Tim Lancaster

Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library

Peto estimates that current cigarette smoking will cause about 450 million deaths worldwide in the next 50 years. Reducing current smoking by 50% would avoid 20–30 million premature deaths in the first quarter of the century and about 150 million in the second quarter.1 Preventing young people from starting smoking would cut the number of deaths related to tobacco, but not until after 2050. Quitting by current smokers is therefore the only way in which tobacco related mortality can be reduced in the medium term. There is evidence that some form of treatment aids an increasing number of successful attempts to quit.2 This review aims to summarise evidence for the effectiveness of the available interventions. #### Summary points Advice from doctors, structured interventions from nurses, and individual and group counselling are effective interventions Generic self help materials are no better than brief advice but more effective than doing nothing; personalised materials are more effective than standard materials All forms of nicotine replacement therapy are effective The antidepressants bupropion and nortriptyline increased quit rates in a small number of trials; the usefulness of the antihypertensive drug clonidine is limited by side effects Anxiolytics and lobeline are ineffective The effectiveness of aversion therapy, mecamylamine, acupuncture, hypnotherapy, and exercise is uncertain The Cochrane Tobacco Addiction Review group identifies and summarises the evidence for interventions to reduce and prevent tobacco use; it produces and maintains systematic reviews to inform policymakers, clinicians, and individuals wishing to stop smoking. Twenty systematic reviews are available in the Cochrane Library and have contributed to the evidence base for smoking cessation guidelines.3 Details of the methods and results of each review are available in the Cochrane Library (abstracts at www.update-software.com/ccweb/cochrane/revabstr/g160index.htm). The reviews summarise results from randomised controlled trials with at least six …

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

A systematic review of interventions for smokers who contact quitlines

Objective: To evaluate the effect of different types of adjunctive support to stop smoking for individuals contacting telephone “quitlines,” including call-back counselling, different counselling techniques and provision of self help materials. Data sources: This review includes quitline studies identified as part of Cochrane reviews of telephone counselling and self help materials for smoking cessation. We updated the searches for this review. Study selection: We included studies that were randomised or quasi-randomised controlled trials of any quitline or related service with follow-up of at least six months. Data extraction: Data were extracted by one author and checked by a second. The cessation outcome was numbers quit at longest follow-up taking the strictest definition of abstinence available, and assuming participants lost to follow-up continued to smoke. Data synthesis: We identified 14 relevant studies. Eight studies (18 500 participants) comparing multiple call-backs to a single contact increased quitting in the intervention group (Mantel-Haenszel fixed effect odds ratio 1.41, 95% confidence interval 1.27 to 1.57). Two unpublished studies without sufficient data to include in the meta-analysis also reported positive effects. Three call-back trials compared two schedules of multiple calls. Two found a significant dose-response effect and one did not detect a difference. We did not find consistent differences in comparisons between counselling approaches (two trials) or between different types of self help materials supplied following quitline contact (three trials). Conclusions: Multiple call-back counselling improves long term cessation for smokers who contact quitline services. Offering more calls may improve success rates. We failed to detect an effect of the type of counselling or the type of self help materials supplied as adjuncts to quitline counselling.

Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews.

BACKGROUND AND AIMS The Cochrane Collaboration is an international not-for-profit organization which produces and disseminates systematic reviews of health-care interventions. This paper is the first in a series of annual updates of Cochrane reviews on tobacco addiction interventions. It also provides an up-to-date overview of review findings in this area to date and summary statistics for cessation reviews in which meta-analyses were conducted. METHODS In 2012, the Group published seven new reviews and updated 13 others. This update summarizes and comments on these reviews. It also summarizes key findings from all the other reviews in this area. RESULTS New reviews in 2012 found that in smokers using pharmacotherapy, behavioural support improves success rates [risk ratio (RR) 1.16, 95% confidence interval (CI) = 1.09-1.24], and that combining behavioural support and pharmacotherapy aids cessation (RR 1.82, 95% CI = 1.66-2.00). Updated reviews established mobile phones as potentially helpful in aiding cessation (RR 1.71, 95% CI = 1.47-1.99), found that cytisine (RR 3.98, 95% CI = 2.01-7.87) and low-dose varenicline (RR 2.09, 95% CI = 1.56-2.78) aid smoking cessation, and found that training health professionals in smoking cessation improves patient cessation rates (RR 1.60, 95% CI = 1.26-2.03). The updated reviews confirmed the benefits of nicotine replacement therapy, standard dose varenicline and providing cessation treatment free of charge. Lack of demonstrated efficacy remained for partner support, expired-air carbon monoxide feedback and lung function feedback. CONCLUSIONS Cochrane systematic review evidence for the first time establishes the efficacy of behavioural support over and above pharmacotherapy, as well as the efficacy of cytisine, mobile phone technology, low-dose varenicline and health professional training in promoting smoking cessation.

