Does it matter who you see to help you stop smoking? Short-term quit rates across specialist stop smoking practitioners in England

Covariates of success in quitting smoking: a systematic review of studies from 2008 to 2021 conducted to inform the statistical analyses of quitting outcomes of a hospital-based tobacco dependence treatment service in the United Kingdom

Background

Smoking cessation interventions are being introduced into routine secondary care in the United Kingdom (UK), but there are person and setting-related factors that could moderate their success in quitting smoking. This review was conducted as part of an evaluation of the QUIT hospital-based tobacco dependence treatment service ( https://sybics-quit.co.uk). The aim of the review was to identify a comprehensive set of variables associated with quitting success among tobacco smokers contacting secondary healthcare services in the UK who are offered support to quit smoking and subsequently set a quit date. The results would then be used to inform the development of a statistical analysis plan to investigate quitting outcomes.

Methods

Systematic literature review of five electronic databases. Studies eligible for inclusion investigated quitting success in one of three contexts: (a) the general population in the UK; (b) people with a mental health condition; (c) quit attempts initiated within a secondary care setting. The outcome measures were parameters from statistical analysis showing the effects of covariates on quitting success with a statistically significant (i.e., p-value <0.05) association.

Results

The review identified 29 relevant studies and 14 covariates of quitting success, which we grouped into four categories: demographics (age; sex; ethnicity; socio-economic conditions; relationship status, cohabitation and social network), individual health status and healthcare setting (physical health, mental health), tobacco smoking variables (current tobacco consumption, smoking history, nicotine dependence; motivation to quit; quitting history), and intervention characteristics (reduction in amount smoked prior to quitting, the nature of behavioural support, tobacco dependence treatment duration, pharmacological aids).

Conclusions

In total, 14 data fields were identified that should be considered for inclusion in datasets and statistical analysis plans for evaluating the quitting outcomes of smoking cessation interventions initiated in secondary care contexts in the UK.

PROSPERO registration

CRD42021254551 (13/05/2021).

Variability in outcomes and quality-of-care indicators across clinics participating in a large smoking-cessation program

BACKGROUND

The effectiveness of care for substance-related problems varies across providers. Best-known treatments are rarely universally applied, and various process differences can affect participant outcomes. Measuring and understanding this variability can suggest changes that will improve system performance.

METHODS

We measure variability in 7-day cigarette abstinence at a six-month follow-up; return for a second clinical visit; and receipt of combination nicotine replacement therapy across 223 primary care clinics participating in the Smoking Treatment for Ontario Patients program, a large smoking cessation initiative in Ontario, Canada. We include 41,992 enrolments from April 11, 2016 and May 31, 2019. We risk adjust for demographic and clinical case-mix differences and characterize variability using funnel plots and measures based on clinic-level variance explained. The abstinence outcome is missing for 38% of participants. We adjust for missingness using multiple imputation and inverse probability weighting.

RESULTS

Abstinence was achieved by 28.0% (95% CI = 27.5%-28.5%) of participants, 63.2% (62.8%-63.7%) received combination NRT, and 72.9% (72.4%-73.3%) returned for a second clinical visit. Variability was moderate for abstinence (median odds ratio (MOR) = 1.16) and pronounced for return visit (MOR = 1.29) and combination therapy (MOR = 1.89).

CONCLUSION

Outcomes and processes vary significantly across clinics within a program with shared guidelines and standards. Differences across providers may be greater in other contexts. Results underscore the importance of measuring and understanding variability, and of ongoing maintenance and improvement. The existence of high outliers holds out the possibility of identifying practices that might be more widely adopted.

The Emerging Global Tobacco Treatment Workforce: Characteristics of Tobacco Treatment Specialists Trained in Council-Accredited Training Programs from 2017 to 2019

