The impact of low-energy total diet replacement with behavioural support for remission of type 2 diabetes on disordered eating (ARIADNE): Protocol for a non-inferiority randomised controlled trial

INTRODUCTION

The National Health Service (NHS) in England is currently piloting a weight loss programme for remission of newly diagnosed type 2 diabetes (T2D), where participants replace all food with low-energy nutritionally complete formula products for 12 weeks (total diet replacement, TDR) and receive behavioural support. In a clinical trial, this programme led to remission in nearly half the participants. However, this weight loss programme might also worsen disordered eating and prompt eating disorders in susceptible people. We aim to investigate if the TDR programme is non-inferior to standard care in terms of disordered eating in susceptible individuals.

METHODS

Fifty six people with newly diagnosed T2D, BMI ≥ 27 kg/m2, and medium to high scores of disordered eating based on the Eating Disorders Examination questionnaire (EDE-Q) will be randomised 1:1 to TDR receiving remote weekly/bi-weekly dietetic support or standard care. Participants will be re-assessed remotely at 1, 3, 4, 6, and 12 months. The primary outcome will be the between-group difference in the score of the EDE-Q. If the sample size can be expanded to 150, we will reduce the non-inferiority boundary. Weight, glycated haemoglobin (HbA1c), impairment from disordered eating, and distress will be secondary outcomes. Using the recorded consultations, we will evaluate the process in observed changes in eating behaviour and disordered eating.

CONCLUSIONS

If TDR for T2D remission is deemed non-inferior to standard care, more people may enrol and benefit from T2D remission. If TDR exacerbates disordered eating, screening may reduce unintended harm.

TRIAL REGISTRATION

NCT05744232 (ClinicalTrials.gov, prospectively registered).

Brief opportunistic interventions by general practitioners to promote smoking cessation: A conversation analytic study

Very brief opportunistic interventions for smoking cessation are effective, cost-saving for health systems, and universally recommended in guidelines. However, evidence suggests that clinicians are reluctant to intervene, citing interactional difficulties. Only one UK study has specifically examined smoking discussions, within naturally occurring primary care consultations. However smoking cessation treatment was not available at the time. We examined existing datasets amounting to 519 video-recordings of GP consultations in England for instances of talk about smoking. We used conversation analytic methods to assess patients' responses to doctors asking about smoking, giving advice on smoking, and offering cessation treatment. In 31 recordings it was apparent that the patient smoked, and, in 25/31 consultations, doctors initiated the topic of smoking. They did so by asking about smoking status, commonly during the history-taking phase of the consultation. In many instances, these questions led to active resistance from patients against being placed in a discreditable category, for example by minimising their smoking. This was more pronounced when GPs pursued efforts to quantify the amount smoked. Thereafter, where doctors returned to the topic of smoking, they did so typically by linking smoking to the patient's medical condition, which likewise led to resistance. Guidance recommends that GPs advise on how best to quit smoking where patients are interested in doing so, but this was only evident in a minority of consultations. Where GPs offered support for cessation, they did so using interactional practices that minimised the need for the patient to respond and thereby accept. Interactional difficulties were found to be common in consultations between GPs and people who smoke when GPs actions aligned with some VBA guidelines. Future research should examine when and how advice on how best to quit, and offers of support, should be delivered within primary care consultations.

Cost-effectiveness of bariatric surgery and non-surgical weight management programmes for adults with severe obesity: a decision analysis model

OBJECTIVES

To determine the most cost-effective weight management programmes (WMPs) for adults, in England with severe obesity (BMI ≥ 35 kg/m2), who are more at risk of obesity related diseases.

METHODS

An economic evaluation of five different WMPs: 1) low intensity (WMP1); 2) very low calorie diets (VLCD) added to WMP1; 3) moderate intensity (WMP2); 4) high intensity (Look AHEAD); and 5) Roux-en-Y gastric bypass (RYGB) surgery, all compared to a baseline scenario representing no WMP. We also compare a VLCD added to WMP1 vs. WMP1 alone. A microsimulation decision analysis model was used to extrapolate the impact of changes in BMI, obtained from a systematic review and meta-analysis of randomised controlled trials (RCTs) of WMPs and bariatric surgery, on long-term risks of obesity related disease, costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) measured as incremental cost per QALY gained over a 30-year time horizon from a UK National Health Service (NHS) perspective. Sensitivity analyses explored the impact of long-term weight regain assumptions on results.

RESULTS

RYGB was the most costly intervention but also generated the lowest incidence of obesity related disease and hence the highest QALY gains. Base case ICERs for WMP1, a VLCD added to WMP1, WMP2, Look AHEAD, and RYGB compared to no WMP were £557, £6628, £1540, £23,725 and £10,126 per QALY gained respectively. Adding a VLCD to WMP1 generated an ICER of over £121,000 per QALY compared to WMP1 alone. Sensitivity analysis found that all ICERs were sensitive to the modelled base case, five year post intervention cessation, weight regain assumption.

CONCLUSIONS

RYGB surgery was the most effective and cost-effective use of scarce NHS funding resources. However, where fixed healthcare budgets or patient preferences exclude surgery as an option, a standard 12 week behavioural WMP (WMP1) was the next most cost-effective intervention.

A systematic review of UK-based long-term nonsurgical interventions for people with severe obesity (BMI ≥35 kg m-2 )

Introduction

The aim of this project was to systematically review UK evidence on the effectiveness of long‐term (≥12 months) weight management services (WMSs) for weight loss and weight maintenance for adults (≥16 years) with severe obesity (body mass index ≥35 kg m⁻²), who would generally be eligible for Tier 3 services.

Methods

Four data sources were searched from 1999 to October 2018.

Results

Our searches identified 20 studies, mostly noncomparative studies: 10 primary care interventions, nine in secondary care specialist weight management clinics and one commercial setting intervention. A programme including a phase of low energy formula diet (810–833 kcal day⁻¹) showed the largest mean (SD) weight change at 12 months of –12.4 (11.4) kg for complete cases, with 25.3% dropout. Limitations or differences in evaluation and reporting (particularly for denominators), unclear dropout rates, and differences between participant groups in terms of comorbidities and psychological characteristics, made comparisons between WMSs and inferences challenging.

Conclusions

There is a persistent and clear need for guidance on long‐term weight data collection and reporting methods to allow comparisons across studies and services for participants with severe obesity. Data could also include quality of life, clinical outcomes, adverse events, costs and economic outcomes. A randomised trial comparison of National Health Service Tier 3 services with commercial WMSs would be of value.

Determinants and extent of weight recording in UK primary care: an analysis of 5 million adults' electronic health records from 2000 to 2017

BACKGROUND

Excess weight and unexpected weight loss are associated with multiple disease states and increased morbidity and mortality, but weight measurement is not routine in many primary care settings. The aim of this study was to characterise who has had their weight recorded in UK primary care, how frequently, by whom and in relation to which clinical events, symptoms and diagnoses.

METHODS

A longitudinal analysis of UK primary care electronic health records (EHR) data from 2000 to 2017. Descriptive statistics were used to summarise weight recording in terms of patient sociodemographic characteristics, health professional encounters, clinical events, symptoms and diagnoses. Negative binomial regression was used to model the likelihood of having a weight record each year, and Cox regression to the likelihood of repeated weight recording.

