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Ranney L, Melvin C, Lux L, et al. Tobacco Use: Prevention, Cessation, and Control. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Jun. (Evidence Reports/Technology Assessments, No. 140.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Tobacco Use: Prevention, Cessation, and Control.

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Executive Summary

Introduction

The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) conducted a systematic review of the literature on issues of tobacco use, prevention, cessation, and control on behalf of the National Institutes of Health (NIH), Office of Medical Applications of Research (OMAR), through the Agency for Healthcare Research and Quality (AHRQ). OMAR commissioned this review to summarize the available literature, frame the discussions regarding benefits and harms, and highlight the limitations of the entire evidence base for a State-of-the-Science (SOS) conference in June 2006.

We synthesized existing literature on five main research issues needed to make progress toward public health gains worldwide. Specific substantive key questions (KQs) were:

1.

What are the effective population- and community-based interventions to prevent tobacco use in diverse populations of adolescents and young adults?

2.

What are effective strategies for increasing consumer demand among diverse populations for and use of proven individually oriented cessation treatments?

3.

What are effective strategies for increasing implementation of proven population-level tobacco use cessation strategies, particularly by health care systems and communities?

4.

What effect does smokeless tobacco product marketing and use have on population harm from tobacco use?

5.

What is the effectiveness of prevention and of cessation interventions in populations with co-occurring morbidities and risk behaviors?

Methods

Literature Searches

We searched MEDLINE®, the Cumulative Index to Nursing and Applied Health (CINAHL), The Cochrane Library, Psychological Abstracts, and Sociological Abstracts using Medical Subject Headings as search terms or key words when appropriate; we also manually searched reference lists. With our Technical Expert Panel (TEP), we generated a list of inclusion and exclusion for each question. We limited our review to human studies conducted in developed countries and published in English. We considered studies with participants ages 13 and older, of both sexes, and of diverse racial and ethnic populations. We limited studies to those with study duration of more than 6 months and minimum sample sizes of 30 for randomized controlled trials (RCTs) and 100 for other experimental or observational studies. We excluded articles that did not report outcomes related to our KQs or provide sufficient information to be abstracted. We also excluded all editorials, letters, and commentaries.

Finally, for work on KQs 1, 2, 3, and 5, we relied on prior systematic reviews (publication dates in parentheses):

  • The Guide to Community Preventive Services (2005),
  • Treating Tobacco Use and Dependence (2000),
  • Reducing Tobacco Use: A Report of the Surgeon General (2000),
  • Several Cochrane Collaboration Reviews (1998-2005),
  • Treating nicotine use and dependence of pregnant and parenting smokers: an update (2004),
  • Smoking cessation approaches for persons with mental illness or addictive disorders (2002),
  • A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery (2004), and
  • Growing up tobacco free: preventing nicotine addiction in children and youths (1994).

We included original research studies (1) published beyond the date range included in the systematic reviews, (2) concerning topics related to the questions not covered by the reviews, and (3) providing sufficient detail regarding their methods and outcomes.

We made decisions about including studies only after dual review. We assessed the quality of trials or other types of study using criteria from the U.S. Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. We rated strength of evidence using categories (strong, sufficient, insufficient) based on criteria from the Task Force on Community Preventive Services.

Results

KQ 1. Effective Population- and Community-Based Interventions to Prevent Tobacco Use in Adolescents and Young Adults

Population-based interventions. Prior systematic reviews investigating tobacco prevention among adolescents and young adults reported strong evidence of effectiveness for increasing the unit price of tobacco products and mass media campaigns run concurrently with other interventions. Evidence of effectiveness was sufficient for restricting tobacco product distribution, regulating the mechanisms of sale, enforcing access-to-minors laws, and merchant education and training when conducted in conjunction with community mobilization.

Two population-based studies had some success in reducing tobacco initiation among adolescents and young adults. Alone, they provided little conclusive evidence about such programs. One study on regulating and enforcing youth access laws augments sufficient evidence from prior reviews. We found no other research to add to existing evidence for population-based interventions.

