Quitting smoking is the easy part, staying quit is hard

This article was originally written by Paul Christiansen for the Lifestyle Elf website, you can find the original here. 

During 2010/11 there were 1.53 million hospital admissions for illnesses directly attributable to smoking in the UK. These admissions, along with other smoking-related expenses, cost the NHS approximately £5 billion pounds per year.

Fortunately, the NHS is spending £88.2 million per year on cessation treatments, many of which have been repeatedly demonstrated to be highly efficacious. Indeed, Dr Andrew Jones and I recently wrote a Mental Elf blog on a Cochrane review that reported impressive outcomes for several pharmacological smoking cessation treatments.

Sounds good doesn’t it? A relatively small outlay on cessation treatment should have a massive impact on reducing smoking-related illness saving the NHS billions.

Things are, of course, not so simple; quitting is one thing staying abstinent is another. Indeed, 75% of quitters relapse within 12 months (Agboola, 2009) and, problematically, frequency of previous relapses are associated with decreased chances of maintaining abstinence following future attempts to quit (Zhou, 2009).

Three out of four people who quit smoking will start again within one year

The efficacy of relapse prevention treatments are the focus of this Cochrane review. The authors analyse the efficacy of behavioural based strategies (e.g. face to face and web-based counselling) of differing durations, as well as pharmacological treatments (e.g. nicotine replacement therapy [NRT] and bupropion).

This review also investigates whether treatment efficacy differs in people quitting for different reasons, i.e. forced cessation (due to pregnancy, hospitalization or military training) or voluntary cessation.

Methods

The authors conducted a meta analysis on 63 studies that explicitly focused upon relapse prevention and had a minimum 6 month follow up. 

The primary outcome was the number of individuals who maintained abstinence in the longest follow-up. It is notable that the authors reported risk ratios (RR), rather than odds ratios. Risk ratios are generally a conservative measure (unless event rates are particularly low). Analyses were conducted separately for ‘trials in abstainers’ and ‘trials in those allocated before quit date’.

Trials in abstainers

This refers to those who were abstinent on presentation to the trial and includes special populations (pregnant, hospitalisation and military recruits; behavioural interventions only) as well as those from unselected populations (those who quit voluntarily or as part of a program; behavioural and pharmacological interventions).

Trials in those allocated before quit date

Only behavioural interventions are reported for those assigned to treatment groups before their quit day, (although one behavioural + NRT is reported). Analyses in this group are broken down into different forms of intervention.

Results

Trials in abstainers

Special populations:

Although many women quit smoking during pregnancy, subsequent relapse remains high

• 
  
• There was no evidence that any behavioral relapse prevention interventions had a significant effect on relapse following: 
• 
  
• - birth (RR 1.04 95% CI 0.95 – 1.11), 
• - the postpartum period (RR 1.08 95% CI 0.99 – 1.19)
• - or in those hospitalized for other reasons (RR 0.94 95% CI 0.78 – 1.13).

• 
  
• The picture in military recruits was less clear, there was some evidence that behavioural interventions could increase abstinence (OR [reported in this case only] 1.23 95% CI 1.07-1.41) although the absolute rates of abstinence in this sample were still very low.
• 
  

Unselected populations:

• - There was no significant impact of behavioural relapse prevention interventions in unaided quitters (RR 1.08 95% CI 0.98 – 1.19)
• - Although there was some evidence for the efficacy of NRT (RR 1.24 95% CI 1.04 to 1.47).
• 
  

With regards to those who quit through formal treatment behavioural interventions (RR 1.00 95% CI 0.87 -1.15), NRT (RR 1.04 95% CI 0.77 to 1.40), bupropion (RR 1.15 CI 0.98 to 1.35) and bupropion in combination with NRT (RR 1.18 95% CI 0.75 to 1.87) all failed to reduce relapse. However, varenicline (1 study; RR 1.18 95% CI 1.03 to 1.36) and rimonbant significantly reduced relapse although the latter recently had its license withdrawn due to safety concerns.

Trials in those allocated before quit date

Data revealed a similar pattern of results to the abstainers; there was no evidence that relapse rates were reduced by:

• 
  

  Evidence for the efficacy of telephone and face-to-face counselling is lacking
  - face to face intervention (RR 1.01 95% CI 0.80 to 1.27),
• - extended contact phone calls (RR 1.06 95% CI 0.90 to 1.23),
• - or web support (RR 1.27 95% CI 0.70 to 2.31).
• 
  

Furthermore telephone counseling in conjunction with NRT also failed to reduce relapse (RR 1.28 95% CI 0.94 to 1.75).