RESULTS

A total of 14,049,871 weight records were identified in the EHR of 4,918,746 patients during the study period, representing 26,998,591 person-years of observation. Around a third of patients had a weight record each year. Forty-nine percent of weight records were repeated within a year with an average time to a repeat weight record of 1.92 years. Weight records were most often taken by nursing staff (38-42%) and GPs (37-39%) as part of a routine clinical care, such as chronic disease reviews (16%), medication reviews (6-8%) and health checks (6-7%), or were associated with consultations for contraception (5-8%), respiratory disease (5%) and obesity (1%). Patient characteristics independently associated with an increased likelihood of weight recording were as follows: female sex, younger and older adults, non-drinkers, ex-smokers, low or high BMI, being more deprived, diagnosed with a greater number of comorbidities and consulting more frequently. The effect of policy-level incentives to record weight did not appear to be sustained after they were removed.

CONCLUSION

Weight recording is not a routine activity in UK primary care. It is recorded for around a third of patients each year and is repeated on average every 2 years for these patients. It is more common in females with higher BMI and in those with comorbidity. Incentive payments and their removal appear to be associated with increases and decreases in weight recording.

Communication practices for delivering health behaviour change conversations in primary care: a systematic review and thematic synthesis

BACKGROUND

Clinical guidelines exhort clinicians to encourage patients to improve their health behaviours. However, most offer little support on how to have these conversations in practice. Clinicians fear that health behaviour change talk will create interactional difficulties and discomfort for both clinician and patient. This review aims to identify how healthcare professionals can best communicate with patients about health behaviour change (HBC).

METHODS

We included studies which used conversation analysis or discourse analysis to study recorded interactions between healthcare professionals and patients. We followed an aggregative thematic synthesis approach. This involved line-by-line coding of the results and discussion sections of included studies, and the inductive development and hierarchical grouping of descriptive themes. Top-level themes were organised to reflect their conversational positioning.

RESULTS

Of the 17,562 studies identified through systematic searching, ten papers were included. Analysis resulted in 10 top-level descriptive themes grouped into three domains: initiating; carrying out; and closing health behaviour change talk. Of three methods of initiation, two facilitated further discussion, and one was associated with outright resistance. Of two methods of conducting behaviour change talk, one was associated with only minimal patient responses. One way of closing was identified, and patients did not seem to respond to this positively. Results demonstrated a series of specific conversational practices which clinicians use when talking about HBC, and how patients respond to these. Our results largely complemented clinical guidelines, providing further detail on how they can best be delivered in practice. However, one recommended practice - linking a patient's health concerns and their health behaviours - was shown to receive variable responses and to often generate resistance displays.

CONCLUSIONS

Health behaviour change talk is smoothly initiated, conducted, and terminated by clinicians and this rarely causes interactional difficulty. However, initiating conversations by linking a person's current health concern with their health behaviour can lead to resistance to advice, while other strategies such as capitalising on patient initiated discussions, or collaborating through question-answer sequences, may be well received.

Prevention and reversal of Type 2 diabetes: highlights from a symposium at the 2019 Diabetes UK Annual Professional Conference

AIM

This symposium covers the gamut of Type 2 diabetes prevention, reversing established Type 2 diabetes, population-level delivery of weight loss programmes and personal insights into achieving and retaining substantial weight loss.

RESULTS

The NHS Diabetes Prevention Programme was launched in 2016 and rates of referral and attendance have both exceeded expectations. By March 2018, mean weight loss for completers (those attending more than 60% of sessions) was 3.2 kg reflecting considerable health benefits. Established Type 2 diabetes is now known to be a reversible condition in the early years, and the underlying mechanism is the removal of the excess fat from within liver and pancreas in these susceptible individuals. The Diabetes Remission Clinical Trial has shown that around half of a primary care population of people with Type 2 diabetes of less than 6 years' duration can be returned to non-diabetic blood glucose control which lasts at least 12 months. This raises the question of population-level intervention to achieve weight loss. The success of some mass weight loss programmes requires to be recognized. Reframing mass provision of weight loss support should be a vital part of our clinical strategy to prevent and treat Type 2 diabetes. However, the current obesogenic environment is a reality in which individuals must live. A personal account of achieving substantial and maintaining substantial weight loss provides an invaluable insight into practical problems encountered. All health professionals dealing with weight control should assimilate and reflect upon this understanding.

CONCLUSIONS

Effective prevention and long term reversal of Type 2 diabetes is feasible. The impact upon the individual must be considered during delivery of advice and support.

The equity impact of brief opportunistic interventions to promote weight loss in primary care: secondary analysis of the BWeL randomised trial

BACKGROUND

Guidelines recommend that clinicians should make brief opportunistic behavioural interventions to patients who are obese to increase the uptake of effective weight loss programmes. The objective was to assess the effect of this policy on socioeconomic equity.

METHODS

One thousand eight hundred eighty-two consecutively attending patients with obesity and who were not seeking support for weight loss from their GP were enrolled in a trial. Towards the end of each consultation, GPs randomly assigned participants to one of two 30-s interventions. In the active intervention (support arm), the GP offered referral to a weight management group. In the control intervention (advice arm), the GP advised the patient that their health would benefit from weight loss. Agreement to attend a behavioural weight loss programme, attendance at the programme and weight loss at 12 months were analysed by socioeconomic status, measured by postcode using the Index of Multiple Deprivation (IMD).

RESULTS

Mean weight loss was 2.43 kg (sd 6.49) in the support group and 1.04 kg (sd 5.50) for the advice only group, but these effects were moderated by IMD (p = 0.039 for the interaction). In the support arm, weight loss was greater in higher socioeconomic groups. Participants from lower socioeconomic backgrounds were more likely to accept the offer and equally likely to attend a weight loss referral but attended fewer sessions. Adjusting for these sequentially reduced the gradient for the association of socioeconomic status with weight loss from + 0.035 to - 0.001 kg/IMD point. In the advice only arm, 10% took effective action to promote weight loss. The decision to seek support for weight loss outside of the trial did not differ by socioeconomic status, but weight loss among deprived participants who used external support was greater than among more affluent participants (p = 0.025).

CONCLUSION

Participants' responses to GPs' brief opportunistic interventions to promote weight loss differed by socioeconomic status and trial arm. In the support arm, more deprived people lost less weight because they attended fewer sessions at the programme. In the advice arm, more deprived people who sought and paid for support for weight loss themselves lost more weight than more affluent people who sought support.

TRIAL REGISTRATION

This trial is registered with the ISRCTN registry, number ISRCTN26563137 . Date of registration: January 3, 2013; date of first participant recruited: June 4, 2014.

Weight loss as a predictor of cancer and serious disease in primary care: an ISAC-approved CPRD protocol for a retrospective cohort study using routinely collected primary care data from the UK

BACKGROUND

Unexpected weight loss is a symptom of serious disease in primary care, for example between 1 in 200 and 1 in 30 patients with unexpected weight loss go on to develop cancer. However, it remains unclear how and when general practitioners (GPs) should investigate unexpected weight loss. Without clarification, GPs may wait too long before referring (choosing to watch and wait and potentially missing a diagnosis) or not long enough (overburdening hospital services and exposing patients to the risks of investigation). The overall aim of this study is to provide the evidence necessary to allow GPs to more effectively manage patients with unexpected weight loss.