Tobacco use is projected to kill 1 billion people in the 21st century. Tobacco Use Disorder (TUD) is one of the most common substance use disorders in the world. Evidence-based treatment of TUD is effective, but treatment accessibility remains very low. A dearth of specially trained clinicians is a significant barrier to treatment accessibility, even within systems of care that implement brief intervention models. The treatment of TUD is becoming more complex and tailoring treatment to address new and traditional tobacco products is needed. The Council for Tobacco Treatment Training Programs (Council) is the accrediting body for Tobacco Treatment Specialist (TTS) training programs. Between 2016 and 2019, n = 7761 trainees completed Council-accredited TTS training programs. Trainees were primarily from North America (92.6%) and the Eastern Mediterranean (6.1%) and were trained via in-person group workshops in medical and academic settings. From 2016 to 2019, the number of Council-accredited training programs increased from 14 to 22 and annual number of trainees increased by 28.5%. Trainees have diverse professional backgrounds and work in diverse settings but were primarily White (69.1%) and female (78.7%) located in North America. Nearly two-thirds intended to implement tobacco treatment services in their setting; two-thirds had been providing tobacco treatment for 1 year or less; and 20% were sent to training by their employers. These findings suggest that the training programs are contributing to the development of a new workforce of TTSs as well as the development of new programmatic tobacco treatment services in diverse settings. Developing strategies to support attendance from demographically and geographically diverse professionals might increase the proportion of trainees from marginalized groups and regions of the world with significant tobacco-related inequities.

How Has Intervention Fidelity Been Assessed in Smoking Cessation Interventions? A Systematic Review

INTRODUCTION

Intervention fidelity concerns the degree to which interventions are implemented as intended. Fidelity frameworks propose fidelity is a multidimensional concept relevant at intervention designer, provider, and recipient levels; yet the extent to which it is assessed multidimensionally is unclear. Smoking cessation interventions are complex, including multiple components, often delivered over multiple sessions and/or at scale in clinical practice; this increases susceptibility variation in the fidelity with which they are delivered. This review examined the extent to which five dimensions from the Behaviour Change Consortium fidelity framework (design, training, delivery, receipt, and enactment) were assessed in fidelity assessments of smoking cessation interventions (randomised control trials (RCTs)).

METHODS

Five electronic databases were searched using terms "smoking cessation," "interventions," "fidelity," and "randomised control trials." Eligible studies included RCTs of smoking cessation behavioural interventions, published post 2006 after publication of the framework, reporting assessment of fidelity. The data extraction form was structured around the framework, which specifies a number of items regarding assessment and reporting of each dimension. Data extraction included study characteristics, dimensions assessed, data collection, and analysis strategies. A score per dimension was calculated, indicating its presence.

RESULTS

55 studies were reviewed. There was a wide variability in data collection approaches used to assess fidelity. Fidelity of delivery was the most commonly assessed and linked to the intervention outcomes (73% of the studies). Fidelity of enactment scored the highest according to the framework (average of 92.7%), and fidelity of training scored the lowest (average of 37.1%). Only a quarter of studies linked fidelity data to outcomes (27%).

CONCLUSION

There is wide variability in methodological and analytical approaches that precludes comparison and synthesis. In order to realise the potential of fidelity investigations to increase scientific confidence in the interpretation of observed trial outcomes, studies should include analyses of the association between fidelity data and outcomes. Findings have highlighted recommendations for improving fidelity evaluations and reporting practices.

Impact of specialist and primary care stop smoking support on socio-economic inequalities in cessation in the United Kingdom: a systematic review and national equity initial review completed 22 January 2019; final version accepted 19 July 2019 analysis

AIM

To assess the impact of UK specialist and primary care-based stop smoking support on socio-economic inequalities in cessation.

METHODS

Systematic review and narrative synthesis, with a national equity analysis of stop smoking services (SSS). Ten bibliographic databases were searched for studies of any design, published since 2012, which evaluated specialist or primary care-based stop smoking support by socio-economic status (SES) or within a disadvantaged group. Studies could report on any cessation-related outcome. National Statistics were combined to estimate population-level SSS reach and impact among all smokers by SES. Overall, we included 27 published studies and three collated, national SSS reports for England, Scotland and Northern Ireland (equivalent data for Wales were unavailable).

RESULTS

Primary care providers and SSS in the United Kingdom were particularly effective at engaging and supporting disadvantaged smokers. Low SES groups were more likely to have their smoking status assessed, to receive general practitioner brief cessation advice/SSS referral and to attempt a quit with SSS support. Although disadvantaged SSS clients were less successful in quitting, increased service reach offset these lower quit rates, resulting in higher service impact among smokers from low SES groups. Interventions that offer tailored and targeted support have the potential to improve quit outcomes among disadvantaged smokers.

CONCLUSIONS

Equity-orientated stop smoking support can compensate for lower quit rates among disadvantaged smokers through the use of equity-based performance targets, provision of targeted services and the development of tailored interventions.

