1 / 42

A review of the evidence of quit-lines: gaps in the evidence and how to close them

A review of the evidence of quit-lines: gaps in the evidence and how to close them. Dr Lion Shahab CRUK Health Behaviour Research Centre Department of Epidemiology & Public Health University College London lion.shahab@ucl.ac.uk. Overview. Why - the case for quitlines

hanh
Télécharger la présentation

A review of the evidence of quit-lines: gaps in the evidence and how to close them

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A review of the evidence of quit-lines: gaps in the evidence and how to close them Dr Lion Shahab CRUK Health Behaviour Research Centre Department of Epidemiology & Public Health University College London lion.shahab@ucl.ac.uk

  2. Overview • Why - the case for quitlines • What - evidence for the efficacy of quitlines • Where to – future questions to be answered • How - state of the art in assessing smoking cessation interventions

  3. I. Why – the case for quitlines Goals of Tobacco Control

  4. I. Why – the case for quitlines Approaches to Tobacco Control Basic Research Public Awareness Values Slama, 2004 Intervention Programmes Legislation & Policy

  5. I. Why – the case for quitlines Goals of Tobacco Control

  6. I. Why – the case for quitlines Predicted death-toll

  7. I. Why – the case for quitlines Approaches to Tobacco Control – Impact on Prevalence Efficacy x Reach = Impact on Prevalence Low Efficacy High Low Reach High Number of people quitting

  8. I. Why – the case for quitlines Approaches to Tobacco Control – Impact on Prevalence Intervention Programmes Legislation & Policy Basic Research Public Awareness Values Low Efficacy High Low Reach High

  9. I. Why – the case for quitlines Advantages of quitlines • Potential high efficacy • Can emulate individual counselling delivered on-site in smoking cessation services • Flexibility of application – stand alone, or as addition to online interventions, minimal/leaflet interventions or face-to-face support • Potential wide reach • Easy access for users (flexible and near universal coverage) • Can attract additional smokers who would not normally seek help: those living in remote areas, with physical disabilities, those fearing stigmatisation • Cheaper than other high-intensity interventions • Possibility of computerised delivery

  10. I. Why – the case for quitlines The path to smoking cessation Smokers 60 % Want to quit1 Sources: 1 Smoking Toolkit Study 2 Cochrane Database 39 % Attempt to quit1 21 % use treatment1 18 % go ‘cold turkey’1 12 % buy NRT1 6 % get a prescription1 2.3 % use clinic1 0.7 % use quitline1 Success 8 % 8% 15 % 11 % 4% Rates2 1 % + 0.5 % + 0.35 % + 0.08 % + 0.72 = 2.65 % stop smoking 0.08% of 8.500.000 smokers = 6.800 ex-smokers ~ 15.000 life-years saved yearly

  11. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Types of telephone counselling • Proactive vs Reactive • Stand-alone vs Adjunctive • RCT, quasi-randomised control trials • 6-months abstinence • 65 studies included with sample size of 73,000 participants

  12. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Study characteristics • Mostly from North America (52) • Older adults (average age 40) • Most evaluated proactive counselling (60) • Wide range of number of calls (1-12) • Call duration similar (10-20 min) • Mostly delivered by trained HP/counsellors

  13. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Reactive telephone counselling • Single call • Self-help vs. telephone counselling (1) • Different interventions (general vs. target) (2) • Multiple calls • Reactive counselling at first call + self-help vs. further proactive calls (9)

  14. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Proactive telephone counselling • Multiple phone calls vs. self-help/minimal control (27)

  15. II. What - evidence for the efficacy of quitlines

  16. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Proactive telephone counselling • Multiple phone calls vs. self-help/minimal control (27) • Multiple phone calls + brief intervention/counselling vs. brief intervention/counselling alone (9)

  17. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Proactive telephone counselling • Multiple phone calls vs. self-help/minimal control (27) • Multiple phone calls + brief intervention/counselling vs. brief intervention/counselling alone (9) • Multiple phone calls + pharmacotherapy vs. pharmacotherapy along (9)

  18. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Proactive telephone counselling • Multiple phone calls vs. self-help/minimal control (27) • Multiple phone calls + brief intervention/counselling vs. brief intervention/counselling alone (9) • Multiple phone calls + pharmacotherapy vs. pharmacotherapy along (9) • Comparisons by different counselling intensities • 1-2 (9); 3-6 (28); 7+ (7)

  19. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Proactive telephone counselling • Multiple phone calls vs. self-help/minimal control (27) • Multiple phone calls + brief intervention/counselling vs. brief intervention/counselling alone (9) • Multiple phone calls + pharmacotherapy vs. pharmacotherapy along (9) • Comparisons by different counselling intensities • 1-2 (9); 3-6 (28); 7+ (7) • Comparison by motivation to stop smoking • Smokers recruited for motivation (14) or not (30)

  20. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Review provides good evidence for effectiveness of telephone counselling ?  ?  

  21. II. What - evidence for the efficacy of quitlines Telephone counselling for smokingcessation – a Cochrane review (2009) • Review provides good evidence for effectiveness of telephone counselling • The more intensive, the better • No difference by motivation of smokers

  22. III. Where to – future questions to be answered Remaining empirical uncertainties • Is reactive telephone counselling effective? • What is the ideal number of proactive sessions? • How best to increase uptake of telephone counselling?