METHODS

A retrospective cohort analysis of UK Clinical Practice Research Datalink (CPRD) data to: (1) describe how often in UK primary care the symptom of reported weight loss is coded, when weight is measured, and how GPs respond to a patient attending with unexpected weight loss; (2) identify the predictive value of recorded weight loss for cancer and serious disease in primary care, using cumulative incidence plots to compare outcomes between subgroups and Cox regression to explore and adjust for covariates. Preliminary work in CPRD estimates that weight loss as a symptom is recorded for approximately 148,000 eligible patients > 18 years and is distributed evenly across decades of age, providing adequate statistical power and precision in relation to cancer overall and common cancers individually. Further stratification by cancer stage will be attempted but may not be possible as not all practices within CPRD are eligible for cancer registry linkage, and staging information is often incomplete. The feasibility of using multiple imputation to address missing covariate values will be explored.

DISCUSSION

This will be the largest reported retrospective cohort of primary care patients with weight measurements and unexpected weight loss codes used to understand the association between weight measurement, unexpected weight loss, and serious disease including cancer. Our findings will directly inform international guidelines for the management of unexpected weight loss in primary care populations.

Smoking cessation and survival in lung, upper aero-digestive tract and bladder cancer: cohort study

Background:

The aim was to examine the association between smoking cessation and prognosis in smoking-related cancer as it is unclear that cessation reduces mortality.

Methods:

In this retrospective cohort study from 1999 to 2013, we assessed the association between cessation during the first year after diagnosis and all-cause and cancer-specific mortality.

Results:

Of 2882 lung, 757 upper aero-digestive tract (UAT) and 1733 bladder cancer patients 27%, 29% and 21% of lung, UAT and bladder cancer patients quit smoking. In lung cancer patients that quit, all-cause mortality was significantly lower (HR: 0.82 (0.74–0.92), while cancer-specific mortality (HR: 0.89 (0.76–1.04) and death due to index cancer (HR: 0.90 (0.77–1.05) were non-significantly lower. In UAT cancer, all-cause mortality (HR: 0.81 (0.58–1.14), cancer-specific mortality (HR: 0.84 (0.48–1.45), and death due to index cancer (HR: 0.75 (0.42–1.34) were non-significantly lower. There was no evidence of an association between quitting and mortality in bladder cancer. The HRs were 1.02 (0.81–1.30) for all-cause, 1.23 (0.81–1.86) for cancer specific, and 1.25 (0.71–2.20) for death due to index cancer. These showed a non-significantly lower risk in sensitivity analyses.

Conclusions:

People with lung and possibly UAT cancer who quit smoking have a lower risk of mortality than people who continue smoking.

Cognitive and behavioural strategies for self-directed weight loss: systematic review of qualitative studies

AIM

We conducted a systematic review of qualitative studies to examine the strategies people employ as part of self-directed weight loss attempts, map these to an existing behaviour change taxonomy and explore attitudes and beliefs surrounding these strategies.

METHODS

Seven electronic databases were searched in December 2015 for qualitative studies in overweight and obese adults attempting to lose weight through behaviour change. We were interested in strategies used by participants in self-directed efforts to lose weight. Two reviewers extracted data from included studies. Thematic and narrative synthesis techniques were used.

RESULTS

Thirty one studies, representing over 1,000 participants, were included. Quality of the included studies was mixed. The most commonly covered types of strategies were restrictions, self-monitoring, scheduling, professional support and weight management aids. With the exception of scheduling, for which participant experiences were predominantly positive, participants' attitudes and beliefs surrounding implementation of these groups of strategies were mixed. Two new groups of strategies were added to the existing taxonomy: reframing and self-experimentation.

CONCLUSIONS

This review demonstrates that at present, interventions targeting individuals engaged in self-management of weight do not necessarily reflect lived experiences of self-directed weight loss.

Factors associated with study attrition in a pilot randomised controlled trial to explore the role of exercise-assisted reduction to stop (EARS) smoking in disadvantaged groups

Background

Study attrition has the potential to compromise a trial’s internal and external validity. The aim of the present study was to identify factors associated with participant attrition in a pilot trial of the effectiveness of a novel behavioural support intervention focused on increasing physical activity to reduce smoking, to inform the methods to reduce attrition in a definitive trial.

Methods

Disadvantaged smokers who wanted to reduce but not quit were randomised (N = 99), of whom 61 (62 %) completed follow-up assessments at 16 weeks. Univariable logistic regression was conducted to determine the effects of intervention arm, method of recruitment, and participant characteristics (sociodemographic factors, and lifestyle, behavioural and attitudinal characteristics) on attrition, followed by multivariable logistic regression on those factors found to be related to attrition.

Results

Participants with low confidence to quit, and who were undertaking less than 150 mins of moderate and vigorous physical activity per week at baseline were less likely to complete the 16-week follow-up assessment. Exploratory analysis revealed that those who were lost to follow-up early in the trial (i.e., by 4 weeks), compared with those completing the study, were younger, had smoked for fewer years and had lower confidence to quit in the next 6 months. Participants who recorded a higher expired air carbon monoxide reading at baseline were more likely to drop out late in the study, as were those recruited via follow-up telephone calls. Multivariable analyses showed that only completing less than 150 mins of physical activity retained any confidence in predicting attrition in the presence of other variables.

Conclusions

The findings indicate that those who take more effort to be recruited, are younger, are heavier smokers, have less confidence to quit, and are less physically active are more likely to withdraw or be lost to follow-up.

Recent trends in weight loss attempts: repeated cross-sectional analyses from the health survey for England

BACKGROUND

Public policies and clinical guidelines encourage people to achieve and maintain a healthy weight and societal culture, especially among women who tend to idealise thinness.

OBJECTIVES

To examine trends over time in the prevalence of weight loss attempts in England (1997-2013) and to investigate if the characteristics associated with attempts to lose weight have changed.

METHODS

Observational study using nationally representative data on adults ⩾18 years who participated in the Health Survey for England (HSE) in 1997 (n=8066), 1998 (n=14 733), 2002 (n=8803), 2012 (n=7132) and 2013 (n=7591), with self-reported attempts to lose weight, cardiovascular disease (CVD) events or medications and measured height, weight and blood pressure. Multivariable logistic regression was used to assess the association between weight loss attempts and survey year, socio-demographic variables and health status.

RESULTS

The age-standardised prevalence of weight loss attempts in the English population increased from 39% in 1997 to 47% in 2013. In 2013, 10% of those with BMI <22; 30% with BMI ⩾22 to <25; 53% with BMI ⩾25 to <30; and 76% with BMI ⩾30 were trying to lose weight. The odds of trying to lose weight increased linearly with each year: odds ratio (OR) 1.021 (95% confidence interval (CI) 1.018-1.024) and 1.024 (95% CI 1.008-1.039) after adjustment for changes in BMI and population characteristics. The biggest predictors of weight loss attempts were being in the overweight/obese categories: 5.42 (95% CI 5.05-5.81) and 12.68 (95% CI 11.52-13.96), respectively; and among women: 3.01 (95% CI 2.85-3.18). Having a BMI >25 and a CVD-related condition was associated with only a small increase in the odds of trying to lose weight. There was no evidence that these predictors changed over time.