Theory Content, Question-Behavior Effects, or Form of Delivery Effects for Intention to Become an Organ Donor? Two Randomized Trials

Eliciting different attitudes with survey questionnaires may impact on intention to donate organs. Previous research used varying numbers of questionnaire items, or different modes of intervention delivery, when comparing groups. We aimed to determine whether intention to donate organs differed among groups exposed to different theoretical content, but similar questionnaire length, in different countries. We tested the effect of excluding affective attitudinal items on intention to donate, using constant item numbers in two modes of intervention delivery. Study 1: A multi-country, interviewer-led, cross-sectional randomized trial recruited 1007 participants, who completed questionnaires as per group assignment: including all affective attitude items, affective attitude items replaced, negatively-worded affective attitude items replaced. Study 2 recruited a UK-representative, cross-sectional sample of 616 participants using an online methodology, randomly assigned to the same conditions. Multilevel models assessed effects of group membership on outcomes: intention to donate (primary), taking a donor card, following a web-link (secondary). In study 1, intention to donate did not differ among groups. Study 2 found a small, significantly higher intention to donate in the negatively-worded affective attitudes replaced group. Combining data yielded no group differences. No differences were seen for secondary outcomes. Ancillary analyses suggest significant interviewer effects. Contrary to previous research, theoretical content may be less relevant than number or valence of questionnaire items, or form of intervention delivery, for increasing intention to donate organs.

Addition of one session with a specialist counselor did not increase efficacy of a family physician-led smoking cessation program

Objective Higher-intensity counseling sessions increase the smoking abstinence rate. However, counselors are limited in Taiwan. This study was performed to determine whether the addition of one session with a specialist counselor increases the efficacy of a family physician-led smoking cessation program. Methods Participants opted to either visit a family physician for brief counseling and pharmacotherapy (Po) or visit a specialist counselor for an initial session followed by a family physician for brief counseling sessions with pharmacotherapy (P+). The 7-day point prevalence (PP) rate was evaluated at weeks 12 and 24. Results In total, 356 patients were enrolled. In the intention-to-treat analysis, the PP rate at week 12 was higher in the Po than P+ group, but there was no significant difference at week 24. In the per-protocol analysis, the PP rates at weeks 12 and 24 were not significantly different between the Po and P+ groups. The adjusted odds ratios also revealed no significant differences in either the intention-to-treat analysis or the per-protocol analysis between the two groups. Conclusion The addition of one session with a specialist counselor had no benefit over the provision of counseling through a family physician at either 12 or 24 weeks of follow-up.

Effects of Trained Health Professionals' Behavioral Counseling Skills on Smoking Cessation Outcomes

Background

There is evidence that training health professionals in behavioral counseling skills can lead to greater success in helping their smokers to quit. However, it is still unknown how counseling skills relate to counseling effects.

Purpose

We established a method of skills evaluation of health professionals for smoking cessation counseling based on videotaped counseling sessions with a standardized smoker, and examined the relationship between skill levels and smoking cessation outcomes.

Methods

Twenty-three health professionals at Japanese workplaces underwent a training program. Their counseling skills were evaluated before and after the program using a structured evaluation form-based analysis of videotaped interactions between participants and a standardized smoker. A total of 858 smokers then received individual smoking cessation counseling by the trained health professionals at an annual health checkup. These patients were followed-up through surveys after 1 year.

Results

On a scale from 0 to 24, Total skill scores, which ranged from 0 to 24, were significantly higher after the training than before the training (p < .001). Multiple two-level logistic regression analysis adjusted for smokers' characteristics showed that the odds ratios of skill scores after the training for point prevalence and sustained abstinence rates among smokers who received counseling were 1.21 (95% confidence interval: 1.03-1.42) and 1.26 (1.05-1.50), respectively.

Conclusions

This study demonstrates that higher behavioral counseling skills were associated with better smoking cessation outcomes. This research is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes.

Associations between Practitioner Personality and Client Quit Rates in Smoking Cessation Behavioural Support Interventions

