Table 1.
Major characteristics of the articles included in the review of complex interventions to promote smoking cessation
| Panel A | ||||
|---|---|---|---|---|
| Reference (year of publication) | Type of study | Study population (inclusion criteria, study location) | Key elements of intervention | Type of intervention |
| Daughton et al (1998)33 | RCT | 369 smokers of 20 or more cigarettes/day, aged 19–65 years recruited in Nebraska (USA). Period NS | Presential visits Professional training Medication |
Control group: two primary care visits devoted to smoking cessation and 10 weeks of wearing a placebo patch Intervention group: two primary care visits devoted to smoking cessation and 10 weeks of wearing a nicotine patch Set a D-day. Contacted participants for follow-up visits at 3, 6 and 12 months after D-day (4 visits). Training was provided, although the authors do not indicate its duration. Intervention model not described |
| Grandes et al (2000)29 | Non-RCT | 1768 smokers in the preparation phase of change; primary care patients in the Basque Country (Spain) in 1995–1996 | Presential visits Telephone calls Medication |
Control group: usual care Intervention group: intervention based on clinical practice recommendations and based on identifying smokers, advise them about smoking cessation, help them through motivational interview to stop smoking, encourage the use of NRT to stop smoking and schedule follow-up visits Training (20 h) provided for all participants. Intervention group participates in 3 office visits. The time the doctor spends on each visit was measured in a sample of 50 visits: 23 s were spent identifying the smoker; 3 min, 28 s on counselling, motivating and offering a treatment plan. Patients who declared a desire to quit smoking followed a treatment plan monitored by the doctor during 3 in-person appointments and 2 telephone calls, and received a stop-smoking guide. A D-day was established |
| Torrecilla et al (2001)38 | RCT | 304 smokers older than 18 years recruited in Salamanca (Spain) in 1997 | Presential visits Written support materials Medication |
Patients with low nicotine dependence were randomised to two types of intervention (doctor's counselling alone or within a ‘minimal intervention’, conducted systematically). Patients with moderate-high nicotine dependence received minimal intervention and NRT (nicotine patch). Systematic minimal intervention (systematic antismoking counselling at any opportunity during the office visit, provision of written support materials that follow SEPAR recommendations, psychological support and scheduled follow-up visits to monitor the patient's process of breaking the habit. In the minimal intervention group, follow-up visits were scheduled at 15 days and 1, 2, 3, 6 and 12 months (6 visits). Transtheoretical model of change was used. D-day was set. A third group within the MI group served as a control group |
| Twardella and Brenner (2007)32 | Clustered RCT | 577 smokers aged 36–75 years in Germany in 2002–2003 | Presential visits Professional training Financial remuneration Medication |
Control group: usual care Intervention group 1 (training+incentive, TI): 2 h of training for doctors on promoting smoking cessation (counselling, transtheoretical model of change, medications) and financial remuneration of the doctor for every patient who remains a non-smoker at 12-month follow-up Intervention group 2 (training+medication, TM): 2 h of training for doctors on promoting smoking cessation (counselling, transtheoretical model of change, medications) and free medications (nicotine and/or bupropion) for their patients who want to quit. Intervention group 3: This group received TI+TM TI and TM group doctors received a free 2 h group training session, using a transtheoretical model of change. Groups of doctors were randomised to 3 study arms. No information about length of intervention or number of visits. No indication of D-day |
| Secades-Villa et al (2009)36 | RCT | 89 smokers aged 19–65 years in Asturias (Spain). Period NS | Presential visits Telephone calls Written support materials |
Brief counselling: in about a 7 min session, the doctor provides brief counselling, informing about the negative effects of tobacco and the advantages of smoking cessation. The following recommendations are made: set a D-day, reduce cigarette consumption by one-third the week before D-day, carry out activities different from smoking a cigarette (physical exercise, handicrafts, etc). Hand out a brochure on the ‘6 reasons and 6 steps to stop smoking’ Self-help manual with telephone follow-up: carried out by the doctor and two primary care nurses. The intervention began with brief counselling (same as above) and distribution of 25-page multicomponent self-help manual covering the phases of preparation, cessation and maintenance (included the essential motivation messages, emphasising the advantages of smoking cessation, a weekly reduction in the number of cigarettes smoked, controlling the symptoms of withdrawal, identifying risk situations and preparing for D-day). Four follow-up telephone calls were made, in weeks 1, 4, 8 and 12. In each call, the smoker verified his or her cessation status, whether he or she was practising the manual's recommendations, and was offered brief counselling Intensive behavioural therapy: carried out by a clinical psychologist and based on the 5-week Becoña smoking cessation programme of a 20 min session each week. The programme includes information about the effects of tobacco, a contract in which the patient makes a commitment to stop smoking and to attend the weekly sessions, self-reporting and graphic representation of the cigarettes smoked, gradual reduction in the number of cigarettes smoked, social support for smoking abstinence, controlling the symptoms of withdrawal, biochemical feedback on cigarettes smoked (measurement of exhaled CO) and strategies to avoid relapse |