CONCLUSIONS

More people are making weight loss attempts each year across all BMI categories. Having a health condition that would improve with weight loss was only very modestly associated with an increase in reported weight loss attempts, which reinforces data that suggests people's prime motivation to lose weight is unrelated to health.

Clinical effectiveness of very-low-energy diets in the management of weight loss: a systematic review and meta-analysis of randomized controlled trials

Guidelines suggest that very-low-energy diets (VLEDs) should be used to treat obesity only when rapid weight loss is clinically indicated because of concerns about rapid weight regain. Literature databases were searched from inception to November 2014. Randomized trials were included where the intervention included a VLED and the comparator was no intervention or an intervention that could be given in a general medical setting in adults that were overweight. Two reviewers characterized the population, intervention, control groups, outcomes and appraised quality. The primary outcome was weight change at 12 months from baseline. Compared with a behavioural programme alone, VLEDs combined with a behavioural programme achieved -3.9 kg [95% confidence interval (CI) -6.7 to -1.1] at 1 year. The difference at 24 months was -1.4 kg (95%CI -2.6 to -0.2) and at 38-60 months was -1.3 kg (95%CI -2.9 to 0.2). Nineteen per cent of the VLED group discontinued treatment prematurely compared with 20% of the comparator groups, relative risk 0.96 (0.56 to 1.66). One serious adverse event, hospitalization with cholecystitis, was reported in the VLED group and none in the comparator group. Very-low-energy diets with behavioural programmes achieve greater long-term weight loss than behavioural programmes alone, appear tolerable and lead to few adverse events suggesting they could be more widely used than current guidelines suggest.

Effectiveness of regular weighing, weight target setting and feedback by community midwives within routine antenatal care in preventing excessive gestational weight gain: randomised controlled trial

Background

Many pregnant women gain excess weight during pregnancy which increases the health risks to the mother and her baby. Interventions to prevent excess weight gain need to be given to the whole population to prevent excess weight gain. The aim of this study was to assess the effectiveness of a simple and brief intervention embedded withinroutine antenatal care to prevent excessive gestation weight gain.

Methods

Six hundred and ten pregnant women (between 10-14 weeks gestation), aged ≥18 years with a body mass index (BMI) ≥18.5 kg/m2, planned to receive community midwife led care or shared care at the time of recruitment are eligible to take part in the study. Women will be recruited from four maternity centres in England. Community midwives complete a short training module before delivering the intervention. In the intervention, midwives weigh women, set maximum weight limits for weight gain at each antenatal appointment and ask women to monitor their weight at home. Themaximum weight limit is adjusted by the midwife at each antenatal appointment if women have exceeded their maximum weight gain limit set at their previous appointment. The intervention will be compared with usual antenatal care. The primary outcome is the proportion of women per group who exceed the Institute of Medicine guidelines for gestational weight gain at 38 weeks of pregnancy according to their early pregnancy BMI category.

Discussion

The proposed trial will test a brief intervention comprising regular weighing, target setting and monitoring ofweight during pregnancy that can be delivered at scale as part of routine antenatal care. Using the professional expertise of community midwives, but without specialist training in weight management, the intervention will incur minimal additionalhealthcare costs, and if effective at reducing excess weight gain, is likely to be very cost effective.

Trial registration

Current controlled trials ISRCTN67427351. Date assigned 29/10/2014.

Feasibility and acceptability of regular weighing, setting weight gain limits and providing feedback by community midwives to prevent excess weight gain during pregnancy: randomised controlled trial and qualitative study

Background

Regular weighing in pregnant women is not currently recommended in many countries but has been suggested to prevent excessive gestational weight gain. This study aimed to establish the feasibility and acceptability of incorporating regular weighing, setting maximum weight gain targets and feedback by community midwives.

Methods

Low risk pregnant women cared for by eight community midwives were randomised to usual care or usual care plus the intervention at 10–14 weeks of pregnancy. The intervention involved community midwives weighing and plotting weight on a weight gain chart, setting weight gain limit targets, giving brief feedback at each antenatal appointment and encouraging women to weigh themselves weekly between antenatal appointments. Women and midwives were interviewed about their views of the intervention. The focus of the study was on process evaluation.

Results

Community midwives referred 123 women and 115 were scheduled for their dating scan within the study period. Of these, 84/115 were approached at their dating scan and 76/84 (90.5 %) randomised. Data showed a modest difference favouring the intervention group in the percentage of women gaining excessive gestational weight (23.5 % versus 29.4 %). The intervention group consistently reported smaller increases in depression and anxiety scores throughout pregnancy compared with usual care. Most women commented the intervention was useful in encouraging them to think about their weight and believed it should be part of routine antenatal care. Community midwives felt the intervention could be implemented within routine care without adding substantially to consultation length, thus not perceived as adding substantially to their workload.

Conclusions

The intervention was feasible and acceptable to pregnant women and community midwives and was readily implemented in routine care.

Trial registration

ISRCTN81605162

Behavioural weight management programmes for adults assessed by trials conducted in everyday contexts: systematic review and meta-analysis

This systematic review and meta-analysis of effectiveness trials comparing multicomponent behavioural weight management programmes with controls in overweight and obese adults set out to determine the effectiveness of these interventions implemented in routine practice. To be included, interventions must have been multicomponent, delivered by the therapists who would deliver the intervention in routine practice and in that same context, and must be widely available or feasible to implement with little additional infrastructure or staffing. Searches of electronic databases were conducted, and augmented by screening reference lists and contacting experts (November 2012). Data were extracted by two reviewers, with mean difference between intervention and control for 12-month change in weight, blood pressure, lipids and glucose calculated using baseline observation carried forward. Data were also extracted on adverse events, quality of life and mood measures. Although there were many published efficacy trials, only eight effectiveness trials met the inclusion criteria. Pooled results from five study arms providing access to commercial weight management programmes detected significant weight loss at 12 months (mean difference -2.22 kg, 95% confidence interval [CI] -2.90 to -1.54). Results from two arms of a study testing a commercial programme providing meal replacements also detected significant weight loss (mean difference -6.83 kg, 95% CI -8.39 to -5.26). In contrast, pooled results from five interventions delivered by primary care teams showed no evidence of an effect on weight (mean difference -0.45 kg, 95% CI -1.34 to 0.43). One study testing an interactive web-based intervention detected a significant effect in favour of the intervention at 12 months, but the study was judged to be at high risk of bias and the effect did not persist at 18 months. Few studies reported other outcomes, limiting comparisons between interventions. Few trials have examined the effectiveness of behavioural weight loss programmes delivered in everyday contexts. These trials suggest that commercial interventions delivered in the community are effective for achieving weight loss. There is no evidence that interventions delivered within primary care settings by generalist primary care teams trained in weight management achieve meaningful weight loss.