Introduction: There is wide variation in the success rates of practitioners employed to help smokers to stop, even once a range of potential confounding factors has been taken into account. Aim: This paper examined whether personality characteristics of practitioners might play a role success rates. Methods: Data from 1,958 stop-smoking treatment episodes in two stop-smoking services (SSS) involving 19 stop-smoking practitioners were used in the analysis. The outcome measure was clients' biochemically verified quit status 4 weeks after the target quit date. The five dimensions of personality, as assessed by the Ten-Item Personality Inventory, were included as predictor variables: openness, conscientiousness, agreeableness, extraversion, and neuroticism. A range of client and other practitioner characteristics were used as covariates. A sensitivity analysis was conducted to determine if managers' ratings of practitioner personality were also associated with clients' quit status. Results: Multi-level random intercept models indicated that clients of practitioners with a higher extraversion score had greater odds of being abstinent at four weeks (self-assessed: OR = 1.10, 95% CI = 1.01-1.19; manager-assessed: OR = 1.32, 95% CI = 1.21-1.44). Conclusions: More extraverted stop smoking practitioners appear to have greater success in advising their clients to quit smoking. Findings need to be confirmed in larger practitioner populations, other SSS, and in different smoking cessation contexts. If confirmed, specific training may be needed to assist more introverted stop smoking practitioners.

Start2quit: a randomised clinical controlled trial to evaluate the effectiveness and cost-effectiveness of using personal tailored risk information and taster sessions to increase the uptake of the NHS Stop Smoking Services

BACKGROUND

The NHS Stop Smoking Services (SSSs) offer help to smokers who want to quit. However, the proportion of smokers attending the SSSs is low and current figures show a continuing downward trend. This research addressed the problem of how to motivate more smokers to accept help to quit.

OBJECTIVES

To assess the relative effectiveness, and cost-effectiveness, of an intervention consisting of proactive recruitment by a brief computer-tailored personal risk letter and an invitation to a 'Come and Try it' taster session to provide information about the SSSs, compared with a standard generic letter advertising the service, in terms of attendance at the SSSs of at least one session and validated 7-day point prevalent abstinence at the 6-month follow-up.

DESIGN

Randomised controlled trial of a complex intervention with follow-up 6 months after the date of randomisation.

SETTING

SSSs and general practices in England.

PARTICIPANTS

All smokers aged ≥ 16 years identified from medical records in participating practices who were motivated to quit and who had not attended the SSS in the previous 12 months. Participants were randomised in the ratio 3 : 2 (intervention to control) by a computer program.

INTERVENTIONS

Intervention - brief personalised and tailored letter sent from the general practitioner using information obtained from the screening questionnaire and from medical records, and an invitation to attend a taster session, run by the local SSS. Control - standard generic letter from the general practice advertising the local SSS and the therapies available, and asking the smoker to contact the service to make an appointment.

MAIN OUTCOME MEASURES

(1) Proportion of people attending the first session of a 6-week course over a period of 6 months from the receipt of the invitation letter, measured by records of attendance at the SSSs; (2) 7-day point prevalent abstinence at the 6-month follow-up, validated by salivary cotinine analysis; and (3) cost-effectiveness of the intervention.

RESULTS

Eighteen SSSs and 99 practices within the SSS areas participated; 4384 participants were randomised to the intervention (n = 2636) or control (n = 1748). One participant withdrew and 4383 were analysed. The proportion of people attending the first session of a SSS course was significantly higher in the intervention group than in the control group [17.4% vs. 9.0%; unadjusted odds ratio (OR) 2.12, 95% confidence interval (CI) 1.75 to 2.57; p < 0.001]. The validated 7-day point prevalent abstinence at the 6-month follow-up was significantly higher in the intervention group than in the control group (9.0% vs. 5.6%; unadjusted OR 1.68, 95% CI 1.32 to 2.15; p < 0.001), as was the validated 3-month prolonged abstinence and all other periods of abstinence measured by self-report. Using the National Institute for Health and Care Excellence decision-making threshold range of £20,000-30,000 per quality-adjusted life-year gained, the probability that the intervention was more cost-effective than the control was up to 27% at 6 months and > 86% over a lifetime horizon.

LIMITATIONS

Participating SSSs may not be representative of all SSSs in England. Recruitment was low, at 4%.

CONCLUSIONS

The Start2quit trial added to evidence that a proactive approach with an intensive intervention to deliver personalised risk information and offer a no-commitment introductory session can be successful in reaching more smokers and increasing the uptake of the SSS and quit rates. The intervention appears less likely to be cost-effective in the short term, but is highly likely to be cost-effective over a lifetime horizon.

FUTURE WORK

Further research could assess the separate effects of these components.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76561916.

FUNDING DETAILS

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. 21, No. 3. See the NIHR Journals Library website for further project information.