Conclusions

This review highlights two fundamental issues in the area of relapse prevention in ex-smokers. Firstly, there was a near universal failure to detect any clinically efficacious interventions. This is perhaps surprising, many pharmacological interventions for smoking cessation have very good efficacy.

Indeed, it is notable that one of the only relapse prevention techniques that had a significant effect on relapse prevention was varenicline which is also the most efficacious quitting agent.

There are many effective interventions to help you quit, but this is only half the battle

Then again, the results reported may not be so surprising. The overall GRADE quality of the reviewed studies was relatively low; sample sizes tended to be relatively small and behavioural treatments focused on single treatments rather than addressing the multiple causes of relapse such as craving, stress and cue reactivity in a more holistic manner.

Indeed, a combination of behavioural and incentive based strategies are associated with reduces relapse rates at 6 months (Gadomski, 2011). Furthermore, we are starting to see a first wave of studies looking at E-Cigarettes which have promising results (Etter, in press).

So although the current review seems to offer little encouragement for quitters, tailored interventions dealing with multiple aspects of the causes of relapse as well as continuing pharmacological-based developments offer some real hope.

Links

Hajek P, Stead LF, West R, Jarvis M, Hartmann-Boyce J, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003999. DOI: 10.1002/14651858.CD003999.pub4.

Jones, A and Christiansen, P. New Cochrane review finds that NRT, bupropion and varenicline are effective treatments for smoking cessation. The Mental Elf, 31 May 2013.

Agboola SA, Coleman TJ, McNeill AD. Relapse prevention in UK Stop Smoking Services: a qualitative study of health professionals’ views and beliefs. BMC Health Serv Res. 2009 Apr 24;9:67. doi: 10.1186/1472-6963-9-67.

Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addict Behav. 2009 Apr;34(4):365-73. doi: 10.1016/j.addbeh.2008.11.013. Epub 2008 Nov 24. [PubMed abstract]

Gadomski A, Adams L, Tallman N, Krupa N, Jenkins P. Effectiveness of a combined prenatal and postpartum smoking cessation program. Matern Child Health J. 2011 Feb;15(2):188-97. doi: 10.1007/s10995-010-0568-9. [Pubmed Abstract]

Etter, JF Bullen, C. A longitudinal study of electronic cigarette users. Addictive Behaviors, in press. doi: 10.1016/j.addbeh.2013.10.028. [Science direct abstract].

  Follow @ChristiansenLiv on twitter.

New Cochrane review examines the effectiveness of smoking cessation strategies in young people

This post was written by Andrew Jones for the Mental Elf, you can find the original here.

Worldwide, around 100 000 young people take up smoking every day and approximately 1 in 4 young people in the UK and USA smoke regularly. Although these figures have been falling over the last 20 years, they still represent a major public health concern. Evidence suggests that addiction to nicotine develops quickly in adolescence, and most adult smokers will acquire the habit during this time. Furthermore, whilst the global disease burden is primarily focused on problems in adulthood, young smokers can suffer complications in lung growth and function.


The majority of adolescent programs focus on the prevention of smoking uptake (which have been covered by previous systematic reviews), however there are some programs aimed at helping young people to give up once they have started smoking. These interventions may prove useful as many of these individuals report that they often try to quit without help. A recent review published by the Cochrane Collaboration set out to examine the effectiveness of strategies that might help young people to quit smoking. This was an update of a Cochrane review conducted in 2006.

Methods

The authors targeted three types of studies; randomised controlled trials (RCTs), cluster-randomised controlled trials (C-RCTs) and controlled trials, comparing an intervention to a control condition in individuals aged less than 20 years old, who were regular smokers. To be included, interventions had to be aimed at helping young people to stop smoking and have follow up data for at least 6 months.

The interventions ranged from simple pharmacotherapy through to more complex strategies encompassing several active components and targeting organisations such as schools and communities. Control conditions included; no intervention, delayed intervention beyond the last date of data acquisition, general tobacco information and information on stopping smoking.

The authors searched the Cochrane Tobacco Addiction Group Specialised Register to identify relevant trials. Where possible, they also searched unpublished literature and contacted manufacturers of smoking cessation products. They found 28 relevant studies for inclusion (consisting of approximately 6000 young smokers in total). The primary outcome was smoking status after at least six months follow-up among those who smoked at baseline.

