Interventions in the preoperative clinic for long term smoking cessation: a quantitative systematic review.

Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
Canadian Journal of Anaesthesia (Impact Factor: 2.5). 06/2008; 55(1):11-21. DOI: 10.1007/BF03017592
Source: PubMed

ABSTRACT To assess the efficacy of interventions offered to patients in the preoperative clinic to promote long-term (> or = three months) smoking cessation following surgery.
We searched The Cochrane Library, MEDLINE, EMBASE and CINAHL for all randomized controlled trials (RCTs) on smoking-cessation interventions initiated in the preoperative clinic. Trial inclusion, quality assessment, and data extraction were performed independently by two authors. Standard meta-analytic techniques were applied.
Four RCTs (n = 610 patients) were included in the review. Interventions included pharmacotherapy, counseling, educational literature and postoperative telephone follow-up. The follow-up period ranged between three to 12 months with only one RCT following up patients for > one year. Two studies used biochemical methods to validate subjects' self-reporting of smoking cessation at the follow-up assessment. Overall, the interventions were associated with a significantly higher cessation rate vs control at the three to six month follow-up period (pooled odds ratio: 1.58, 95% confidence interval (CI) 1.02-2.45, P value = 0.01, I(2) = 0%). The only trial with longer follow-up period (12 months), however, failed to show any significant difference between the intervention and control groups (odds ratio: 1.05, 95% CI 0.53-2.09, P value = 0.88).
This systematic review suggests that smoking-cessation interventions initiated at the preoperative clinic can increase the odds of abstinence by up to 60% within a three- to six-month follow-up period. To evaluate the possibility of longer abstinence, future trials with at least one-year follow-up are recommended.

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    ABSTRACT: Tobacco smoking has a negative influence on the outcome of surgery due to an increase in peri-and post-operative morbidity and mortality. Smokers show impaired wound healing and more post-operative infection and thromboembolic episodes. Several studies have reported that patients who stop smoking following surgery have a better prognosis than those who continue to smoke. For example, a 20-yr follow-up cohort study of 985 patients following coronary artery bypass surgery showed that patients who continued to smoke had a greater risk of death (relative risk (RR) 1.75; 95% confidence interval (CI) 1.33–2.13) and repeat revascularisation procedures (RR 1.41; 95% CI 1.02– 1.94) than subjects who stopped smoking [1]. The scientific documentation regarding the efficacy and timing of pre-operative smoking cessation in relation to post-operative abstinence and complication rate is much more sparse. The aims of the present chapter are to revise the scientific evidence regarding the efficacy of pre-operative smoking cessation programmes as regards post-operative abstinence rates and complications following surgery. In addition, smoking habits in lung cancer patients in relation to diagnosis, radiotherapy and chemotherapy are discussed. Efficacy of pre-operative smoking cessation as regards quit rates In a review of studies of interventions offered pre-operatively to smokers in order to promote long-term smoking cessation following surgery, only four randomised controlled trials could be found (table 1). Only two studies had small numbers of smokers enrolled, i.e. 47 and 116, whereas the other two had adequate numbers included, i.e. 210 and 237 [2–5]. One study showed no difference in quit rates in the two groups, whereas the other three found a nonsignificant increase in quit rates. In the meta-analysis, interventions were more effective than controls 3–6 months post-operatively, with an odds ratio of 1.58 and abstinence rates of 25 versus 17% [6]. The smoking intervention was delivered from 1–14 weeks before surgery. Counselling was combined with bupropion or nicotine replacement therapy (NRT) in all trials. Abstinence at the time of surgery was reported in five studies, and, in four of these studies, there was a significant increase in quit rates for the intervention groups (table 2) [2, 4, 5, 7, 8]. However, in three studies, the number of patients in each arm ranged 9–56. Combining the results of all of the studies, 77% were abstinent in the intervention groups versus 45% for the control groups. In summary, each of these studies were small compared with the y200 randomised placebo-controlled smoking cessation trials with NRT, bupropion and varenicline. The numbers of smokers in each arm of the pre-operative studies were up to 100, whereas an Eur Respir Mon, 2008, 42, 113–120. Printed in UK -all rights reserved. Copyright ERS Journals Ltd 2008; European Respiratory Monograph; ISSN 1025-448x.
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    ABSTRACT: Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. Search methods: We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. Selection criteria: We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Data collection and analysis: We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
    Cochrane database of systematic reviews (Online) 04/2014; 4(4):CD007768. DOI:10.1002/14651858.CD007768.pub3 · 5.94 Impact Factor
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