Proportion of Time Spent Delivering Support Predicts Stop Smoking Advisor Quit Rate Independently of Training, Experience, and Education

Despite a downwards trend in smoking prevalence, smoking remains the UK's biggest preventable cause of premature mortality. Specialist stop smoking support programmes provided by the NHS have helped to reduce smoking prevalence and whilst there has been a vast amount of research investigating the most effective behavioural and pharmacological support models, little is known about the impact of smoking cessation advisor's smoking status and clinical effectiveness on quit rates. This study aimed to identify factors that contribute to NHS stop smoking advisor performance using a quantitative cross-sectional design via an online survey that was completed by 159 participants in 24 London boroughs. Multiple regression analyses revealed that level of training, years practiced, level of advisor education, number of patients supported in a given year, and smoking status had no significant impact on NHS stop smoking advisor quit rate in this sample. However, the model revealed that proportion of time spent delivering smoking cessation support was significantly associated with quit rate. It is imperative that this finding is considered when recruiting, commissioning, and training new smoking cessation advisors or provider organisations.

Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study

BACKGROUND

NHS Stop Smoking Services (SSSs) provide free at the point of use treatment for smokers who would like to stop. Since their inception in 1999 they have evolved to offer a variety of support options. Given the changes that have happened in the provision of services and the ongoing need for evidence on effectiveness, the Evaluating Long-term Outcomes for NHS Stop Smoking Services (ELONS) study was commissioned.

OBJECTIVES

The main aim of the study was to explore the factors that determine longer-term abstinence from smoking following intervention by SSSs. There were also a number of additional objectives.

DESIGN

The ELONS study was an observational study with two main stages: secondary analysis of routine data collected by SSSs and a prospective cohort study of service clients. The prospective study had additional elements on client satisfaction, well-being and longer-term nicotine replacement therapy (NRT) use.

SETTING

The setting for the study was SSSs in England. For the secondary analysis, routine data from 49 services were obtained. For the prospective study and its added elements, nine services were involved. The target population was clients of these services.

PARTICIPANTS

There were 202,804 cases included in secondary analysis and 3075 in the prospective study.

INTERVENTIONS

A combination of behavioural support and stop smoking medication delivered by SSS practitioners.

MAIN OUTCOME MEASURES

Abstinence from smoking at 4 and 52 weeks after setting a quit date, validated by a carbon monoxide (CO) breath test.

RESULTS

Just over 4 in 10 smokers (41%) recruited to the prospective study were biochemically validated as abstinent from smoking at 4 weeks (which was broadly comparable with findings from the secondary analysis of routine service data, where self-reported 4-week quit rates were 48%, falling to 34% when biochemical validation had occurred). At the 1-year follow-up, 8% of prospective study clients were CO validated as abstinent from smoking. Clients who received specialist one-to-one behavioural support were twice as likely to have remained abstinent than those who were seen by a general practitioner (GP) practice and pharmacy providers [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2 to 4.6]. Clients who received group behavioural support (either closed or rolling groups) were three times more likely to stop smoking than those who were seen by a GP practice or pharmacy providers (OR 3.4, 95% CI 1.7 to 6.7). Satisfaction with services was high and well-being at baseline was found to be a predictor of abstinence from smoking at longer-term follow-up. Continued use of NRT at 1 year was rare, but no evidence of harm from longer-term use was identified from the data collected.

CONCLUSIONS

Stop Smoking Services in England are effective in helping smokers to move away from tobacco use. Using the 52-week CO-validated quit rate of 8% found in this study, we estimate that in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives. This is a substantial figure and provides one indicator of the ongoing value of the treatment that the services provide. The study raises a number of issues for future research including (1) examining the role of electronic cigarettes (e-cigarettes) in smoking cessation for service clients [this study did not look at e-cigarette use (except briefly in the longer-term NRT study) but this is a priority for future studies]; (2) more detailed comparisons of rolling groups with other forms of behavioural support; (3) further exploration of the role of practitioner knowledge, skills and use of effective behaviour change techniques in supporting service clients to stop smoking; (4) surveillance of the impact of structural and funding changes on the future development and sustainability of SSSs; and (5) more detailed analysis of well-being over time between those who successfully stop smoking and those who relapse. Further research on longer-term use of non-combustible nicotine products that measures a wider array of biomarkers of smoking-related harm such as lung function tests or carcinogen metabolites.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term NRT study.

Lifestyle Vaccines and Public Health: Exploring Policy Options for a Vaccine to Stop Smoking

Experimental vaccines are being developed for the treatment of 'unhealthy lifestyles' and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of 'lifestyle vaccines' for public health. Based on findings from a qualitative study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The 'vaccinization' of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future.

