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Training health professionals in smoking cessation

  1. Kristin V Carson1,*,
  2. Marjolein EA Verbiest2,
  3. Mathilde R Crone2,
  4. Malcolm P Brinn3,
  5. Adrian J Esterman4,
  6. Willem JJ Assendelft5,
  7. Brian J Smith1

Editorial Group: Cochrane Tobacco Addiction Group

Published Online: 16 MAY 2012

Assessed as up-to-date: 13 APR 2012

DOI: 10.1002/14651858.CD000214.pub2


How to Cite

Carson KV, Verbiest MEA, Crone MR, Brinn MP, Esterman AJ, Assendelft WJJ, Smith BJ. Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD000214. DOI: 10.1002/14651858.CD000214.pub2.

Author Information

  1. 1

    The Queen Elizabeth Hospital, Department of Medicine, University of Adelaide, Adelaide, Australia

  2. 2

    Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, Netherlands

  3. 3

    The Queen Elizabeth Hospital, Clinical Practice Unit, Adelaide, South Australia, Australia

  4. 4

    University of South Australia, Division of Health Sciences, Adelaide, Australia

  5. 5

    Radboud University Nijmegen Medical Center, Department of Primary and Community Care, 117 ELG, Nijmegen, Netherlands

*Kristin V Carson, Department of Medicine, University of Adelaide, The Queen Elizabeth Hospital, Adelaide, Australia. kristin.carson@health.sa.gov.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 16 MAY 2012

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison. Training health professionals for smoking cessation

Training health professionals for smoking cessation

Patient or population: Smokers treated by health professionals
Intervention: Training

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlTraining health professionals

Point prevalence of smoking cessation
self-report and some biologically validated
Follow-up: 6 to 14 months
78 per 1000107 per 1000
(88 to 131)
OR 1.41
(1.13 to 1.77)
13459
(14 studies)
⊕⊕⊕⊝
moderate1,2

Continuous smoking abstinence
self-report and some biologically validated
Follow-up: 6 to 14 months
27 per 100042 per 1000
(28 to 62)
OR 1.60
(1.26 to 2.03)
9443
(8 studies)
⊕⊕⊕⊝
moderate1,2

Number of smokers counselled
self-report
Follow-up: 6 to 48 months
465 per 1000664 per 1000
(578 to 739)
OR 2.28
(1.58 to 3.27)
8531
(14 studies)
⊕⊕⊝⊝
low1,3

Patients asked to make a follow-up appointment
self-report
Follow-up: 6 to 12 months
166 per 1000400 per 1000
(233 to 593)
OR 3.34
(1.52 to 7.30)
3114
(7 studies)
⊕⊝⊝⊝
very low1,2,3

Number of smokers receiving self-help material
self-report
Follow-up: 6 to 48 months
134 per 1000351 per 1000
(227 to 500)
OR 3.51
(1.90 to 6.47)
4925
(9 studies)
⊕⊝⊝⊝
very low1,2,3

Number of smokers receiving nicotine gum/replacement therapy
self-report
Follow-up: 12 to 48 months
312 per 1000416 per 1000
(283 to 563)
OR 1.57
(0.87 to 2.84)
5073
(9 studies)
⊕⊕⊝⊝
low1,3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Unclear methods of sequence generation and allocation concealment in the majority of studies and all studies had inadequate blinding of participants
2 Wide confidence intervals around the estimate of effect
3 Significantly large amounts of heterogeneity were observed (I² >90%)

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of the condition

Every year approximately 5.4 million people die from tobacco-related diseases, translating to 1 in every 10 deaths among adults world wide (Mathers 2006; WHO 2008). Approximately 80% of those deaths are from people living in less developed countries and by 2030 this figure will increase to more than 8 million per year if no action is taken (Mathers 2006). If current trends continue on this trajectory, an estimated 500 million people alive today will be killed by tobacco. In the 27 countries that form the European Union, over 25% of cancer deaths and 15% of all deaths can be attributed to smoking (European Commission 2004). Smoked tobacco is known to cause up to 90% of all lung cancers and is a significant risk factor for strokes and fatal heart attacks. In addition, tobacco use is linked to the development and treatment of many oral diseases (Bergstrom 2000; Balaji 2008; Petersen 2009) including oral cancer, delayed wound healing and peridentitis contributing to loss of teeth and edentulism (Tomar 2000; Mohammad 2006; Gordon 2009).

 

Description of the intervention

Health professionals are at the forefront of tobacco epidemics as they consult millions of people and can encourage them to quit smoking (WHO 2005; Zwar 2009). In developed countries, more than 80% of the population will see a primary care physician at least once a year, with doctors perceived to be influential sources of information on smoking cessation (Mullins 1999; Richmond 1999; Zwar 2009). It has been reported that most dentists and dental hygienists believe the lack of skills and training is a significant barrier to effectively providing tobacco cessation interventions into routine care (Gelskey 2002; Warnakulasuriya 2002; Gordon 2009; Rosseel 2009).

Providing training in smoking cessation care is one possible method for increasing the number and quality of delivered interventions by primary care health professionals, and a variety of training methods are available (Anderson 2004; Twardella 2004; Stead 2009). To date, individual studies have shown an effect of training on physician's activities, but there have been doubts about the extent to which this translates into changes in patient behaviour and actual smoking abstinence (Kottke 1989; Cummings 1989a; Cummings 1989b). Training health professionals to deliver smoking cessation messages has been known to increase the frequency with which interventions are offered to patients in the clinical context (Thorogood 2006).

 

How the intervention might work

Provision of advice and support to smokers by healthcare professionals in primary care settings has been shown to be the most cost-effective preventive service and has a small but significant effect on cessation rates (Maciosek 2006; Solberg 2006; Stead 2008). Even though these rates appear low from the perspective of many clinicians, they could translate into a substantial public health benefit if consistently provided, as approximately 70-80% of adults have contact with a health care practitioner, usually in primary care, at least once each year (Mullins 1999; Richmond 1999; Hung 2009; Zwar 2009). It is therefore disappointing that despite ongoing developments in this field worldwide, the number of patients who report receiving advice on smoking cessation from health professionals is still low (CDC 2007).

 

Why it is important to do this review

On a worldwide scale, tobacco use currently costs hundreds of billions of dollars each year (WHO 2008). Data on the global impact of tobacco is incomplete, however it is known to be high, with annual tobacco related health care costs being US$81 billion for the USA, US$7 billion for Germany and US$1 billion for Australia (Guindon 2008).

The first systematic review on this topic was published over a decade ago and showed that training health professionals to provide smoking cessation interventions had a positive effect on professional performance. However, there was no strong evidence that it changed smoking behavior of patients (Lancaster 2008). Since then, a number of new trials have examined whether specific skills training for health professionals leads them to overcome frequently mentioned barriers and to have greater success in helping their patients to quit smoking.

We therefore systematically identified and reviewed the evidence from new published randomized controlled trials that have studied the effects of training and supporting health care professionals in providing smoking cessation advice. Furthermore, we assessed the effects of training characteristics, such as the content, setting, and intensity.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The aim of this review was to assess the effectiveness of training health care professionals to deliver smoking cessation interventions to their patients, and to assess the effects of training characteristics (such as contents, setting, delivery and intensity).

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We considered only randomized controlled trials.

 

Types of participants

We considered trials in which the unit of randomization was a healthcare practitioner or practice, and that reported the effects on patients who were smokers.

 

Types of interventions

We considered interventions in which health care professionals were trained in methods to promote smoking cessation among their patients. To be included in the review studies had to have allocated healthcare professionals to at least two groups (including one which received some form of training) by a formal randomization process. Studies that used historical controls were excluded. We included studies that compared a trained group to an untrained control group, and studies that examined the effectiveness of adding prompts and reminders to training.

 

Types of outcome measures

 

Primary outcomes

The primary outcome measure was abstinence from smoking six months or more after the start of the intervention, assessed as:

  • point prevalence (defined as not smoking at a set period (e.g., seven days) prior to the follow-up), and
  • continuous abstinence (defined as not smoking for an extended/prolonged period at follow-up)

The definition of point prevalence and continuous abstinence for each study can be found in the 'Outcomes' section of the Characteristics of included studies table.

