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Guidelines With Global Implications

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Title: Guidelines With Global Implications


1
Guidelines With Global Implications
  • Robert West, PhD

2
Outline
  • Need for a global evidence base
  • Aims and methods
  • Examples of evidence statements
  • Conclusions

3
Need for Global Evidence Base
  • Guideline development is an ongoing process
    worldwide
  • Repeating evidence reviews in each case is
    potentially wasteful, error-prone, and a source
    of inconsistencies
  • Guidelines themselves must take account of local
    circumstances, but the global evidence baseis
    generalisable

4
Aim
  • To present up-to-date, top-line conclusions on
    efficacy and effect size estimates of major
    clinical smoking-cessation interventions,
    together with caveats and qualifications, using a
    consistent format that can be used to calculate
    the cost-effectiveness of these interventions in
    preventing morbidity and mortality

5
Methods
  • Evidence base
  • Cochrane Reviews supplemented by individual
    studies to provide caveats and qualifications or
    to utilize when Cochrane Reviews are not
    available
  • Effect size estimate
  • 6-month continuous abstinence rate
  • Divide by 2 to get effect on permanent
    cessation
  • Basis of effect size estimate
  • Russell Standard where possible (West et al.
    2005)

6
Clear Evidence
  • When given to population category,
    intervention category has been found in type
    of study/analysis to increase 6-month
    abstinence rates by range of values/NT range
    compared with comparator

7
Suggestive Evidence
  • When given to population category, evidence
    from type of study/analysis suggests that
    intervention category increases 6-month
    abstinence rates by range of values compared
    with comparator

8
Inconsistent Evidence
  • Evidence from type of study/analysis is
    inconsistent on the effectiveness of
    intervention category compared with
    comparator

9
Negative Evidence
  • Adequately powered and designed studies have
    failed to find an effect of intervention
    category compared with comparator

10
Insufficient Evidence
  • Insufficient evidence is available from which to
    draw conclusions about/regarding statement
    concerning intervention category

11
Caveats and Qualifications
  • Factors that may limit generalisability
  • Additional comparisons
  • Observational evidence of effectiveness
    intoreal-world settings

12
Brief Advice Evidence Statement
  • Brief opportunistic advice involves a health
    professional raising the topic of smoking with a
    patient, advising the patient to stop, and
    offering support and follow-up
  • When given to unselected smokers attending a
    consultation for some other condition, brief
    advice has been found in multiple randomised
    controlled trials to increase 6-month abstinence
    rates by an average of 1 to 3 over a baseline
    quit rate of 3 (NNT33-100) compared with doing
    nothing

13
Brief Advice Caveats and Qualifications 1
  • There is insufficient evidence to draw firm
    conclusions regarding the optimal manner in which
    the advice is given, and in any event this advice
    may vary according to the prevailing culture.
    Some guidelines have suggested an approach based
    on the 5 As Ask, Advise, Assess, Assist,
    Arrange. However, no evidence suggests that such
    an approach is more effective than one that, for
    example, asks about smoking and at the same time
    offers helpwith stopping
  • There is insufficient information to draw
    conclusions about whether this type of advice
    given by health professionals who are not
    physicians is effective

14
Brief Advice Caveats and Qualifications 2
  • The studies to date have mostly been carried out
    in a context in which medication and specialist
    behavioural support to aid cessation were not
    available. Encouraging smokers to use these
    treatments may increase the net effect of
    opportunistic advice
  • The studies were carried out in a context in
    which few other environmental factors promoting
    smoking cessation were present in the population
    (eg, indoor smoking restrictions). The effect in
    other contexts may vary
  • Brief opportunistic advice appears to have its
    effect by triggering a quit attempt. Whether quit
    attempts triggered in this way are more likely to
    be successful than quit attempts triggered in
    other ways is not known

15
Behavioural SupportEvidence Statements
  • Behavioural support involves providing advice and
    encouragement and sometimes practical exercises
    designed to bolster and sustain motivation to
    remain abstinent and minimize motivation to smoke
    during a quit attempt
  • When given to smokers seeking help with stopping,
    behavioural support has been found in multiple
    randomised controlled trials to increase 6-month
    continuous abstinence rates by 3 to 7
    (NNT14-33) compared with a control group quit
    rate of 5 for patients trying to quit but not
    receiving face-to-face support, only written
    materials, or brief advice

16
Behavioural Support Caveats and Qualifications 1
  • The studies conducted to date have usually
    involved multiple sessions provided by specially
    trained health professionals over a period of 1
    to more than 4 weeks after a clearly specified
    target quit date. Single sessions of support or
    support provided by individuals who have not been
    specially trained or who are mainly employed on
    other duties and have to fit the behavioural
    support into those duties do not have clear
    evidence of effectiveness
  • The support can be provided to groups of smokers
    or individual smokers face to face or by
    telephone. Insufficient evidence is available
    from which to draw firm conclusions about whether
    any of these modes of delivery are likely to be
    more effective than others
  • Adding scheduled sessions of telephone support to
    face-to-face support has been found in multiple
    randomized controlled trials to increase 6-month
    continuous abstinence rates by 2 to 3
    (NNT33-50)

17
Behavioural Support Caveats and Qualifications 2
  • Insufficient evidence is available from which to
    draw conclusions about whether different
    approaches to behavioural support are more
    effective than others. Specifically, whether
    cognitive behavioural therapy or motivational
    interviewing is more effective than support not
    based on any particular theoretical position is
    not known
  • Insufficient evidence is available from which to
    draw conclusions about whether behavioural
    support is effective for long-term cessation,
    specifically in patients awaiting surgery
  • When given to hospital inpatients, behavioural
    support only appearsto be effective in promoting
    long-term smoking cessation if it continues for
    at least 1 month after discharge
  • Adequately powered and designed studies have
    failed to find an effect of relapse-prevention
    sessions after the initial acute withdrawal
    period (usually 4 weeks) compared with no
    additional intervention

18
Conclusions
  • A need exists for a global evidence base for use
    in treatment guidelines with findings expressed
    in a consistent format that can be used to
    determine cost-effectiveness
  • The current review uses the most rigorous
    available reviews supplemented by additional
    studies to
  • Provide quantitative effect size estimates
  • List caveats and qualifications that are
    important in interpreting these estimates
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