Pharmacological treatments for smoking cessation.

CLINICAL QUESTION Among the 3 first-line smoking cessation treatments (nicotine replacement therapy [NRT], bupropion, and varenicline), which is most effective in helping people who smoke achieve and maintain abstinence from smoking for at least 6 months, and what serious adverse events are associated with each? BOTTOM LINE Higher rates of smoking cessation were associated with NRT (17.6%) and bupropion (19.1%) compared with placebo (10.6%). Varenicline (27.6%) and combination NRT (31.5%) (eg, patch plus inhaler) were most effective for achieving smoking cessation. None of the therapies was associated with an increased rate of serious adverse events.

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

Nortriptyline for smoking cessation : A review

This article reviews the efficacy of nortriptyline for smoking cessation based on a meta-analysis of the Cochrane Library. Six placebo-controlled trials have shown nortriptyline (75-100 mg) doubles quit rates (OR = 2.1). Between 4% and 12% of smokers dropped out because of adverse events, but no serious adverse events occurred. The efficacy of nortriptyline did not appear to be related to its antidepressant actions. Nortriptyline is an efficacious aid to smoking cessation with a magnitude of effect similar to that for bupropion and nicotine replacement therapies. Whether nortriptyline produces serious side effects at these doses in healthy, nondepressed smokers remains unclear because it has been tested in only 500 smokers. The finding that nortriptyline and bupropion are effective for smoking cessation but that selective serotonin-reuptake inhibitors are not suggests that dopaminergic or adrenergic, but not serotonergic, activity is important for cessation efficacy. Until further studies can verify a low incidence of significant adverse events, nortriptyline should be a second-line treatment for smoking cessation.

A Preliminary Benefit-Risk Assessment of Varenicline in Smoking Cessation

Varenicline is a recently developed medication for smoking cessation, which has been available on prescription since 2006. It is a selective nicotinic acetylcholine receptor partial agonist, and is designed to reduce withdrawal symptoms and to lessen the rewards of continued smoking. Our objective in this article is to assess the efficacy of varenicline as an aid to smoking cessation and to weigh the potential benefits against the possible risks. We identified ten randomized controlled trials and one cohort study with historical controls. In total there were 7999 participants, 5112 of whom received varenicline. Eight of the trials compared varenicline with placebo for cessation, two compared it with nicotine replacement therapy and one tested extended use for relapse prevention. Three of the varenicline/placebo trials also included a bupropion arm. The recommended dosage of varenicline 1 mg twice daily more than doubled the chances of quitting at 6 months or longer, with a relative risk (RR) compared with placebo of 2.38 (95% CI 2.00, 2.84). It also outperformed bupropion (RR 1.52 [95% CI 1.22, 1.88]) and nicotine replacement (RR 1.31 [95%CI 1.01,1.71]). A reduced dosage regimen of 1 mg daily also increased cessation (RR 1.88 [95% CI 1.35, 2.60]). In the trials, varenicline significantly reduced craving and other withdrawal symptoms. The most frequent adverse event was nausea, occurring in 30–40% of varenicline users. However, this was generally reported at mild to moderate levels, diminished over time and was associated with attributable discontinuation rates of between 0.6% and 7.6%. Other commonly occurring adverse events included insomnia, abnormal dreams and headache. Serious adverse events were rare, with no treatment-related deaths during the treatment or follow-up phases.Postmarketing surveillance has raised new questions about the safety of varenicline. In February 2008, the US FDA issued a public health advisory note, reporting a possible association between varenicline and an increased risk of behaviour change, agitation, depressed mood, and suicidal ideation and behaviour. They have required the manufacturers to revise the labelling of varenicline and the Summary of Product Characteristics, and to issue a medication guide. It is arguable that much of the reported behavioural and mood changes may be associated with nicotine withdrawal, although some effects occurred in people who continued to smoke while taking the medication. In view of the potential, if unproven, risk that varenicline may be associated with serious neuropsychiatric adverse outcomes, patients attempting to quit smoking with varenicline, and their families and caregivers, should be alerted about the need to monitor for neuropsychiatric symptoms, including changes in behaviour, agitation, depressed mood, suicidal ideation and sui-cidal behaviour, and to report such symptoms immediately to the patient’s healthcare provider.