The strictest available criteria to define abstinence were used. In studies where biochemical validation of cessation was available, only those participants who met the criteria for biochemically confirmed abstinence were regarded as being abstinent. Those lost to follow-up were regarded as being continuing smokers.

 

Secondary outcomes

Secondary ‘patient level’ outcome measures included process variables such as the number of smokers who were:

  • asked to set a date for stopping (quit date)
  • given a follow-up appointment
  • counselled
  • given self-help materials
  • offered nicotine gum/replacement therapy
  • prescribed a quit date, and
  • cost effectiveness for interventions.

Secondary ‘physician level’ outcome measures include the number of referrals made (to local smoking cessation services).

To be included in the review, studies had to assess changes in the long term smoking behaviour of patients. Studies which only assessed the effect of training on the consultation process were excluded.

 

Search methods for identification of studies

We identified potentially relevant study reports from the Cochrane Tobacco Addiction Group Specialised Register. This Register includes reports of trials and other evaluations of interventions for smoking cessation and prevention, based on regular highly sensitive searches of multiple electronic databases including MEDLINE, EMBASE, PsycINFO and CENTRAL, and handsearches of conference abstracts. For details of search strategies and dates see the Cochrane Tobacco Addiction Group Module in the Cochrane Library. The most recent search of the Register was in March 2012. Records were identified from the Register as potentially relevant if they included the free text terms ‘training’ or ‘trained’ or the MeSH keywords ‘Education, Premedical’ or ‘Education, Professional’ or ‘Inservice Training’ or ‘Physician's Practice Patterns’ or ‘Dentist's Practice Patterns’ or ‘Delivery of Health Care’ or ‘Comprehensive Health Care’ or ‘Critical Pathways’ or ‘Disease Management’ or the EMBASE indexing terms ‘clinical education’ or ‘continuing education provider’ or ‘continuing education’ or ‘medical education’ as indexing terms. We conducted an additional search of MEDLINE (via OVID, to 2012 Feb week 5) exploding the same MeSH keywords in combination with the terms for smoking cessation and controlled trials used in the regular search of MEDLINE for the Specialised Register. See Appendix 1 for this strategy. Records included definite and probable reports of randomized trials, and reviews.

 

Data collection and analysis

 

Selection of studies

Two reviewers (KC, MV) prescreened all study reports identified from the Specialised Register (limited to papers published after 1999 for this update). Articles were rejected if the title and/or abstract did not meet the inclusion/exclusion criteria. In instances where the study could not be categorically rejected, the full text was obtained and screened. Reference lists of screened articles were scanned for other potentially relevant articles.

Two reviewers then independently assessed the relevant studies for inclusion (KC and MV), with discrepancies resolved by consensus. Studies which were excluded though relevant to the review topic are listed in the Characteristics of excluded studies table, with the reason for their exclusion described.

 

Data extraction and management

A combination of two reviewers independently extracted data from published reports (KC, MV, and MB). Disagreements were resolved by referral to a third party. No attempt was made to blind any of these reviewers to either the results of the primary studies or the intervention the subjects received.

The data extraction process identified information on the following design characteristics:

  • Country and setting of study
  • Description of training delivery method, duration, content
  • Number of therapists (intervention, control, post randomization dropouts)
  • Number of patient participants (intervention, control, losses to follow-up in each condition), method of identification/enrolment
  • Number of patients per therapist (range and/or average)
  • Description of intervention and control conditions
  • Definition of abstinence for smoking cessation outcome(s), duration of follow-up, method of biochemical validation if used
  • Secondary outcomes reported

Data was extracted and entered into Review Manager for the following outcome variables, where reported:

  • Point prevalence abstinence at longest follow-up (preferred outcome for meta-analysis is continuous or sustained abstinence)
  • Continuous or sustained smoking abstinence at longest follow-up
  • Cost effectiveness analysis for intervention

We also extracted data on process outcomes where reported. These included patient reported or documented delivery of interventions, such as: setting a quit date, making a follow-up appointment, number of smokers counselled, provision of self-help materials, prescription of nicotine replacement therapy and/or prescription of a quit date.

 

Assessment of risk of bias in included studies

Two reviewers independently assessed the full text versions for of all included papers for risk of bias using the Cochrane Handbook guidelines, using a domain-based evaluation (Higgins 2009). In addition, extra criteria developed by the Cochrane EPOC Group (EPOC 2009) were used to address potential sources of bias related to clustering effects. These domains included sequence generation, allocation concealment, blinding for participants, blinding for outcome assessors, incomplete outcome data, selective reporting, imbalance of outcome measures at baseline, comparability of intervention and control group characteristics at baseline, protection against contamination, selective recruitment of participants and any other sources of potential biases. The risk of bias was assessed for each domain as 'high risk', 'low risk', and 'unclear risk' (using the guidelines from Table 8.5.c of the Cochrane Handbook, Higgins 2009). Two of three reviewers (KC, MV or MB) independently assessed the included studies for risk of bias. Conflicts were resolved by consensus or by referring to a third party if disagreement persisted.

 

Unit of analysis issues

The trials included in the review used cluster randomization. Outcomes relate to individual patients whilst allocation to the intervention is by provider or practice, and ignoring this may introduce unit of analysis errors. Using statistical methods which assume for example that all patients’ chances of quitting are independent ignores the possible similarity between outcomes for patients seen by the same provider. This may underestimate standard errors and give misleadingly narrow confidence intervals, leading to the possibility of a type 1 error (Altman 1997). All trials were expected to be cluster randomized studies, with analysis performed at the level of individuals whilst accounting for the clustering in the data. This was performed by using a random effects model for pooled meta-analysis as recommended in the Cochrane Handbook (Chapter 16.3.3, Higgins 2009) and checked by a statistician (AE). For those studies which did not adjust for clustering the actual sample size was replaced with the effective sample size (ESS), calculated using a rho= 0.02 as per Campbell 2000. Trials may use a variety of statistical methods to investigate or compensate for clustering; we have recorded whether studies used these and whether the significance of any effect was altered. In instances where the studies appeared homogenous via a combination of the statistical I² test in addition to homogeneity expressed in the visual inspection of a Funnel plot we meta-analysed using a fixed effect model. However in the presence of significant heterogeneity (as defined below under ‘Data Synthesis’) the random effects model was used.

In the case of multi-arm trials each pair-wise comparison was included separately, but with shared intervention groups divided out approximately evenly among the comparators. However, if the intervention groups were deemed similar enough to be pooled, the groups were combined using appropriate formulas in the Cochrane Handbook (Table 7.7.a for continuous data and Chapter 16.5.4 for dichotomous data, Higgins 2009).

 

Dealing with missing data

Missing participant data were evaluated on an available case analysis basis as described in Chapter 16.2.2 of the Cochrane Handbook (Higgins 2009). Missing standard deviations were addressed by imputing data from the studies within the same meta-analysis or from a different meta-analysis as long as these use the same measurement scale, have the same degree of measurement error and the same time periods (between baseline and final value measurement, as per Chapter 16.1.3.2 of the Cochrane Handbook, Higgins 2009). Where statistics essential for analysis were missing (e.g. group means and standard deviations for both groups are not reported) and could not be calculated from other data, we attempted to contact the authors to obtain data. Loss of participants that occurred prior to performance of baseline measurements was assumed to have no effect on the eventual outcome data of the study. Losses after the baseline measurement were taken were assessed and discussed. Studies that had more than 30% attrition (i.e., deaths and withdrawals) were reported in text only and excluded from the meta-analysis. 

We made an attempt to contact all authors for verification of methodological quality, classification of the intervention(s) and outcomes data. We attempted to contact the second author if we were unsuccessful in contacting the first author.

