Introduction

Smoking is estimated to cause 5 million premature deaths each year and is the leading cause of possible prevention of lung cancer and chronic obstructive pulmonary disease. The success rate of helpless attempts is very low, less than 5%. Fortunately, effective forms of care are available, including nicotine replacement therapy (NRT), bupropion and varenicline, as well as behavioral support.1 In 1999, the UK became the first country to establish a comprehensive national network of smoking cessation services (SSS). a combination of medication and behavioral support.2 These are now among the best life-saving interventions in the UK NHS.2

There are about 150 SSSs in the UK and there is ample scope for the type of intervention offered. There has been a wide change in the success rates for services. In 2009-10, biochemically approved 4-week withdrawal rates (the Department of Health’s standard criteria for assessing success rates) ranged from 3% to 58% (34% on average) .3 Some of the changes will be due to differences in data. collection, recording experiments, biochemical inspection levels and customer characteristics. However, differences may also be related to variation in the content, type, and purpose of the intervention provided. Many SSSs provide basic information about customer characteristics and interference guarantees, which can help us understand where the sources of performance variation come from. Potentially relevant customer characteristics include age, gender, economic deprivation level, and nicotine dependence.4 Motivation to stop is not often measured, but has been found to have little or no correlation with success rates in western smokers.5 Potential Significant Intervention Factors include: (1) the type of drug used, where evidence from randomized clinical trials (RCTs) suggests that varenicline and combination NRT (patch and faster-acting form) may be more effective than NRT alone; (2) individual behavioral support for the group when comparing effectiveness levels between RCTs when group support is thought to be more effective; and (3) comparison of specialist clinics with pharmacies and primary care facilities.

Once adapted to customer specifications, evaluating how intervention features affect efficiency should help create optimal service configurations. The results should help inform awareness of intervention guarantees, both in the UK and internationally, and show whether RCT evidence has become a daily practice. The aim of this study was to assess the relationship between the main aspects of care and treatment outcome in a large sample of smokers participating in British SSS while adapting to the characteristics of the main smoker.

Methods

Example

QuitManager (North51, Nottingham, UK) is an online database system for recording data on smokers and interference characteristics in accordance with the Department of Health’s standard monitoring requirements.6 Twenty-four of the first 40 SSS that use it have agreed to share anonymous data. current audit. All “completed treatment episodes” between April 1, 2009 and June 30, 2010 were included as individual records. A completed treatment episode involves the smoker setting a specific date with the service and at least 4 weeks from that point to the data collection point.

Result size

Outcome measures Successfully quit smoking as determined by the Department of Health, ie those who reported not smoking for at least 2 weeks and the concentration of carbon monoxide (CO) in expired air 4 weeks after the scheduled quitting date. <10 ppm.6 As in standard practice, customers lost during follow-up were considered smokers.6 Long-term withdrawal rates can be reliably estimated based on CO-approved 4-week withdrawal rates, and comparable smoking cessation rates are stable over a short period of time. long-term persecution6, and therefore there is a reasonable degree of confidence that any association observed will turn into long-term differences.

Predictive variables: intervention characteristics

These include medications (non-drug, single NRT, combined NRT, bupropion, varenicline), type of intervention (one-on-one, drop-down, open-group, closed-group, telephone support and “other” such as couple / family sessions) and intervention conditions (specialist clinics, such as first aid, pharmacies and prisons (“other”).

Possible confusing factors: customer characteristics

These include age, gender, ethnicity, occupation, exemption from prescription fees (as a valid measure for economic deprivation) and whether this is the first or subsequent treatment episode. Sensitivity analysis covers only the first treatment episodes. Nicotine addiction levels (Fagerstrom test for nicotine addiction (FTND): possible range 0-10, higher scores indicate higher levels of addiction7) were recorded for a small number of clients (6%) and smoking per day (16%). ) and time before the first cigarette (11%) and therefore not included in the main analysis. However, the dependencies between the intervention options were compared to determine if this could explain the resulting differences.

Data analysis

SPSS 17.0 and Stata 11.0 were used. Complex samples were performed to analyze the extent of differences in success rates between intervention options, taking into account customer characteristics and interdependence in SSSs, with multiple logistics regression analyzes defined as clusters. A separate logistic regression was performed with the SSS as a predictive variable, rather than as a set, to assess the differences in success rates between SSSs that adapted to other intervention and client characteristics. Moderate nicotine dependence was compared with post-hoc pairing comparisons with unilateral ANOVA between interventions.