| Ramos et al (2010)37 | RCT | 287 smokers older than 18 years with the intention to quit smoking, in Mallorca (Spain) in 2005–2006 | Professional training Presential visits Group interventions Medication |
Control group: MI. Health professionals received basic preparation and training Intervention group I: III. Health professionals received prior training. Individual intervention consisted of 6 standardised weekly visits. The protocol recommended that the first visit last 20 min and the remainder 10 min, although more time was actually spent Intervention group II: IGI. Health professionals received prior training. The IGI consisted of 6 standardised weekly visits lasting 60 min each, although in practice more time was spent After the intervention, visits were scheduled after 1, 2, 3, 6, 9 and 12 months. The Prochaska model was used. NRT and bupropion were used at the doctor's discretion. A D-day was set |
| Cabezas et al (2011)30 Puente et al (2011)31 |
Clustered RCT | 2827 smokers aged 14–85 years, primary care patients in Spain in 2003–2005 | Professional training Presential visits Medication |
Control group: usual care Intervention group: implementation of clinical practice guidelines recommendations during 6 months, including motivational interviews with smokers at the precontemplation-contemplation stage of change, a brief intervention with smokers in the preparation-action stage who do not want additional help, intensive intervention with pharmacological support for smokers in the preparation-action stage who want help, and reinforcement of the intervention with patients in the maintenance stage. The Prochaska model was used. A D-day was set. Medications were used at the doctor's discretion. A motivational intervention was used, and 6 office visits (intensive intervention). A 20 h training activity was provided before the trial |
| Lou et al (2013)34 | Clustered RCT | 3562 smokers with COPD in 14 primary care centres in the rural city of Xuzhou, China in 2008 | Presential visit Written materials |
All participants had an appointment with their doctor and the care team in the healthcare centre. Those who want to stop smoking receive a brochure indicating the toxic components in cigarettes, diseases related to smoking, benefits of smoking cessation, ways to stop smoking. Control group: usual care Intervention group: behavioural intervention and motivational interview Two-year intervention. No pharmacological treatment provided during the study |
| Smit et al (2013)35 | RCT | 414 smokers older than 18 years in the Netherlands, motivated to stop smoking within 6 months and with internet access in 2009–2010 | Presential visits Feedback letters Telephone calls |
Intervention group 1 (multiple tailoring): after setting a D-day to stop smoking, participants received 4 feedback letters: at the starting point, 2 days after D-day, after 6 weeks, and after 6 months. This feedback was personalised according to the characteristics of the participant. The feedback letters were 4–5 pages long and included 7 components: (1) introduction to the intention to stop smoking, (2) feedback related to the patient's attitude, (3) feedback related to the social influences surrounding tobacco, (4) feedback about how to handle situations that made him or her want to smoke, (5) feedback about actions that patients want to take to stop smoking, (6) feedback on how to handle situations where not smoking is difficult and (7) closing. Participants had access to the letters after they had completed an online questionnaire. It was also possible to send additional feedback letters by email Intervention group 2 (multiple tailoring+counselling group): after receiving the first personalised letter, participants were prompted to schedule a visit with the nurse within the following 6–8 weeks for a personalised counselling session with a set protocol (instead of a third personalised letter). After 6 months, the nurse telephoned the patients to gather information about how they were progressing with smoking abstinence Control group: usual care and recommendations |
| Panel B | ||||
|---|---|---|---|---|
| Reference (year of publication) | Smoking abstinence | Main results | Author conclusions | Quality of the study* |