The feasibility and acceptability of regular weighing of pregnant women by community midwives to prevent excessive weight gain: RCT

Pregnancy is a critical period for the development of later obesity. Regular weighing of pregnant women is not currently recommended in the UK. This study aimed to demonstrate the feasibility of regular weighing by community midwives (CMWs) as a potential intervention to prevent excessive gestational weight gain. Low risk healthy/overweight pregnant women cared for by eight CMWs were randomised to usual care or usual care plus the intervention at 10-14 weeks of pregnancy. The intervention involved CMWs weighing and charting weight gain on an IOM weight gain chart, setting a weight target and giving brief feedback at antenatal appointments. The focus of the study was on process evaluation outcomes. Data on other outcomes were also collected including gestational weight gain. We interviewed women and CMWs about their views of the intervention. CMWs referred 123 women, 95 agreed to participate and 76 were randomised. Over 90% of women were weighed at 38 weeks of pregnancy demonstrating high follow up. There was no evidence the intervention caused anxiety. Most women commented they had found the intervention useful in encouraging them to think about their weight and believed it should be part of routine antenatal care. CMW's felt the intervention could be implemented within antenatal care without adding substantially to consultation length. To conclude, pregnant women were keen to participate in the study and the intervention was acceptable to pregnant women and CMWs. An effectiveness trial is now planned.

Effect of behavioural techniques and delivery mode on effectiveness of weight management: systematic review, meta-analysis and meta-regression

A systematic review, meta-analysis and meta-regression were conducted to evaluate the effectiveness of behavioural weight management programmes and examine how programme characteristics affect mean weight loss. Randomized controlled trials of multicomponent behavioural weight management programmes in overweight and obese adults were included. References were obtained through systematic searches of electronic databases (conducted November 2012), screening reference lists and contacting experts. Two reviewers extracted data and evaluated risk of bias. Thirty-seven studies, representing over 16,000 participants, were included. The pooled mean difference in weight loss at 12 months was -2.8 kg (95% confidence interval [CI] -3.6 to -2.1, P < 0.001). I(2) indicated that 93% of the variability in outcome was due to differences in programme effectiveness. Meta-analysis showed no evidence that supervised physical activity sessions (mean difference 1.1 kg, 95% CI -2.65 to 4.79, P = 0.08), more frequent contact (mean difference -0.3 kg, 95% CI -0.7 to 0.2, P = 0.25) or in-person contact (mean difference 0.0 kg, 95% CI -1.8 to 1.8, P = 0.06) were related to programme effectiveness at 12 months. In meta-regression, calorie counting (-3.3 kg, 95% CI -4.6 to -2.0, P = 0.027), contact with a dietitian (-1.5 kg, 95% CI -2.9 to -0.2, P < 0.001) and use of behaviour change techniques that compare participants' behaviour with others (-1.5 kg, 95% CI -2.9 to -0.1, P = 0.032) were associated with greater weight loss. There was no evidence that other programme characteristics were associated with programme effectiveness. Most but not all behavioural weight management programmes are effective. Programmes that support participants to count calories or include a dietitian may be more effective, but the programme characteristics explaining success are mainly unknown.

Effectiveness and cost-effectiveness of computer and other electronic aids for smoking cessation: a systematic review and network meta-analysis

BACKGROUND

Smoking is harmful to health. On average, lifelong smokers lose 10 years of life, and about half of all lifelong smokers have their lives shortened by smoking. Stopping smoking reverses or prevents many of these harms. However, cessation services in the NHS achieve variable success rates with smokers who want to quit. Approaches to behaviour change can be supplemented with electronic aids, and this may significantly increase quit rates and prevent a proportion of cases that relapse.

OBJECTIVE

The primary research question we sought to answer was: What is the effectiveness and cost-effectiveness of internet, pc and other electronic aids to help people stop smoking? We addressed the following three questions: (1) What is the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids for smoking cessation and/or reducing relapse? (2) What is the cost-effectiveness of incorporating internet sites, computer programs, mobile telephone text messages and other electronic aids into current nhs smoking cessation programmes? and (3) What are the current gaps in research into the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids to help people stop smoking?

DATA SOURCES

For the effectiveness review, relevant primary studies were sought from The Cochrane Library [Cochrane Central Register of Controlled Trials (CENTRAL)] 2009, Issue 4, and MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Health Management Information Consortium (HMIC) (Ovid) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost) from 1980 to December 2009. In addition, NHS Economic Evaluation Database (NHS EED) and Database of Abstracts of Reviews of Effects (DARE) were searched for information on cost-effectiveness and modelling for the same period. Reference lists of included studies and of relevant systematic reviews were examined to identify further potentially relevant studies. Research registries of ongoing studies including National Institute for Health Research (NIHR) Clinical Research Network Portfolio Database, Current Controlled Trials and ClinicalTrials.gov were also searched, and further information was sought from contacts with experts.

REVIEW METHODS

Randomised controlled trials (RCTs) and quasi-RCTs evaluating smoking cessation programmes that utilise computer, internet, mobile telephone or other electronic aids in adult smokers were included in the effectiveness review. Relevant studies of other design were included in the cost-effectiveness review and supplementary review. Pair-wise meta-analyses using both random- and fixed-effects models were carried out. Bayesian mixed-treatment comparisons (MTCs) were also performed. A de novo decision-analytical model was constructed for estimating the cost-effectiveness of interventions. Expected value of perfect information (EVPI) was calculated. Narrative synthesis of key themes and issues that may influence the acceptability and usability of electronic aids was provided in the supplementary review.

RESULTS

This effectiveness review included 60 RCTs/quasi-RCTs reported in 77 publications. Pooled estimate for prolonged abstinence [relative risk (RR) = 1.32, 95% confidence interval (CI) 1.21 to 1.45] and point prevalence abstinence (RR = 1.14, 95% CI 1.07 to 1.22) suggested that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials. There was no significant difference in effect sizes between aid to cessation studies (which provide support to smokers who are ready to quit) and cessation induction studies (which attempt to encourage a cessation attempt in smokers who are not yet ready to quit). Results from MTC also showed small but significant intervention effect (time to relapse, mean hazard ratio 0.87, 95% credible interval 0.83 to 0.92). Cost-threshold analyses indicated some form of electronic intervention is likely to be cost-effective when added to non-electronic behavioural support, but there is substantial uncertainty with regard to what the most effective (thus most cost-effective) type of electronic intervention is, which warrants further research. EVPI calculations suggested the upper limit for the benefit of this research is around £ 2000-3000 per person.

LIMITATIONS

The review focuses on smoking cessation programmes in the adult population, but does not cover smoking cessation in adolescents. Most available evidence relates to interventions with a single tailored component, while evidence for different modes of delivery (e.g. e-mail, text messaging) is limited. Therefore, the findings of lack of sufficient evidence for proving or refuting effectiveness should not be regarded as evidence of ineffectiveness. We have examined only a small number of factors that could potentially influence the effectiveness of the interventions. A comprehensive evaluation of potential effect modifiers at study level in a systematic review of complex interventions remains challenging. Information presented in published papers is often insufficient to allow accurate coding of each intervention or comparator. A limitation of the cost-effectiveness analysis, shared with several previous cost-effectiveness analyses of smoking cessation interventions, is that intervention benefit is restricted to the first quit attempt. Exploring the impact of interventions on subsequent attempts requires more detailed information on patient event histories than is available from current evidence.

