Internet-based interventions for smoking cessation

BACKGROUND

Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide, making the Internet a potential platform to help people quit smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, which included searches of MEDLINE, Embase and PsycINFO (through OVID). There were no restrictions placed on language, publication status or publication date. The most recent search was conducted in August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention. To be included, studies must have measured smoking cessation at four weeks or longer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and extracted data. We extracted and, where appropriate, pooled smoking cessation outcomes of six-month follow-up or more, reporting short-term outcomes narratively where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI).We grouped studies according to whether they (1) compared an Internet intervention with a non-active control arm (e.g. printed self-help guides), (2) compared an Internet intervention with an active control arm (e.g. face-to-face counselling), (3) evaluated the addition of behavioural support to an Internet programme, or (4) compared one Internet intervention with another. Where appropriate we grouped studies by age.

MAIN RESULTS

We identified 67 RCTs, including data from over 110,000 participants. We pooled data from 35,969 participants.There were only four RCTs conducted in adolescence or young adults that were eligible for meta-analysis.Results for trials in adults: Eight trials compared a tailored and interactive Internet intervention to a non-active control. Pooled results demonstrated an effect in favour of the intervention (RR 1.15, 95% CI 1.01 to 1.30, n = 6786). However, statistical heterogeneity was high (I² = 58%) and was unexplained, and the overall quality of evidence was low according to GRADE. Five trials compared an Internet intervention to an active control. The pooled effect estimate favoured the control group, but crossed the null (RR 0.92, 95% CI 0.78 to 1.09, n = 3806, I² = 0%); GRADE quality rating was moderate. Five studies evaluated an Internet programme plus behavioural support compared to a non-active control (n = 2334). Pooled, these studies indicated a positive effect of the intervention (RR 1.69, 95% CI 1.30 to 2.18). Although statistical heterogeneity was substantial (I² = 60%) and was unexplained, the GRADE rating was moderate. Four studies evaluated the Internet plus behavioural support compared to active control. None of the studies detected a difference between trial arms (RR 1.00, 95% CI 0.84 to 1.18, n = 2769, I² = 0%); GRADE rating was moderate. Seven studies compared an interactive or tailored Internet intervention, or both, to an Internet intervention that was not tailored/interactive. Pooled results favoured the interactive or tailored programme, but the estimate crossed the null (RR 1.10, 95% CI 0.99 to 1.22, n = 14,623, I² = 0%); GRADE rating was moderate. Three studies compared tailored with non-tailored Internet-based messages, compared to non-tailored messages. The tailored messages produced higher cessation rates compared to control, but the estimate was not precise (RR 1.17, 95% CI 0.97 to 1.41, n = 4040), and there was evidence of unexplained substantial statistical heterogeneity (I² = 57%); GRADE rating was low.Results should be interpreted with caution as we judged some of the included studies to be at high risk of bias.

AUTHORS' CONCLUSIONS

The evidence from trials in adults suggests that interactive and tailored Internet-based interventions with or without additional behavioural support are moderately more effective than non-active controls at six months or longer, but there was no evidence that these interventions were better than other active smoking treatments. However some of the studies were at high risk of bias, and there was evidence of substantial statistical heterogeneity. Treatment effectiveness in younger people is unknown.

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.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to quit smoking.

OBJECTIVES

To determine whether or not motivational interviewing (MI) promotes smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. Date of the most recent search: August 2014.

SELECTION CRITERIA

Randomized controlled trials in which motivational interviewing or its variants were offered to tobacco users to assist cessation.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We counted participants lost to follow-up as continuing smoking or relapsed. We performed meta-analysis using a fixed-effect Mantel-Haenszel model.

MAIN RESULTS

We identified 28 studies published between 1997 and 2014, involving over 16,000 participants. MI was conducted in one to six sessions, with the duration of each session ranging from 10 to 60 minutes. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio (RR) 1.26; 95% confidence interval (CI) 1.16 to 1.36; 28 studies; N = 16,803). Subgroup analyses found that MI delivered by primary care physicians resulted in an RR of 3.49 (95% CI 1.53 to 7.94; 2 trials; N = 736). When delivered by counsellors the RR was smaller (1.25; 95% CI 1.15 to 1.63; 22 trials; N = 13,593) but MI still resulted in higher quit rates than brief advice or usual care. When we compared MI interventions conducted through shorter sessions (less than 20 minutes per session) to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651). Single-session treatments might increase the likelihood of quitting over multiple sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing. Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports.  

AUTHORS' CONCLUSIONS

Motivational interviewing may assist people to quit smoking. However, the results should be interpreted with caution, due to variations in study quality, treatment fidelity, between-study heterogeneity and the possibility of publication or selective reporting bias.