Effectiveness and cost-effectiveness of computer and other electronic aids for smoking cessation: A systematic review and network meta-analysis

School of Health and Population Sciences, University of Birmingham, Birmingham, UK.
Health technology assessment (Winchester, England) 10/2012; 16(38):1-205. DOI: 10.3310/hta16380
Source: PubMed


Smoking is harmful to health. On average, lifelong smokers lose 10 years of life, and about half of all lifelong smokers have their lives shortened by smoking. Stopping smoking reverses or prevents many of these harms. However, cessation services in the NHS achieve variable success rates with smokers who want to quit. Approaches to behaviour change can be supplemented with electronic aids, and this may significantly increase quit rates and prevent a proportion of cases that relapse.
The primary research question we sought to answer was: What is the effectiveness and cost-effectiveness of internet, pc and other electronic aids to help people stop smoking? We addressed the following three questions: (1) What is the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids for smoking cessation and/or reducing relapse? (2) What is the cost-effectiveness of incorporating internet sites, computer programs, mobile telephone text messages and other electronic aids into current nhs smoking cessation programmes? and (3) What are the current gaps in research into the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids to help people stop smoking?
For the effectiveness review, relevant primary studies were sought from The Cochrane Library [Cochrane Central Register of Controlled Trials (CENTRAL)] 2009, Issue 4, and MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Health Management Information Consortium (HMIC) (Ovid) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost) from 1980 to December 2009. In addition, NHS Economic Evaluation Database (NHS EED) and Database of Abstracts of Reviews of Effects (DARE) were searched for information on cost-effectiveness and modelling for the same period. Reference lists of included studies and of relevant systematic reviews were examined to identify further potentially relevant studies. Research registries of ongoing studies including National Institute for Health Research (NIHR) Clinical Research Network Portfolio Database, Current Controlled Trials and were also searched, and further information was sought from contacts with experts.
Randomised controlled trials (RCTs) and quasi-RCTs evaluating smoking cessation programmes that utilise computer, internet, mobile telephone or other electronic aids in adult smokers were included in the effectiveness review. Relevant studies of other design were included in the cost-effectiveness review and supplementary review. Pair-wise meta-analyses using both random- and fixed-effects models were carried out. Bayesian mixed-treatment comparisons (MTCs) were also performed. A de novo decision-analytical model was constructed for estimating the cost-effectiveness of interventions. Expected value of perfect information (EVPI) was calculated. Narrative synthesis of key themes and issues that may influence the acceptability and usability of electronic aids was provided in the supplementary review.
This effectiveness review included 60 RCTs/quasi-RCTs reported in 77 publications. Pooled estimate for prolonged abstinence [relative risk (RR) = 1.32, 95% confidence interval (CI) 1.21 to 1.45] and point prevalence abstinence (RR = 1.14, 95% CI 1.07 to 1.22) suggested that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials. There was no significant difference in effect sizes between aid to cessation studies (which provide support to smokers who are ready to quit) and cessation induction studies (which attempt to encourage a cessation attempt in smokers who are not yet ready to quit). Results from MTC also showed small but significant intervention effect (time to relapse, mean hazard ratio 0.87, 95% credible interval 0.83 to 0.92). Cost-threshold analyses indicated some form of electronic intervention is likely to be cost-effective when added to non-electronic behavioural support, but there is substantial uncertainty with regard to what the most effective (thus most cost-effective) type of electronic intervention is, which warrants further research. EVPI calculations suggested the upper limit for the benefit of this research is around £2000-3000 per person.
The review focuses on smoking cessation programmes in the adult population, but does not cover smoking cessation in adolescents. Most available evidence relates to interventions with a single tailored component, while evidence for different modes of delivery (e.g. e-mail, text messaging) is limited. Therefore, the findings of lack of sufficient evidence for proving or refuting effectiveness should not be regarded as evidence of ineffectiveness. We have examined only a small number of factors that could potentially influence the effectiveness of the interventions. A comprehensive evaluation of potential effect modifiers at study level in a systematic review of complex interventions remains challenging. Information presented in published papers is often insufficient to allow accurate coding of each intervention or comparator. A limitation of the cost-effectiveness analysis, shared with several previous cost-effectiveness analyses of smoking cessation interventions, is that intervention benefit is restricted to the first quit attempt. Exploring the impact of interventions on subsequent attempts requires more detailed information on patient event histories than is available from current evidence.
Our effectiveness review concluded that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials, but the effect is small. The effectiveness does not appear to vary with respect to mode of delivery and concurrent non-electronic co-interventions. Our cost-effectiveness review suggests that making some form of electronic support available to smokers actively seeking to quit is highly likely to be cost-effective. This is true whether the electronic intervention is delivered alongside brief advice or more intensive counselling. The key source of uncertainty is that around the comparative effectiveness of different types of electronic interventions. Our review suggests that further research is needed on the relative benefits of different forms of delivery for electronic aids, the content of delivery, and the acceptability of these technologies for smoking cessation with subpopulations of smokers, particularly disadvantaged groups. More evidence is also required on the relationship between involving users in the design of interventions and the impact this has on effectiveness, and finally on how electronic aids developed and tested in research settings are applied in routine practice and in the community.
The National Institute for Health Research Health Technology Assessment programme.

