The effectiveness of covering smoking cessation services for medicare beneficiaries

Eliminating the Medicare Coverage Gap for Intranasal Naloxone and Nicotine Replacement Therapy

This Viewpoint explores how FDA approval of intranasal naloxone and nicotine replacement therapy as over-the-counter drugs adversely affects Medicare patients because the treatments are no longer covered and urges policymakers to address this coverage gap.

Cost-Effectiveness Analysis of Smoking Cessation Interventions With Behavioral Support: A Study Based on the Benefits of Smoking Cessation on Outcomes (BENESCO) Model

INTRODUCTION

Few studies have compared cost-effectiveness of different smoking cessation interventions (SCIs) that include behavioral support, considering smoking-related diseases. Therefore, we compare the cost-effectiveness of SCIs with behavioral support in South Korea using the Benefits of Smoking Cessation on Outcomes (BENESCO) model.

AIMS AND METHODS

We used the BENESCO model to estimate the cost and utility of the SCIs with behavioral support, including pharmacist counseling with nicotine replacement therapy (pharmacist+NRT), expert counseling with NRT (expert+NRT), and expert counseling with varenicline (expert+varenicline). The target population was adult smokers who wanted to cease smoking within 1 month. We applied transitional probabilities and epidemiological data from the literature. Medical costs and utilities were calculated using claims and national survey data, respectively. Cost-effectiveness was evaluated within the threshold (17 926 USD per quality-adjusted life years [QALYs]) by incremental cost-effectiveness ratio (ICER).

RESULTS

The model cohort included 1 219 390 male and 298 511 female smokers. The pharmacist+NRT group had 32 842 more QALYs gained and 26 689 958 USD less expended than the expert+NRT group. The ICER for the expert+varenicline group versus the pharmacist+NRT and expert+NRT groups was 27 247 and 4074 USD per QALY, respectively. The robustness of the results was confirmed by sensitivity analyses, except for the discount rate and cost of the expert+varenicline group.

CONCLUSIONS

In Korea, pharmacist counseling with NRT showed higher QALY gains and lower costs than expert counseling with NRT. Expert counseling with varenicline was more effective for smoking cessation and more cost-effective than expert counseling with NRT but was not cost-effective compared with pharmacist counseling with NRT.

IMPLICATIONS

This study provides evidence for decision-making on smoking cessation programs by evaluating the cost-effectiveness of SCIs. Furthermore, we attempted to use the BENESCO model to compare and evaluate the cost-effectiveness of SCIs with behavioral support. It is meaningful because this study showed the availability of using the BENESCO model in the future cost-effectiveness analysis of various SCIs.

A Randomized Trial of Telephone-Based Smoking Cessation Treatment in the Lung Cancer Screening Setting

BACKGROUND

Lung cancer mortality is reduced via low-dose CT screening and treatment of early-stage disease. Evidence-based smoking cessation treatment in the lung screening setting can further reduce mortality. We report the results of a cessation trial from the NCI's SCALE collaboration.

METHODS

Eligible patients (N = 818) aged 50-80 were randomized (May 2017-January 2021) to the Intensive vs. Minimal arms (8 vs. 3 phone sessions plus 8 vs. 2 weeks of nicotine patches, respectively). Bio-verified (primary) and self-reported 7-day abstinence rates were assessed 3-, 6-, and 12-months post-randomization. Logistic regression analyses evaluated the effects of study arm. All statistical tests were two-sided.

RESULTS

Participants reported 48.0 (SD = 17.2) pack-years and 51.6% were not ready to quit in < 30 days. Self-reported 3-month quit rates were significantly higher in the Intensive vs. Minimal arm (14.3% vs. 7.9%; OR = 2.00, 95% confidence interval [CI] = 1.26,3.18). Bio-verified abstinence was lower but with similar relative differences between arms (9.1% vs. 3.9%; OR = 2.70, 95% CI = 1.44, 5.08). Compared to the Minimal arm, the Intensive arm was more effective among those with greater nicotine dependence (OR = 3.47, 95% CI = 1.55, 7.76), normal screening results (OR = 2.58, 95% CI = 1.32, 5.03), high engagement in counseling (OR = 3.03, 95% CI = 1.50, 6.14) and patch use (OR = 2.81, 95% CI = 1.39, 5.68). Abstinence rates did not differ significantly between arms at 6-months (OR = 1.2, 95% CI = 0.68, 2.11) or 12-months (OR = 1.4, 95% CI = 0.82, 2.42).

CONCLUSIONS

Delivering intensive telephone counseling and nicotine replacement with lung screening is an effective strategy to increase short-term smoking cessation. Methods to maintain short-term effects are needed. Even with modest quit rates, integrating cessation treatment into lung screening programs may have a large impact on tobacco-related mortality.

Cost-Effectiveness of a Telephone-Based Smoking Cessation Randomized Trial in the Lung Cancer Screening Setting

BACKGROUND

There are limited data on the cost-effectiveness of smoking cessation interventions in lung cancer screening settings. We conducted an economic analysis embedded in a national randomized trial of 2 telephone counseling cessation interventions.

METHODS

We used a societal perspective to compare the short-term cost per 6-month bio-verified quit and long-term cost-effectiveness of the interventions. Trial data were used to micro-cost intervention delivery, and the data were extended to a lifetime horizon using an established Cancer Intervention Surveillance and Modeling Network lung cancer model. We modeled the impact of screening accompanied by 8 weeks vs 3 weeks of telephone counseling (plus nicotine replacement) vs screening alone based on 2021 screening eligibility. Lifetime downstream costs (2021 dollars) and effects (life-years gained, quality-adjusted life-years [QALYs]) saved were discounted at 3%. Sensitivity analyses tested the effects of varying quit rates and costs; all analyses assumed nonrelapse after quitting.

RESULTS

The costs for delivery of the 8-week vs 3-week protocol were $380.23 vs $144.93 per person, and quit rates were 7.14% vs 5.96%, respectively. The least costly strategy was a 3-week counseling approach. An 8-week (vs 3-week) counseling approach increased costs but gained QALYs for an incremental cost-effectiveness ratio of $4029 per QALY. Screening alone cost more and saved fewer QALYs than either counseling strategy. Conclusions were robust in sensitivity analyses.

CONCLUSIONS

Telephone-based cessation interventions with nicotine replacement are considered cost-effective in the lung screening setting. Integrating smoking cessation interventions with lung screening programs has the potential to maximize long-term health benefits at reasonable costs.

Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes.

OBJECTIVES

To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes.

DESIGN

Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results.

SETTING

Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes.

PARTICIPANTS

Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes.

INTERVENTIONS

Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies.