Community-based interventions. Prior reviews reported limited and mixed evidence of effectiveness of community-based efforts aimed at tobacco prevention. Sufficient evidence was found for short-term effects (less than 2 years) of school-based prevention programs.

Interventions implemented in a single school year or conducted over multiple school years produced mixed results in 10 school-based studies. Consistent with prior reviews, we found sufficient evidence to demonstrate that prevention measures conducted in schools have positive short-term effects but insufficient evidence for long-term effects. We found no community-based studies.

Provider-based interventions. We did not identify any systematic reviews evaluating provider-based tobacco prevention. Our only provider-based study had no intervention effects, giving us insufficient evidence to determine the effectiveness of such efforts.

KQ 2. Effective Strategies for Increasing Consumer Demand for and Use of Proven Individually Oriented Cessation Treatments

Multicomponent strategies to increase the number of users who attempt to quit. Prior reviews found strong evidence of effectiveness for telephone cessation support to increase tobacco use cessation for adults, especially when combined with other counseling formats. We identified three studies of telephone counseling with related print materials. Consistent with prior reviews, two trials reported significant increases in cessation in the short term. One trial reported no difference.

Two studies showed telephone counseling targeting youth and young adults achieves quit rates comparable to those for adults. Though promising, the small number of studies is insufficient to confirm the effect of telephone counseling for these groups.

Strategies to improve the success of quit attempts. Prior systematic reviews reported consistent evidence that counseling by a trained therapist in one or more face-to-face sessions is effective for assisting smokers in their quit attempts. Evidence was insufficient to evaluate whether groups are more effective than intensive individual counseling or to support the use of particular psychological components beyond typically included support and skills training. Limited evidence suggests that adding group therapy to other forms of treatment produces extra benefit.

Prior systematic reviews reported insufficient evidence of the effectiveness of self-help in assisting smokers in their quit attempts. Meta-analyses reported strong, consistent evidence that pharmacologic treatments for smoking cessation can help people quit smoking and some evidence that the combination of the nicotine patch with a self-administered form of nicotine replacement therapy is more effective than a single form of nicotine replacement.

We identified studies evaluating the efficacy of self-help strategies, counseling, single pharmaceuticals, combination pharmacotherapy, and pharmacotherapy combined with psychological counseling. Studies in our review of strategies to improve success of quit attempts were consistent with previous reviews in finding that self-help strategies alone are not efficacious and that the use of counseling, pharmacotherapies either alone or in combination, or pharmacotherapies combined with psychological counseling increases the likelihood of successful quitting.

Strategies to improve the success of quit attempts for special populations. In a meta-analysis comparing augmented smoking cessation treatment with usual care for hospitalized patients, smoking cessation treatments were effective for hospitalized patients. Another review showed no strong evidence that clinical diagnosis affects the likelihood of quitting among hospitalized patients. The same review found that intensive intervention (inpatient contact plus followup for at least 1 month) with hospitalized patients was associated with a significantly higher quit rate compared to control. Prior reviews of interventions with pregnant smokers included studies with substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy and found that participants in intervention conditions experience significant reduction in continued smoking in late pregnancy. An earlier review showed that smoking cessation treatments are effective across different racial and ethnic minorities and should be offered to members of those groups.

We found results both consistent and inconsistent with prior reviews for interventions with special populations. When evaluating interventions with hospitalized patients by diagnosis, studies in our review were in agreement with findings of a prior review showing no strong evidence that clinical diagnosis affects the likelihood of quitting. Results of our review were inconsistent with two prior reviews indicating that hospitalized patients were more likely to quit smoking as the intensity of intervention increased. Although some studies in our review found significant gains in abstinence in the short term, all studies showed an absence of effect at 12-month assessment. The findings of our review remain consistent with those of prior reviews that counseling does increase the likelihood of abstinence among pregnant smokers. Investigators found quit rates for indigenous Maori in New Zealand similar to those observed in other trials of bupropion. These findings are consistent with an earlier review showing that smoking cessation treatments are effective for racial and ethnic minorities.