CONCLUSIONS

Our effectiveness review concluded that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials, but the effect is small. The effectiveness does not appear to vary with respect to mode of delivery and concurrent non-electronic co-interventions. Our cost-effectiveness review suggests that making some form of electronic support available to smokers actively seeking to quit is highly likely to be cost-effective. This is true whether the electronic intervention is delivered alongside brief advice or more intensive counselling. The key source of uncertainty is that around the comparative effectiveness of different types of electronic interventions. Our review suggests that further research is needed on the relative benefits of different forms of delivery for electronic aids, the content of delivery, and the acceptability of these technologies for smoking cessation with subpopulations of smokers, particularly disadvantaged groups. More evidence is also required on the relationship between involving users in the design of interventions and the impact this has on effectiveness, and finally on how electronic aids developed and tested in research settings are applied in routine practice and in the community.

Mediation analysis of the association between use of NRT for smoking reduction and attempts to stop smoking

OBJECTIVES

Use of nicotine replacement therapy (NRT) for smoking reduction (SR) is linked to higher quit attempt rates than SR without NRT. This study aimed to assess the possible mediating roles of confidence in ability to quit, enjoyment of smoking and motivation to quit in this association.

DESIGN

Cross-sectional survey.

MAIN OUTCOME MEASURES

Smokers were asked if they were currently attempting SR, and if they were, whether they were using NRT. Motivation to stop, enjoyment of smoking, confidence in ability to stop, and previous quit attempts, were also assessed.

RESULTS

There was no evidence that confidence in ability to quit or enjoyment of smoking mediated the association between the use of NRT for SR and attempts to quit. Only motivation to stop partially mediated between the use of NRT for SR and attempts to stop (indirect effect: odds ratio 1.08, p < 0.001).

CONCLUSION

Although this study is limited by its cross-sectional design, the findings point towards the possibility that the use of NRT to aid SR may promote attempts to stop through increasing motivation to quit but not by increasing confidence or by reducing enjoyment of smoking. Longitudinal studies are required to draw firmer conclusions about the possible mediating effects of motivation to quit.

Use of nicotine replacement therapy for smoking reduction and during enforced temporary abstinence: a national survey of English smokers

AIMS

To assess the prevalence of nicotine replacement therapy (NRT) use for smoking reduction (SR) and temporary abstinence (TA), the association between the two and the strength of the association between NRT use for SR or TA and socio-demographic characteristics, cigarette consumption and past quit attempts.

DESIGN

Cross-sectional monthly surveys.

SETTING

England.

PARTICIPANTS

A total of 11, 414 smokers.

MEASUREMENTS

Participants were asked (i) whether they were reducing the amount they smoked: if so, whether they used NRT; and (ii) whether they used NRT for TA. Demographic characteristics, daily cigarette consumption and whether a quit attempt had been made in the past 12 months were also assessed.

FINDINGS

Of the participants, 56% were attempting SR, 14% were using NRT for SR and 14% were using NRT for TA. Use of NRT for SR and TA were highly correlated. The nicotine patch was the most commonly used form of NRT. The use of NRT for SR, compared with unassisted SR, was more common among older smokers, while the use of NRT for TA was more common among women. Cigarette consumption was higher in those using NRT for SR than those attempting SR without NRT. The use of NRT for SR and TA was associated positively with past quit attempts.

CONCLUSIONS

Nicotine replacement therapy use for smoking reduction and temporary abstinence is common in England. The use of NRT for SR and TA does not appear to be associated with lower cigarette consumption relative to SR or TA without NRT, but is associated with a higher rate of past quit attempts.

Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis

OBJECTIVE

To systematically review the evidence that smoking cessation after diagnosis of a primary lung tumour affects prognosis.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

CINAHL (from 1981), Embase (from 1980), Medline (from 1966), Web of Science (from 1966), CENTRAL (from 1977) to December 2008, and reference lists of included studies.

STUDY SELECTION

Randomised controlled trials or observational longitudinal studies that measured the effect of quitting smoking after diagnosis of lung cancer on prognostic outcomes, regardless of stage at presentation or tumour histology, were included.

DATA EXTRACTION

Two researchers independently identified studies for inclusion and extracted data. Estimates were combined by using a random effects model, and the I(2) statistic was used to examine heterogeneity. Life tables were used to model five year survival for early stage non-small cell lung cancer and limited stage small cell lung cancer, using death rates for continuing smokers and quitters obtained from this review.

RESULTS

In 9/10 included studies, most patients studied were diagnosed as having an early stage lung tumour. Continued smoking was associated with a significantly increased risk of all cause mortality (hazard ratio 2.94, 95% confidence interval 1.15 to 7.54) and recurrence (1.86, 1.01 to 3.41) in early stage non-small cell lung cancer and of all cause mortality (1.86, 1.33 to 2.59), development of a second primary tumour (4.31, 1.09 to 16.98), and recurrence (1.26, 1.06 to 1.50) in limited stage small cell lung cancer. No study contained data on the effect of quitting smoking on cancer specific mortality or on development of a second primary tumour in non-small cell lung cancer. Life table modelling on the basis of these data estimated 33% five year survival in 65 year old patients with early stage non-small cell lung cancer who continued to smoke compared with 70% in those who quit smoking. In limited stage small cell lung cancer, an estimated 29% of continuing smokers would survive for five years compared with 63% of quitters on the basis of the data from this review.

CONCLUSIONS

This review provides preliminary evidence that smoking cessation after diagnosis of early stage lung cancer improves prognostic outcomes. From life table modelling, the estimated number of deaths prevented is larger than would be expected from reduction of cardiorespiratory deaths after smoking cessation, so most of the mortality gain is likely to be due to reduced cancer progression. These findings indicate that offering smoking cessation treatment to patients presenting with early stage lung cancer may be beneficial.

'Cut down to quit' with nicotine replacement therapies in smoking cessation: a systematic review of effectiveness and economic analysis

OBJECTIVES

To examine the effectiveness and cost-effectiveness of nicotine replacement therapy (NRT) for 'cut down to quit' (CDTQ) smoking.

DATA SOURCES

Major electronic databases were searched up to July 2006.

REVIEW METHODS

Data from studies meeting the criteria were reviewed and analysed. A decision analytical model was constructed to estimate the cost-effectiveness of CDTQ from the NHS perspective.