MAIN OUTCOME MEASURES

Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events.

DATA SOURCES

Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019.

REVIEW METHODS

Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model.

RESULTS

Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard.

LIMITATIONS

Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified.

CONCLUSIONS

Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK.

FUTURE WORK

Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041302.

FUNDING

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. 25, No. 59. See the NIHR Journals Library website for further project information.

Smoking-Related Health Beliefs in a Sample of Psychiatric Patients: Factors Associated with the Health Beliefs and Validation of the Health Belief Questionnaire

This study examined the (a) health beliefs and emotions (perception of risk, benefits, severity, and worry) about smoking among current and former smokers, (b) their awareness of health warnings, (c) factors associated with smoking-related health beliefs, and (d) the factor structure of the health belief questionnaire. Participants (n = 184) were recruited from a tertiary psychiatric care hospital. Current smokers showed a significantly higher risk perception and lower perceived benefits compared to former smokers. Younger age (<40 years), nicotine dependence (ND), a history of smoking-related diseases (SRD), and intention to quit were significantly associated with a higher risk perception in current smokers. Younger age, a history of SRDs, and motivation to quit were positively associated with health beliefs, while the latter two were associated with worry. Motivation and younger age were associated with a better perception of benefits and severity. Information on the cigarette packets was the major source of awareness for the sample, and 69% reported that existing campaigns were not effective in discouraging their smoking. Personalized risk communication and educational initiatives must focus on improving the knowledge of risk, benefits, and increase motivation to promote health cognition and thus smoking cessation.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

BACKGROUND

Pharmacotherapies for smoking cessation increase the likelihood of achieving abstinence in a quit attempt. It is plausible that providing support, or, if support is offered, offering more intensive support or support including particular components may increase abstinence further.

OBJECTIVES

To evaluate the effect of adding or increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition. We also looked at studies which directly compare behavioural interventions matched for contact time, where pharmacotherapy is provided to both groups (e.g. tests of different components or approaches to behavioural support as an adjunct to pharmacotherapy).

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP in June 2018 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline, that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount or type of behavioural support. The intervention condition had to involve person-to-person contact (defined as face-to-face or telephone). The control condition could receive less intensive personal contact, a different type of personal contact, written information, or no behavioural support at all. We excluded trials recruiting only pregnant women and trials which did not set out to assess smoking cessation at six months or longer.

DATA COLLECTION AND ANALYSIS

For this update, screening and data extraction followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates, if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

Eighty-three studies, 36 of which were new to this update, met the inclusion criteria, representing 29,536 participants. Overall, we judged 16 studies to be at low risk of bias and 21 studies to be at high risk of bias. All other studies were judged to be at unclear risk of bias. Results were not sensitive to the exclusion of studies at high risk of bias. We pooled all studies comparing more versus less support in the main analysis. Findings demonstrated a benefit of behavioural support in addition to pharmacotherapy. When all studies of additional behavioural therapy were pooled, there was evidence of a statistically significant benefit from additional support (RR 1.15, 95% CI 1.08 to 1.22, I² = 8%, 65 studies, n = 23,331) for abstinence at longest follow-up, and this effect was not different when we compared subgroups by type of pharmacotherapy or intensity of contact. This effect was similar in the subgroup of eight studies in which the control group received no behavioural support (RR 1.20, 95% CI 1.02 to 1.43, I² = 20%, n = 4,018). Seventeen studies compared interventions matched for contact time but that differed in terms of the behavioural components or approaches employed. Of the 15 comparisons, all had small numbers of participants and events. Only one detected a statistically significant effect, favouring a health education approach (which the authors described as standard counselling containing information and advice) over motivational interviewing approach (RR 0.56, 95% CI 0.33 to 0.94, n = 378).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking increases quit rates. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 20%, based on a pooled estimate from 65 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support. More research is needed to assess the effectiveness of specific components that comprise behavioural support.

Study protocol for a telephone-based smoking cessation randomized controlled trial in the lung cancer screening setting: The lung screening, tobacco, and health trial

Lung cancer mortality can be reduced by 20% via low dose CT lung cancer screening (LCS) and treatment of early-stage disease. Providing tobacco use treatment to high risk cigarette smokers in the LCS setting may result in health benefits beyond the impact of LCS. As one of the nine trials in the National Cancer Institute's Smoking Cessation at Lung Examination (SCALE) collaboration, the goal of the Lung Screening, Tobacco, and Health (LSTH) trial is to develop a scalable and cost-effective cessation intervention for subsequent implementation by LCS programs. Guided by the RE-AIM Framework, the LSTH trial is a two-arm RCT (N = 1330) enrolling English- and Spanish-speaking smokers registered for LCS at one of seven collaborating sites. Participants are randomly assigned to Usual Care (UC; three proactive telephone counseling sessions/two weeks of nicotine patches) vs. Intensive Telephone Counseling (ITC; eight proactive sessions/eight weeks of nicotine patches, plus discussion of the LCS results to increase motivation to quit). Telephone counseling is provided by tobacco treatment specialists. To increase continuity of care, referring physicians are notified of participant enrollment and smoking status following the intervention. Outcomes include: 1) self-reported 7-day, 30-day, and sustained abstinence, and biochemically-verified at 3-, 6-, and 12-months post-randomization, 2) reach and engagement of the interventions, and 3) cost-effectiveness of the interventions. The Cancer Intervention and Surveillance Modeling Network (CISNET) will model long-term impacts of six SCALE trials on the cost per life year saved, quality-adjusted life years saved, lung cancer mortality reduction, and population mortality. CLINICAL TRIALS REGISTRATION: The trial is registered at clinical trials.gov: NCT03200236.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I2 statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I2 = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I2 = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I2 = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

Tobacco smoking is the leading preventable cause of death worldwide, which makes it essential to stimulate smoking cessation. The financial cost of smoking cessation treatment can act as a barrier to those seeking support. We hypothesised that provision of financial assistance for people trying to quit smoking, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. This is an update of the original 2005 review.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs for tobacco smokers or healthcare providers for using or providing smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use or prescription of smoking cessation treatment, or both, and on the number of smokers making a quit attempt (quitting smoking for at least 24 hours). We also assessed the cost effectiveness of different financial interventions, and analysed the costs per additional quitter, or per quality-adjusted life year (QALY) gained.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in September 2016.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers, or both.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the quality of the included studies. We calculated risk ratios (RR) for individual studies on an intention-to-treat basis and performed meta-analysis using a random-effects model.

