Godfrey Fowler

Meta-analysis on efficacy of nicotine replacement therapies in smoking cessation

Nicotine-replacement therapy (NRT) by gum, transdermal patch, intranasal spray, or inhalation is expensive but how effective is it? We have done a meta-analysis of controlled trials to see how effects on abstinence rates are influenced by the clinical setting, the level of nicotine dependency, the dosage of NRT, and the intensity of additional advice and support offered. Published or unpublished randomised controlled trials of NRT that have assessed abstinence at least 6 months after the start of NRT were identified and 53 trials (42 gum, 9 patch, 1 intranasal spray, 1 inhaler), with data from 17,703 subjects, were included in the analyses. Use of NRT increased the odds ratio (OR) of abstinence to 1.71 (95% confidence interval 1.56-1.87) compared with those allocated to the control interventions. The ORs for the different forms of NRT were 1.61 for gum, 2.07 for transdermal patch, 2.92 for nasal spray, and 3.05 for inhaled nicotine. These odds were non-significantly higher in subjects with higher levels of nicotine dependence but they were largely independent of the intensity of additional support provided or the setting in which NRT was offered. We conclude that the currently available forms of NRT are effective therapies to aid smoking cessation.

Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects.

Abstract Objectives: To estimate the efficacy of dietary advice to lower blood total cholesterol concentration in free-living subjects and to investigate the efficacy of different dietary recommendations. Design: Systematic overview of 19 randomised controlled trials including 28 comparisons. Subjects: Free-living subjects. Interventions: Individualised dietary advice to modify fat intake. Main outcome measure: Percentage difference in blood total cholesterol concentration between the intervention and control groups. Results: The percentage reduction in blood total cholesterol attributable to dietary advice after at least six months of intervention was 5.3% (95% confidence interval 4.7% to 5.9%). Including both short and long duration studies, the effect was 8.5% at 3 months and 5.5% at 12 months. Diets equivalent to the step 2 diet of the American Heart Association were of similar efficacy to diets that aimed to lower total fat intake or to raise the polyunsaturated to saturated fatty acid ratio. These diets were moderately more effective than the step 1 diet of the American Heart Association (6.1% v 3.0% reduction in blood total cholesterol concentration; P<0.0001). On the basis of reported food intake, the targets for dietary change were seldom achieved. The observed reductions in blood total cholesterol concentrations in the individual trials were consistent with those predicted from dietary intake on the basis of the Keys equation. Conclusions: Individualised dietary advice for reducing cholesterol concentration is modestly effective in free-living subjects. More intensive diets achieve a greater reduction in serum cholesterol concentration. Failure to comply fully with dietary recommendations is the likely explanation for this limited efficacy. Key messages Results from metabolic ward studies suggest that dietary change can reduce blood cholesterol concentrations by up to 15% In free-living subjects the standard step 1 diet of the American Heart Association lowers cholesterol concentration by about 3%, and about another 3% can be achieved with more intensive diets Difficulties in complying with the prescribed dietary change explain the failure to achieve the expected reductions in cholesterol concentrations It is important to be realistic about the reductions in cardiovascular risk that can be achieved by individual dietary counselling

Diabetes in the Elderly: The Oxford Community Diabetes Study

Most diabetic patients are elderly but their clinical characteristics remain poorly defined. A population survey identified 259 known diabetic patients aged 60 years or more giving a prevalence of 3% in this age group. A total of 193 patients (75%) were interviewed and examined, 155 (80%) of whom had been diagnosed at under 70 years of age. Forty‐two patients (22%) were insulin‐treated but clinical characteristics suggested that at least 95% of all elderly patients had Type 2 diabetes. Blood glucose control was poor with median HbA1 9.7% (range 4.9–17.1%, normal reference range 5.0–7.5%), and 55% were either overweight or obese. There was a high morbidity from diabetes and other conditions: the prevalence of hypertension (untreated blood pressure of 160/95 mmHg or more or antihypertensive medication) was 52%, of stroke 5%, of nephropathy (urinary albumin concentration ≥300 mg I−1) 3%, of lower limb amputations 4%, and of foot ulcers 7%. The prevalence of symmetrically impaired distal vibration perception was 23%, and 54% of patients either needed or were receiving chiropody. The prevalence of a corrected distant visual acuity of 6/12 or worse was 32% and of retinopathy of any degree was 26%. There was extensive co‐morbidity which was not confined to a single subgroup of patients.