 

Assessment of heterogeneity

The review was expected to have some heterogeneity due to factors such as differing characteristics of clinics, practices and medical surgeries, differences in intervention characteristics and varying measurement tools used to assess outcomes. The Chi² and I² statistic (Higgins 2009) were used to quantify inconsistency across studies. The presence of significant heterogeneity was further explored through subgroup analyses. These were conducted for:

  1. ‘treatment type’ (e.g., counselling alone, counselling plus nicotine replacement therapy, counselling plus request for additional appointments, etc.)
  2. ‘treatment intensity’ (number of sessions)
  3. ‘treatment intensity’ (total exposure)
  4. ‘mode of delivery’ (e.g., face-to-face, group sessions or both)
  5. ‘behavioural change techniques’ (e.g., prompting, providing feedback, use of behavioural change theories)
  6. ‘type of professional being trained’ (e.g., dentist, doctor, health care worker etc.)
  7. ‘length of follow-up’ (i.e., >6 to <9 months, >9 to <12 months, >12 to <24 months), and
  8. ‘risk of bias’ (i.e., high risk of bias for: < 2 domains, 3 – 5 domains, 6 – 8 domains or > 9 domains).

The likelihood of false positive results among subgroup analyses increase with the number of potential effect modifiers being investigated (Higgins 2009). As such we have adjusted these analyses using a Holm-Bonferroni method (Holm 1979) using α= 0.05.

 

Assessment of reporting biases

With the inclusion of more than ten included studies, potential reporting biases were assessed using a funnel plot. Asymmetry in the plot could be attributed to publication bias, but may well be due to true heterogeneity, poor methodological design or artefact. Contour lines corresponding to perceived milestones of statistical significance (p= 0.01, 0.05, 0.1 etc.) were applied to funnel plots, which may help to differentiate between asymmetry due to publication bias from that due to other factors (Higgins 2009).

 

Data synthesis

1. For dichotomous outcomes the fixed effect model with an odds ratio (OR) was calculated with 95% confidence interval (CI), which was synthesised using inverse variance. However for outcomes with greater than 10 included studies a test for heterogeneity was conducted using a combination of two methods. If heterogeneity was found (defined as the I² test >60% and visual inspection of the funnel plot indicating no clustering of large or small studies) the random effects model was used in place of the fixed effect model, as suggested by the Cochrane Handbook (Section 9.5.2 and 9.5.3, Higgins 2009). Reasons for heterogeneity are further explored in the discussion. When studies appeared homogenous, the meta-analysis was redone using the fixed effect model. 

2. For continuous outcomes, a fixed effect model with a weighted mean difference (WMD) or standardised mean difference (SMD) with 95% confidence intervals were calculated as appropriate. However, in the presence of significant heterogeneity (as defined above) the random effects model was used in place of the fixed effect model.

 

Sensitivity analysis

Sensitivity analysis was conducted on studies with an unclear or high risk of bias for sequence generation and/or allocation concealment. 

We include the Tobacco Addiction Group glossary of tobacco-specific terms (Appendix 2).

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

See the Characteristics of included studies and Characteristics of excluded studies tables.

 

Results of the search

Of 381 articles screened, 17 studies met all of the inclusion criteria (see Figure 1 for PRISMA diagram). Detailed information relating to each included study is reported in the Characteristics of included studies table (for information relating to the 65 excluded studies see Characteristics of excluded studies).

 FigureFigure 1. Study flow diagram

 

Included studies

 

Design

All 17 included studies used a randomized controlled trial design with clustering and eleven studies also adopted nesting of participants within practices/hospitals (Wilson 1988; Cohen (Dent) 1989; Cohen (Doc) 1989; Cummings (Priv) 1989; Kottke 1989; Lennox 1998; Strecher 1991; Hymowitz 2007; Twardella 2007; Unrod 2007; Gordon 2010). One study (Twardella 2007) incorporated a 2x2 factorial design with randomization to: training plus incentive, training plus medication, training plus incentive and medication or usual care.

 

Sample sizes

In total 28,531 patients were assessed at baseline (following randomization) with 21,031 remaining in the studies at final follow-up. Authors report a total of 1,434 individual health professionals recruited at baseline (across a known 260 practices) with follow-up available for 1,204. Sample sizes for individual studies were medium to large, with the smallest number of patients (randomized at baseline) found in the Wang 1994 study (n= 93) and the largest in the Kottke 1989 study. The smallest sample at follow-up remained with the Wang 1994 study (n= 82), and the largest remained with the Kottke 1989 study (n= 5266) . At the health professional level, the Hymowitz 2007 study had the largest number of residents randomized at baseline (n= 275) and follow-up (n= 235) and likewise, Wang 1994 had the smallest number of residents at baseline and follow-up (n= 27 for both). Seven studies also reported baseline cluster sizes at the practice level: Lennox 1998 (n= 16); Sinclair 1998 (n= 62); Swartz 2002 (n= 50); Joseph 2004 (n= 20); Hymowitz 2007 (n= 16); Twardella 2007 (n= 82); and Gordon 2010 (n= 14).

 

Setting

Eleven of the 17 studies were conducted in the USA, one in Canada (Wilson 1988), one in Taiwan (Wang 1994), one in Scotland (Sinclair 1998), one in the United Kingdom (Lennox 1998), one in Switzerland (Cornuz 2002) and one in Germany (Twardella 2007). Two studies were performed in a dentistry setting (Cohen (Dent) 1989; Gordon 2010), whilst the remaining 15 were conducted within primary care clinics, HMO (Health Maintenance Organisation) medical centres (Cummings 1989; Swartz 2002), VAMC's (Veterans Affairs Medicial Centres) (Joseph 2004) and one in a pharmacy setting (Sinclair 1998).

 

Participants

At the health professional level, two studies were performed with dentists (Cohen (Dent) 1989; Gordon 2010), six studies included only primary care physicians (Wilson 1988; Cohen (Doc) 1989; Cummings (Priv) 1989; Kottke 1989 Twardella 2007; Unrod 2007), two studies were conducted with residents (Cornuz 2002 and paediatric residents in Hymowitz 2007), three studies incorporated a combination of primary care physicians and internists (Cummings 1989; Strecher 1991; Wang 1994), one study used pharmacists (Sinclair 1998), whilst the remaining three studies used a combination of health professionals including physicians, nurse practitioners, physician assistants, psychologists, pharmacists and other health visitors (Lennox 1998; Swartz 2002; Joseph 2004).

The individual patients in 16 of the 17 included studies were those visiting their health professional during the recruitment phase of each study. They were recruited during standard GP, dentist or outpatient visits, emergency department visits or from waiting rooms. The Hymowitz 2007 study was the only one to perform the training in a paediatric setting, targeting the parents/guardians of children visiting 16 primary care clinics.

 

Interventions

 
Treatment type

Six studies provided patients with a counselling plus nicotine replacement therapy intervention arm (Wilson 1988; Cohen (Dent) 1989; Cohen (Doc) 1989; Sinclair 1998; Joseph 2004; Twardella 2007). The two Cohen et al studies had a second intervention arm of counselling plus a reminder for physicians to ask about smoking (chart prompt), and a third intervention arm combining the counselling, nicotine replacement therapy and chart prompt (Cohen (Dent) 1989; Cohen (Doc) 1989). Another study (Twardella 2007) also had three intervention arms: counselling plus nicotine replacement therapy; counselling plus a monetary incentive to the physician following study completion per successful smoke-free participant (€130); and a counselling plus nicotine replacement therapy plus incentive arm. The Wilson 1988 study had two intervention arms in addition to usual care: counselling and nicotine gum (as mentioned above) and a second arm of nicotine gum plus usual care (i.e., physicians were not trained in counselling). Three studies included multiple intervention methods to curtail smoking including counselling, nicotine replacement therapy, request for additional follow-up appointments and provision of self-help materials (Cummings (Priv) 1989; Cummings 1989; Gordon 2010), whilst one study combined three of those four (counselling, nicotine replacement therapy, and self-help materials, Cornuz 2002). Five studies used counselling alone (Strecher 1991; Wang 1994; Lennox 1998; Swartz 2002; Unrod 2007) and two studies used counselling with the addition of self-help materials (Kottke 1989; Hymowitz 2007).