MAIN RESULTS

In the current update, we have added six new relevant studies, resulting in a total of 17 studies included in this review involving financial interventions directed at smokers or healthcare providers, or both.Full financial interventions directed at smokers had a favourable effect on abstinence at six months or longer when compared to no intervention (RR 1.77, 95% CI 1.37 to 2.28, I² = 33%, 9333 participants). There was no evidence that full coverage interventions increased smoking abstinence compared to partial coverage interventions (RR 1.02, 95% CI 0.71 to 1.48, I² = 64%, 5914 participants), but partial coverage interventions were more effective in increasing abstinence than no intervention (RR 1.27 95% CI 1.02 to 1.59, I² = 21%, 7108 participants). The economic evaluation showed costs per additional quitter ranging from USD 97 to USD 7646 for the comparison of full coverage with partial or no coverage.There was no clear evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%, 2311 participants).Full financial interventions increased the number of participants making a quit attempt when compared to no interventions (RR 1.11, 95% CI 1.04 to 1.17, I² = 15%, 9065 participants). There was insufficient evidence to show whether partial financial interventions increased quit attempts compared to no interventions (RR 1.13, 95% CI 0.98 to 1.31, I² = 88%, 6944 participants).Full financial interventions increased the use of smoking cessation treatment compared to no interventions with regard to various pharmacological and behavioural treatments: nicotine replacement therapy (NRT): RR 1.79, 95% CI 1.54 to 2.09, I² = 35%, 9455 participants; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%, 6321 participants; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65, I² = 75%, 9215 participants.There was evidence that partial coverage compared to no coverage reported a small positive effect on the use of bupropion (RR 1.15, 95% CI 1.03 to 1.29, I² = 0%, 6765 participants). Interventions directed at healthcare providers increased the use of behavioural therapy (RR 1.69, 95% CI 1.01 to 2.86, I² = 85%, 25820 participants), but not the use of NRT and/or bupropion (RR 0.94, 95% CI 0.76 to 1.18, I² = 6%, 2311 participants).We assessed the quality of the evidence for the main outcome, abstinence from smoking, as moderate. In most studies participants were not blinded to the different study arms and researchers were not blinded to the allocated interventions. Furthermore, there was not always sufficient information on attrition rates. We detected some imprecision but we judged this to be of minor consequence on the outcomes of this study.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting. There was no clear and consistent evidence of an effect on smoking cessation from financial incentives directed at healthcare providers. We are only moderately confident in the effect estimate because there was some risk of bias due to a lack of blinding in participants and researchers, and insufficient information on attrition rates.

A Proactive Telephone-Delivered Risk Communication Intervention for Smokers Participating in Lung Cancer Screening: A Pilot Feasibility Trial

Introduction: Many barriers exist to integrating smoking cessation into delivery of lung cancer screening including limited provider time and patient misconceptions.

Aims: To demonstrate that proactive outreach from a telephone counsellor outside of the patient's usual care team is feasible and acceptable to patients.

Methods: Smokers undergoing lung cancer screening were approached for a telephone counselling study. Patients agreeing to participate in the intervention (n = 27) received two telephone counselling sessions. A 30-day follow-up evaluation was conducted, which also included screening participants receiving usual care (n = 56).

Results/Findings: Most (89%) intervention participants reported being satisfied with the proactive calls, and 81% reported the sessions were helpful. Use of behavioural cessation support programs in the intervention group was four times higher (44%) compared to the usual care group (11%); Relative Risk (RR) = 4.1; 95% CI: 1.7 to 9.9), and seven-day abstinence in the intervention group was double (19%) compared to the usual care group (7%); RR = 2.6; 95% CI: 0.8 to 8.9).

Conclusions: This practical telephone-based approach, which included risk messages clarifying continued risks of smoking in the context of screening results, suggests such messaging can boost utilisation of evidence-based tobacco treatment, self-efficacy, and potentially increase the likelihood of successful quitting.

Preliminary evaluation of a telephone-based smoking cessation intervention in the lung cancer screening setting: A randomized clinical trial

Incorporating effective smoking cessation interventions into lung cancer screening (LCS) programs will be essential to realizing the full benefit of screening. We conducted a pilot randomized trial to determine the feasibility and efficacy of a telephone-counseling (TC) smoking cessation intervention vs. usual care (UC) in the LCS setting. In collaboration with 3 geographically diverse LCS programs, we enrolled current smokers (61.5% participation rate) who were: registered to undergo LCS, 50-77 years old, and had a 20+ pack-year smoking history. Eligibility was not based on readiness to quit. Participants completed pre-LCS (T0) and post-LCS (T1) telephone assessments, were randomized to TC (N=46) vs. UC (N=46), and completed a final 3-month telephone assessment (T2). Both study arms received a list of evidence-based cessation resources. TC participants also received up to 6 brief counseling calls with a trained cessation counselor. Counseling calls incorporated motivational interviewing and utilized the screening result as a motivator for quitting. The outcome was biochemically verified 7-day point prevalence cessation at 3-months post-randomization. Participants (56.5% female) were 60.2 (SD=5.4) years old and reported 47.1 (SD=22.2) pack years; 30% were ready to stop smoking in the next 30 days. TC participants completed an average of 4.4 (SD=2.3) sessions. Using intent-to-treat analyses, biochemically verified quit rates were 17.4% (TC) vs. 4.3% (UC), p<.05. This study provides preliminary evidence that telephone-based cessation counseling is feasible and efficacious in the LCS setting. As millions of current smokers are now eligible for lung cancer screening, this setting represents an important opportunity to exert a large public health impact on cessation among smokers who are at very high risk for multiple tobacco-related diseases. If this evidence-based, brief, and scalable intervention is replicated, TC could help to improve the overall cost-effectiveness of LCS.

TRIAL REGISTRATION

NCT02267096, https://clinicaltrials.gov.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Trends in Use of Medications for Smoking Cessation in Medicare, 2007-2012

INTRODUCTION

Smoking-related disease accounts for 10% of Medicare expenditures. Although clinical guidelines recommend smoking-cessation medications, they are subject to safety warnings from the U.S. Food and Drug Administration (FDA). This study investigated trends in utilization of smoking-cessation medications in Medicare from 2007 to 2012.

METHODS

Data on medical claims and prescription drugs for a nationally representative sample of Medicare beneficiaries were used to study trends from 2007 to 2012 in use of smoking-cessation medications (bupropion, nicotine-replacement therapy, varenicline), among beneficiaries who used tobacco (N=205,675). Analyses were conducted in 2015. Multinomial logistic regression was used to examine differences in use of bupropion, nicotine-replacement therapy, varenicline, or more than one medication, relative to none, by beneficiaries' health and demographic characteristics. Binary logistic regression calculated average predicted probabilities of cardiovascular disease or depression among medication users before and after FDA safety warnings related to those conditions.