Results

The analysis was based on 126,890 consecutive treatment episodes. Participants’ demographics and intervention characteristics were similar to those of all clients participating in SSS in the UK (see Table S1 in the online appendix). For most clients, this was the first treatment episode, about half used NRT or a combination of varenicline, one-third was seen in specialist clinics, and the vast majority received one-on-one support (see Table S1 in the online supplement). The average CO-approved exit rate was 36.0% (3.8-56.4%), which is slightly higher than 33.9% for all British SSS.3

Those who use NRT alone have a higher success rate than those who do not. Combined NRT and varenicline have a significantly higher chance of success compared to single NRT (Table 1). Group sessions were more successful than one-on-one support; hospitalized clinics were the least successful type of intervention. Specialist clinics were more successful than first aid. Success rates did not differ between the first and subsequent treatment episodes.

Table 1

Numerous logistic regression (n = 126 671) predicting abstinence of complex patterns (SSS as a cluster)

In multiple regression, using SSS as an additional predictor rather than as a clustering variable, SSS emerged as a highly important predictor of success after adjustment for client and intervention variables, as in the main analysis (p <0.001). Using the SSS closest to the mean (35.5%), the ORs for success in 24 SSSs were 0.07 (95% CI 0.06-0.08) and 2.19 (respectively). 95% CI ranged between 1.93-2.49).

Nicotine dependence varies according to the medication used (F (4.7761) = 37.91, p <0.001); Those taking varenicline (moderate (SD) 5.68 (2.15)) or combination NRT (5.52 (2.26)) were significantly more likely to receive (p <0.001) than those without medication (4.57 (2.72)) or single NRT (4.88 (2.44)). is high. . Clients in specialist clinics (5.48 (2.27)) were more dependent than those with undefined "other" parameters (5.12 (2.36), p = 0.03); other differences in parameters were not significant. Dependence varied by type of intervention (F (5.7660) = 11.15, p <0.001); Individual support clients compared to those in open clinics (5.56 (2.28), p = 0.001) or open groups (5.80 (2.08), p <0.001) (5.31 (2, 39)) scored lower.

Discussion

We found that smokers who participated in groups managed by specialists using NRT or a combination of varenicline had a higher chance of success than those treated in first aid with single support and single NRT. Thus, the results of RCTs6 are well translated into clinical practice. However, the most effective forms of intervention are rare.3 It can be argued that this reflects the choices of smokers. However, many services do not offer optimal options.3 Smokers who use more successful intervention options are more dependent, so higher success rates are unlikely to be associated with an “easy” client.

The potential limitation is that we have only selected the SSS subset. However, the characteristics of smokers and interventions were similar to those of all SSSs. Another limitation is to rely on 4-week output data as a result measure. However, long-term success rates can be predicted using short-term success. Prejudice may arise from the use of less tracking services, as well as intervention options that we consider less effective. In contrast, the 4-week session was part of the intervention6, and the findings remained as adjusted for the SSS as a predictor (data not shown). The effects of other factors, such as differences in motivation, cannot be completely ruled out.

The analysis did not take into account the possibility that some smokers may have more than one treatment episode in their database. However, analyzes limited to initial treatment episodes have very similar results, with pharmacies and primary care facilities performing worse than specialized clinics (see Table S2 in the online appendix).

One of the possible reasons for the lack of optimization of the quality of the intervention is not to focus on the number of smokers who help to quit, but on the number of quitters for 4 weeks. Assuming that 25% of customers can only succeed with medication in 4 weeks6, there may be a strong situation where services are judged by the number of 4-week refusals that are created more and more (customer group according to some changes).

In summary, a number of service delivery features are associated with higher success rates. There is an important opportunity for commissioners and providers to increase optimal service delivery and save more lives.

Thanks

In North51, Ian Baker collected and transmitted raw data. David Boniface conducted additional analyzes.

References

  1. National Institute for Health and Clinical Excellence (NICE). Smoking Composition Services in Primary Care, Pharmacies, Local Governments and Workplaces, especially Manual Working Groups, Pregnant Women and Difficult Communities. London: EXCELLENT, 2008.