 
Treatment intensity

The level of training intensity for health professionals ranged from one 40-minute session in the Unrod 2007 study, to 'four or five' day long sessions in the Joseph 2004 study. Nine studies had a training session for one day or less: Wilson 1988 (four hours), Cohen (Dent) 1989 (one hour), Cohen (Doc) 1989 (one hour), Kottke 1989 (6 hours), Lennox 1998 (one day), Sinclair 1998 (two hours), Twardella 2007 (two hours), Unrod 2007 (40 minutes) and Gordon 2010 (three hours). Four studies had two separate sessions: Strecher 1991 (two, one hour sessions scheduled two weeks apart), Wang 1994 (two sessions of unknown duration), Cornuz 2002 (two, four hour training sessions scheduled two weeks apart) and Swartz 2002 (two, 20 minute training sessions and another session of unknown duration, where residents were able to practice counselling techniques with standardised patients). Four studies had three or more sessions: Cummings (Priv) 1989 and Cummings 1989 both had three, one hour sessions over a four to five week period, Hymowitz 2007 had four, one hour sessions, four times a year and Joseph 2004 had four to five, day long sessions within six months.

 
Mode of intervention delivery

Three different modes of intervention delivery were used being groups sessions, one-on-one or a combination of the two. Two studies only used one-on-one sessions (Joseph 2004; Unrod 2007), eleven studies delivered the intervention in a group setting only (Wilson 1988; Cummings 1989; Kottke 1989; Strecher 1991; Wang 1994; Lennox 1998; Sinclair 1998; Swartz 2002; Hymowitz 2007; Twardella 2007; Gordon 2010) with an eighth study using group delivery as the primary mode, however doctors who were unable to attend received a private session in their office (Cummings (Priv) 1989). Finally three studies used both modes of intervention delivery (Cohen (Dent) 1989; Cohen (Doc) 1989; Cornuz 2002), with health professionals in the two Cohen et al studies provided the option of a group or individual session.

 
Theoretical model - behavioural change technique

Nine studies used behavioural change theories to underpin the intervention techniques. These included the 'stages of change' (also known as the trans-theoretical) model (Kottke 1989; Strecher 1991; Wang 1994; Lennox 1998; Sinclair 1998; Cornuz 2002; Twardella 2007) and the '5A' (Ask, Assess, Advise, Assist and Arrange) approach (Unrod 2007; Gordon 2010). Three studies incorporated prompting or reminders to ask about tobacco use (Cohen (Dent) 1989; Cohen (Doc) 1989; Hymowitz 2007) and four provided feedback to the health providers, for example number of patients counselled (Cornuz 2002; Swartz 2002; Joseph 2004; Unrod 2007).

 
Type of professional being trained:

Two studies only focused on dentists (Cohen (Dent) 1989; Gordon 2010), one focused on pharmacists (Sinclair 1998), and the remaining fourteen studies all involved doctors. Five of these fourteen studies included doctors still undergoing training, either residents (Strecher 1991; Wang 1994; Cornuz 2002; Hymowitz 2007) or a combination of physicians and internists (Cummings 1989). Three other studies included training to other health care workers as well as doctors: Lennox 1998 also involved nurses and other health visitors; Swartz 2002 also trained nurse practitioners, physicians assistants and other health professionals; and, in addition to doctors, Joseph 2004 included nurses, psychologists and pharmacists.

 
Length of follow-up

Eight studies reported follow-up periods between six and nine-months post intervention (Cohen (Dent) 1989; Cohen (Doc) 1989; Strecher 1991; Wang 1994; Lennox 1998; Sinclair 1998; Unrod 2007; Gordon 2010), eleven studies presented 12 month follow-up data (Wilson 1988; Cohen (Dent) 1989; Cohen (Doc) 1989; Cummings 1989; Kottke 1989; Wang 1994; Cornuz 2002; Swartz 2002; Joseph 2004; Twardella 2007; Gordon 2010) and two studies assessed extended follow-up periods of 14 months (Lennox 1998) and four years (Hymowitz 2007). However, only two-year post intervention data was available for Hymowitz 2007 at the time of writing.

 

Outcomes

Smoking abstinence was assessed in all included studies through self-report of either continuous abstinence (no smoking for an extended period of time) or point prevalence (for example, no smoking for seven days prior to the time of outcome collection). Of the eight studies that reported continuous abstinence, six (Cummings (Priv) 1989; Cummings 1989; Gordon 2010; Lennox 1998; Sinclair 1998; Wilson 1988) also reported a point prevalence measure of abstinence. Ten of the included studies used biochemical validation through either exhaled carbon monoxide (Cohen (Dent) 1989; Cohen (Doc) 1989; Strecher 1991; Cornuz 2002), serum cotinine (Kottke 1989; Twardella 2007), saliva cotinine (Wilson 1988; Unrod 2007) or a combination of exhaled carbon monoxide and serum cotinine (Cummings (Priv) 1989; Cummings 1989). A number of secondary outcomes measures were reported by some studies including: patients asked to set a quit date; patients asked to make a follow-up appointment; number of smokers counselled; number of smokers receiving self-help material; number of smokers receiving nicotine gum/replacement therapy; and number of smokers prescribed a quit date.

Two studies reported n-values as a total across both intervention and control arms (Cohen (Dent) 1989; Cohen (Doc) 1989) and six studies reported n-values as percentages, which had to be transformed into whole numbers (Wilson 1988; Cornuz 2002; Swartz 2002; Joseph 2004; Hymowitz 2007; Unrod 2007). As such there is likely to be some small variance between actual n-values and those reported in these analyses, but this is not significant. Seven studies had multiple intervention arms, which were considered similar enough to be pooled together, two in the Wilson 1988, Kottke 1989 and Wang 1994 studies and three intervention arms in the Cohen (Dent) 1989, Cohen (Doc) 1989, Strecher 1991 and Twardella 2007 studies. One study did not report the n-value for subjects at randomization, and hence this was calculated based on the number eligible for study and the number at follow-up (Strecher 1991). The Kottke 1989 study reported all outcome data as continuous variables, as such it was unable to be pooled in the meta-analyses. Smoking related outcomes in the Hymowitz 2007 study were unable to be pooled as only change scores from baseline were presented.

 

Excluded studies

Sixty-five studies (71 articles) were excluded for the following reasons: 21 included consultation process only, 18 did not include a control group, 13 failed to measure smoking related outcome data, 12 were considered to be inadequately randomized and one only reported on smokeless tobacco use. See the Characteristics of excluded studies table for more detailed information relating to each excluded study.

 

Risk of bias in included studies

Methodological details for the 17 included studies are provided in the 'risk of bias table' at the end of the Characteristics of included studies tables. Key methodological features are also summarised in Figure 2.

 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias judgement presented as percentages across all included studies

 

Random sequence generation (selection bias)

Five studies reported adequate methods of sequence generation (Cummings 1989; Cornuz 2002; Hymowitz 2007; Twardella 2007; Unrod 2007), two had inadequate methods (Kottke 1989; Strecher 1991) whilst the remaining ten did not provide enough information to assess risk of bias for sequence generation and were hence judged to be at unclear risk in this category. Adequate methods included the use of a random number generator or coin toss, whilst unclear methods were described as being 'random' in design, however methods were not described. The Kottke 1989 study required some physicians to be re-assigned due to inappropriate allocation methods during assignment. For the Strecher 1991 study appropriate randomization did not occur as residents were randomly assigned by clinic half-day session to one of four groups, which risks introducing bias. All 17 trials used cluster randomization, with five studies inadequately accounting for potential clustering effects in the data, requiring manual clustering adjustments (Wilson 1988; Cummings (Priv) 1989; Cummings 1989; Kottke 1989; Wang 1994). Only two studies (Kottke 1989; Hymowitz 2007) reported outcome data at the level of randomization. No authors reported that differences in the method of analysis affected the results.

 

Allocation concealment (selection bias)

Allocation concealment was unclear in all 17 included studies as authors did not describe methods of allocation concealment. Authors of the Lennox 1998 study report that physicians were randomly and blindly allocated to control or intervention groups, however the methods were not described. Another study mentioned that an independent research assistant concealed the result of randomization until two weeks before the intervention, when residents were provided with details about training sessions, however, methods of concealment were again not reported (Cornuz 2002).

 

Blinding (performance bias and detection bias) of participants

Only one study reported adequately blinding participants to the intervention (Cornuz 2002), as residents were not informed about the aim of the trial and were advised only that a survey on cardiovascular risk factors and prevention would be conducted. Authors announced that a training program in clinical prevention that included sessions on smoking cessation and management of dyslipidaemia was being conducted. Authors also report that patients were blinded to the aim of the study and group allocation of their physician. Due to the nature of the intervention, blinding of participants was not possible for the remaining 16 studies. An attempt was made to blind physicians in the Unrod 2007 study, with physicians learning their group assignment only after signing the informed consent, however they were not blinded during the study intervention period and follow-up.

