Do implementation issues influence the effectiveness of medications? The case of nicotine replacement therapy and bupropion in UK Stop Smoking Services

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).

Developing standards for reporting implementation studies of complex interventions (StaRI): a systematic review and e-Delphi

BACKGROUND

Dissemination and implementation of health care interventions are currently hampered by the variable quality of reporting of implementation research. Reporting of other study types has been improved by the introduction of reporting standards (e.g. CONSORT). We are therefore developing guidelines for reporting implementation studies (StaRI).

METHODS

Using established methodology for developing health research reporting guidelines, we systematically reviewed the literature to generate items for a checklist of reporting standards. We then recruited an international, multidisciplinary panel for an e-Delphi consensus-building exercise which comprised an initial open round to revise/suggest a list of potential items for scoring in the subsequent two scoring rounds (scale 1 to 9). Consensus was defined a priori as 80% agreement with the priority scores of 7, 8, or 9.

RESULTS

We identified eight papers from the literature review from which we derived 36 potential items. We recruited 23 experts to the e-Delphi panel. Open round comments resulted in revisions, and 47 items went forward to the scoring rounds. Thirty-five items achieved consensus: 19 achieved 100% agreement. Prioritised items addressed the need to: provide an evidence-based justification for implementation; describe the setting, professional/service requirements, eligible population and intervention in detail; measure process and clinical outcomes at population level (using routine data); report impact on health care resources; describe local adaptations to the implementation strategy and describe barriers/facilitators. Over-arching themes from the free-text comments included balancing the need for detailed descriptions of interventions with publishing constraints, addressing the dual aims of reporting on the process of implementation and effectiveness of the intervention and monitoring fidelity to an intervention whilst encouraging adaptation to suit diverse local contexts.

CONCLUSIONS

We have identified priority items for reporting implementation studies and key issues for further discussion. An international, multidisciplinary workshop, where participants will debate the issues raised, clarify specific items and develop StaRI standards that fit within the suite of EQUATOR reporting guidelines, is planned.

REGISTRATION

The protocol is registered with Equator: http://www.equator-network.org/library/reporting-guidelines-under-development/#17 .

Equity impact of European individual-level smoking cessation interventions to reduce smoking in adults: a systematic review

BACKGROUND

Smoking is the leading cause of health inequalities in Europe. Adults from lower socioeconomic status (SES) groups are more likely to smoke and less likely to quit than adults from higher SES groups. Smoking cessation support is an important element of tobacco control; however, the equity impact of individual-level cessation support is uncertain.

METHODS

Systematic review of individual-level smoking cessation interventions delivered in European countries, reporting a smoking cessation outcome (quit) in adults of lower compared with higher SES. Equity impact was assessed as positive (reduced inequality), neutral (no difference by SES), negative (increased inequality) or unclear.

RESULTS

Twenty-nine studies were included using different types of support: behavioural and pharmacological (17); behavioural only (11), including specialist (5), brief advice (1), mass media (2), text-based (1) and Internet-based (2); and pharmacological only (1). The distribution of equity effects on quitting was 10 neutral, 18 negative and 1 unclear. Two national studies of UK National Health Service (NHS) stop-smoking services showed overall positive equity impact on smoking prevalence. The evidence suggests that UK NHS services that target low-SES smokers achieve a relatively higher service uptake among low-SES smokers, which can compensate for their lower quit rates.

CONCLUSIONS

Untargeted smoking cessation interventions in Europe may have contributed to reducing adult smoking but are, on balance, likely to have increased inequalities in smoking. However, UK NHS stop-smoking services appear to reduce inequalities in smoking through increased relative reach through targeting services to low-SES smokers. More research is needed to strengthen the evidence-base for reducing smoking inequalities.

Impact of access restrictions on varenicline utilization

AIM

To assess the impact of access restrictions on varenicline utilization.

METHODS

Employer-sponsored health plans contributing to the MarketScan Commercial Claims and Encounters Database were categorized according to 2009 varenicline access restrictions: no coverage; prior authorization; smoking cessation program requirement; no restrictions. The cohort comprised all adults continuously enrolled in plans during 2009. Each restriction cohort was compared with the no restrictions cohort using descriptive analyses. Data were assessed using logistic regression; demographic and clinical characteristics were covariates.

RESULTS

In this study (no coverage, n = 454,419; prior authorization, n = 171,530; smoking cessation program, n = 108,181; no restrictions, n = 607,389), compared with the no restrictions cohort, the odds of treatment were 71% lower (odds ratio: 0.29; 95% CI: 0.26, 0.31) in the smoking cessation program cohort (p < 0.001) and 80% lower (odds ratio: 0.20; 95% CI: 0.19, 0.22) in the prior authorization cohort (p < 0.001).

CONCLUSIONS

Access restrictions were associated with significantly lower odds for varenicline utilization.

Pharmacotherapy for smoking cessation: current advances and research topics

Promoting smoking cessation is among the key medical interventions aimed at reducing worldwide morbidity and mortality in this century. Both behavioural counselling and pharmacotherapy have been shown to significantly increase long-term abstinence rates, and combining the two treatment modalities is recommended. This article provides an update on pharmacotherapy for smoking cessation in the general population. Current first-line agents used to support quit attempts are nicotine replacement therapy (NRT), bupropion and varenicline. Research suggests that abstinence rates can be increased by combining different forms of NRT or simultaneously administering NRT and non-nicotine medications. New treatments targeting the nicotinic acetylcholine receptor as well as other pathophysiological pathways involved in nicotine addiction are being developed, with nicotine vaccines now being tested in phase III clinical trials. Among the numerous research topics currently addressed, pharmacogenetics and tailoring therapy to specific groups of smokers look most promising. However, substantial progress is unlikely to be made unless social gradients impeding effective treatment of all smokers are overcome. In addition, public smoking bans and reimbursement of medication costs are crucial in reducing the future burden of disease caused by smoking on a global level.

A smoking ban in public places increases the efficacy of bupropion and counseling on cessation outcomes at 1 year

INTRODUCTION

Legal restrictions have contributed to the decline in smoking prevalence in several European countries. We investigated the impact of the Italian 2005 indoor smoking ban on the efficacy of counseling alone or in combination with bupropion for smoking cessation.

METHODS

Before and after the introduction of the ban (2001-2006), 550 smokers were enrolled in the smoking cessation program in Rome and were asked to choose between a 6-week group counseling therapy (GCT) given alone or in combination with 7 weeks of daily bupropion. Follow-up was completed 12, 26, and 52 weeks after the quit day. Due to the observational nature of the study, we used propensity scores to match 138 and 290 subjects (pre-/postban) in the bupropion- and GCT-only groups, respectively.

RESULTS

Covariate balance in the two matched samples was adequate for all variables except "coffee consumption" in the GCT-only group. The regression adjusted odds ratios indicated that the introduction of the ban resulted in 52% reduced odds of continued smoking at 12 months among the GCT + bupropion group and 41% reduced odds in the GCT-only group. We observed that the ban was associated with both increased 12-month abstinence rates and motivation to quit. In a mediation analysis, we determined that the total effect of the smoking ban on the abstinence rate was reduced after controlling for motivation, which confirmed that motivation was a partial mediator.

DISCUSSION

The introduction of an indoor smoking ban improved the efficacy of smoking cessation treatments by possibly providing a setting that increased the level of motivation to stop smoking.