  23. III. Where to – future questions to be answered Remaining empirical uncertainties • Is reactive telephone counselling effective? • Problems: can’t use ‘pure’ RCT • What is appropriate control condition? • Elicit further calls? Control (Self-help) 1837 Intervention (generic) 1837 Intervention (tailored) 1837

  24. III. Where to – future questions to be answered Remaining empirical uncertainties • Is reactive telephone counselling effective? • What is the ideal number of proactive sessions? • How best to increase uptake of telephone counselling?

  25. III. Where to – future questions to be answered Remaining empirical uncertainties • What is the ideal number of proactive sessions? • Problem: Have to make a priori assumptions about cost-effectiveness • NNT=100 at £100 (1 %) assumed to be cost-effective at QALY of £3000 (5 times better than average medical treatment) 1 session (£50) NNT=400 2 sessions (£100) NNT=200 3 sessions (£150) NNT=100 4 sessions (£200) NNT=50

  26. III. Where to – future questions to be answered Remaining empirical uncertainties • Is reactive telephone counselling effective? • What is the ideal number of proactive sessions? • How best to increase uptake of telephone counselling?

  27. III. Where to – future questions to be answered Remaining empirical uncertainties • How best to increase uptake of telephone counselling? • Enormous benefits 165 mil. smokers 66 mil. smokers 16.5 mil. Attempt Use QL Stop 1.8 Would safe 242.000 human beings from disability and early death

  28. III. Where to – future questions to be answered Remaining empirical uncertainties • How best to increase uptake of telephone counselling? • Enormous benefits • Use of mass media and development of closer relationship with health care system • Displaying phone numbers on tobacco or smoking cessation products • Best assessed with quasi-experimental or RCT design

  29. III. Where to – future questions to be answered Remaining empirical uncertainties Mass media campaign in Country B only • How best to increase uptake of telephone counselling? Country A Country B Use of quit-lines Before After Net change

  30. III. Where to – future questions to be answered Remaining empirical uncertainties • How best to increase uptake of telephone counselling? Control (no info on QL) Control (NRT) Treatment (info on QL) Treatment (NRT+ QL number)

  31. IV. How - assessing smoking cessation interventions Remaining methodological uncertainties • Studies often did not provide information on adequate randomisation or allocation concealment • Abstinence was not consistently validated and many used point-prevalence • Studies were underpowered

  32. IV. How - assessing smoking cessation interventions 10 common issues • inappropriate research question • inadequate sample size • inappropriate sample • inadequate recruitment rate • inappropriate study design • poorly specified intervention and control • inadequate implementation • weak outcome measure • failure to address potential bias • over-claiming from the results

  33. IV. How - assessing smoking cessation interventions Key areas to consider • Study sample • Study design • Outcome assessment

  34. Priorities to be balanced generalisation to population of interest safety cost practicability red tape IV. How - assessing smoking cessation interventions Study Sample Options to discuss • settings • General practice • University • Community • Other • size • method of recruitment • exclusion and inclusion criteria

  35. Priorities internal validity generalisation practicability Options to discuss design type RCT (double-blind vs. unblinded) Cluster randomised trial Fractional factorial design Quasi-experimental study Longitudinal study Cross-sectional survey intervention comparison condition(s) IV. How - assessing smoking cessation interventions Study design Cigarette smokers 10 years

  36. IV. How - assessing smoking cessation interventions The problem of causality • Direction: Stay middle class to avoid schizophrenic episodes!? Socioeconomic Status Schizophrenia • Higher order variables: If you want to live long, eat breakfast!? Smoking Behaviour Breakfast Longevity

  37. Priorities theoretical significance clinical significance practicability Options to discuss smoking status motivation to smoke withdrawal symptoms IV. How - assessing smoking cessation interventions Outcome assessment

  38. IV. How - assessing smoking cessation interventions Some principles: sample • always base size on ≥80% power for what would be a meaningful effect size (usually 1-5% difference in pivotal trials, i.e. those that will form basis for recommendations) • usually use dependent smokers (not students) • recruit from community or healthcare settings • minimise exclusion criteria in pivotal trials, allow for up to 50% wastage

  39. IV. How - assessing smoking cessation interventions Some principles: design • where ethical and practicable use RCT but not at the expense of getting a sensible answer • do not overcomplicate with too many factors • consider fractional factorial designs when trying to deconstruct multi-component interventions

  40. IV. How - assessing smoking cessation interventions Some principles: outcome assessment • pivotal studies require ≥6 months’ follow-up • use self-report of continuous abstinence verified by CO • do not use reduction • use intent to treat • aim for at least 70% follow-up rate • for withdrawal symptoms and craving use MPSS or MNWS Location of filter vent holes outside ISO testing machine Location of filter vent holes

  41. Further reading • Stead, L. F., Perera, R., & Lancaster, T. (2006). Telephone counselling for smoking cessation. Cochrane Database Syst.Rev., 3, CD002850. • Borland, R. & Segan, C. J. (2006). The potential of quitlines to increase smoking cessation. Drug Alcohol Rev.,25, 73-78. • West, R., et al., Outcome criteria in smoking cessation trials: proposal for a common standard. Addiction, 2005. 100(3): p. 299-303. • Shiffman, S., R. West, and D. Gilbert, Recommendation for the assessment of tobacco craving and withdrawal in smoking cessation trials. Nicotine Tob Res, 2004. 6(4): p. 599-614. • Strecher, V.J., et al., Web-based smoking-cessation programs: results of a randomized trial. Am J Prev Med, 2008. 34(5): p. 373-81.

  42. Any questions?

More Related