KQ 3. Effective Strategies for Increasing the Implementation of Proven Population-Level Tobacco Use Cessation Strategies, Particularly by Health Care Systems and Communities

Community-based strategies. Past systematic reviews reported little convincing evidence that community interventions reduce adult smoking. Three new studies focusing on different strategies and populations produced inconsistent results. Positive results emerged only in a trial using community-based pharmacists to discuss smoking cessation when smokers sought a variety of other services. These results are consistent with prior reviews.

Provider and health care system-based strategies. Prior reviews reported strong evidence of effectiveness for provider reminder systems with provider education, with or without client education, and for multicomponent interventions that include client telephone support. However, they reported insufficient evidence of effectiveness to recommend provider education alone and provider feedback and assessment. Sufficient evidence in our review indicated that implementing provider-based interventions such as training improves provider delivery of cessation treatment, but evidence was insufficient to conclude that implementing these approaches leads to higher abstinence.

In examining interventions in health care systems, we found sufficient evidence that academic detailing improves provider delivery of effective smoking cessation treatments. Family physicians and providers in office-based private practices, public clinics, hospitals, and orthodontist offices improved their knowledge and use of effective strategies from personal educational visits in their own practice setting, including education, audit, and feedback.

The evidence was insufficient to suggest that resultant improvement in treatment practices leads to significant, long-term increases in cessation among those being treated. Too few studies reported quit rates for the population served; those that did showed no long-term, consistent effects on cessation. One study tested the relationship between provider attitudes and smoking behavior on uptake and use of effective interventions, but found no effect.

Evidence was promising but insufficient to suggest that interventions proven effective in earlier trials could be sustained as part of routine care. Only one study examined this important aspect of improving the odds of maintaining an effective program. Investigators found that successfully implementing a proven strategy after completion of the original trial is possible, that the sustained program produced quit rates comparable with those observed in the trial, and that success was more likely among cancer, cardiovascular, and pulmonary patients.

KQ 4. Effect of Smokeless Tobacco Product Marketing and Use on Population Harm from Tobacco Use

Prior systematic reviews did not address these issues directly. Two new studies focused on smokeless tobacco use. One reported smokers were more likely to quit smoking than become users of smokeless tobacco, and users of smokeless tobacco were significantly more likely than nonusers of tobacco to become smokers. Another study found advertising exposure increased adolescent susceptibility to smokeless tobacco, resulting in a sevenfold increase in current use. We found no evidence on how smokeless tobacco marketing affects population harm. Based on these studies, we found insufficient evidence to draw firm conclusions about the impact of marketing these products on increased use or substitution of smokeless tobacco for smoking.

KQ 5. Effectiveness of Prevention and of Cessation Interventions in Populations with Co-occurring Morbidities and Risk Behaviors

Tobacco cessation for persons with comorbidities. Past reviews agree that, absent relevant studies on smoking cessation in psychiatric populations, clinicians should use smoking cessation treatments recommended for the general population. Three studies evaluated smoking cessation for people with psychiatric conditions. In one, pharmacotherapy was effective (consistent with prior reviews). In a second study, counseling and cognitive behavioral therapy were not effective for adults with a history of major depressive disorder (MDD), except in a secondary analysis categorizing adults into single-episode MDD and recurring MDD. In the third study, motivational interviewing or brief advice was not effective for adolescents hospitalized for psychiatric and substance use problems. Prior reviews did not report effective adolescent interventions. Evidence is insufficient and inconsistent to draw conclusions about the effectiveness of interventions in these populations or to overturn the current recommendation.

Tobacco cessation for persons with substance abuse addictions. Prior meta-analyses reported that people with chemical and nicotine dependency should receive counseling and pharmacotherapy to assist with smoking cessation. These types of interventions had positive short-term effects for stopping smoking but not for long-term abstinence. Two studies of smoking cessation interventions among alcohol and substance abusers reported significant effects for smoking cessation when compared to a control group. Both studies treated nicotine dependency concurrently with other addiction treatment. One study reported no effects on abstinence for other addictive substances; the other reported lower alcohol abstinence with concurrent treatments. The findings support past recommendations that counseling and pharmacotherapy have positive short-term effects for such interventions, but the body of evidence is insufficient, given the number of studies, to merit recommendations.