RESULTS

Sixteen percent of tobacco users ever filled a prescription for a smoking-cessation medication. The proportion of beneficiaries who filled prescriptions for varenicline increased in 2007 but sharply declined corresponding to public warnings about adverse effects, although the same trends did not occur for bupropion or nicotine-replacement therapy. After FDA safety concerns were published, the average predicted probability of beneficiaries filling varenicline prescriptions with cardiovascular disease declined by 31%, although the average predicted probability of depression did not decline.

CONCLUSIONS

Use of smoking-cessation medications among Medicare beneficiaries remains low. Health effects of Medicare policies that increase coverage for medical support for smoking cessation may be limited by low utilization of effective medications.

Trends in cigarette smoking and cessation among Medicare managed care recipients, 2005-2012

OBJECTIVES

To examine recent trends in cigarette smoking among older (65 years and above) adults in the United States.

METHODS

We used data from the Medicare Health Outcomes Survey dataset to estimate rates of smoking, quitting, and (re)starting from 2005 to 2012. Medicare Advantage enrollees completed mail surveys at baseline and two years later. We included subgroup analyses by sex, race, and self-rated health.

RESULTS

Smoking prevalence declined slightly, with most of the decline occurring over the course of a single year (2007-2008). Rates of quitting declined slightly (meaning fewer people were quitting), and (re)starting marginally declined from 2005 to 2012. There were no substantial differences between subgroups. We did not observe any significant changes in prevalence or cessation of smoking among Medicare Advantage participants during this time.

CONCLUSIONS

Smoking remains a public health problem for older adults. We did not find evidence of significant changes in smoking prevalence or cessation for older adults during the time period we examined.

Combined pharmacotherapy and behavioural interventions for smoking cessation

BACKGROUND

Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear.

OBJECTIVES

To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2015 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by two authors. Data was extracted by one author and checked by another.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Fifty-three studies with a total of more than 25,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the six studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 52 studies (19,488 participants) there was high quality evidence (using GRADE) for a benefit of combined pharmacotherapy and behavioural treatment compared to usual care, brief advice or less intensive behavioural support (RR 1.83, 95% CI 1.68 to 1.98) with moderate statistical heterogeneity (I² = 36%).The pooled estimate for 43 trials that recruited participants in healthcare settings (RR 1.97, 95% CI 1.79 to 2.18) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Compared to the first version of the review, previous weak evidence of differences in other subgroup analyses has disappeared. We did not detect differences between subgroups defined by motivation to quit, treatment provider, number or duration of support sessions, or take-up of treatment.

AUTHORS' CONCLUSIONS

Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Updating this review with an additional 12 studies (5,000 participants) did not materially change the effect estimate. Although trials differed in the details of their populations and interventions, we did not detect any factors that modified treatment effects apart from the recruitment setting. We did not find evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects.

Pharmacological Smoking Cessation Therapies in Older Adults: A Review of the Evidence

Nearly 12% of adults 65 years and over in Europe and 9% in the USA are current cigarette smokers. Numerous studies have demonstrated tangible benefits of smoking cessation, regardless of advanced age. However, it is unclear which pharmacotherapy strategies are most effective in the elderly population. To that end, the literature on smoking cessation in older adults was reviewed with the aim of identifying the safest and most effective cessation pharmacotherapies. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for all articles pertaining to elderly smoking cessation strategies. Randomized controlled trials and cohort studies were included. Studies were included without regard to population or intervention, as long as results were analyzed with a group of smokers aged 60 years and above and at least one arm of the study involved a pharmacotherapy. Only 12 studies were identified that met our inclusion criteria. The limited existing literature does not allow for a definitive answer to the most effective pharmacotherapy for smoking cessation in older adult smokers. Nicotine replacement therapy (NRT) is the pharmacotherapy most studied in older adults, and the limited evidence that exists suggests that NRT is effective for smoking cessation among this population. Higher-quality studies that directly compare cessation strategies, including bupropion and varenicline, are needed in the older population in order to guide treatment decision making.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

BACKGROUND

Effective pharmacotherapies are available to help people who are trying to stop smoking, but quitting can still be difficult and providing higher levels of behavioural support may increase success rates further.

OBJECTIVES

To evaluate the effect of increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in May 2015 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount of behavioural support. The intervention condition had to involve person-to-person contact. The control condition could receive less intensive personal contact, or just written information. We did not include studies that used a contact-matched control to evaluate differences between types or components of support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

One author prescreened search results and two authors agreed inclusion or exclusion of potentially relevant trials. One author extracted data and another checked them.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Forty-seven studies met the inclusion criteria with over 18,000 participants in the relevant arms. There was little evidence of statistical heterogeneity (I² = 18%) so we pooled all studies in the main analysis. There was evidence of a small but statistically significant benefit from more intensive support (RR 1.17, 95% CI 1.11 to 1.24) for abstinence at longest follow-up. All but four of the included studies provided four or more sessions of support to the intervention group. Most trials used NRT. We did not detect significant effects for studies where the pharmacotherapy was nortriptyline (two trials) or varenicline (one trial), but this reflects the absence of evidence.In subgroup analyses, studies that provided at least four sessions of personal contact for the intervention and no personal contact for the control had slightly larger estimated effects (RR 1.25, 95% CI 1.08 to 1.45; 6 trials, 3762 participants), although a formal test for subgroup differences was not significant. Studies where all intervention counselling was via telephone (RR 1.28, 95% CI 1.17 to 1.41; 6 trials, 5311 participants) also had slightly larger effects, and the test for subgroup differences was significant, but this subgroup analysis was not prespecified. In this update, the benefit of providing additional behavioural support was similar for the subgroup of trials in which all participants, including controls, had at least 30 minutes of personal contact (RR 1.18, 95% CI 1.06 to 1.32; 21 trials, 5166 participants); previously the evidence of benefit in this subgroup had been weaker. This subgroup was not prespecified and a test for subgroup differences was not significant. We judged the quality of the evidence to be high, using the GRADE approach. We judged a small number of trials to be at high risk of bias on one or more domains, but findings were not sensitive to their exclusion.

AUTHORS' CONCLUSIONS

Providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking has a small but important effect. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 25%, based on a pooled estimate from 47 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support.

Smoking cessation interventions for adults aged 50 or older: A systematic review and meta-analysis

BACKGROUND

The older population size has increased substantially, and a considerable proportion of older adults are cigarette smokers. Quitting smoking is associated with reduced health risk. This review is among the first to quantitatively assess the relative efficacy of types of cessation interventions for smokers aged ≥50 years.

