INTERVENTIONS

The intervention group received brief advice (about 1 minute) and could choose their own quit schedules (immediate or progressive). The control group received a smoking cessation leaflet.

MAIN OUTCOMES AND MEASURES

Follow-up visits were conducted at 1, 3, 6, and 12 months. The primary outcome measure, by intent to treat, was biochemically validated abstinence at 6 months.

RESULTS

Participants (N = 1571) included 1381 men (87.9%); the mean (SD) age at baseline was 47.4 (16.4) years. Among participants who self-reported abstinence at 6 months, 50.3% (85 of 169) had biochemical validation by both an exhaled carbon monoxide test and a saliva cotinine test. Compared with the control group, the intervention group had statistically higher biochemically validated abstinence at 6 months: 6.7% (53 of 787) vs 2.8% (22 of 784) (P < .001), with an adjusted relative risk of 3.21 (95% CI, 1.74-5.93; P < .001). The intervention group also had higher self-reported quit rates at 6 months (12.2% [96 of 787] vs 9.3% [73 of 784], P = .04) and 12 months (13.0% [102 of 787] vs 8.5% [67 of 784], P < .01), as well as higher biochemically validated abstinence at 12 months (7.0% [55 of 787] vs 3.7% [29 of 784], P < .001). The additional cost for each intervention group participant was US $0.47, with an estimated gain of 0.0238 quality-adjusted life-year. The incremental cost per quality-adjusted life-year (US $19.53) fell within acceptable thresholds.

CONCLUSIONS AND RELEVANCE

This brief, low-cost self-determination theory-based intervention for smokers presenting at EDs effectively increased the biochemically validated quit rate at 6 months. If delivered routinely, such a simple intervention may offer a cost-effective and sustainable approach to help many smokers quit smoking.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02660957.

A Meta-Analysis of Brief Tobacco Interventions for Use in Integrated Primary Care

Introduction

The integration of behavioral health services in primary care settings presents an opportunity to enhance the delivery of tobacco cessation interventions in the primary care setting, but guidance on evidence-based treatments for tobacco use disorder that fits the brief format of integrated primary care (IPC) is limited. This meta-analysis summarizes the outcomes of brief behavioral interventions targeting tobacco use that can be delivered in IPC settings.

Methods

A literature search was conducted to locate empirical studies examining tobacco cessation interventions that could be implemented in an IPC setting. A random effects meta-analytic approach was utilized with odds ratios as the effect size. Subgroup analyses were conducted to determine the extent to which a number of study, participant, and intervention characteristics affected treatment outcome.

Results

A total of 36 studies were included (n = 12975 patients). Patients in the intervention groups exhibited significantly greater odds of smoking cessation compared with those in the comparison groups (OR = 1.78, p < .001). Subgroup analyses did not reveal significant sources of heterogeneity attributable to moderators such as methodological quality, gender, bioverification, follow-up time period, or intervention characteristics (such as setting, type, or length of intervention).

Conclusions

Brief tobacco cessation interventions that can be delivered in IPC settings were found to be effective. Future research in this area might evaluate ways to improve the dissemination and implementation of these types of interventions in IPC settings.

Implications

The integration of behavioral health services into primary care presents a unique opportunity to increase the delivery of tobacco cessation interventions, as behavioral health providers in these settings are experts in behavior change interventions and may have more time to deliver these interventions than primary care providers. Results from the current meta-analysis demonstrate that brief tobacco cessation interventions that can be implemented in the IPC setting are effective. Future research in this area might examine ways to improve the dissemination and implementation of brief interventions for tobacco use in IPC settings.

A study protocol for a randomised controlled trial evaluating the use of information communication technology (WhatsApp/WeChat) to deliver brief motivational interviewing (i-BMI) in promoting smoking cessation among smokers with chronic diseases

Background

The recent development of smoking cessation interventions for smokers with chronic diseases has focused heavily on brief interventions. However, these interventions are too brief to make an impact on these smokers, especially when most of them are without any intention to quit. Previous studies showed that smokers who did not want to quit might be interested in changing other health behaviours. Also, once people engage in a health behaviour, they are found more likely to change other unhealthy habits. Hence, a general health promotion approach could be a feasible approach to motivate smokers who do not want to quit to first engage in any desirable health behaviour, and later quit smoking when they intend to do so. This study aims to determine the potential efficacy and effect size of such intervention approach in promoting smoking cessation for smokers with chronic diseases.