Discussion

General Conclusions

In most instances, evidence from new research covered in our review was consistent with previous systematic reviews. Even in combination with previous reviews, our findings are insufficient to draw new or different conclusions from those offered by earlier reviews. Overall, the evidence base to address the numerous issues raised for the SOS conference has critical gaps and deficiencies, particularly for questions unaddressed by prior reviews.

Future Research

Lacunae in the literature can be addressed by both future research and improvement in methods. We recommend efforts to examine the following key-question-specific issues, focusing on whether, how, and how well certain programs work to influence tobacco initiation, use, or cessation.

KQ 1: Tobacco prevention

  • Effect of tobacco industry and product restrictions (specifically, laws that regulate the content, labeling, promotion, and advertising of tobacco products) on adolescents and young adults;
  • Community mobilization with increased enforcement of tobacco youth access laws and regulations;
  • Concurrent implementation of effective population-based tobacco interventions (e.g., pricing, restricting access, regulations, and media campaigns) in different combinations;
  • Community-based tobacco prevention strategies implemented simultaneously;
  • Combinations of school-based interventions with community mobilization, media campaigns, and enforcement of tobacco youth access laws and regulations; and
  • Tobacco prevention efforts in provider-based settings for adolescents and young adults.

KQ 2: Attempts to quit tobacco use

  • Role of mass media in driving individuals to quit lines and other cessation services;
  • Audience research on effectiveness of messages to motivate target audiences of adolescents, young adults, and persons with low income and educational status;
  • Comparisons of specific components of telephone counseling and their relative impact on enrollment and continuation, individual motivation to quit, and smoking status;
  • Appropriateness of cessation services such as number and timing of calls, role of feedback to the caller's primary provider, and participants' satisfaction;
  • Relative population impact of proven cessation interventions, such as proactive telephone counseling support compared with in-person intervention;
  • Differential rates of success and enrollment and whether they offset or enhance each other;
  • Effectiveness of multiple intervention formats, of combination pharmacotherapy, and of adjuncts other than pharmacotherapy in comparison with individual counseling;
  • Ways to reduce withdrawal symptoms and cravings among those attempting to quit using tobacco products;
  • Ways to minimize side effects associated with use of individual pharmacotherapies and combined pharmaceutical regimes; and
  • Techniques to increase persistence of effect on smoking abstinence over time.

KQ 3: Cessation efforts in different settings

  • Ways to reach out to smokers in the general population and to special populations with messages that motivate individuals to become aware of, promote, and use existing cessation services;
  • Interventions to change provider practice patterns and related smoking outcomes for patients;
  • Academic detailing strategies and their impact across and within practice types;
  • Relationship of provider attitudes and smoking behavior to provider use of effective interventions; and
  • Institutional barriers hampering adoption of effective strategies in health systems and among providers.

KQ 4: Smokeless tobacco marketing and use

  • Impact of tobacco industry marketing on use of smokeless tobacco and whether populations are differentially affected;
  • Possible links between point-of-purchase tobacco promotion and advertising and increased use of smokeless tobacco among adolescents and young adults; and
  • Treatments to complement efforts aimed at smokeless tobacco cessation.

KQ 5: Populations with psychiatric comorbidities and risk behaviors

  • Tailored treatments and therapies for populations with psychiatric comorbidities and risk behaviors;
  • Effects of combined pharmacotherapies for population with psychiatric comorbidities and risk behaviors;
  • Effects of pharmacotherapy for people with a history of depression and people currently diagnosed with clinical depression;
  • Timing (e.g., simultaneous, before, or after) of tobacco use treatment and treatment for psychiatric and substance abuse problems; and
  • Barriers to tobacco treatment in patients with other health problems such as contraindications of pharmacotherapy and validity of clinicians' concerns about hindering sobriety.

Improved Methods

Investigators need to use markedly better and more rigorous methods for all new research into tobacco prevention, control, and cessation. Critical improvements include more rigorous and longer studies, standardized definitions of interventions, appropriate measurement tools (including biomarkers for verification), better statistical and analytic approaches (e.g., use of intent-to-treat methods), improved tactics for reducing attrition, and better documentation of methods and results.

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