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.

Are Nurses and Auxiliary Healthcare Workers Equally Effective in Delivering Smoking Cessation Support in Primary Care?

Introduction:

Smoking cessation support is increasingly delivered in primary care by auxiliary healthcare workers in place of healthcare professionals. However, it is unknown whether this shift might affect the quality and impact of the support delivered.

Methods:

Data from the iQuit in Practice randomized control trial of cessation support in General Practice was used (N = 602). Analyses assessed whether cessation advisor type (nurse or healthcare assistant [HCA]) was associated with abstinence (primary outcome: self-reported 2-week point prevalence abstinence at 8 weeks follow-up), the advice delivered during the initial consultation, pharmacotherapies prescribed, patient satisfaction, initial consultation length, and the number and type of interim contacts.

Results:

There were no statistically significant differences in abstinence for support delivered by HCAs versus nurses at 8 weeks (HCAs 42.8%, nurses 42.6%; unadjusted odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.73 to 1.40), or at 4 weeks or 6 months follow-up. There were no statistically significant differences in advice delivered, the types of pharmacotherapies prescribed or patient satisfaction. Compared with nurses, HCA consultations were longer on average (HCAs 23.6 minutes, nurses 20.8 minutes; P = .002) and they undertook more interim contacts (HCAs median 2, nurses median 1; P < .001), with contact more likely to be face-to-face than phone call (HCAs 91.2%, nurses 70.9%; OR = 4.23, 95% CI = 2.86 to 6.26).

Conclusions:

HCAs appear equally effective as nurses in supporting smoking cessation, although they do this with greater patient contact. Using auxiliary practitioners to deliver cessation support could free up nurse time and reduce costs.

Implications:

This study found that primary care patients receiving smoking cessation support from auxiliary healthcare workers were just as likely to be abstinent up to 6 months later as those patients seen by nurses. While the auxiliary healthcare workers achieved this with slightly increased patient contact time, the advice delivered, pharmacotherapies provided and patient satisfaction were similar to that of nurses. Expanding the auxiliary healthcare worker role to include smoking cessation support could increase role satisfaction and reduce the costs of cessation support delivery in primary care.

Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development

AIMS

This paper provides a concise review of the efficacy, effectiveness and affordability of health-care interventions to promote and assist tobacco cessation, in order to inform national guideline development and assist countries in planning their provision of tobacco cessation support.

METHODS

Cochrane reviews of randomized controlled trials (RCTs) of major health-care tobacco cessation interventions were used to derive efficacy estimates in terms of percentage-point increases relative to comparison conditions in 6-12-month continuous abstinence rates. This was combined with analysis and evidence from 'real world' studies to form a judgement on the probable effectiveness of each intervention in different settings. The affordability of each intervention was assessed for exemplar countries in each World Bank income category (low, lower middle, upper middle, high). Based on World Health Organization (WHO) criteria, an intervention was judged as affordable for a given income category if the estimated extra cost of saving a life-year was less than or equal to the per-capita gross domestic product for that category of country.

RESULTS

Brief advice from a health-care worker given opportunistically to smokers attending health-care services can promote smoking cessation, and is affordable for countries in all World Bank income categories (i.e. globally). Proactive telephone support, automated text messaging programmes and printed self-help materials can assist smokers wanting help with a quit attempt and are affordable globally. Multi-session, face-to-face behavioural support can increase quit success for cigarettes and smokeless tobacco and is affordable in middle- and high-income countries. Nicotine replacement therapy, bupropion, nortriptyline, varenicline and cytisine can all aid quitting smoking when given with at least some behavioural support; of these, cytisine and nortriptyline are affordable globally.

CONCLUSIONS

Brief advice from a health-care worker, telephone helplines, automated text messaging, printed self-help materials, cytisine and nortriptyline are globally affordable health-care interventions to promote and assist smoking cessation. Evidence on smokeless tobacco cessation suggests that face-to-face behavioural support and varenicline can promote cessation.

Treatment manuals, training and successful provision of stop smoking behavioural support

OBJECTIVE

Translating evidence-based behaviour change interventions into practice is aided by use of treatment manuals specifying the recommended content and format of interventions, and evidence-based training. This study examined whether outcomes of stop smoking behavioural support differed with practitioner's use and evaluation of treatment manuals, or practitioner's training.