RESULTS

No systematic reviews of the effectiveness of CDTQ and no randomised controlled trials (RCTs) specifically addressing CDTQ were identified. Seven randomised placebo-controlled trials satisfied the inclusion criteria; six of these were industry sponsored. However, sustained smoking cessation was only reported as a secondary outcome in these trials and required commencement of cessation within the first 6 weeks of treatment. Meta-analyses of the study level results demonstrated statistically significant superiority of NRT compared with placebo. Individual patient data from unpublished reports of five RCTs were used to calculate sustained abstinence of at least 6 months starting at any time during the treatment period (generally 12 months). From this the meta-analysis indicated statistically significant superiority of NRT versus placebo [relative risk 2.06, 95% confidence interval (CI) 1.34 to 3.15]. The proportions achieving this outcome across all five RCTs were 6.75% of participants in receipt of NRT and 3.29% of those receiving placebo. The number-needed-to-treat was 29. This measure of sustained abstinence was used for economic modelling. No existing economic analyses of CDTQ were identified. A de novo decision analytic model was constructed to estimate the cost-effectiveness of making CDTQ with NRT available for smokers unwilling or unable to attempt an abrupt quit. The outcome measure was expected quality-adjusted life-years (QALYs). The model results suggest that CDTQ with NRT delivers incremental cost-effectiveness ratios (ICERs) ranging from around 1500 pounds/QALY to 7700 pounds/QALY depending on the age at which smoking cessation was achieved and the modes of CDTQ delivery. Assuming applicability to a single population, CDTQ was not cost-effective compared with abrupt quitting. If CDTQ with NRT were to be offered on the NHS as a matter of policy, the base-case results suggest that it would only be effective and cost-effective if a substantial majority of the people attempting CDTQ with NRT were those who would otherwise make no attempt to quit. This result is robust to considerable variation in the forms of CDTQ with NRT offered, and to the assumptions about QALY gained per quit success.

CONCLUSIONS

Meta-analysis of RCT evidence of quit rates in NRT-supported smoking reduction studies indicates that NRT is an effective intervention in achieving sustained smoking abstinence for smokers who declare unwillingness or inability to attempt an abrupt quit. The 12-month sustained abstinence success rate in this population (approximately 5.3% with NRT versus approximately 2.6% with placebo) is considerably less than that documented for an abrupt quit NRT regime in smokers willing to attempt an abrupt quit with NRT (which according to other systematic reviews is around 16% with NRT versus 10% with placebo). Most of the evidence of effectiveness of CDTQ came from trials that required considerable patient-investigator contact. Therefore, for CDTQ with NRT to generate similar abstinence rates for this recalcitrant population in a real-world setting would probably require a similar mode of delivery. The modelling undertaken, which was based on reasonable assumptions about costs, benefits and success rates, suggests that CDTQ is highly cost-effective compared with no quit attempt. CDTQ remains cost-effective if dilution from abrupt quitting forms a small proportion of CDTQ attempts. In an alternative analysis in which smokers who switch from an abrupt quit to CDTQ retain the success rate of abrupt quitters, all forms of CDTQ appear cost-effective. Randomised trials in recalcitrant smokers allowing head-to-head comparison of CDTQ delivered with various modalities would be informative.

A cluster randomised controlled trial of smoking cessation in pregnant women comparing interventions based on the transtheoretical (stages of change) model to standard care

OBJECTIVES

To evaluate the effectiveness in helping pregnant women stop smoking of two interventions (Pro-Change for a healthy pregnancy) based on the transtheoretical model of behaviour change (TTM) compared to current standard care.

DESIGN

Cluster randomised trial.

SETTING

Antenatal clinics in West Midlands, UK general practices.

PARTICIPANTS

918 pregnant smokers

INTERVENTIONS

100 general practices were randomised into the three trial arms. Midwives in these practices delivered three interventions: A (standard care), B (TTM based self help manuals), and C (TTM based self help manuals plus sessions with an interactive computer program giving individualised smoking cessation advice).

MAIN OUTCOME MEASURES

Biochemically confirmed smoking cessation for 10 weeks previously, and point prevalence abstinence, both measured at 30 weeks of pregnancy and 10 days after delivery.

RESULTS

There were small differences between the TTM arms. Combining the two arms, the odds ratios at 30 weeks were 2.09 (95% confidence interval (CI) 0.90 to 4.85) for 10 week sustained abstinence and 2.92 (95% CI 1.42 to 6.03) for point prevalence abstinence relative to controls. At 10 days after delivery, the odds ratios were 2.81 (95% CI 1.11 to 7.13) and 1.85 (95% CI 1.00 to 3.41) for 10 week and point prevalence abstinence respectively.

CONCLUSIONS

While there is a small borderline significant increase in quitting in the combined intervention arms compared with the controls, the effect of the intervention is small. At 30 weeks gestation and at 10 days postnatal, only about 3% of the intervention groups achieved sustained cessation, with numbers needed to treat of 67 (30 weeks of gestation) and 53 (10 weeks postnatal) for one additional woman to achieve sustained confirmed cessation. Given also that the intervention was resource intensive, it is of doubtful benefit.

The importance of social sources of cigarettes to school students

OBJECTIVE

To discover the importance of social sources of tobacco to young people as opposed to commercial sources; to describe the peer market for cigarettes in schools and the consequences for young people of their involvement in it.

STUDY DESIGN

Cross sectional questionnaire survey, one-to-one interviews, and focus groups.

SETTING

Seven schools in Birmingham, UK.

SUBJECTS

All students in two randomly selected classes from each school completed the questionnaire, and never smokers, occasional smokers, and regular smokers were interviewed.

RESULTS

Two thirds of occasional smokers and one quarter of regular smokers obtained cigarettes socially, mostly for free. A few smokers regularly bought their cigarettes from others. Among friendship groups, both smokers and non-smokers were involved in the exchange of cigarettes, often for money, which is a common activity. A few young people use the selling of cigarettes to fund their own smoking. Some young people, smokers and non-smokers, are involved in semi-commercial selling of cigarettes. All school students are aware of where to purchase cigarettes from non-friends, which is only used "in emergency" because of the high price. One school had a strong punishment policy for students caught with cigarettes. In this school, more people bought singles from the peer market and the price was higher.

CONCLUSIONS

The passing and selling of cigarettes in school is a common activity, which from the young persons perspective, ensures that all share cross counter purchases. A few people are prepared to use the peer market for monetary gain and it appears to be responsive to external conditions. The peer market might mean that efforts to control illegal sales of cigarettes are not as effective as hoped.

The relationship between mean birth weight and poverty using the Townsend deprivation score and the Super Profile classification system

Super Profiles have been used as alternative methods of characterising the deprivation of an area. Some reports suggest that Super Profiles are as accurate as established indices such as the Townsend score (TS). This was a test of this assertion.A total of 138 696 live born singleton births to Birmingham residents born between 1986 and 1996 (inclusive) were allocated to enumeration districts (EDs) by linkage from the postcode. We allocated the TS of the individual's ED. We allocated a Lifestyle and Target Market (TM) from Super Profiles by linkage to the ED. We examined the gradient between mean birth weight and the 10 Super Profile Lifestyles and compared this to the gradient between 10 Townsend groups and mean birth weight. We repeated this approach using the 40 TMs and 40 Townsend groups. We used both the median income and a census-derived deprivation measure to rank Lifestyles and TMs. The gradient between mean birth weight and area deprivation was linear for Townsend groups but not linear using either Lifestyles or TMs whichever method of ranking Lifestyles or TMs was used. Where Lifestyles or TMs were out of line with their neighbours, the TS of that group mostly explained this. As Super Profiles are generated using nationally representative data, applying the affluence ranking to small areas can lead to inaccuracies, as shown in this data. We conclude that Super Profiles are probably unsuitable as measures of deprivation of small areas.