 

Blinding (performance bias and detection bias) of outcome assessors

Three studies reported methods blinding of outcome assessors that we judged at low risk of bias. Authors of Cummings (Priv) 1989 stated that 'outcome assessors were blinded', authors of the Joseph 2004 study report interviewers collecting patient outcomes were blinded to subject treatment status and authors in the Strecher 1991 study report that telephone interviewers, who were blinded to residents’ and patients’ group assignments, obtained the patient reports. The remaining 14 studies did not report any attempts to blind outcome assessors and as such are unclear for this category.

 

Incomplete outcome data (attrition bias)

Incomplete outcome data was adequately addressed in three studies (Cummings (Priv) 1989; Cummings 1989; Gordon 2010) and unclear in the remaining 14 studies. The Cummings (Priv) 1989 and Cummings 1989 studies reported that missing data was accounted for in analyses, whilst the Gordon 2010 study reported the use of multiple imputation procedures to account for missing data with participants lost to attrition discussed in the text. All unclear studies failed to mention if there was any missing outcome data and if so, how this was addressed when reporting results.

 

Selective reporting (reporting bias)

Selective reporting was evident in three studies (Hymowitz 2007; Unrod 2007; Gordon 2010), unclear in three studies (Kottke 1989; Strecher 1991; Wang 1994) and not detected in the remaining 11. Although all pre-specified outcomes were addressed in the four year follow-up for the Hymowitz 2007 study, the authors mention that outcome data for year one was omitted in order to provide a 'cleaner look' at the progress of the data. In the Unrod 2007 study, smoking abstinence from baseline to follow-up (an outcome that would be expected to have been assessed in this study) was not reported. The Gordon 2010 authors report that secondary participant outcomes were examined with no significant differences on any variables, and that therefore they were not presented in the publication. Also, receipt of intervention was reported in text as percentages, however no information regarding this outcome was reported for the control.

 

Imbalance of outcome measures at baseline

One study did not report data for baseline smoking and made no mention of statistical analyses to potentially adjust for any imbalances (Wang 1994), as such the risk of bias category was assessed as unclear. All remaining studies adequately addressed imbalances of outcome measures at baseline. Thirteen studies accounted for baseline imbalances through analysis of covariance, regression analyses or other analysis techniques, whilst three studies reported outcomes at baseline to be similar across groups and as such did not require adjustment (Cummings (Priv) 1989; Lennox 1998; Sinclair 1998).

 

Comparability of intervention and control group characteristics at baseline

Five studies had unclear comparability between intervention and control groups at baseline (Wilson 1988; Cohen (Dent) 1989; Cohen (Doc) 1989; Cummings 1989; Twardella 2007) and the remaining twelve studies adequately addressed any differences found between groups via appropriate analysis methods.

 

Protection against contamination

Two studies reported contamination. In Gordon 2010, authors reported contamination due to a tax increase on cigarettes in New York, which resulted in a drop in smoking prevalence from 18.4% in 2006 to 15.8% in 2008. Authors believed that this tax increase contributed to the unusually high rate of smoking cessation in the usual care patients, thereby affecting the relative impact of the intervention. Authors of the second study, Strecher 1991, mention that "all four groups worked closely with one another at each site", leading to the possibility of contamination, however they also state that “...the effects appeared to be slight.” Nine studies had unclear risk of bias for contamination with insufficient information to permit a judgement of yes or no, whilst the remaining six studies (Wilson 1988; Cummings (Priv) 1989; Cummings 1989; Kottke 1989; Lennox 1998; Cornuz 2002) reported no potential contamination during the study period.

 

Selective recruitment of participants

Although no studies were identified as having selectively recruited participants, this could not be completely ruled out for eleven studies, which were determined to have an unclear risk of bias for this outcome (Wilson 1988; Cohen (Dent) 1989; Cohen (Doc) 1989; Cummings (Priv) 1989; Kottke 1989; Strecher 1991; Wang 1994; Sinclair 1998; Swartz 2002; Twardella 2007; Gordon 2010). The sampling frames in these studies were unclear and as such, generalisability is of a potential concern. The remaining six studies adequately reported recruitment methods and were determined as having a low risk of bias.

 

Other bias

No other biases were identified for the 17 included studies.

 

Effects of interventions

See:  Summary of findings for the main comparison Training health professionals for smoking cessation

Intervention effectiveness was assessed in all seventeen included studies through smoking prevalence, as well as through multiple secondary outcomes (see  Summary of findings for the main comparison). All data were analysed as per the pre-defined methodology outlined in the Methods section. For a summary of intervention effectiveness for each of these outcomes see  Table 1.

 

Overall summary of smoking behaviour

Four out of 13 studies detected significant intervention effectiveness in training health professionals to influence point prevalence of smoking in their patients at primary follow-up (Cohen (Doc) 1989; Cornuz 2002; Twardella 2007; Gordon 2010). Out of the eight studies reporting continuous abstinence at primary follow-up, only one reported a statistically significant effect in favour of the intervention (Gordon 2010). Fifteen of the 17 included studies (the exceptions being Kottke 1989 and Hymowitz 2007) could be included in a meta-analysis for the primary outcome of smoking ( Analysis 1.1). Using a fixed effect model there was a statistically and clinically significant effect in favour of the intervention for point prevalence abstinence (OR 1.36, 95% CI 1.20 to 1.55, 14 trials, I² = 57%) and continuous abstinence (OR 1.60, 95% CI 1.26 to 2.03, 8 trials, I² = 59%) (Figure 3). Using only the stricter outcome of continuous abstinence for studies reporting both types of cessation, a pooled estimate for all 15 trials gave a similar estimate (OR 1.60, 95% CI 1.35 to 1.89, I² = 55%, data not displayed). Since the heterogeneity in this analysis approached the level at which we proposed a random-effects model we did a sensitivity analysis; the point estimates were similar and the wider confidence intervals continued to exclude no effect. The trial contributing most evidently to the heterogeneity, particularly for the continuous outcome, was Lennox 1998 in which the point estimates for both abstinence outcomes favoured the control group.

 FigureFigure 3. Forest plot of comparison: 1 The effect of training health professionals on patient smoking cessation

Two studies could not be included in the meta-analyses. In the Kottke 1989 study at one year follow-up almost half of the participants in each group who were smoking at baseline reported quit attempts for at least 24 hours during the previous year, with a mean duration of cessation of two months. No differences between the three groups were identified. For the Hymowitz 2007 study there was an increase in the special training condition of reported quitting during the past year of 3.8% (an 8.5% increase over baseline levels), however the change from baseline failed to achieve statistical significance. Among parents associated with standard training, the change was only 0.8%.

As per pre-specified methodology, a funnel plot examined the primary outcome of smoking cessation using contour lines to assess the presence of reporting biases. No publication biases were identified (Figure 4).

 FigureFigure 4. Funnel plot of comparison: 1 The effect of training health professionals on patient smoking cessation

 

Overall summary of secondary outcomes

 

Asked to set a quit date for stopping (quit date)

Nine studies reported the effect of training health professionals on the number of patients being asked to set a quit date, eight of which could be included in the meta-analysis producing a significant result (random effects OR 4.98, 95% CI 2.29 to 10.86,  Analysis 1.2). Only three of the seven studies crossed the line of no effect (Strecher 1991; Cornuz 2002; Swartz 2002) but there was a very high level of heterogeneity (I² = 90%) suggesting that not all interventions had the same impact on this outcome. Subgroup analyses suggest that some of the heterogeneity might be due to whether or not the patient intervention included an offer of NRT. The two studies (Strecher 1991; Swartz 2002) that reported this outcome and did not include NRT showed no difference between groups. The other studies showed more consistent evidence that intervention increased numbers although the size of effect remained variable ( Analysis 2.1). Contrary to what might have been expected, the studies where training took only a single session had higher effect sizes (Cohen (Dent) 1989; Cohen (Doc) 1989; Wilson 1988,  Analysis 3.1) compared to the five studies using multiple sessions. Duration of training was similar for the three sub-groups being examined ( Analysis 4.1) as was intervention delivery via one-on-one compared to group sessions ( Analysis 5.1). There was a large amount of variability between the use of prompting and provision of feedback, however this difference was not significant ( Analysis 6.1). Intervention delivery by a doctor (six studies) or dentist (one study) produced a larger effect size compared to delivery by a healthcare worker (Swartz 2002), which may also explain some of the heterogeneity ( Analysis 7.1). When comparing follow-up periods, studies reporting between six and nine months (Cohen (Dent) 1989; Cohen (Doc) 1989; Strecher 1991) and between nine and 12 months (seven studies) produced similar effect sizes and large amounts of variability ( Analysis 8.1). Studies judged to be at lower risk of bias were more likely to show evidence of an effect (seven studies) compared to studies with between three and five categories rated at high risk of bias (Strecher 1991), however the between group analysis did not suggest that this was a source of heterogeneity ( Analysis 9.1).