METHODS

English stop smoking practitioners were invited to complete an online survey including questions on: practitioners' training, availability, use and perceived utility of manuals, and annual biochemically-validated success rates of quit attempts supported (practitioner-reported). Mean success rates were compared between practitioners with/without access to manuals, those using/not using manuals, perceived utility ratings of manuals, and consecutive levels of training completed.

RESULTS

Success rates were higher if practitioners had a manual (Mean (SD) = 54.0 (24.0) versus 48.0 (25.3), t(838) = 2.48, p = 0.013; n = 840), used a manual (F(2,8237) = 4.78, p = 0.009, n = 840), perceived manuals as more useful (F(3,834) = 2.90, p = 0.034, n = 840), and had completed training (F(3,709) = 4.81, p = 0.002, n = 713). Differences were diminished when adjusting for professional and demographic characteristics and no longer reached statistical significance using a conventional alpha for perceived utility of manuals and training status (both p = 0.1).

CONCLUSIONS

Practitioners' performance in supporting smokers to quit varied with availability and use of treatment manuals. Evidence was weaker for perceived utility of manuals and practitioners' evidence-based training. Ensuring practitioners have access to treatment manuals within their service, promoting manual use, and training practitioners to competently apply manuals is likely to contribute to higher success rates in clinical practice.

Prospective cohort study of the effectiveness of smoking cessation treatments used in the "real world"

OBJECTIVE

To estimate the "real-world" effectiveness of commonly used aids to smoking cessation in England by using longitudinal data.

PATIENTS AND METHODS

We conducted a prospective cohort study in 1560 adult smokers who participated in an English national household survey in the period from November 2006 to March 2012, responded to a 6-month follow-up survey, and made at least 1 quit attempt between the 2 measurements. The quitting method was classified as follows: (1) prescription medication (nicotine replacement therapy [NRT], bupropion, or varenicline) in combination with specialist behavioral support delivered by a National Health Service Stop Smoking Service; (2) prescription medication with brief advice; (3) NRT bought over the counter; (4) none of these. The primary outcome measure was self-reported abstinence up to the time of the 6-month follow-up survey, adjusted for key potential confounders including cigarette dependence.

RESULTS

Compared with smokers using none of the cessation aids, the adjusted odds of remaining abstinent up to the time of the 6-month follow-up survey were 2.58 (95% CI, 1.48-4.52) times higher in users of prescription medication in combination with specialist behavioral support and 1.55 (95% CI, 1.11-2.16) times higher in users of prescription medication with brief advice. The use of NRT bought over the counter was associated with a lower odds of abstinence (odds ratio, 0.68; 95% CI, 0.49-0.94).

CONCLUSION

Prescription medication offered with specialist behavioral support and that offered with minimal behavioral support are successful methods of stopping cigarette smoking in England.

How stable are stop smoking practitioner success rates over time?

Stop smoking practitioners appear to differ in effectiveness, but the stability of their success rates over time is unknown. The purpose of this study was to assess the degree of stability of success rates of stop smoking practitioners over several years of practice. Using routinely collected practice data, the success rates of 197 practitioners active between April 2009 and April 2012 in the English stop smoking services were correlated across years before and after adjusting for client and intervention characteristics. Changes in client and intervention characteristics were assessed. Success rates for individual practitioners correlated highly in successive years (r = 0.64 to 0.68, p < 0.001, ICC = 0.56) and moderately over non-successive years (r = 0.39 to 0.51, p < 0.001). There was no evidence for increasing effectiveness over time. Practitioners' effectiveness is moderately stable over time. Research is needed to establish what characterises the practice of the more successful practitioners.

'Real-world' effectiveness of smoking cessation treatments: a population study

BACKGROUND AND AIMS

There is a need for more evidence on the 'real-world' effectiveness of commonly used aids to smoking cessation from population-level studies. This study assessed the association between abstinence and use of different smoking cessation treatments after adjusting for key potential confounding factors.

DESIGN

Cross-sectional data from aggregated monthly waves of a household survey: the Smoking Toolkit Study.

SETTING

England.

PARTICIPANTS

A total of 10 335 adults who smoked within the previous 12 months and had made at least one quit attempt during that time.

MEASUREMENTS

Participants were classified according to their use of cessation aids in their most recent quit attempt: (i) medication (nicotine replacement therapy, bupropion or varenicline) in combination with specialist behavioural support delivered by a National Health Service Stop Smoking Service; (ii) medication provided by the prescribing health-care professional without specialist behavioural support; (iii) nicotine replacement therapy (NRT) bought over the counter; and (iv) none of these. The main outcome measure was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including tobacco dependence.