Methods

This is a randomized controlled trial. A convenience sample of 60 smokers with chronic diseases will be randomly assigned into either experimental (n = 30) or control group (n = 30). Smokers in the experimental group will receive an individual face-to-face brief motivational interviewing (MI) with generic advice on selected health behaviour. More brief MI messages will be delivered to them via WhatsApp/WeChat for 6 months. For subject in the control group, they will be asked to indicate their desirable health-related practice. However, no MI and booster interventions will be given. All subjects will complete a questionnaire at 1, 3, 6 and 12 months. Subjects abstinent from cigarettes at 12 months will perform a biochemical validation. The primary outcome is biochemically validated smoking abstinence at 12 months. Effect size of the intervention will be estimated by the odd ratios using intention-to-treat.

Discussion

This is the first study to determine the potential efficacy for the use of a personalized general health promotion approach in promoting smoking cessation for smokers with chronic diseases. If our proposed intervention is effective, we will able to assist smokers with chronic disease to quit smoking and change their health behaviour simultaneously.

Trial registration

CinicalTrials.gov NCT03983330 (Prospectively registered), registered on June 12, 2019.

Comparison of two approaches in achieving smoking abstinence among patients in an outpatient clinic: A Phase 2 randomized controlled trial

OBJECTIVES

To compare the effectiveness of quitting immediately and cutting down to quit in promoting smoking abstinence among smokers in an outpatient clinic.

METHODS

A total of 100 subjects were randomized into two groups, 50 in the quit immediately group, who received an intervention on abruptly quitting, and 50 in the cut down to quit group, who received an intervention on gradual reduction. All subjects were followed up at 6 and 12 months via telephone. The intention-to-treat principle was used.

RESULTS

At the 6-month follow-up, the self-reported quit rate of subjects in the quit immediately group was significantly higher than in the cut down to quit group (18.0% vs. 4.0%, p = 0.04). However, this difference was not significant at the 12-month follow-up (12.0% vs. 4.0%, p = 0.16).

CONCLUSION

These data suggest that quitting immediately might be more effective than cutting down to quit at 6 months but not at 12 months.

PRACTICE IMPLICATIONS

It is crucial to allow smokers to select quitting immediately or reducing the number of cigarettes smoked. Further studies are warranted to compare the effectiveness of various approaches for achieving smoking abstinence.

Helping cancer patients quit smoking using brief advice based on risk communication: A randomized controlled trial

This randomized controlled trial aimed to examine the effectiveness of a smoking cessation intervention using a risk communication approach. A total of 528 smoking cancer patients were randomly allocated either into an intervention group (n = 268) to receive brief advice based on risk communication by a nurse counselor or a control group (n = 260) to receive standard care. Subjects in both groups received a smoking cessation booklet. Patient follow-ups were at 1 week and at 1, 3, 6, 9 and 12 months. No significant differences were found in self-reported point-prevalence 7-day abstinence between the intervention and control groups at 6 months (15.7% vs 16.5%; OR 0.94, 95% CI 0.59-1.50). The rate of at least 50% self-reported reduction of smoking at 6 months, was higher in the intervention group than in the control group (16.8% vs 12.3%; OR 1.43, 95% CI 0.88-2.35). The biochemically validated quit rate at the 6-month follow-up was higher in the intervention group than in the control group (5.2% vs 3.8%; OR 1.38, 95% CI 0.60-3.16). These data suggest that advice based on risk communication was not effective for quitting but improved the rate of smoking reduction among smoking cancer patients.

Effects of a Nurse-Led, Stage-Matched, Tailored Program for Smoking Cessation in Health Education Centers: A Prospective, Randomized, Controlled Trial

The purpose of this study was to examine the effectiveness of a stage-matched intervention performed at outpatient clinics. Participants were randomly assigned to an intervention group (IG) or usual care group (UCG). The trial was targeted on smoking patients with coronary heart disease or diabetes. After completing the 3-month intervention, both groups received a telephone follow-up at 6 months. This analysis showed that the outcomes of the IG for the 7-day point prevalence (PP) of abstinence (odds ratio [OR] = 2.00; p = .001) and 30-day PP (OR = 2.27; p = .004) at 6 months were significantly better than the UCG. Stage of change (OR = 4.06; p < .001) and decreased daily cigarette consumption by 50% at 6 months (OR = 2.26; p = .019) outcomes also improved significantly. The preliminary results showed that a nurse-led cessation intervention in clinics may be an effective approach to help outpatients quit smoking.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I² = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.