Does smoking status influence the prognosis of bladder cancer? A systematic review

OBJECTIVE

To summarize, in a systematic review, the evidence for the effect of stopping smoking on recurrence, cancer-specific and all cause-mortality among smokers with newly diagnosed bladder cancer.

MATERIALS AND METHODS

Two electronic databases and the reference lists of identified primary studies and reviews were searched. Studies were included if a hazard ratio and its confidence intervals could be extracted. A predefined set of study characteristics was extracted which defined whether studies were giving valid prognostic data on the effects of smoking in reasonably homogenous cohorts. The results of studies were synthesized qualitatively.

RESULTS

Fifteen relevant studies were identified; former and current smokers were combined in many studies. Many studies produced information on prognosis that was confounded by the mixing of incident and prevalent cases. Only three studies examined the influence of smoking on prognosis in only incident cases, most of whom had superficial disease. Of these, only one was of high quality. These three studies and the other 12 showed suggestive evidence that continued smoking or a lifetime of smoking constitutes a moderate risk factor for recurrence and death, and that stopping smoking could favourably change this. However, the evidence base for this is weak because of the methodological shortcomings and because most studies' results were not statistically significant. A life-table model showed that if stopping smoking altered the prognosis, the size of the benefit would be clinically worthwhile.

CONCLUSION

There is suggestive evidence that stopping smoking might favourably alter the course of bladder cancer, but this is insufficient for clinicians to inform patients that doing so will improve their prognosis, and for providing specialized services to assist in stopping smoking to patients with bladder cancer.

The change-in-stage and updated smoking status results from a cluster-randomized trial of smoking prevention and cessation using the transtheoretical model among British adolescents

BACKGROUND

The transtheoretical model (TTM) and computer technology are promising technologies for changing health behavior, but there is little evidence of their effectiveness among adolescents.

METHOD

Four thousand two hundred twenty-seven Year 9 (ages 13-14) pupils in 26 schools were randomly allocated to control and 4,125 in 26 schools were allocated to TTM intervention. TTM pupils received three whole class lessons and three sessions with an interactive computer program. Control pupils received no special intervention. Positive change in stage and smoking status was assessed from a questionnaire completed at baseline, 1 year, and 2 years. Random effects logistic regression was used to compare the change in stage and smoking status between the arms.

RESULTS

Eighty-nine percent of the TTM group and 89.3% of the control group were present at 1-year and 86.0 and 83.1%, respectively, were present at 2-year follow-up. The adjusted odds ratio (95% confidence interval) for positive stage movement in the TTM relative to control was 1.13 (0.91-1.41) at 1 year and 1.25 (0.95-1.64) at 2 years and for regular smoking was 1.14 (0.93-1.39) at 1 year and 1.06 (0.86-1.31) at 2 years. Subgroup analysis by initial smoking status revealed no benefit for prevention or cessation.

CONCLUSIONS

The intervention was ineffective.

The cost effectiveness of including pencils and erasers with self-completion epidemiological questionnaires

It is cheap to process epidemiological data from optical mark read (OMR) questionnaires. Respondents should use a pencil to complete OMR questionnaires, but many will not unless these are supplied. Sending pencils and erasers is expensive. Does sending pencils and erasers increase the response rate as cost-effectively as sending reminders, or does this decrease the error rate and offset data checking costs? We mailed 300 smokers and half were randomised to receive pencils and erasers. The relative risk (95% confidence intervals) for the response rate for the pencil group relative to the non-pencil group was 0.77 (0.46-1.29) and for the error rate was 1.31 (0.78-2.21). Sending pencils and erasers was not cost-effective in sensitivity analysis with any response rate or using the confidence intervals. Including pencils with mailed epidemiological questionnaires probably has no benefit and any plausible benefit does not offset the costs of sending pencils and erasers.

Does the multidimensional nature of Super Profiles help district health authorities understand the way social capital affects health?

BACKGROUND

Social capital describes the notion that the social processes in an area can lead to benefits in health. As Super Profiles describe the social character of an area and they are easy for health authorities to use, they could provide a simple method for local assessment of how social organization affects health.

METHODS

We calculated the expected mean birthweight for the enumeration districts of Birmingham based upon marital status, registration details of the child, year of birth, the mother's country of birth, fetal sex and deprivation as judged by the Townsend score using data from 138,696 live-born singleton births for the years 1986-1996 inclusive. We classified enumeration districts into Target Markets, derived from Super Profiles. For each Target Market, we calculated the observed mean birthweight and the difference and 95 per cent confidence interval between the observed and expected birthweights. We used information in Super Profiles to speculate about the social processes that led to some Target Markets having mean birthweights that were significantly different from those expected.

RESULTS

Fifteen of the 40 Target Markets had significant differences between predicted and observed mean birthweight, but these differences were less than 50 g. There were no common characteristics of Target Markets that were consistently advantageous for birthweight and none that were disadvantageous.

CONCLUSION

The information in the Super Profiles does not illuminate the way that social processes affect health, and the variation in mean birthweight between areas explained by social processes as measured by Super Profiles is small.

Cluster randomised controlled trial of expert system based on the transtheoretical ("stages of change") model for smoking prevention and cessation in schools

OBJECTIVES

To examine whether a year long programme based on the transtheoretical model of behaviour change, incorporating three sessions using an expert system computer program and three class lessons, could reduce the prevalence of teenage smoking.

DESIGN

Cluster randomised trial comparing the intervention to a control group exposed only to health education as part of the English national curriculum.

SETTING

52 schools in the West Midlands region.

PARTICIPANTS

8352 students in year 9 (age 13-14 years) at those schools.

MAIN OUTCOME MEASURES

Prevalence of teenage smoking 12 months after the start of the intervention.

RESULTS

Of the 8352 students recruited, 7444 (89.1%) were followed up at 12 months. The intention to treat odds ratio for smoking in the intervention group relative to control was 1.08 (95% confidence interval 0.89 to 1.33). Sensitivity analysis for loss to follow up and adjustment for potential confounders did not alter these findings.

CONCLUSIONS

The smoking prevention and cessation intervention based on the transtheoretical model, as delivered in this trial, is ineffective in schoolchildren aged 13-14.

A fresh look at proportional mortality ratios

This is a review of the use of proportional mortality ratios (PMRs). District health authorities rarely concern themselves with searching for unknown causes of disease but do need to monitor the health of a population. PMRs are a good way to do this. Textbooks of epidemiology tend to see PMRs as biased measures of risk and give them little attention. This review shows that the bias is small and of no practical importance. PMR studies can be seen as case-control studies and the major bias in these studies as analogous to Berkson's fallacy. We can then use the same techniques to reduce bias in PMR studies that are used in case-control studies. These are the use of several controls, the use of positive and negative controls, and the use of only one type of death in the denominator, rather than all causes of death. This article reviews these means of minimising bias using examples to show that careful selection of controls can overcome many of the supposed problems of PMR studies. It also shows how PMRs can control confounding in a way that SMRs cannot. PMR studies should be more widely used to monitor the health of the population.