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    • "i n v e n t -j o u r n a l . c o m / way of reaching a large amount of smokers including those who cannot afford traditional consumable interventions (Chen et al., 2012). Although , to date, there have been 28 randomized control trials on Internet-based interventions for smoking cessation which have included over 45,000 participants (Civljak et al., 2013), little is known about how socioeconomic factors impact the effectiveness of these interventions. "
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    ABSTRACT: Objective: This article studies the impact of country level and individual level socioeconomic factors as predictors of smoking cessation from a worldwide online smoking cessation participant preference study conducted from 2008 to 2011. Method: We collected data through the San Francisco Stop Smoking Internet website. A total of 13,620 adult smokers from 109 countries and territories entered the study. Participants were able to choose from among nine components. Once selected, participants had access to their customized homepage that displayed a navigation bar with only the selected elements. The intervention was designed to take up to 8 weeks to complete. Participants received emails to complete follow-up assessments at 1, 3, 6, and 12 months after enrolling in the study. Results: Of those who provided data at any follow-up (n = 4678), 38.3% reported quitting smoking for at least seven days at one of the follow-ups. Multilevel logistic regression models demonstrated that greater gross domestic product (GDP) per capita, higher level of individual education, and subjective socioeconomic status, significantly predicted the likelihood of quitting at 1-month follow-up. Conclusions: Higher socioeconomic status at country and individual levels are associated with greater success in online smoking interventions. Future studies should address this disparity.
    Internet Interventions 11/2015; DOI:10.1016/j.invent.2015.10.001
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    • "Media technologies, such as the internet and mobile devices, have shown considerable promise in the delivery of behavioral therapies targeting problematic substance use (Chen et al., 2012; White et al., 2010). Recent systematic reviews and meta-analyses indicate that technology-mediated interventions are effective in the prevention, treatment, and recovery support of substance use disorders (SUDs; Marsch and Dallery, 2012; Moore et al., 2011; Riper et al., 2011). "
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    ABSTRACT: Background: Although empirical evidence for the effectiveness of technology-mediated interventions for substance use disorders is rapidly growing, the role of baseline characteristics of patients in predicting treatment outcomes of a technology-based therapy is largely unknown. Method: Participants were randomly assigned to either standard methadone maintenance treatment or reduced standard treatment combined with the computer-based therapeutic education system (TES). An array of demographic and behavioral characteristics of participants (N=160) was measured at baseline. Opioid abstinence and treatment retention were measured weekly for a 52-week intervention period. Generalized linear model and Cox-regression were used to estimate the predictive roles of baseline characteristics in predicting treatment outcomes. Results: We found significant predictors of opioid abstinence and treatment retention within and across conditions. Among 21 baseline characteristics of participants, employment status, anxiety, and ambivalent attitudes toward substance use predicted better opioid abstinence in the reduced-standard-plus-TES condition compared to standard treatment. Participants who had used cocaine/crack in the past 30 days at baseline showed lower dropout rates in standard treatment, whereas those who had not used exhibited lower dropout rates in the reduced-standard-plus-TES condition. Conclusions: This study is the first randomized controlled trial, evaluating over a 12-month period, how various aspects of participant characteristics impact outcomes for treatments that do or do not include technology-based therapy. Compared to standard alone treatment, including TES as part of the care was preferable for patients who were employed, highly anxious, and ambivalent about substance use and did not produce worse outcomes for any subgroups of participants.
    Drug and Alcohol Dependence 10/2015; DOI:10.1016/j.drugalcdep.2015.09.019 · 3.42 Impact Factor
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    • "Study quality was assessed with the Drummond 35-item checklist (Drummond & Jefferson, 1996). This tool has been widely used in systematic reviews to assess the quality of economic evaluations (Chen et al. 2012; Rodgers et al. 2012) and considers a broad range of factors including: the study question; selection of alternatives; form of evaluation; effectiveness data; benefit measurement and valuation of costs and consequences ; costing; modelling; adjustments for timing of costs and benefits; allowance for uncertainty; clear presentation of results. Since we have excluded modelling studies, items 20 and 21 regarding 'modelling' were not applicable. "
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    ABSTRACT: Internet interventions are assumed to be cost-effective. However, it is unclear how strong this evidence is, and what the quality of this evidence is. A comprehensive literature search (1990-2014) in Medline, EMBASE, the Cochrane Central Register of Controlled Trials, NHS Economic Evaluations Database, NHS Health Technology Assessment Database, Office of Health Economics Evaluations Database, Compendex and Inspec was conducted. We included economic evaluations alongside randomized controlled trials of Internet interventions for a range of mental health symptoms compared to a control group, consisting of a psychological or pharmaceutical intervention, treatment-as-usual (TAU), wait-list or an attention control group. Of the 6587 abstracts identified, 16 papers met the inclusion criteria. Nine studies featured a societal perspective. Results demonstrated that guided Internet interventions for depression, anxiety, smoking cessation and alcohol consumption had favourable probabilities of being more cost-effective when compared to wait-list, TAU, group cognitive behaviour therapy (CBGT), attention control, telephone counselling or unguided Internet CBT. Unguided Internet interventions for suicide prevention, depression and smoking cessation demonstrated cost-effectiveness compared to TAU or attention control. In general, results from cost-utility analyses using more generic health outcomes (quality of life) were less favourable for unguided Internet interventions. Most studies adhered reasonably to economic guidelines. Results of guided Internet interventions being cost-effective are promising with most studies adhering to publication standards, but more economic evaluations are needed in order to determine cost-effectiveness of Internet interventions compared to the most cost-effective treatment currently available.
    Psychological Medicine 08/2015; -1(16):1-20. DOI:10.1017/S0033291715001427 · 5.94 Impact Factor
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