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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Online support for smoking cessation: a systematic review of the literature

L Shahab and A McEwen.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

The review found that interactive web-based interventions for smoking cessation could be effective and were generally considered to be acceptable. Further research is required to compare interactive with static websites. Overall, the conclusions seem reasonable, but should be considered with caution due to potential methodological weaknesses and poor reporting.

Authors' objectives

To review the acceptability and effectiveness of interactive online interventions for smoking cessation.

Searching

The following databases were searched from 1990 to 2008: PubMed, PsycINFO, CINAHL, EconLit, Web of Science and Cochrane Central Register of Controlled Trials (CENTRAL). Search terms were reported. Bibliographic searches were also carried out. Only English-language published papers were considered for selection.

Study selection

Randomised controlled trials (RCTs) of current smokers that assessed interactive online smoking cessation interventions were eligible. Included trials were required to have a minimum follow-up period of one month. The primary outcome was specified as smoking cessation (not further defined).

The included trials were all published since 2005. Most trials were carried out in the USA. All but two trials recruited participants from the general population; most required people to be intending to stop smoking when entering the study. The mean age across trials ranged from 15.7 years to around 42 years. The percentage of females ranged from 49.6 to 72.9%. The average number of cigarettes smoked on entry to the study varied from less than two to around 23 per day. All of these characteristics were based on data as reported, not all trials reported all information.

The interventions were all rated as high in complexity; their length ranged from eight weeks to one year. A variety of tailored programmes were used incorporating some or all of the following components: interactive web pages, emails, text messages, phone calls, videos, and nicotine replacement therapy. The control groups received either a minimal static intervention, such as a booklet or information page, wait-list control or face-to-face counselling. Multi-armed trials also evaluated adding interactive Internet interventions in to behavioural programmes. The complexity rating of the control condition varied with most rated as low or medium. The outcome measures were not detailed; two trials validated cessation measures.

The authors did not report how many reviewers performed the study selection.

Assessment of study quality

The primary trials were assessed for quality based on randomisation, baseline characteristics, validation of outcomes, staff details, blinding, attrition and analysis.

The authors did not report how many reviewers performed the validity assessment.

Data extraction

Smoking cessation measures were extracted as rate ratios (RRs) and, where appropriate, risk differences (RDs) were calculated.

The authors did not report how many reviewers performed the data extraction.

Methods of synthesis

The primary trials were pooled where possible using Mantel-Haenszel random-effect models to produce rate ratios and risk differences with associated 95% confidence intervals (CI). Heterogeneity was assessed using the I2 test.

Publication bias was assessed using Egger's and Begg's methods.

Due to diversity of methodology and interventions, trials were pooled across common methodological criteria and outcomes. Abstinence at six months was used as a proxy to estimate permanent abstinence rates.

Results of the review

A total of 11 RCTs were included (n=15,511 participants). Attrition rates varied widely and intention-to-treat analysis was used by all but one trial. The populations appeared to be homogeneous, although insufficient data were reported in the primary trials. Outcome assessor blinding was poorly reported. Trials used varying definitions of the term abstinence. Treatment and control intervention content were reported as poorly matched and only two trials reporting having carried out power calculations.

There was a significant increase in quit rates for participants using interactive online interventions versus any minimal control condition (RR 1.5, 95% CI 1.2 to 1.9; six trials), although there was also significant heterogeneity. Grouping the analyses according to type of minimal control found a significant non-heterogeneous effect for comparison with booklet or email controls (RR 1.8, 95% CI 1.4 to 2.3; three trials), and a non-significant heterogeneous difference versus static website controls (two trials). One trial reporting interactive online intervention versus waiting-list control found a significant benefit in favour of the online group.

Interactive on-line interventions increased abstinence by 17% (95% CI 12 to 21) compared with minimal controls at six months (RR 1.93, 95% CI 1.44 to 2.6; three trials) although these data were based on point prevalence.

Two trials compared interactive online interventions with face-to-face counselling, and two trials compared behavioural treatment alone versus behavioural treatment plus online components. Neither of these groups found any significant differences between the intervention arms.

No significant results for the publication bias tests were reported.

The full paper also reported details of analyses around effect moderators and variables. In summary, there appeared to be no impact according to length of treatment, no clear impact of automated versus non-automated interventions, and no effect of pharmacotherapy use such as nicotine replacement therapy.

Satisfaction was reported in three trials: overall rates were around 90% and tailored interactive interventions were significantly rated more highly than non-tailored static interventions (details not reported).

Authors' conclusions

Interactive web-based interventions for smoking cessation could be effective and were generally considered to be acceptable. Further research is required to compare interactive with static websites.

CRD commentary

This review addressed a clear question with relevant inclusion criteria and adequate database searches. However, limiting studies to English-language and published research may have introduced both language and publication biases. The review processes of study selection, data extraction and quality assessment were not described, which made it difficult to rule out reviewer error and/or bias.

The validity assessment appeared to have been informal, but detailed and relevant aspects of each included trial were described. The analyses were appropriately cautious given the clinical heterogeneity and difficulty in combining different measures of abstinence.

Overall the conclusions seem reasonable, but should be considered with caution due to potential methodological weaknesses and poor reporting.

Both authors disclosed links with manufacturers of smoking cessation products.

Implications of the review for practice and research

Practice: The authors made no direct recommendations for practice.

Research: The authors suggested that further research is required to compare interactive with static websites and counselling. These trials should follow reporting guidelines.

Funding

Department of Health, England.

Bibliographic details

Shahab L, McEwen A. Online support for smoking cessation: a systematic review of the literature. Addiction 2009; 104(11): 1792-1804. [PubMed: 19832783]

Indexing Status

Subject indexing assigned by NLM

MeSH

Female; Humans; Intention; Internet; Male; Outcome Assessment (Health Care) /statistics & numerical data; Pamphlets; Patient Acceptance of Health Care /statistics & numerical data; Patient Education as Topic /methods; Randomized Controlled Trials as Topic; Self Care /methods /utilization; Smoking /therapy; Smoking Cessation /methods /psychology /statistics & numerical data; Therapy, Computer-Assisted /methods; Treatment Outcome

AccessionNumber

12009110306

Database entry date

25/08/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19832783

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