Brief intervention to promote smoking cessation and improve glycemic control in smokers with type 2 diabetes: a randomized controlled trial

The aim of the study was to examine the effects of a brief stage-matched smoking cessation intervention group compared with a control group (with usual care) in type 2 diabetes mellitus patients who smoked by randomized controlled trial. There were 557 patients, randomized either into the intervention group (n = 283) who received brief (20- minute) individualized face-to-face counseling by trained nurses and a diabetes mellitus-specific leaflet, or a control group (n = 274) who received standard care. Patient follow-ups were at 1 week, 1 month, 3 months, 6 months, and 12 months via telephone, and assessment of smoking status from 2012 to 2014. Patients smoked an average of 14 cigarettes per day for more than 37 years, and more than 70% were in the precontemplation stage of quitting. The primary outcome showed that both the intervention and control groups had similar 7-day point-prevalence smoking abstinence (9.2% vs. 13.9%; p = 0.08). The secondary outcome showed that HbA1c levels with 7.95% [63 mmol/mol] vs. 8.05% [64 mmol/mol], p = 0.49 at 12 months, respectively. There was no evidence for effectiveness in promoting the brief stage-matched smoking cessation or improving glycemic control in smokers with type 2 diabetes mellitus, particularly those in the pre-contemplation stage.

Individual behavioural counselling for smoking cessation

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.

Effectiveness of additional follow-up telephone counseling in a smoking cessation clinic in Beijing and predictors of quitting among Chinese male smokers

BACKGROUND

No previous studies have investigated whether additional telephone follow-up counseling sessions after face-to-face counseling can increase quitting in China, and whether this strategy is feasible and effective for promoting smoking cessation is still unclear.

METHODS

A non-randomized controlled study was conducted in Beijing. We compared the quit rates of one group which received face-to-face counseling (FC) alone (one session of 40 min) to another group which received the same face-to-face counseling plus four follow-up sessions of brief telephone counseling (15-20 min each) at 1 week, 1, 3 and 6 month follow-up (FCF). No smoking cessation medication was provided. From October 2008 to August 2013, Chinese male smokers who sought treatment in a part-time regular smoking cessation clinic of a large general hospital in Beijing were invited to participate in the present study. Eligible male smokers (n = 547) were divided into two groups: FC (n = 149) and FCF (n = 398). Main outcomes were self-reported 7-day point prevalence and 6 month continuous quit rates at 12 month follow-up.

RESULTS

By intention to treat, at 12 month follow-up, the 7-day point prevalence and 6 month continuous quit rates of FC and FCF were 14.8 % and 26.4 %, and 10.7 % and 19.6 % respectively. The adjusted odds ratios (95 % confidence intervals) of quitting in FCF compared to FC was 2.34 (1.34-4.10) (P = 0.003) and 2.41 (1.28-4.52) (P = 0.006), respectively. Stepwise logistic regression showed that FCF, being married, unemployed and a lower Fagerström score were significant independent predictors of 6 month continuous quitting at 12 month follow-up.

CONCLUSIONS

Using systematically collected data from real-world practice, our smoking cessation clinic has shown that the additional telephone follow-up counseling sessions doubled the quit rate.

Enhancing the effectiveness of smoking treatment research: conceptual bases and progress

BACKGROUND AND AIMS

A chronic care strategy could potentially enhance the reach and effectiveness of smoking treatment by providing effective interventions for all smokers, including those who are initially unwilling to quit. This paper describes the conceptual bases of a National Cancer Institute-funded research program designed to develop an optimized, comprehensive, chronic care smoking treatment.

METHODS

This research is grounded in three methodological approaches: (1) the Phase-Based Model, which guides the selection of intervention components to be experimentally evaluated for the different phases of smoking treatment (motivation, preparation, cessation, and maintenance); (2) the Multiphase Optimization Strategy (MOST), which guides the screening of intervention components via efficient experimental designs and, ultimately, the assembly of promising components into an optimized treatment package; and (3) pragmatic research methods, such as electronic health record recruitment, that facilitate the efficient translation of research findings into clinical practice. Using this foundation and working in primary care clinics, we conducted three factorial experiments (reported in three accompanying papers) to screen 15 motivation, preparation, cessation and maintenance phase intervention components for possible inclusion in a chronic care smoking treatment program.