METHODS

We conducted searches of the Cochrane Library, Embase, MEDLINE, and PsycINFO to identify smoking cessation studies on adults aged ≥50 years. Twenty-nine randomized clinical trials met the inclusion criteria. Three main types of interventions were identified. We analyzed relative cessation rates or Risk Ratios (RRs) between the type of intervention groups and the control group by fixed- and random-effects meta-analyses at the study level. We conducted a weighted least squares meta-regression of cessation rates on trial and sample characteristics to determine sources of outcome heterogeneity.

RESULTS

Fixed-effects analysis showed significant treatment effects for pharmacological (RR=3.18, 95% CI: 1.89-5.36), non-pharmacological (RR=1.80, 95% CI: 1.67-1.94), and multimodal interventions (RR=1.61, 95% CI: 1.41-1.84) compared with control group. Estimations based on meta-regression suggested that pharmacological intervention (mean point prevalence abstinence rate (PPA)=26.10%, CI: 15.20-37.00) resembled non-pharmacological (27.97%, CI: 24.00-31.94), and multimodal interventions (36.64%, CI: 31.66-41.62); and non-pharmacological and multimodal interventions had higher PPAs than the control group (18.80%, CI: 14.48-23.12), after adjusting for a number of trial and sample characteristics.

CONCLUSIONS

A small number of smoking cessation studies examined smokers aged ≥50 years. Additional research is recommended to determine smoking cessation efficacy for diverse older population groups (e.g., ethnic minorities).

Efficacy of a tobacco quitline among adult cancer survivors

OBJECTIVE

The purpose of the study (conducted 2010-2013) was to determine the efficacy of two common types of tobacco quitlines in adult cancer survivors who regularly smoked cigarettes.

METHOD

Adult onset cancer survivors in Memphis, Tennessee (n=427, 67% female, 60% Caucasian) were randomized either to a Proactive (i.e., counselor-initiated calls) or Reactive (i.e., participant-initiated calls) quitline. Both conditions also received nicotine replacement therapy. The primary outcome was biochemically-verified (i.e., salivary cotinine) smoking cessation.

RESULTS

While 12-month self-reported abstinence was consistent with other published studies of smoking cessation (22% and 26% point prevalence abstinence for Proactive and Reactive conditions, respectively), 48% of participants who were tested for cotinine failed biochemical verification, indicating a considerable falsification of self-reported cessation. Adjusted cessation rates were less than 5% in both intervention conditions.

CONCLUSION

Our results are consistent with other studies indicating that traditional smoking cessation interventions are ineffective among cancer survivors. Moreover, self-reports of cessation were unreliable in cancer survivors participating in a quitline intervention, indicating that future studies should include biochemical verification. Given the importance of smoking cessation among cancer survivors and low cessation rates in the current study, it may be necessary to design alternative interventions for this population. ClinicalTrials.gov identifier: NCT00827866.

Treatment Outcome Assessment of the Pharmacist-Managed Quit Smoking Clinic in Malaysia

Introduction: Evaluating a new health service is different from evaluating a new drug, as the former depends on the local delivery structure and culture. No data are available on the effectiveness of the existing pharmacist-managed quit smoking clinic (PM-QSC) in Malaysia. We evaluated the effectiveness in terms of the quit and default rate, the cost per quitter, cost per patient and the number of days of the patient remained in the managed care of the pharmacist.

Methods: The patients’ medical records at the PM-QSC in a tertiary hospital in Melaka, Malaysia, were examined retrospectively from January 2009 to December 2010. Patients were grouped into current smokers, attempted to quit and quitters. Costs were calculated per patient visit on the basis of resource used (smoking cessation agents (SCAs)) and the personnel involved (time spent by the pharmacist). This study was reviewed and approved by the Malaysia Research Ethics Committee (MREC).

Results: The quit rate between January 2009 and December 2010 was 5.8%, and the default rate was 71.8%. The average quit period for all smokers enrolled was 298 days. From the health provider perspective, the average costs per quitter, per patient and per quit attempt were MYR 953.28 (USD 308), MYR 55.71 (USD 18) and MYR 34.74 (USD 11), respectively.

Conclusion: The pharmacist delivery of cessation services at a public-funded QSC was associated with a high default rate. The pharmacist could not be dismissed entirely as an ineffective health care professional (HCP) for the provision of the cessation service based solely on this preliminary data, but these findings stress the need to address the high default rate prior to the expansion of the service.

[Smoking cessation and social deprivation]

Smoking is a major of public health policy issue; one in two lifelong smokers will die from a disease related to tobacco use. In France, smoking is responsible for more than 70,000 deaths every year. The benefits linked to stopping smoking include reduced mortality and morbidity related to the use of tobacco. Recent data show an increase in the prevalence of smoking in the lowest socioeconomic population. Tobacco control needs a better understanding of the determinants of smoking in this population, which are also factors in the failure of cessation attempts. Based on international literature, this review specifies the educational and socioeconomic factors involved in tobacco smoking and in the result of an attempt to quit. Its aim is to propose ways to improve the management of smoking cessation in a socially deprived population.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2013.

SELECTION CRITERIA

randomized or quasi-randomised controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.

DATA COLLECTION AND ANALYSIS

One author identified and data extracted trials, and a second author checked them. The main outcome measure was the risk ratio for abstinence from smoking after at least six months follow-up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. We considered trials recruiting callers to quitlines separately from studies recruiting in other settings. Where appropriate, we pooled studies using a fixed-effect model. We used a meta-regression to investigate the effect of differences in planned number of calls, selection for motivation, and the nature of the control condition (self help only, minimal intervention, pharmacotherapy) in the group of studies recruiting in non-quitline settings.

MAIN RESULTS

Seventy-seven trials met the inclusion criteria. Some trials were judged to be at risk of bias in some domains but overall we did not judge the results to be at high risk of bias. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, > 24,000 participants, risk ratio (RR) for cessation at longest follow-up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Three studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that tested the provision of access to a hotline two detected a significant benefit and one did not.Telephone counselling not initiated by calls to helplines also increased quitting (51 studies, > 30,000 participants, RR 1.27; 95% CI 1.20 to 1.36). In a meta-regression controlling for other factors the effect was estimated to be slightly larger if more calls were offered, and in trials that specifically recruited smokers motivated to try to quit. The relative extra benefit of counselling was smaller when it was provided in addition to pharmacotherapy (usually nicotine replacement therapy) than when the control group only received self-help material or a brief intervention.A further eight studies were too diverse to contribute to meta-analyses and are discussed separately. Two compared different intensities of counselling, both of which detected a dose response; one of these detected a benefit of multiple counselling sessions over a single call for people prescribed bupropion. The others tested a variety of interventions largely involving offering telephone counselling as part of a referral or systems change and none detected evidence of effect.

