Literature Review for the Revision of the New Zealand Smoking Cessation Guidelines
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)
This document is available on the Ministry of Health website:
Background to this review 1
Purpose of this review 2
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 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
Individual support 20
Group-based support 21
Provision of smoking cessation support by different healthcare professionals 23
Training healthcare professionals 26
Nicotine replacement therapy 28
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
Other treatments and interventions 66
St John’s wort 68
Rongoā Māori 72
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
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.
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:
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.
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.
We searched seven databases:
Each search strategy combined intervention-specific terms with smoking-specific terms. For information about the search strategy, see Appendix 1.