| Daughton et al (1998)33 | 3, 6 and 12 months after D-day; confirmed by urine cotinine | Compared with placebo control group, intervention group participants showed greater abstinence at 3 months (23.4% vs 11.4%; p 0.01) and 6 months (18.5% vs 10.3%; p 0.05). Abstinence at 1 year was 14.7% in the intervention group and 8.7% in the control group (p=0.07) | Use of the nicotine patch together with a brief intervention in primary care increased smoking cessation at 6 months. The duration of counselling, age of the patient, and the level of nicotine dependency may be important factors related to successful tobacco abstinence using nicotine patches for treatment | Acceptable |
| Grandes et al (2000)29 | 6 and 12 months; confirmed by exhaled CO | The programme results were 5 percentage points higher in sustained abstinence at 1 year, with 7.1% | Programmes that combine counselling on how to stop smoking with the offer of support, follow-up, and the prescription of nicotine patches to those smokers who want to stop smoking are feasible and effective in daily clinical practice | Acceptable |
| Torrecilla et al (2001)38 | Continuous abstinence at 6 and 12 months; confirmed by exhaled CO | Point prevalence abstinence achieved at 1 year after the MI was 39% (29.4–49.3%) and continuous abstinence was 30.9% (29.4–49.3%) compared with 11% (5.6–18.8%) point prevalence abstinence in the counselling-only group (p<0.0001). In the NRT group, point prevalence abstinence was 35.3% (24.1–47.8%) and continuous abstinence was 30.8% | Primary care is an ideal framework for antismoking interventions, using any of the established types of intervention: medical counselling only, systematic MI or specialised drug treatments using NRT; therefore, these types of intervention should form part of routine daily activities in the primary care practice | Acceptable |
| Twardella and Brenner (2007)32 | Continuous abstinence at 12 months | Smoking abstinence at 12 months was 3% in the control group, 3% in the intervention with an economic incentive for doctors, 12% when smokers were provided medications free of charge and 15% when both interventions were combined. The intervention with free medication had an OR to stop smoking was 4.77 (95% CI 2.03 to 11.22) | Providing medications free of charge, along with short courses or specific training for healthcare professionals who care for those patients could lead to success in smoking cessation | Acceptable |
| Secades-Villa et al (2009)36 | 12 months; confirmed by exhaled CO | At 12-month follow-up, intensive behavioural therapy (42.8% abstinence) was more effective than a self-help programme (27.5%) and the latter was superior to counselling (12.9%). This pattern was also observed in continuous abstinence. Treatment adherence was higher in the intensive behavioural therapy group (82.8% of all participants attended all therapy sessions) than in the self-help group (61.8% completed the full programme) | Results confirm a dose–response effect in the treatment of smokers and indicate high acceptability of intensive behavioural programmes in primary care | Acceptable |
| Ramos et al (2010)37 | Continuous abstinence at 12 months; confirmed by exhaled CO | Continuous abstinence at 12 months was 1% in the control group, 7.4% in the III and 5.4% in the IGI. No statistical differences between individual and group interventions were observed. No differences were found between the intensive interventions and control group | Intensive interventions were less effective than expected | Acceptable |
| Cabezas et al (2011)30 Puente et al (2011)31 |
12 and 24 months; confirmed by exhaled CO | Continuous abstinence was 8.1% in the intervention group and 5.8% in the control group at 1 year (p=0.014). The odds of smoking cessation in the intervention group compared with controls were 1.50 (95% CI 1.05 to 2.14) | An intervention based on the transtheoretical model of change significantly increased abstinence at 2-year follow-up | Acceptable |
| Lou et al (2013)34 | 24, 30 and 48 months postintervention; confirmed by exhaled CO | Continuous abstinence was greater in members of the intervention group than control group between months 24 and 30 (46.4% vs 3.4%, p<0.001), months 24 and 36 (45.8% vs 4.0%), and months 24 and 48 (44.3% vs 5.1%) | Behavioural intervention doubled the smoking cessation results in patients with COPD | Acceptable |
| Smit et al (2013)35 | Prolonged abstinence at 6 and 12 months postintervention. Confirmed at 12 months by continine measurement in saliva in 65% of those who claimed abstinence | Major results mainly refer to the cost-effectiveness of the intervention One of the tables shows no statistical differences between the 3 study groups at 12 months follow-up |
Reference is made to the cost-effectiveness and cost-benefit analyses. Mention is made that the two proposed interventions have an effect similar to that of usual care | Acceptable |
*Based on SIGN guidelines.
BMI, body mass index; CBT, cognitive behavioural therapy; CO, carbon monoxide; COPD, chronic obstructive pulmonary disease; III, intensive individual intervention; IGI, intensive group intervention; MI, minimum intervention; NRT, nicotine replacement therapy; NS, not specified; RCT, randomised controlled trial; SIGN, Scottish Intercollegiate Guidelines Network.