AUTHORS' CONCLUSIONS

Proactive telephone counselling aids smokers who seek help from quitlines. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness. There is limited evidence about the optimal number of calls. Proactive telephone counselling also helps people who receive it in other settings. There is some evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, or brief advice, or compared to pharmacotherapy alone.

Behavioural interventions as adjuncts to pharmacotherapy for smoking cessation

BACKGROUND

Effective pharmacotherapies are available to help people who are trying to stop smoking, but quitting can still be difficult and providing higher levels of behavioural support may increase success rates further.

OBJECTIVES

To evaluate the effect of increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2012 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount of behavioural support. Controls could receive less intensive personal contact, or just written information. We did not include studies that used a contact matched control to evaluate differences between types or components of support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by both authors. Data were extracted by one author and checked by the other.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Thirty-eight studies met the inclusion criteria with over 15,000 participants in the relevant arms. There was very little evidence of statistical heterogeneity (I² = 3%) so all studies were pooled in the main analysis. There was evidence of a small but statistically significant benefit from more intensive support (RR 1.16, 95% CI 1.09 to 1.24) for abstinence at longest follow-up. All but two of the included studies provided four or more sessions of support. Most trials used nicotine replacement therapy. Significant effects were not detected for studies where the pharmacotherapy was nortriptyline (two trials) or varenicline (one trial), but this reflects the absence of evidence. In subgroup analyses, studies that provided at least four sessions of personal contact for the intervention and no personal contact for the control had slightly larger effects (six trials, RR 1.25, 95% CI 1.08 to 1.45), as did studies where all intervention counselling was via telephone (six trials, RR 1.28, 95% CI 1.17 to 1.41). Weaker evidence for a benefit of providing additional behavioural support was seen in the trials where all participants, including those in the control condition, had at least 30 minutes of personal contact (18 trials, RR 1.11, 95% CI 0.99 to 1.25). None of the differences between subgroups were significant, and the last two subgroup analyses were not prespecified. No trials were judged at high risk of bias on any domain.

AUTHORS' CONCLUSIONS

Providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking has a small but important effect. Increasing the amount of behavioural support is likely to increase the chance of success by about 10 to 25%, based on a pooled estimate from 38 trials. A subgroup analysis of a small number of trials suggests the benefit could be a little greater when the contrast is between a no contact control and a behavioural intervention that provides at least four sessions of contact. Subgroup analysis also suggests that there may be a smaller incremental benefit from providing even more intensive support via more or longer sessions over and above some personal contact.

Combined pharmacotherapy and behavioural interventions for smoking cessation

BACKGROUND

Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear.

OBJECTIVES

To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2012 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by both authors. Data was extracted by one author and checked by the other.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Forty-one studies with a total of more than 20,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the three studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 40 studies (15,021 participants) there was good evidence for a benefit of combination pharmacotherapy and behavioural treatment compared to usual care or brief advice or less intensive behavioural support (RR 1.82, 95% CI 1.66 to 2.00) with moderate statistical heterogeneity (I² = 40%). The pooled estimate for 31 trials that recruited participants in healthcare settings (RR 2.06, 95% CI 1.81 to 2.34) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Pooled estimates were lower in a subgroup of trials where the behavioural intervention was provided by specialist counsellors versus trials where counselling was linked to usual care (specialist: RR 1.73, 95% CI 1.55 to 1.93, 28 trials; usual provider: RR 2.41, 95% CI 1.91 to 3.02, 8 trials) but this was largely attributable to the small effect size in two trials using specialist counsellors where the take-up of the planned intervention was low, and one usual provider trial with alarge effect. There was little indirect evidence that the relative effect of an intervention differed according to whether participants in a trial were required to be motivated to make a quit attempt or not. There was only weak evidence that studies offering more sessions had larger effects and there was not clear evidence that increasing the duration of contact increased the effect, but there was more evidence of a dose-response relationship when analyses were limited to trials where the take-up of treatment was high.

AUTHORS' CONCLUSIONS

Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Further trials would be unlikely to change this conclusion. We did not find strong evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects but this could be because intensive interventions are less likely to be delivered in full.

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use and/or prescription of smoking cessation treatment and on the number of smokers making a quit attempt.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2012.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers or both.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the quality of the included studies. Risk ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random-effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives.

MAIN RESULTS

We found eleven trials involving financial interventions directed at smokers and healthcare providers.Full financial interventions directed at smokers had a statistically significant favourable effect on abstinence at six months or greater when compared to no intervention (RR 2.45, 95% CI 1.17 to 5.12, I² = 59%, 4 studies). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.11, 95% CI 1.04 to 1.32, I² = 15%) and use of smoking cessation treatment (NRT: RR 1.83, 95% CI 1.55 to 2.15, I² = 43%; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65). There was no evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%). Comparisons of full coverage with partial coverage, partial coverage with no coverage, and partial coverage with another partial coverage intervention did not detect significant effects. Comparison of full coverage with partial or no coverage resulted in costs per additional quitter ranging from $119 to $6450.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting.  The absolute differences are small but the costs per additional quitter are low to moderate. We did not detect an effect on smoking cessation from financial incentives directed at healthcare providers. The methodological qualities of the included studies need to be taken into consideration when interpreting the results.

A review of smoking cessation interventions for smokers aged 50 and older

OBJECTIVES

Cigarette smoking poses substantial health risks at any age, but is particularly dangerous for older smokers, who are already at heightened risk for various health conditions. Studies suggest that older smokers are motivated to quit and succeed, but few of these have been randomized controlled trials. There is a need to systematically evaluate the research on effective interventions in older smokers.

METHODS

We followed PRISMA guidelines in the development of this systematic review, which included randomized controlled trials of cessation interventions with smokers aged 50 or older.

RESULTS

We found 740 unique titles matching specified search criteria; 13 met final eligibility criteria. Nearly all the cessation treatments combined counseling with other strategies. Eight studies provided smoking cessation medications. None of the studies used newer forms of technology such as web- or text-based interventions. Nine of the 13 studies reported a significant intervention effect at one or more time points, with three studies reporting sustained treatment effects at 12 mos or longer. In general, more intensive interventions and those with combined approaches including medications and follow-up counseling achieved the best outcomes.

CONCLUSION

The quit rates from these studies and the relative effectiveness of different intervention approaches are consistent with the general smoking cessation literature. However, in most studies, treatment effects were of short duration, and absolute quit rates were low, leaving the vast majority of older smokers at high risk for smoking-related health conditions. This systematic review suggests a need for additional research to design and test future interventions specifically tailored for older smokers.