 

Given a follow-up appointment

There was a significant increase in the intervention arm for patients being asked to make a follow-up appointment, as reported in seven studies available for meta-analysis (random effects OR 3.34, 95% CI 1.51 to 7.37,  Analysis 1.3), although significant heterogeneity was observed (I² =92%). When comparing interventions using NRT with those that used counselling alone, an I² of 96% was observed, meaning any results from a pooled analysis would be too unreliable. As such only a visual analysis of odds ratios and confidence intervals are presented, showing similar variability between sub-groups ( Analysis 2.2). Subgroup analyses for treatment intensity suggest that some of the heterogeneity might be due to whether or not the training sessions were single or multiple. Two studies that employed single sessions (Wilson 1988; Unrod 2007) were more likely to show an effect (although variability was observed), compared to five studies using multiple sessions, which produced a smaller effect estimate with less variability ( Analysis 3.2). When comparing the duration of the training, significant heterogeneity was once again observed between groups, with studies presenting large amounts of variability, resulting in a pooled estimate being unreliable for comparison ( Analysis 4.2). There was little difference between delivery by one-on-one compared to group sessions ( Analysis 5.2), and due to significant heterogeneity (I² =96%) the pooled comparison of prompting and provision of feedback was not possible, although a visual display shows variability is mostly due to the Unrod 2007 study ( Analysis 6.2). Similar to other outcomes, delivery of the intervention by a doctor (assessed in seven studies) meant that more patients were likely to have a follow-up appointment compared to intervention delivery by a healthcare worker (one study), however the Swartz 2002 study was present in both sub-groups as the intervention included delivery by both a doctor and healthcare worker, as such a statistical between group comparison was not performed ( Analysis 7.2). Reporting of results at different follow-up periods were similar between sub-groups, although the five studies with follow-up between nine and 12 months had similar distributions with the exception of the Wilson 1988 study, which significantly favoured the intervention and had wide confidence intervals ( Analysis 8.2). No between group differences were observed for quality of the studies ( Analysis 9.2).

 

Counselled

Fourteen of the fifteen studies reporting on the number of smokers counselled were meta-analysed ( Analysis 1.4). Overall, a statistically and clinically significant effect in favour of the intervention was observed (OR 2.28, 95% CI 1.58 to 3.27, p< 0.00001), assessed using the random effects model due to significant heterogeneity (I²= 93%). An investigation into the causes of heterogeneity found no differences between counselling with and without nicotine replacement therapy ( Analysis 2.3), however implementation via multiple sessions or single sessions did produce between group differences, with a larger effect size for single session delivery ( Analysis 3.3). Duration of intervention delivery also produced significant differences with total exposure of between 40 minutes and two hours producing a larger effect size compared to durations of between two and four hours and greater than four hours ( Analysis 4.3). Mode of intervention delivery (one-on-one compared to group sessions) produced very similar effect sizes ( Analysis 5.3), as did the provision of feedback and prompting to aid intervention delivery by the health professional ( Analysis 6.3). The type of health professional being trained may contribute to the heterogeneity with the one study evaluating dentists (Cohen (Dent) 1989) producing a larger effect size compared to those with doctors and other health professionals which showed a more conservative effect with narrow confidence intervals ( Analysis 7.3). When examining follow-up periods, there was a slightly larger effect and more variability in the studies reporting results between six and nine months compared to results between nine and twelve months and 12 and 24 months ( Analysis 8.3). No sub-group differences were observed when analysing studies based on risks of bias ( Analysis 9.3).

 

Given self-help materials

The number of smokers receiving self-help material increased significantly in favour of the intervention for the nine studies able to be included in the meta-analysis (OR 3.52, 95% CI 1.90 to 6.52, p< 0.0001,  Analysis 1.5). Provision of cessation materials in the Hymowitz 2007 study, which could not be included in the meta-analysis, did increase significantly across both groups over the four year study period when compared to baseline values (intervention 28.8%, control 17.6%) however, this interaction was not statistically different between groups. The other study unable to be meta-analysed (Kottke 1989) also produced a statistically significant effect (p< 0.001). Signficant heterogeneity was observed in the meta-analysis (I²= 91%) which was explored through sub-group analyses. The type of treatment did not show a significant difference between groups, although the counselling plus nicotine replacement therapy group did have a larger effect size compared to counselling alone ( Analysis 2.4). Likewise, no differences were observed for single compared to multiple session delivery ( Analysis 3.4) or duration of delivery ( Analysis 4.4), although the Cornuz 2002 study with a total exposure over four hours did produce a very large effect with wide confidence intervals. No differences were observed for the mode of intervention delivery ( Analysis 5.4) or provision of prompting or feedback to aid health professionals in the provision of self-help materials ( Analysis 6.4). The one study (Swartz 2002) which included healthcare workers for intervention delivery produced less of an effect compared to the pooled result of studies using doctors ( Analysis 7.4). No difference between sub-groups was observed for length of follow-up ( Analysis 8.3) although studies identified as having less risk of bias did have a larger effect size compared to those with larger amounts of bias ( Analysis 9.4).

 

Offered nicotine gum/replacement therapy

Nine studies were pooled to assess the number of smokers receiving nicotine gum/replacement therapy ( Analysis 1.6). The meta-analysis did not produce evidence of an effect (OR 1.57, 95% CI 0.87 to 2.84, p= NS), but significant heterogeneity was detected (I²= 91%). The Hymowitz 2007 study also assessed this outcome with few parents in either condition reporting that residents prescribed nicotine replacement therapy (intervention 7.6%, control 5.9%). An exploration into the possible sources of heterogeneity found no difference between interventions containing counselling with or without nicotine replacement therapy ( Analysis 2.5), however surprising results were observed with much larger effect sizes for single session intervention delivery compared to multiple session ( Analysis 3.5), which could account for some of the heterogeneity. No differences were observed between sub-groups for treatment intensity ( Analysis 4.5), mode of intervention delivery ( Analysis 5.5), use of feedback or prompting ( Analysis 6.5), type of professional being trained ( Analysis 7.5) or length of follow-up ( Analysis 8.5). However studies with less risk of bias did produce larger effect sizes compared to studies with three to five sources of bias identified, which could also contribute to some of the observed heterogeneity ( Analysis 9.5).

 

Prescribed a quit date

Only three studies reported on smokers being prescribed a quit date (Wilson 1988; Cummings 1989; Strecher 1991). Pooling these together produced a statistically and clinically significant effect in favour of the intervention (OR 14.18, 95% CI 6.57 to 30.61, p< 0.00001,  Analysis 1.7), with minimal observed heterogeneity. As such, sub-group analyses were not necessary for this outcome.

 

Cost effectiveness of interventions

Cost effectiveness data was presented in one study (Cornuz 2002), with the incremental cost of the intervention reported to amount to (U.S.) $2.58 per consultation by a smoker. When considering 'cost per life-year saved', this translated to (U.S.) $25.40 for men and $35.20 for women, with one-way sensitivity analyses yielding a range of $4.00 to $107.10 in men and $9.70 to $148.60 in women. The Joseph 2004 study reported that the dollar spent per 1000 primary care patients did increase in the intervention sites and decrease in control sites, however this was not significant.

 

Number of referrals made

No studies reported on the number of referrals made to local smoking cessation services.