A systematic review of interventions for preventing tobacco sales to minors

OBJECTIVE To assess the effectiveness of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales. METHOD Systematic literature review. DATA SOURCES The Cochrane Tobacco Addiction group specialised register and Medline. Studies of interventions to alter retailer behaviour were identified. The terms used for searching combined terms for smoking and tobacco use with terms for minors, children or young people, and retailers, sales or commerce. STUDY SELECTION Studies in which there was an intervention with retailers of tobacco, either through education about, or enforcement of, local ordinances. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young peoples perceived ease of access to tobacco products, and changes in smoking behaviour. Controlled studies with or without random allocation of retail outlets or communities, and uncontrolled studies with pre- and post intervention assessment, were included. DATA EXTRACTION Two reviewers assessed studies for inclusion. One extracted data with checking by the second. DATA SYNTHESIS The results were synthesised qualitatively, with greater weight given to controlled studies. Thirteen of 27 included studies used controls. RESULTS Giving retailers information was less effective in reducing illegal sales than active enforcement and/or multicomponent educational strategies. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking. CONCLUSIONS Interventions with retailers can lead to large decreases in the number of outlets selling tobacco to youths. However, few of the communities studied in this review achieved sustained levels of high compliance. This may explain why there is limited evidence for an effect of intervention on youth perception of ease of access to tobacco, and on smoking behaviour.

Interventions for smoking cessation in hospitalised patients: a systematic review

BACKGROUND An admission to hospital provides an opportunity to help people stop smoking. Individuals may be more open to help at a time of perceived vulnerability, and may find it easier to quit in an environment where smoking is restricted or prohibited. Providing smoking cessation services during hospitalisation may help more people to attempt and sustain an attempt to quit. The purpose of this paper is to systematically review the effectiveness of interventions for smoking cessation in hospitalised patients. METHODS We searched the Cochrane Tobacco Addiction Group register, CINAHL, and the Smoking and Health database for studies of interventions for smoking cessation in hospitalised patients. Randomised and quasi-randomised trials of behavioural, pharmacological, or multi-component interventions to help patients stop smoking conducted with hospitalised patients who were current smokers or recent quitters were included. Studies of patients admitted for psychiatric disorders or substance abuse, those that did not report abstinence rates, and those with follow up of less than 6 months were excluded. Two of the authors extracted data independently for each paper, with assistance from others. RESULTS Intensive intervention (inpatient contact plus follow up for at least 1 month) was associated with a significantly higher cessation rate compared with controls (Peto odds ratio (OR) 1.82, 95% CI 1.49 to 2.22). Any contact during hospitalisation followed by minimal follow up failed to detect a statistically significant effect on cessation rate, but did not rule out a 30% increase in smoking cessation (Peto OR 1.09, 95% CI 0.91 to 1.31). There was insufficient evidence to judge the effect of interventions delivered only during the hospital stay. Although the interventions increased quit rates irrespective of whether nicotine replacement therapy (NRT) was used, the results for NRT were compatible with other data indicating that it increases quit rates. There was no strong evidence that clinical diagnosis affected the likelihood of quitting. CONCLUSIONS High intensity behavioural interventions that include at least 1 month of follow up contact are effective in promoting smoking cessation in hospitalised patients.