RESULTS

This research identified intervention components with relatively strong evidence of effectiveness at particular phases of smoking treatment and it demonstrated the efficiency of the MOST approach in terms both of the number of intervention components tested and of the richness of the information yielded.

CONCLUSIONS

A new, synthesized research approach efficiently evaluates multiple intervention components to identify promising components for every phase of smoking treatment. Many intervention components interact with one another, supporting the use of factorial experiments in smoking treatment development.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND

This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.

OBJECTIVES

This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).

AUTHORS' CONCLUSIONS

Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

Helping cancer patients quit smoking by increasing their risk perception: a study protocol of a cluster randomized controlled trial

Background

Despite smoking cessation can largely improve cancer prognosis and quality of life, many patients continued smoking after the diagnosis of cancer. This study aims to test the effectiveness of a smoking cessation intervention using risk communication approach to help cancer patients quit smoking, and to improve their health related quality of life.

Methods

A cluster randomized controlled trial will be employed. Cancer patients who continued smoking after the diagnosis of cancer and have medical follow-up at the out-patient clinics of the five acute hospitals in Hong Kong will be invited to participate. Subjects in the experimental group will receive (1) health warnings of smoking based on a special designed leaflet; and (2) a patient-centred counseling from nurse counselors with emphasis on risk perceptions of smoking to cancer prognosis. Additionally, they will receive two more telephone counseling at 1-week and 1-month. Control group receive standard care and a generic self-help smoking cessation booklet. Outcomes measure include (a) self-reported and the biochemically validated quit rate, (b) patient’s smoking reduction by at least 50 % compared to baseline, (c) quit attempt(s), (d) change in the intention to quit, (e) change in risk perceptions of smoking, and (f) change in health related quality of life.

Discussion

This study will make an important contribution to evidence-based practice by testing the effectiveness of a tailored smoking cessation intervention for cancer patients. The results will support the development of clinical practice guidelines to promote smoking cessation in cancer patients to improve their prognosis and quality of life.

Trial registration

ClinicalTrials.gov NCT01685723. Registered 9 November 2012.

A systematic review of patient education in cardiac patients: do they increase knowledge and promote health behavior change?

OBJECTIVE

(1) To investigate the impact of education on patients' knowledge; (2) to determine if educational interventions are related to health behavior change in cardiac patients; and (3) to describe the nature of educational interventions.

METHODS

A literature search of several electronic databases was conducted for published articles from database inception to August 2012. Eligible articles included cardiac patients, and described delivery of educational interventions by a healthcare provider. Outcomes were knowledge, smoking, physical activity, dietary habits, response to symptoms, medication adherence, and psychosocial well-being. Articles were reviewed by 2 authors independently.

RESULTS

Overall, 42 articles were included, of which 23 (55%) were randomized controlled trials, and 16 (38%) were considered "good" quality. Eleven studies (26%) assessed knowledge, and 10 showed a significant increase with education. With regard to outcomes, educational interventions were significantly and positively related to physical activity, dietary habits, and smoking cessation. The nature of interventions was poorly described and most frequently delivered post-discharge, by a nurse, and in groups.

CONCLUSIONS

Findings support the benefits of educational interventions in CHD, though increase in patients' knowledge and behavior change.

PRACTICE IMPLICATIONS

Future reporting of education interventions should be more explicitly characterized, in order to be reproducible and assessed.

A Retrospective Review of Pilot Outcomes from an Out-patient Tobacco Treatment Programme Within Cardiology Services

Introduction: Due to the challenging nature of tobacco addiction, individuals with cardiac conditions often continue to smoke at high rates (up to 62%), even after experiencing life-threatening events.

Aims: This study examines pilot outcomes of a longitudinal Smoking Cessation Clinic (SCC) within cardiology services.

Methods: This study is based on a retrospective review of the charts of 117 participants of the SCC (between September 2010 and May 2012). The main outcome of interest is self-reported 7-day point-prevalence of smoking abstinence verified by expired CO level. A secondary outcome was smoking reduction, defined as consuming 50% (or lower) than the baseline number cigarettes in the past week.

Results: Thirty-five per cent of participants achieved smoking cessation, whereas 42.1% reduced their cigarette consumption. In multivariate regression analyses, salient predictors of smoking cessation included being male and a greater length of visiting the smoking cessation clinic.