Effectiveness of health and wellness initiatives for seniors

Given the increasing prevalence of obesity and lifestyle-related chronic diseases in the United States and abroad, senior wellness initiatives have emerged as a means to stem the troubling trends that threaten the well-being and the economy of many nations. Seniors are an important demographic for such programs because this age group is growing, both as a proportion of the overall population and as a contributor to health care cost escalation. The goal of senior wellness programs is to improve the overall health of seniors through a variety of approaches, including increased physical activity, better nutrition, smoking cessation, and support of other healthy behaviors. Outcome metrics of particular interest are the effects of participation in these programs on health care utilization and expenditures. This review describes several studies that demonstrate reduced inpatient admissions and health care costs, as well as improved health-related quality of life as a direct result of participation in large-scale senior wellness programs. Programs that effectively engage seniors in, and change behavior as a direct result of, participation provide strong evidence that health improvements and decreased health care expenditures can be achieved. However, solutions to the challenges of broader enrollment and sustained participation in these programs would increase the impact of their outcomes and health-related benefits.

A discrete-event simulation of smoking-cessation strategies based on varenicline pivotal trial data

BACKGROUND

Smoking is the leading cause of preventable death in the US. While one in five individuals smoke, and 70% of these indicate a desire to quit, <5% of unaided quit attempts succeed. Cessation aids can double or triple the odds of successfully quitting. Models of smoking-cessation behaviour can elucidate the implications of individual abstinence patterns to allow better tailoring of quit attempts to an individual's characteristics.

OBJECTIVE

The objectives of this study were to develop and validate a discrete-event simulation (DES) to evaluate the benefits of smoking abstinence using data from the pooled pivotal clinical trials of varenicline versus bupropion or placebo for smoking cessation and to provide a foundation for the development of a lifetime smoking-cessation model.

METHODS

The DES model simulated the outcome of a single smoking-cessation attempt over 1 year, in accordance with the clinical trial timeframes. Pharmaceutical costs were assessed from the perspective of a healthcare payer. The model randomly sampled patient profiles from the pooled varenicline clinical trials. All patients were physically and mentally healthy adult smokers who were motivated to quit abruptly. The model allowed for comparisons of up to five distinct treatment approaches for smoking cessation. In the current analyses, three interventions corresponding to the clinical trials were evaluated, which included brief counselling plus varenicline 1.0 mg twice daily (bid) or bupropion SR 150 mg bid versus placebo (i.e. brief counselling only). The treatment periods in the clinical trials were 12 weeks (target quit date: day 8), with a 40-week non-treatment follow-up, and counselling continuing over the entire 52-week period in all treatment groups. The main outcome modelled was the continuous abstinence rate (CAR; defined as complete abstinence from smoking and confirmed by exhaled carbon monoxide ≤ 10 ppm) at end of treatment (weeks 9-12) and long-term follow-up (weeks 9-52), and total time abstinent from smoking over the course of 52 weeks. The model also evaluated costs and cost-effectiveness outcomes.

RESULTS

For the varenicline, bupropion and placebo cohorts, respectively, the model predicted CARs for weeks 9-12 of 44.3%, 30.4% and 18.6% compared with observed rates of 44.0%, 29.7% and 17.7%; over weeks 9-52, predicted CARs in the model compared with observed rates in the pooled clinical studies were 22.9%, 16.4% and 9.4% versus 22.4%, 15.4% and 9.3%, respectively. Total mean abstinence times accrued in the model varenicline, bupropion and placebo groups, respectively, were 3.6, 2.6 and 1.5 months and total pharmaceutical treatment costs were $US261, $US442 and $US0 (year 2008 values) over the 1-year model period. Using cost per abstinent-month achieved as a measure of cost effectiveness, varenicline dominated bupropion and yielded an incremental cost-effectiveness ratio of $US124 compared with placebo.

CONCLUSION

The model accurately replicated abstinence patterns observed in the clinical trial data using individualized predictions and indicated that varenicline was more effective and may be less costly than bupropion. This simulation incorporated individual predictions of abstinence and relapse, and provides a framework for lifetime modelling that considers multiple quit attempts over time in diverse patient populations using a variety of quit attempt strategies.

Clinical management of smoking cessation: patient factors affecting a reward-based approach

Although the majority of current smokers indicate they would like to quit, only about half of smokers make a quit attempt each year. Of those who attempt to quit, only about 5% are successful. Many effective products and programs are available to assist in smoking cessation; however those interested in quitting often do not make use of these resources. To increase use of cessation products in order to improve successful cessation rates, the Consumer Demand Roundtable has argued that smokers need to be viewed as consumers of cessation products rather than as patients needing treatment. With this consumer-based approach in mind, the current review examines how participant characteristics, perceptions, and behavior influence, and are influenced by, contingency management (CM) paradigms in various settings. Findings suggest that participant factors associated with success in these programs include demographic characteristics (eg, gender, marital status), self-efficacy, motivation to quit, and impulsivity. Overall, participants perceive incentives for successful cessation as motivating. However, such programs may involve greater withdrawal symptoms (eg, craving for cigarettes) initially, but these symptoms tend to decrease at a greater rate over time compared with nonincentive group participants. CM programs have also been shown to be successful across a number of settings (eg, communities, schools), including settings in which smokers are often considered difficult to treat (eg, substance abuse treatment centers). Overall, CM programs are perceived positively by participants and can increase rates of successful cessation. Furthermore, CM interventions have the flexibility to adapt to individual preferences and needs, leading to greater participation and likelihood of successful cessation. Thus, CM provides an important framework for addressing the need for consumer-focused smoking cessation interventions.

Smoking cessation quitlines: an underrecognized intervention success story

Quitlines providing telephone counseling for smoking cessation derive from behavioral research and theory, have been shown to be effective, and have been adopted and then institutionalized at both the state and national levels. Although psychologists have made seminal contributions to quitline development and evaluation, this accomplishment has gone largely unnoticed by the practice and research communities in clinical, counseling, and health psychology. This article summarizes the development, content, structure, empirical status, and current reach of cessation quitlines. We note the rich research opportunities afforded by quitlines, describe some recent approaches to improving their effectiveness, and suggest that an understanding of how quitlines work could also improve their effectiveness. The implications for practitioners and the potential application of telephone counseling to other disorders are also considered.

If you try to stop smoking, should we pay for it? The cost-utility of reimbursing smoking cessation support in the Netherlands

BACKGROUND

Smoking cessation can be encouraged by reimbursing the costs of smoking cessation support (SCS). The short-term efficiency of reimbursement has been evaluated previously. However, a thorough estimate of the long-term cost-utility is lacking.