 

Statistical analyses and cluster adjustments

All 17 studies used a cluster randomized design for practical reasons, with the unit of randomization being the health care practitioner or practice. However, in 15 of the 17 studies patients were the unit of analysis. Hymowitz 2007 and Kottke 1989 were the exceptions, reporting outcomes at the level of randomization (the doctor/resident). The majority of studies that reported outcomes at the level of patient accounted for potential clustering effects within their reported results, with four studies (three in the late 1980's Wilson 1988; Cummings (Priv) 1989; Cummings 1989 and one in the mid-1990's Wang 1994) being the exceptions. The two Cummings et al studies did perform clustering analyses, however they were not included in the published results as they were seen to have had no effect on the final outcome. As such, the data for these studies were manually adjusted for potential clustering effects as per the pre-specified methodology outlined in the Unit of analysis issues section of this review.

 

Sub-group analyses

Multiple sub-group analyses have been considered as per the pre-defined methodology to further explore heterogeneity. When considering these outcomes the level of statistical significance should be considered at p< 0.01, to account for potential false positive results (as per the Bonferroni adjustment described Assessment of heterogeneity), which increase with the number of potential effect modifiers being investigated. Total study confidence intervals were assessed at the 99% level for all sub-group analyses. Significant heterogeneity was determined through a combination of the I² statistic (I² >60%), Chi² statistic and visual inspection of the Forest plots, and was present for all outcomes with the exception of 'Smoking cessation at longest follow-up' and 'Number of smokers prescribed a quit date' where significant heterogeneity was not identified. In the presence of heterogeneity based on the I² statistic of > 96%, the pooled estimate has been removed, as the outcomes are considered too different to be combined in meta-analysis. Likewise, when a comparison contained the same study in different sub-groups, the pooled estimate was not used.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Summary of main results

Seventeen completed studies (total 28,531 subjects) assessed the benefits of interventions to train health professionals to provide smoking cessation initiatives to their patients. Whilst some methodological variations occurred between studies in relation to intervention, delivery mode, type of health professional and duration, they were all aimed at training health professionals to help their patients stop smoking. The primary outcome of smoking cessation was presented in pooled meta-analyses as point prevalence (14 studies) and continuous abstinence (eight studies). A statistically and clinically significant effect in favour of the intervention was observed for both of these outcomes at final follow-up (see  Summary of findings for the main comparison). All secondary outcomes (with one exception) produced a statistically and clinically significant effect in favour of the intervention at final follow-up. These outcomes include asking patients to set a quit date, asking patients to make follow-up appointments, counselling of smokers, provision of self-help material and prescription of a quit date. No evidence of an effect was observed for the secondary outcome of providing patients with nicotine gum/replacement therapy. No studies were able to be meta-analysed to assess the cost effectiveness of interventions.

 

Overall completeness and applicability of evidence

In the context of current practice, this review should be used to provide readers with an outline of what interventions have a proven effect, and where resources need to be directed for future investigations. Studies which incorporated multiple intervention components such as provision of nicotine replacement therapy, requests for follow-up appointments and provision of self-help material were more likely to be successful than those with interventions of counselling alone. Surprisingly, health professionals who were trained using only a single session and in a group setting were just as likely if not more likely to have patients quit smoking as those being trained with multiple delivery sessions and one-on-one training (i.e., face to face with the trainer). Similarly, the duration of training for the health professional of between 40 minutes to two hours was just as effective, and in some cases more so, than a duration of greater than two hours. Studies with multiple follow-up periods and closer monitoring of outcomes by investigators (including the provision of feedback) were more successful than those of lesser intensity. Smoking cessation interventions delivered by a doctor or dentist were more likely to produce successful quit attempts than those delivered by other health care workers.

To ensure methodological rigour, future studies should aim to incorporate the following into the study design:

  • Report patient level outcomes (e.g., smoking cessation) as well as health professional outcomes (e.g., physician report of number of smokers counselled) rather than providing details only relating to the consultation process
  • Adequate methods of randomization and allocation concealment
  • Report smoking related outcome data both pre and post intervention
  • Incorporate a control group which adequately matches the demographic characteristics of the intervention population.

 

Quality of the evidence

Study quality was a potential issue in this review with many of the studies being of unclear methodological design. It is extremely difficult to blind participants in relation to what intervention they will be receiving, as there are two levels to consider: the health professional and the patient. All 17 included studies had unclear allocation concealment whilst only five studies adequately reported methods of random sequence generation, two had a high risk of bias with the remaining ten studies being unclear. Overall, the body of evidence identified permits a moderately robust conclusion regarding the objectives of this review, with 17 included studies (28,531 participants).

Evidence presented in the summary of findings table was downgraded to take into account:

  • limitations in design: methods of randomization, allocation concealment and/or blinding were not described or inadequate for the majority of studies assessing the particular outcome (-1)
  • Inconsistencies: significant heterogeneity (-1)
  • Imprecision: only few participants in few studies available to assess the outcome (-1)

 

Potential biases in the review process

A potential bias in the review process is exclusion of studies examining interventions that train health professionals in smoking cessation that are of questionable methodological design. This review does sacrifice inclusion of some relevant information, however the trade off is a meta-analysis of higher quality evidence on which future investigations can be based. Some of the pertinent information from these studies is discussed below under Agreements and disagreements with other studies or reviews though results should be interpreted with caution. Another limitation to the review is the under-reporting of the intervention for included studies. This means that some studies may have indeed included additional intervention components that, had we known they existed, would have led us to classify the study differently within the sub-groups. One key strength of the review process to address potential biases is the use of two experienced and independent review authors who assessed the studies for risk of bias, although this can do little to account for biases which occur in the methodological designs of the included studies.

 

Agreements and disagreements with other studies or reviews

A compilation of systematic reviews and surveys of key informants were published as a special edition in the journal 'Drug and Alcohol Review' in 2009, relating to the education and training of health professionals and students in tobacco, alcohol and other drugs (Richmond 2009a). The first published survey of 21 key informants from eight countries found a high level of consistency in the content of the smoking cessation interventions, with 72% of programs using the 5A (Ask, Assess, Advise, Assist, Arange) model, 64% using the stages of change (trans-theoretical) model, 84% including pharmacotherapies, with 84% having some reference to clinical practice guidelines (Zwar 2009). Only five of the seventeen included studies in our review had reference to any particular behavioural change technique, however it is quite likely that the majority of studies are based around some kind of theoretical behavioural change context, which is not reported in the publication. These results are similar to the those reported in Richmond 2009b. The authors identified a lack of interest (with other continuing education topics considered to be a higher priority) and lack of funding for interventions to be the major barriers for the uptake and sustainability of training programs (Zwar 2009). Some possible solutions were provided to address these barriers including raising awareness of the importance of smoking cessation for the health of patients and incorporating education on smoking cessation into vocational courses for specialties. Another systematic review of postgraduate smoking cessation training for physicians in 28 European countries found nine studies which met all of the inclusion criteria containing a total of 170 postgraduate training programs (Kralikova 2009). The key implications reported by the authors were that postgraduate training in smoking cessation may not be reaching physicians and was not rigorously evaluated. To combat this problem multiple authors suggest that future research needs to incorporate methods of disseminating effective educational activities with the intention of increasing participation (Kralikova 2009; Muramoto 2009). It is also imperative that health professional organisations advocate for the systematic implementation of comprehensive tobacco cessation training programs to increase the number of patients receiving tobacco cessation interventions (Botelho 2009). Another study using direct observation of physician-patient encounters found similar results and concluded that strategies are needed to assist physicians to incorporate systematic approaches that will standardise smoking cessation care (Ellerbeck 2001). In this investigation, discussions around tobacco were more common in practices that utilised standard forms for recording smoking status and during new patient visits. Interestingly, the authors also found that discussions around tobacco use occurred less often among physicians in practice for more than 10 years and with older patients (Ellerbeck 2001), which is similar to an observational study by Bertakis 2007 investigating the factors associated with physician discussion of tobacco use with patients. Considerable resistance was also observed in a cohort of physicians receiving academic detailing to promote tobacco-use cessation counselling in dental offices. Dental staff members (including receptionists, office managers, dental assistants and dental hygienists) were reluctant to participate in the interventions due to increased paperwork, having to deal with uncooperative patients, and the perception that only a few patients use tobacco anyway and that counselling does not work (Albert 2004). However, the resistance observed did decrease as follow-up visits progressed and staff became more comfortable with the intervention and the procedures involved. This evidence suggests that through the provision of first-hand experience prior to guiding patients through the same process, physicians may feel more comfortable in implementing smoking cessation interventions into standard practice, which has the potential to be highly cost-effective. One of the included studies by Cornuz 2002 reported that training residents in smoking cessation counselling is very cost-effective and may be more efficient than the majority of currently accepted tobacco control interventions. This has also been supported by more recent systematic reviews and investigations (Maciosek 2006; Solberg 2006; Stead 2008). As such, the provision of counselling, advice and/or offers of assistance to the patient has the potential to significantly increase the number of quit attempts, which subsequently has the potential to reduce health related costs as well as morbidity and mortality associated with ongoing chronic tobacco use.