Randomised trial of lipid lowering dietary advice in general practice: the effects on serum lipids, lipoproteins, and antioxidants

Abstract Objective: To determine the relative efficacy in general practice of dietary advice given by a dietitian, a practice nurse, or a diet leaflet alone in reducing total and low density lipoprotein cholesterol concentration. Design: Randomised six month parallel trial. Setting: A general practice in Oxfordshire. Subjects: 2004 subjects aged 35-64 years were screened for hypercholesterolaemia; 163 men and 146 women with a repeat total cholesterol concentration of 6.0-8.5 mmol/l entered the trial. Interventions: Individual advice provided by a dietitian using a diet history, a practice nurse using a structured food frequency questionnaire, or a detailed diet leaflet sent by post. All three groups were advised to limit the energy provided by fat to 30% or less and to increase carbohydrate and dietary fibre. Main outcome measures: Concentrations of total cholesterol and low density and high density lipoprotein cholesterol after six months; antioxidant concentration and body mass index. Results: No significant differences were found at the end of the trial between groups in mean concentrations of lipids, lipoproteins, and antioxidants or body mass index. After data were pooled from the three groups, the mean total cholesterol concentration fell by 1.9% (0.13 mmol/l, 95% confidence interval 0.06 to 0.22, P<0.001) to 7.00 mmol/l, and low density lipoprotein cholesterol also fell. The total carotenoid concentration increased by 53 nmol/l (95% confidence interval 3.0 to 103, P=0.039). Conclusions: Dietary advice is equally effective when given by a dietitian, a practice nurse, or a diet leaflet alone but results in only a small reduction in total and low density lipoprotein cholesterol. To obtain a better response more intensive intervention than is normally available in primary care is probably necessary. Key messages Key messages In this study dietary advice had only a modest effect on lipid and lipoprotein concentrations Personalised advice from a nurse or dietitian was no more effective than a detailed diet leaflet Antioxidant concentrations increased slightly, but this requires further study A mass approach to dietary change is needed to produce significant change

Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study.

Abstract Objective: To measure the costs and cost effectiveness of the Oxcheck cardiovascular risk factor screening and intervention programme. Design: Cost effectiveness analysis of a randomised controlled trial using clinical and economc data taken from the trial. Setting: Five general practices in Luton and Dunstable, England. Subjects: 2205 patients who attended a health check in 1989-90 and were scheduled for re-examination in 1992-3 (intervention group); 1916 patients who attended their initial health check in 1992-3 (control group). Participants were men and women aged 35-64years. Intervention: Health check conducted by nurse, with health education and follow up according to degree of risk. Main outcome measures: Cost of health check programme; cost per 1 % reduction in coronary risk. Results: Health check and follow up cost £29.27 per patient. Estimated programme cost per 1% reduction in coronary risk per participant was between £1.46 and £2.25; it was nearly twice as much for men as women. Conclusions: The cost to the practice of implementing Oxcheck-style health checks in an average sized practice of 7500 patients would be £47 000, a proportion of which could be paid for through staff pay reimbursements and Band Three health promotion target payments. This study highlights the considerable difficulties faced when calculating the costs and benefits of a health promotion programme. Economic evaluations should be integrated into the protocols of randomised controlled trials to enable judgments to be made on the relative cost effectiveness of different prevention strategies. Key messages Research was undertaken to estimate the cost of the health checks and relate the cost to changes in the relative risk of cardiovascular disease The immediate cost of implementing Oxcheck-style health checks in an average sized practice of 7500 patients would be £47 000, which is comparable with the immediate cost of a cervical screening programme The actual costs to the practice would be substantially reduced by staff pay reimbursements and health promotion target payments Further research is required to estimate the wider costs of health checks resulting from the additional use of health care services

The "Help Your Patient Stop" initiative. Evaluation of smoking prevalence and dissemination of WHO/UICC guidelines in UK general practice.

The World Health Organisation and the International Agency against Cancer in 1988 published joint guidelines on smoking cessation for primary health care teams. A booklet entitled Help Your Patient Stop was produced in the United Kingdom as a model for the international dissemination of these guidelines. This booklet was sent to UK general practitioners by post; about 4 weeks later, a random sample of 5000 were asked to complete a postal questionnaire about the booklet and their smoking habits. The response rate was 75%. About half (50.5%) remembered receiving the booklet, 27.7% had read it, and only 8.8% could write down any of the three essential activities in smoking cessation which the booklet was intended to promote and which were printed in bold letters on the inside back cover. Although the booklet itself might be an adequate model for other countries, unless dissemination and marketing of the information it contains can be improved, its achievement will be limited. However, the survey did have one optimistic feature: only 13.5% of general practitioners reported that they smoke; and only a third of those who gave full details of their smoking habit smoke cigarettes.