OBJECTIVES

To evaluate long-term effects of reimbursement of SCS.

METHODS

Results from a randomized controlled trial were extrapolated to long-term outcomes in terms of health care costs and (quality adjusted) life years (QALY) gained, using the Chronic Disease Model. Our first scenario was no reimbursement. In a second scenario, the short-term cessation rates from the trial were extrapolated directly. Sensitivity analyses were based on the trial's confidence intervals. In the third scenario the additional use of SCS as found in the trial was combined with cessation rates from international meta-analyses.

RESULTS

Intervention costs per QALY gained compared to the reference scenario were approximately euro1200 extrapolating the trial effects directly, and euro4200 when combining the trial's use of SCS with the cessation rates from the literature. Taking all health care effects into account, even costs in life years gained, resulted in an estimated incremental cost-utility of euro4500 and euro7400, respectively. In both scenarios costs per QALY remained below euro16 000 in sensitivity analyses using a life-time horizon.

CONCLUSIONS

Extrapolating the higher use of SCS due to reimbursement led to more successful quitters and a gain in life years and QALYs. Accounting for overheads, administration costs and the costs of SCS, these health gains could be obtained at relatively low cost, even when including costs in life years gained. Hence, reimbursement of SCS seems to be cost-effective from a health care perspective.

Biopsychosocial characteristics of community-dwelling older adults with limited ability to walk one-quarter of a mile

OBJECTIVES

To establish nationally representative estimates of the prevalence of self-reported difficulty and inability of older adults to walk one-quarter of a mile and to identify the characteristics independently associated with difficulty or inability to walk one-quarter of a mile.

DESIGN

Cross-sectional analysis of data from the 2003 Cost and Use Medicare Current Beneficiary Survey.

SETTING

Community.

PARTICIPANTS

Nine thousand five hundred sixty-three community-dwelling Medicare beneficiaries aged 65 and older, representing an estimated total population of 34.2 million older adults.

MEASUREMENTS

Self-reported ability to walk one-quarter of a mile, sociodemographics, chronic conditions, body mass index, smoking, functional status.

RESULTS

In 2003, an estimated 9.5 million older Medicare beneficiaries had difficulty walking one-quarter of a mile, and 5.9 million were unable to do so. Of the 20.2 million older adults with no difficulty in activities of daily living (ADLs) or instrumental activities of daily living (IADLs), an estimated 4.3 million (21%) had limited ability to walk one-quarter of a mile. Having difficulty or being unable to walk one-quarter of a mile was independently associated with older age, female sex, non-Hispanic ethnicity, lower educational level, Medicaid entitlement, most chronic medical conditions, current smoking, and being overweight or obese.

CONCLUSION

Almost half of older adults and 20% of those reporting no ADL or IADL limitations report limited ability to walk one-quarter of a mile. For functionally independent older adults, reported ability to walk one-quarter of a mile can identify vulnerable older adults with greater medical problems and fewer resources and may be a valuable clinical marker in planning their care. Future work is needed to determine the association between ability to walk one-quarter of a mile walk and subsequent functional decline and healthcare use.

Risk perceptions among participants undergoing lung cancer screening: baseline results from the National Lung Screening Trial

BACKGROUND

Lung cancer screening could present a "teachable moment" for promoting smoking cessation and relapse prevention. Understanding the risk perceptions of older individuals who undergo screening will guide these efforts.

PURPOSE

This paper examines National Lung Screening Trial (NLST) participants' perceptions of risk for lung cancer and other smoking-related diseases. We investigated (1) whether risk perceptions of lung cancer screening participants differed between current and former smokers and (2) which factors (sociodemographic, smoking and medical history, cognitive, emotional, and knowledge) were associated with these risk perceptions.

METHODS

We analyzed baseline data collected from 630 NLST participants prior to their initial screen. Participants were older (55-74 years), heavy (minimum 30 pack years) current or former smokers. A ten-item risk perception measure was developed to assess perceived lifetime risk of lung cancer and other smoking-related diseases.

RESULTS

The risk perception measure had excellent internal consistency (alpha = 0.93). Former smokers had lower risk perceptions compared to current smokers. Factors independently associated with high risk perceptions among current smokers included having a personal history of a smoking-related disease, higher lifetime maximum number of cigarettes smoked daily, having lived with a smoker, high worry, high perceived severity of lung cancer and smoking-related diseases, and accurate knowledge of tenfold increased risk of lung cancer for a one pack per day smoker. Factors independently associated with high risk perceptions among former smokers included being White, past history of smoking within 30 min of waking, high worry, and accurate knowledge of tenfold increased risk of lung cancer for a one pack per day smoker.

CONCLUSIONS

Using a comprehensive risk perception measurement, we found that current and former smokers held different risk perceptions. Former and current smokers' smoking and medical history, race, emotional concerns, behavior change cognitions, and knowledge should be considered during a prescreening risk communication session. We highlight the theoretical and risk communication implications for former and current smokers undergoing lung cancer screening.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of proactive and reactive telephone support to help smokers quit.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for studies using free text term 'telephone*' or the keywords 'telephone counselling' or 'Hotlines' or 'Telephone' . Date of the most recent search: January 2006.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person (LS) and checked by a second (TL). The main outcome measure was the odds ratio for abstinence from smoking after at least six months follow up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst sub groups of clinically comparable studies using the I(2) statistic. Where appropriate, we pooled studies using a fixed-effect model. A meta-regression was used to investigate the effect of differences in planned number of calls.

MAIN RESULTS

Forty-eight trials met the inclusion criteria. Among smokers who contacted helplines, quit rates were higher for groups randomised to receive multiple sessions of call-back counselling (eight studies, >18,000 participants, odds ratio (OR) for long term cessation 1.41, 95% confidence interval (CI) 1.27 to 1.57). Two of these studies showed a significant benefit of more intensive compared to less intensive intervention. Telephone counselling not initiated by calls to helplines also increased quitting (29 studies, >17,000 participants, OR 1.33, 95% CI 1.21 to 1.47). A meta-regression detected a significant association between the maximum number of planned calls and the effect size. There was clearer evidence of benefit in the subgroup of trials recruiting smokers motivated to quit. Of two studies that provided access to a hotline one showed a significant benefit and one did not. Two studies comparing different counselling approaches during a single session did not detect significant differences. A further seven studies were too diverse to contribute to meta-analyses and are discussed separately.

AUTHORS' CONCLUSIONS

Proactive telephone counselling helps smokers interested in quitting. There is evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increases the odds of quitting compared to a minimal intervention such as providing standard self-help materials, brief advice, or compared to pharmacotherapy alone. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness.