This project was led by the Clinical Trials Research Unit, University of Auckland, in association with the Guidelines Development Team icon

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Literature Review for the Revision of the New Zealand Smoking Cessation Guidelines

May 2007

This project was led by the Clinical Trials Research Unit, University of Auckland, in association with the Guidelines Development Team.


Citation: Ministry of Health. 2008. Literature Review for the Revision
of the New Zealand Smoking Cessation Guidelines.

Wellington: Ministry of Health.

Published in June 2008 by the
Ministry of Health
PO Box 5013, Wellington, New Zealand

ISBN: 9780-478-31750-3 (online)
HP 4578

This document is available on the Ministry of Health website:
http://www.moh.govt.nz


Contents


Background to this review 1

Purpose of this review 2

^ Methodology of this review 3

Literature search 3

Selection of studies for inclusion 4

Measurement of cessation outcome 4

Quality appraisal and level of evidence 7

Statistical evaluation 8

Synthesis of evidence statements 10

^ Brief advice to stop smoking from healthcare professionals 11

Brief advice from general practitioners 11

Brief advice from other healthcare workers 12

Written self-help materials 13

Cessation support 15

Telephone support 17

Use of telephone support in specific groups 17

Combined telephone and face-to-face support 18

Adding telephone support to pharmacotherapy 18

Telephone follow-ups to treatment 19

^ Face-to-face support 20

Individual support 20

Group-based support 21

Provision of smoking cessation support by different healthcare professionals 23

Training healthcare professionals 26

Pharmacotherapies 28

Nicotine replacement therapy 28

Bupropion 37

Nortriptyline 40

Varenicline 41

^ Smoking cessation interventions in priority populations 44

Māori 44

Pacific peoples 47

Asian peoples 48

Pregnant and breastfeeding women 48

Young people 50

Hospitalised smokers 53

People who use mental health services 56

People who use addiction treatment services 60

People who make repeat attempts to stop smoking 62

^ Relapse prevention 64

Other treatments and interventions 66

Cytisine 66

Glucose 67

St John’s wort 68

Lobeline 69

Clonidine 69

Anxiolytics 70

Nicobrevin 71

NicoBloc 71

Rongoā Māori 72

Hypnosis 72

Acupuncture 73

Allen Carr’s Easyway method 74

Rapid smoking 75

Competitions and incentives for smoking cessation 77

Quit and Win contests 78

Exercise to aid smoking cessation 78

Partner support 79

Biomedical feedback 80

Cost-effectiveness of smoking cessation treatments 82

Appendix 1: Search strategy 85

Smoking-specific terms 85

Intervention-specific terms 85

References 86



^

Background to this review


Smoking is a major public health problem in New Zealand. About 23% of all New Zealanders are smokers. Smoking is twice as prevalent among Māori than among non-Māori.1 In addition to being directly linked to more than 4,000 deaths each year in New Zealand, smoking causes significant morbidity and contributes to ethnic inequalities in health.2


Abundant evidence shows that stopping smoking is associated with health benefits.


The Ministry of Health allocates half the Tobacco Control budget to smoking cessation treatments. A variety of smoking cessation services exist, including telephone counselling, face-to-face support, and nicotine replacement therapy (NRT) through a subsidised scheme. Furthermore, these services are accessible to a wider number of people now than before the Tobacco Control Policy was implemented. Before the implementation of this policy smokers had a variable degree of access to cessation services provided by private organisations and non-government organisations.


The New Zealand Guidelines for Smoking Cessation, which were first published in 1999, then revised in 2002, have shaped smoking cessation training and treatment.3 Since 2002 new data on best practice and new pharmacotherapy and other treatments have become available.


Patterns of smoking are changing and evidence of the effectiveness of smoking cessation interventions for specific population groups is needed. It is, therefore, timely to evaluate new evidence and, where appropriate, to update practice and training. This document reviews current best evidence for what smoking cessation practices work, paying particular attention to specific population groups such as people who use mental health services, and considers more recent and ‘alternative’ cessation therapies.

^

Purpose of this review


The Ministry of Health contracted us to provide a literature review that accurately summarises the most recent best practice information and evidence in smoking cessation from New Zealand and overseas. This review provides the information and guidance on which to base the revision of the New Zealand Smoking Cessation Guidelines (2002 version).


Specifically, this review summarises the:

  • evidence on smoking cessation for priority groups such as Māori, Pacific peoples, repeat quitters, people who use mental health services, young people, and pregnant women

  • efficacy of alternative therapies for smoking cessation, including hypnotherapy, acupuncture, Allen Carr’s smoking cessation programme, Nicobrevin, and NicoBloc)

  • evidence on the use of NRT:

  • by people aged under 18

  • during pregnancy and breastfeeding

  • in combination with other treatments

  • to reduce cigarette consumption as a means of eventually quitting

  • role of antidepressants and other non-nicotine treatments for smoking cessation.


Treatments were included in the review based on their popularity, the existence of reviewable literature, and their perceived promise. We included all three main treatment approaches commercially available within the United Kingdom (UK) (hypnosis, acupuncture, and Allen Carr’s Easy Way). We also included commercial medications and devices with at least some literature available on their effects (NicoBloc, Nicobrevin, and St John’s wort), pharmacological treatments not commercially disseminated in New Zealand but considered promising by experts in the field (cytisine and glucose), and the behavioural treatment with the largest volume of controlled trials that also has some evidence of efficacy (rapid smoking). Ideally, we would have reviewed a wider range of methods, but time constraints did not allow this.

^

Methodology of this review

Literature search

Key sources of data


The key sources of data were relevant systematic reviews published by the Cochrane Collaboration and a systematic review undertaken by the United States (US) Department of Health and Human Services, which informed the US treating tobacco use guidelines.4 These reviews are the latest and most comprehensive international systematic reviews. They cover the same topics as are covered in this review and are conducted to the highest standard.


The reviews assess studies that directly compare the intervention being examined with appropriate controls, rather than look at differences between studies. They use strict and relatively consistent inclusion criteria (eg, randomised controlled trials that report rates of at least six months’ abstinence), describe the included studies, and are regularly updated. In most cases, these reviews reach the same conclusions.


This approach has some disadvantages. The inclusion of the most recent literature depends on when the review was last updated, so it does not allow statements to be made about topics in papers that have not been submitted for systematic review. Meta-analyses indicate the overall effectiveness of a particular intervention, but some of the true effects of interventions may be masked because of the heterogeneity of study populations and the study’s design.


Therefore, we supplemented the major reviews with findings from other systematic reviews and randomised controlled trials. Only those published in English between the last New Zealand guidelines revision (February 2002) and March 2006 were considered. Unpublished data were also included where appropriate. Studies reporting non-randomised trials were included only when limited higher-level evidence was available. ‘Grey literature’ was not systematically searched.

^

Databases searched and search strategy


We searched seven databases:

  • MEDLINE

  • the Cochrane Database of Systematic Reviews

  • the Cochrane Controlled Trials Register (CENTRAL)

  • DARE

  • AMED

  • Embase

  • PsycINFO.


Each search strategy combined intervention-specific terms with smoking-specific terms. For information about the search strategy, see Appendix 1.





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