Sexual behaviour, contraceptive practice and knowledge of AIDS of Oxford University students

In 1987, a questionnaire was sent to 584 undergraduate students at Oxford University requesting information about their sexual behavior and contraceptive practices as well as the impact of acquired immunodeficiency syndrome (AIDS) on both these factors. Of the 374 responders, 65% of the women and 62% of the men had experienced sexual intercourse; 1st intercourse had occurred at ages 16-20 years for 89% of the experienced women and 83% of the men. For 36% of women and 37% of men intercourse had been with 1 partner only, for 28% of women and 27% of men with 2-3 partners, and for 36% of both men and women with more than 3 partners. 27% of the women reported no contraceptive was used at the time of 1st intercourse. During the 4 weeks preceding completion of the questionnaire, 15% of sexually active female undergraduates reported not using adequate contraception. Users during this period selected the pill (64%), condom (19%), IUD or diaphragm (9%), or withdrawal/rhythm (8%). General knowledge about AIDS was highly accurate among these students. Most students considered themselves to be at lower risk of contracting AIDS than others of their age and sex. Of the 78% of students describing themselves as at lower than average risk, 14% had had intercourse with more than 3 partners, while 50% of the 20% of students who ranked themselves as at average risk had this number of partners. Only 2% placed themselves as at above average risk, and 65% of these students had had more than 3 sexual partners. Of students who were sexually active, 35% of the females and 44% of the males indicated they are now more likely to use a condom because of fear of AIDS. 49% of the females and 30% of the males indicated they had, or would have, fewer sexual partners because of the AIDS risk. However, there was no association between increased likelihood of condom use and the total number of sexual partners and having had intercourse with someone in a high-risk group for AIDS (prostitutes). Overall, however, these findings suggest that the AIDS threat is producing reductions in high-risk behaviors.

Nicotine replacement therapy for a healthier nation: Nictotine replacement is cost effective and should be prescribable on the NHS

News p 1271 The aims of the British governments health policy are to improve the health of the population as a whole and to reduce health inequalities.1 Specific reductions in mortality in four areas (cardiovascular disease, cancer, accidents, and mental health) are set as targets. In the search for specific action to meet these targets helping people to stop smoking would seem to be an obvious candidate. The World Health Organisation has identified smoking as the single most important preventable cause of death in Europe.2 Cigarette smoking is a major cause of morbidity and mortality in two of the governments target areas: cardiovascular disease and cancer.1 Evidence continues to accrue of a contributory role for smoking in a range of other diseases, such as fractures of the hip due to reduced bone mineral density. The adverse health effects of smoking are …

Pharmacoeconomic Considerations in the Management of Smoking Cessation

Smokers are more likely to develop a variety of serious diseases than nonsmokers; the morbidity and mortality from these diseases place a great resource burden on society in respect of demands on healthcare resources and lost productivity.The cost to the healthcare system of treating the consequences of smoking is high. Given the availability of inexpensive pharmaceutical therapies such as sustained-release bupropion (bupropion SR) and nicotine replacement therapy (NRT), which are proven to be effective, there is economic advantage for governments and the medical profession in encouraging patients to quit. The cost effectiveness of effective smoking cessation support is far superior to that of many other potentially life-saving interventions and, indeed, the UK National Institute for Clinical Excellence (NICE) stated in April 2002 that ‘both bupropion and NRT are considered to be amongst the most effective of all healthcare interventions’. Recent economic analyses have confirmed that the use of bupropion SR as an aid to smoking cessation is a highly cost-effective intervention.

Secondary Prevention after Myocardial Infarction: How completely are research findings adopted in practice?

Objectives: Clinical trials have demonstrated that secondary prevention of myocardial infarction is effective, but several studies have suggested that research findings are not adequately implemented in routine clinical practice. This study aimed to determine whether these findings are now being more fully implemented.Methods: A cohort of 608 patients aged less than 80 years, surviving more than 28 days after an acute myocardial infarction, was identified from a population of 568,000 people in Oxfordshire, UK, during a 12-month period from November 1994. The MONICA Project diagnostic criteria for definite or possible myocardial infarction were used to define cases. Hospital and general practice casenotes were reviewed and survivors were asked to complete a questionnaire.Results: Among patients without contraindications to treatment, 430 were prescribed aspirin (97%), 277 β-blockers (66%), and 77 ACE inhibitors (85%) in the first three months after the acute event. Of these drugs, 705 (90%) were prescribed...