FINDINGS

Compared with smokers using none of the cessation aids, the adjusted odds of remaining abstinent up to the time of the survey were 3.25 [95% confidence interval (CI) = 2.05-5.15] greater in users of prescription medication in combination with specialist behavioural support, 1.61 (95% CI = 1.33-1.94) greater in users of prescription medication combined with brief advice and 0.96 (95% CI = 0.81-1.13) in users of NRT bought over the counter.

CONCLUSIONS

After adjusting for major confounding variables such as tobacco dependence, smokers in England who use a combination of behavioural support and pharmacotherapy in their quit attempts have almost three times the odds of success than those who use neither pharmacotherapy nor behavioural support. Smokers who buy nicotine replacement therapy over the counter with no behavioural support have similar odds of success in stopping as those who stop without any aid.

Fifty-two-week continuous abstinence rates of smokers being treated with varenicline versus nicotine replacement therapy

BACKGROUND AND AIMS

Cross-study comparisons of effect sizes suggest that varenicline is more effective than nicotine replacement therapy (NRT) in aiding smoking cessation, but evidence from direct comparisons is limited. This study compared biochemically verified 52-week sustained abstinence rates in smokers attending the same clinical service according to whether they used varenicline or NRT in their quit attempt.

METHODS

This was a prospective cohort study of 855 smokers attending a large smoking cessation clinic who used their choice of NRT product or varenicline in their quit attempt. All received the same behavioural support programme and chose their medication option (n = 519 varenicline; n = 336 NRT). The primary outcome measure was self-report of 52 weeks' abstinence following the target quit date confirmed by expired air carbon monoxide concentration. Baseline measures included socio-demographic variables, mental health diagnoses, measures of smoking, cigarette dependence and past use of NRT or varenicline.

RESULTS

The 52-week abstinence rates were 42.8% versus 31.0% in those using varenicline versus NRT, respectively (P < 0.001). After adjusting for all baseline variables, the odds of remaining abstinent for 52 weeks were 2.03 (95% CI 1.46-2.82), P < 0.001 times higher in those using varenicline than those using NRT.

CONCLUSIONS

Smokers in the same behavioural support programme who use varenicline appear to have a greater probability of achieving long-term abstinence than those using their choice of nicotine replacement therapy options, even after adjusting for potentially confounding smoker characteristics.

Assessing fidelity of delivery of smoking cessation behavioural support in practice

BACKGROUND

Effectiveness of evidence-based behaviour change interventions is likely to be undermined by failure to deliver interventions as planned. Behavioural support for smoking cessation can be a highly cost-effective, life-saving intervention. However, in practice, outcomes are highly variable. Part of this may be due to variability in fidelity of intervention implementation. To date, there have been no published studies on this. The present study aimed to: evaluate a method for assessing fidelity of behavioural support; assess fidelity of delivery in two English Stop-Smoking Services; and compare the extent of fidelity according to session types, duration, individual practitioners, and component behaviour change techniques (BCTs).

METHODS

Treatment manuals and transcripts of 34 audio-recorded behavioural support sessions were obtained from two Stop-Smoking Services and coded into component BCTs using a taxonomy of 43 BCTs. Inter-rater reliability was assessed using percentage agreement. Fidelity was assessed by examining the proportion of BCTs specified in the manuals that were delivered in individual sessions. This was assessed by session type (i.e., pre-quit, quit, post-quit), duration, individual practitioner, and BCT.

RESULTS

Inter-coder reliability was high (87.1%). On average, 66% of manual-specified BCTs were delivered per session (SD 15.3, range: 35% to 90%). In Service 1, average fidelity was highest for post-quit sessions (69%) and lowest for pre-quit (58%). In Service 2, fidelity was highest for quit-day (81%) and lowest for post-quit sessions (56%). Session duration was not significantly correlated with fidelity. Individual practitioner fidelity ranged from 55% to 78%. Individual manual-specified BCTs were delivered on average 63% of the time (SD 28.5, range: 0 to 100%).

CONCLUSIONS

The extent to which smoking cessation behavioural support is delivered as specified in treatment manuals can be reliably assessed using transcripts of audiotaped sessions. This allows the investigation of the implementation of evidence-based practice in relation to smoking cessation, a first step in designing interventions to improve it. There are grounds for believing that fidelity in the English Stop-Smoking Services may be low and that routine monitoring is warranted.