The authors pooled groups of studies that they considered to have similar interventions, comparison groups and participants. This led to three main types of intervention, which were those based on: (1) Transtheoretical Model of Change (TTMC), (2) Psychosocial interventions including motivational enhancement and (3) the Not-on-Tobacco program (NoT).

• TTMC is a model of intentional change and focuses on the decision making of an individual.
• Psychosocial interventions involve motivational interviewing, relapse prevention and resisting social and cultural pressures.
• NoT program is a gender-specific group program implemented in schools or communities, drawing on social cognitive theory.

Results

In order to measure the treatment effect for each individual study, the authors used risk ratios (RR).

Pooled results from 3 TTMC studies demonstrated that there was a significant effect in favour of the intervention on smoking cessation (RR = 1.56, 95% CI 1.21 – 2.01).

Pooled results from 12 Psychosocial interventions were also significantly in favour of the intervention (RR = 1.60. 95% CI 1.28 – 2.01)

Pooled results from 6 NoT interventions demonstrated a marginally statistically significant effect of the intervention (RR = 1.31, 95% CI 1.01 to 1.71). However, none of the six NoT interventions demonstrated significant improvements individually.

Other types of treatment were identified. Four studies used internet and/or computer based interventions however, none relied solely on this technique making it impossible to disentangle treatment effects. One trial examining Nicotine Replacement Therapy and two trials examining pharmacotherapy (Buproprion) demonstrated no beneficial effects on adolescent smoking cessation.

Conclusions

The results of this Cochrane review suggest that interventions which are designed to help adolescent smokers to quit are generally effective. In particular the authors recommend

‘programmes that combine a variety of approaches, including taking into account the young person’s preparation for quitting, supporting behavioural change and enhancing motivation show promise’. 

Limitations


However, the authors also note various issues. Firstly, many of the studies were at a high risk of selection bias, in which groups or individuals were not randomly allocated. Secondly, several individual studies had low statistical power, which the authors suggest may contribute to the null effects of individual NoT studies. Finally, many studies did not use gold standard techniques including biochemical measures of smoking cessation or sustained abstinence measures. These issues reduce the confidence in wider application of these results.

To conclude, there is some evidence to suggest that complex interventions may be effective in increasing smoking cessation in young smokers. Future research should focus on direct comparisons between effective treatments.

Target Paper: Stanton, A., Grimshaw, G. (2013). Tobacco cessation interventions for young people. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003289

Other reading: Carson, K., Brinn, M., Labiszewski, N., Esterman, A., Chang, A., Smith, B. (2011). Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.:CD001291

Grimshaw, G., Stanton, A. (2006). Tobacco cessation interventions for young people. Cochrane Database of Systematic Reviews 2006, Issue 18. Art.No.:CD003289

You Only Live Once

This post was written by Natasha Clarke for her own blog, the original is here. 

As a break to celebrate the end of my Masters, I spent six weeks of my summer in Lake Bled, Slovenia. This is a small and picturesque town, and is also part of the route that many interrailers take. Thus the trip involved a fair amount of bar crawls, and due to this I saw many sights that will stay with me forever. I witnessed a topless primary school teacher parading barefoot on a dance floor covered in smashed glasses. I saw three Kiwis having a group sick session in the same bin. There were also a fair few drunken fights and midnight dips in the lake. Some nights I swear I could have been in Malia.

One night I heard a cross eyed, swaying interrailer slur “YOLO” as he polished off his 10^th shot of the local 30% pelinkovak. Now unless you have been cooped up in a cell with no access to television, radio or any form of social media for the past few years then I am sure the majority of you will have heard the phrase YOLO. Wikipedia says it “implies that one should enjoy life, even if it entails taking risks”. Urban Dictionary describes it as “the dumbass’s excuse for something stupid that they did. Also one of the most annoying abbreviations ever…”. Regardless of which definition one might agree with, it’s an excuse for partaking in behaviour that may be dangerous, and is one that is frequently used amongst young people when it comes to drinking.

Holidays are a time when this phrase will be used frequently, a period when young people are known to take the greatest risk with their health, and every parent dreads the day their teenager utters the numbers 18 and 30. These getaways don’t involve culture and local delicacies; in fact they’re a breed of holiday that should come with a new liver as part of the package. A recent survey of British holidaymakers travelling to Majorca and Ibiza found that over half of participants were intoxicated five or more times and 90% got drunk at least once. Fair enough, everyone likes a few cocktails on the beach, but it’s the dangers associated with this drinking that prove worrying. For instance, 11.6% of those visiting Majorca were involved in a fight, and just over a quarter in both destinations had sex, with a third of individuals not using a condom. Another study with British, German and Spanish holidaymakers in the Balearics supported the finding that heavy drinking is associated with risky sexual behaviour. So not only do you come home with a hefty hangover, but there’s also a high chance you’ll bring back a broken nose and chlamydia.

It’s not just the likes of Malia, Kavos and Ibiza that are associated with heavy drinking. A study on excessive alcohol behaviour in Cusco, Peru, found that in a sample of American, British and Spanish tourists over half of the travellers had consumed alcohol between 50% and 100% of the days they were there. Single males below the age of 26 were most likely to get drunk and this drinking was associated with drug use, sexually transmitted infections and increased illness impact. Furthermore, it’s been found that UK residents show a significant increase in the frequency of alcohol consumption when backpacking in Australia, with those drinking over 5 times a week rising from 20.7% at home, to 40.3% when away. With alcohol use in the UK already at a worrying level, this is a shocking reminder that when out of our home residence, our behaviour with alcohol seems to get worse. It’s worth noting that many of these trips abroad will not just be a week long, they could be a month, or a year. That’s a significant proportion of our year (or the whole of it!), that seems to be emitted from real life behaviour, and many hold the view that the behaviour carried out somewhere new and exciting doesn’t count (or I should I use the phrase “what happens in [insert country], stays in [insert country]”).

It’s a common attitude in young adults that the risks associated with heavy drinking are not applicable at such a young age, particularly the long-term health risks. This is a misconception that may be even further emphasised when travelling. Unfortunately we’re not invincible just because we’re young and off home soil. Although the major health risks with young people are those associated with accidents and injuries, the number of deaths in 25-34 year olds due to chronic liver disease and cirrhosis has steadily risen in England over the past 30 years. The younger we begin heavy drinking, the earlier we see chronic health problems associated with this excess behaviour. It has been suggested that beyond an average consumption of 10g/day (1 unit), our absolute risk of death from an alcohol related condition increases with increasing alcohol consumption. Therefore the more drinking occasions we have throughout our life, at both a young age and an older age, the higher our risk. It’s not only long term health implications we are vulnerable to, during intoxication our blood pressure is raised, and when the alcohol wears off, it falls below the normal level. These changes can increase the likelihood of strokes; therefore showing the effect bingeing can have on the heart.  

This indicates alcohol related harm is still relevant when we are young, and we may be particularly at risk when we are away, but research is sparse and little information is available on British holidaymakers’ alcohol consumption. For researchers, it’s important to note that when looking at long term alcohol consumption, much self-report data will not take into account the amount that is consumed on holiday, and furthermore on special occasions such as birthdays, Christmas, weddings. These are times when our attitudes and behaviour may be similar to when travelling. A substantial proportion of the year drinking may be unaccounted for, and this is supported by recent data showing that self-reported consumption by the UK population and alcohol sales do not match up.

Obviously the last thing I want to do is ruin any fun, and we all want to enjoy ourselves when we’re relaxing abroad, but there are things we could do to reduce the dangers. One option is travelling to a country that doesn’t centre around drinking, when I went to Morocco last year I hardly drank a drop (mostly due to the fact we couldn’t find it anywhere), and it was just as enjoyable as the holidays where I have spent the majority of my time in a bar. In fact, it was better as I remembered every last detail; the drunken photos weren’t the only reminder. But if we are going somewhere we know involves local shots and fishbowls, it’s important to be aware of the potential risks associated with alcohol and measures that can be taken to reduce the risks. Current media attention is attempting to increase our awareness of these dangers and has focused on some of the serious issues surrounding our excessive and carefree attitude. A recent example is “Old Before Our Time”, a documentary on chronic conditions in young people caused by excess drinking at an early age. It’s a hard hitting and eye opening reminder that young people are not immune to the damage alcohol can do. So I return to the phrase “YOLO”, you only live once, surely that’s even more the reason not to ruin it with excessive drinking?  