Conclusions: Providing evidence-based approaches to tobacco treatment within cardiology services is feasible and well received by patients with cardiac and other co-morbidity. The modest outcomes from this pilot study support the need for tobacco treatment in hospital cardiology settings. Such interventions may aid in reducing the disproportionate burden of tobacco-related disease among smokers with medical co-morbidity.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

Use of mobile phone text messaging to deliver an individualized smoking behaviour intervention in Chinese adolescents

We evaluated the effectiveness of a mobile phone text-messaging based smoking cessation intervention package among Chinese adolescent smokers. Students aged 16-19 years were recruited from six vocational high schools located in Shanghai. We assigned the six schools to an intervention group or a control group by cluster randomization. The 92 participants in the intervention group were given tailored information via mobile phone text-messaging for 12 weeks. The 87 participants in the control group were provided with a self-help pamphlet about smoking cessation instead. After the intervention, attitudes towards the disadvantages of smoking were significantly improved, and the level of nicotine dependence and cigarette dependence significantly decreased in the intervention group. The intervention group had a relatively higher self-reported 7-day abstinence compared to the control group and 30-day abstinence, but the differences were not significant. However, the intervention group had a significantly higher rate of smoking reduction (66% vs. 35%) and moving forward in quitting stages (52% vs. 18%) compared to the control group. The interactive and tailored assistance provided by the mobile phone text-messaging was effective in smoking behaviour intervention in Chinese adolescent smokers.

Research priorities for Article 14--demand reduction measures concerning tobacco dependence and cessation

INTRODUCTION

Tobacco dependence treatment (TDT) interventions are often seen as expensive with little impact on the prevalence of tobacco use. However, activities that promote the cessation of tobacco use and support abstinence have an important role in any comprehensive tobacco control program and as such are recognized within Article 14 (A14) of the Framework Convention on Tobacco Control.

OBJECTIVES

To review current evidence for TDT and recommend research priorities that will contribute to more people being helped to stop tobacco use.

METHODS

We used the recommendations within the A14 guidelines to guide a review of current evidence and best practice for promotion of tobacco cessation and TDT, identify gaps, and propose research priorities.

RESULTS

We identified nine areas for future research (a) understanding current tobacco use and the effect of policy on behavior, (b) promoting cessation of tobacco use, (c) implementation of TDT guidelines, (d) increasing training capacity, (e) enhancing population-based TDT interventions, (f) treatment for different types of tobacco use, (g) supply of low-cost pharmaceutical devices/ products, (h) investigation use of nonpharmaceutical devices/ products, and (i) refinement of current TDTs. Specific research topics are suggested within each of these areas and recognize the differences needed between high- and low-/middle-income countries.

CONCLUSIONS

Research should be prioritized toward examining interventions that (a) promote cessation of tobacco use, (b) assist health care workers provide better help to smokers (e.g., through implementation of guidelines and training), (c) enhance population-based TDT interventions, and (d) assist people to cease the use of other tobacco products.

Questions about quitting (Q2): design and methods of a Multiphase Optimization Strategy (MOST) randomized screening experiment for an online, motivational smoking cessation intervention

Effective interventions are needed to improve smokers' motivation for quitting, treatment utilization, and abstinence rates. The Internet provides an ideal modality for delivering such interventions, given the low cost, broad reach, and capacity to individually tailor content, but important methodological questions remain about how to best design and deliver an online, motivational intervention to smokers. The current paper reports on the intervention, study design and research methods of a randomized trial (called Questions about Quitting) designed to address some of these questions. Using a Multi-phase Optimization Strategy (MOST) screening experiment, the trial has two key aims: to examine the impact of four experimental intervention factors (each evaluated on two levels) on smokers' subsequent treatment utilization and abstinence, and to examine select moderators of each sub-factor's effectiveness. The experimental factors of interest are: navigation autonomy (content viewing order is dictated based on stage of change or not), use of self-efficacy based testimonials (yes vs. no), proactive outreach (reminder emails vs. no emails), and decisional framework (prescriptive vs. motivational tone). To our knowledge, this is the first application of the MOST methodology to explore these factors or to explore the optimal design for a motivational intervention targeting smokers not actively trying to quit smoking. The rationale for the experimental factor choice, intervention design, and trial methods are discussed. Outcome data are currently being collected and are not presented, but recruitment data confirm the feasibility of enrolling smokers at varying stages of readiness to quit.