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Mixed effectiveness of population-level interventions to reduce alcohol consumption and harm

This post was written by Matt Field for the Mental Elf, you can find the original here.

Alcohol is responsible for approximately 2.5 million deaths worldwide every year, making it the third largest cause of preventable death after tobacco and obesity. The economic burden to the UK has been estimated in the region of £20 billion per year, comprising the NHS bill, costs to employers and policing costs amongst other things. Reducing harmful use of alcohol is therefore a top priority, and there are two broad ways that this can be achieved. Individual interventions focus on the individual and include things such as medical treatment of people with alcoholism, and brief interventions delivered to young people in healthcare settings. Whereas population interventions are targeted much more broadly, and they aim to reduce alcohol consumption and harms in the population as a whole.

A recent review published in Preventive Medicine investigated the effectiveness of population-level interventions to reduce alcohol consumption and associated harms such as drink-driving and alcohol-related violence. The authors found that overall these interventions were effective but, as always, the devil is in the detail.

What did they do?

This is a narrative review of previously published systematic reviews published from 2002 onwards. They identified 52 primary reviews, and rated them for quality. Twelve were rated as high quality, 29 as medium and 11 as low quality.  Most of the primary studies were conducted in North America, Northern Europe and Australasia.

A diverse range of interventions were considered, some examples of which are listed below (this is not an exhaustive list!):  

• Availability – for example policies that restrict opening hours or alcohol outlet density
• Taxation – for example increasing taxes on alcoholic drinks
• Mass media – for example, health promotion campaigns or restrictions on alcohol advertising
• Drink-driving – for example police checkpoints and random breathalysing
• School interventions – for example extra-curricular programmes
• Higher education interventions – for example alcohol-free accommodation.

After grouping the interventions in this way, the authors performed a narrative review of the systematic reviews.

What did they find?

There was some evidence for the effectiveness of all of the different types of interventions that were studied, although the consistency and quality of the evidence was highly variable.  A general observation was that there was more consistent support for regulatory or statutory enforcement interventions as opposed to local, non-regulatory approaches that targeted particular groups of individuals.

• The following types of interventions were consistently supported, amongst others:

•  Restricting days or hours of sale
• Reducing alcohol outlet density
• Minimum drinking ages
• Drink-driving checkpoints and patrols
• Mass media campaigns
• Increased taxation

• Other interventions had mixed or weaker support: 

• Server-training
• School-based interventions
• Family-based interventions
• Workplace-based  interventions
• Restrictions on alcohol advertising, amongst others

• Higher education interventions were consistently shown to be ineffective

• Whereas a long list of other interventions had insufficient evidence to allow a firm conclusion to be reached, some examples include toughened glassware, and promotion of designated driver schemes

Discussion

The findings from this paper are consistent with two similar reviews published in 2010. Therefore, for people familiar with those earlier reviews, the main take-home message is that nothing much has changed in the previous three years.  

The authors noted the

greater pattern of support from the evidence base for regulatory or statutory enforcement interventions over local non-regulatory approaches targeting specific population groups

This can be seen as good news or bad news, depending on your point of view. Regulatory or statutory interventions (such as tax rises) normally need to be instituted at the national or federal level, which means that not much can be done at the local level. It would take a brave government to introduce some of the more controversial policies, such as minimum unit pricing, and local authorities are powerless to introduce such changes on their own, even if they might want to. Even where local authorities do have the power to change things or introduce new policies (for example attempts to control of the density of alcohol sales outlets), these are often challenged by conflicting regulations.

Limitations

Given the diversity of interventions that were considered, you might wonder if this is a case of “noise in equals noise out”. The authors were aware of this risk, and they comment that any bias that is present in primary studies is compounded by additional layers of bias at the systematic review stage, and a further layer of bias at the next stage of summarizing all of those systematic reviews. However, the authors did their best to mitigate against this, by coding the systematic reviews for quality and plotting the consistency of evidence in different domains.

The authors also noted that some more recent population-level interventions, such as minimum unit pricing, could not be considered because there were not enough primary studies to warrant a systematic review of their effectiveness. Therefore, this kind of uber-review really needs to be repeated every few years, in order to capture the effectiveness of novel interventions.

Link to paper: 

Martineau F, Tyner E, Lorenc T, Petticrew M, Lock K (2013) Population-level interventions to reduce alcohol-related harm: an overview of systematic reviews. Preventive Medicine, 57, 278-296. 

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