The previous version of this Cochrane review (New Reference) included eight studies with six finding no effect of intervention. The authors also stated that effects of training on process outcomes increased if prompts and reminders were used, however they concluded that there was no strong evidence that training health professionals to provide smoking cessation interventions changed smoking behaviour. With the addition of nine studies (more than half the initial number of inclusions), the findings of this review have now changed to support the training health professionals in smoking cessation interventions.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

Overall, a moderately large amount of methodologically rigorous evidence has been presented to support the effectiveness of training health professionals in smoking cessation. The following program characteristics could be considered for individuals involved in future clinical practice initiatives:

  • Combination of multiple intervention components including the provision of counselling, offer of follow-up appointments, setting or being prescribed a quit date and provision of self-help material
  • A one-off group training session for health professionals of between one to two hours duration, providing there is adequate follow-up and monitoring of progress. This will need to include provision of follow-up feedback to health professionals and resources such as patient self-help materials, with consideration given to other intervention components as mentioned above.
  • Consider organisational factors to ensure that smoking cessation messages are reliably delivered. Training can be expensive, and simply providing programs for health care professionals, without addressing the constraints imposed by the conditions in which they practise, is unlikely to be a wise use of health care resources.

 
Implications for research

Multi-component investigations incorporating new pharmacological interventions for smoking cessation (such as varenicline tartrate and bupropion) or other cessation aids (such as electronic cigarettes) alongside physician training should be considered to determine if any additional benefit in long-term abstinence can be obtained. Future research needs to ensure that adequate methodological rigour is met with considerations relating to:

  • Sequence generation and allocation concealment
  • Demographics and comparability of the control comparison
  • Reporting of smoking related outcome data
  • Collection of data both pre and post intervention implementation.

So as to enable interventions to be replicated in clinical practice, it is also important that authors of future trial reports describe the content of the training in sufficient detail, for example detailing the educational methods, strategies and theories used to train the professionals.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Firstly we would like to thank Monaz Mehta, Lindsay Stead, Elizabeth Arnold, Jamie Hartmann-Boyce and the Tobacco Addiction Group editors and personnel for their ongoing assistance and guidance throughout the review process and peer reviewers for their useful comments.

We would also like to acknowledge Dr Tim Cowan and Judith Gordon for supplying unpublished data from their research.

The late Chris Silagy was the second author on the first version of this review. Data analysis in the previous version of this review changed substantially in response to comments received from Jeremy Grimshaw, and discussion at a workshop on analysis of clustered data organised by the Cochrane Statistical Methods Working Group.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. The effect of training health professionals on patient smoking cessation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Smoking cessation at longest follow-up15Odds Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 Point prevalence
1413459Odds Ratio (M-H, Fixed, 95% CI)1.36 [1.20, 1.55]

    1.2 Continuous abstinence
89443Odds Ratio (M-H, Fixed, 95% CI)1.60 [1.26, 2.03]

 2 Patient asked to set a quit date84332Odds Ratio (M-H, Random, 95% CI)4.98 [2.29, 10.86]

 3 Patient asked to make a follow-up appointment73114Odds Ratio (M-H, Random, 95% CI)3.34 [1.51, 7.37]

 4 Number of smokers counselled148531Odds Ratio (M-H, Random, 95% CI)2.28 [1.58, 3.27]

 5 Number of smokers receiving self-help material94925Odds Ratio (M-H, Random, 95% CI)3.52 [1.90, 6.52]

 6 Number of smokers receiving nicotine gum/replacement therapy95073Odds Ratio (M-H, Random, 95% CI)1.57 [0.87, 2.84]

 7 Number of smokers prescribed a quit date31172Odds Ratio (M-H, Fixed, 95% CI)14.18 [6.57, 30.61]

 
Comparison 2. Sub-group: treatment type

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date84332Odds Ratio (M-H, Random, 95% CI)4.98 [1.79, 13.88]

    1.1 Counselling plus NRT
63322Odds Ratio (M-H, Random, 95% CI)7.45 [3.30, 16.85]

    1.2 Counselling alone
21010Odds Ratio (M-H, Random, 95% CI)1.22 [0.78, 1.92]

 2 Patient asked to make a follow-up appointment7Odds Ratio (M-H, Random, 95% CI)Totals not selected

    2.1 Counselling plus NRT
4Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    2.2 Counselling alone
3Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 3 Number of smokers counselled148531Odds Ratio (M-H, Random, 95% CI)2.28 [1.41, 3.67]

    3.1 Counselling plus NRT
95768Odds Ratio (M-H, Random, 95% CI)2.66 [1.33, 5.32]

    3.2 Counselling alone
52763Odds Ratio (M-H, Random, 95% CI)1.71 [1.09, 2.68]

 4 Number of smokers receiving self-help material94925Odds Ratio (M-H, Random, 95% CI)3.52 [1.56, 7.91]

    4.1 Counselling plus NRT
53165Odds Ratio (M-H, Random, 95% CI)5.50 [2.45, 12.36]

    4.2 Counselling alone
41760Odds Ratio (M-H, Random, 95% CI)1.91 [0.56, 6.48]

 5 Number of smokers receiving nicotine gum/replacement therapy95073Odds Ratio (M-H, Random, 95% CI)1.57 [0.72, 3.42]

    5.1 Counselling plus NRT
64122Odds Ratio (M-H, Random, 95% CI)1.78 [0.65, 4.91]

    5.2 Counselling alone
3951Odds Ratio (M-H, Random, 95% CI)1.00 [0.66, 1.50]

 
Comparison 3. Sub-group: treatment intensity - Number of sessions

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date84332Odds Ratio (M-H, Random, 95% CI)4.98 [1.79, 13.88]

    1.1 Single session
31969Odds Ratio (M-H, Random, 95% CI)14.45 [3.98, 52.48]

    1.2 Multiple sessions
52363Odds Ratio (M-H, Random, 95% CI)2.79 [1.03, 7.55]

 2 Patient asked to make a follow-up appointment73114Odds Ratio (M-H, Random, 95% CI)3.34 [1.18, 9.46]

    2.1 Single session
2751Odds Ratio (M-H, Random, 95% CI)13.33 [2.95, 60.24]

    2.2 Multiple sessions
52363Odds Ratio (M-H, Random, 95% CI)1.88 [0.94, 3.74]

 3 Number of smokers counselled148531Odds Ratio (M-H, Random, 95% CI)2.28 [1.41, 3.67]

    3.1 Single session
74213Odds Ratio (M-H, Random, 95% CI)3.39 [1.56, 7.37]

    3.2 Multiple sessions
74318Odds Ratio (M-H, Random, 95% CI)1.50 [1.14, 1.98]

 4 Number of smokers receiving self-help material94925Odds Ratio (M-H, Random, 95% CI)3.52 [1.56, 7.91]

    4.1 Single session
31182Odds Ratio (M-H, Random, 95% CI)6.93 [1.42, 33.76]

    4.2 Multiple sessions
63743Odds Ratio (M-H, Random, 95% CI)2.58 [1.01, 6.60]

 5 Number of smokers receiving nicotine gum/replacement therapy95073Odds Ratio (M-H, Random, 95% CI)1.57 [0.72, 3.42]

    5.1 Single session
32445Odds Ratio (M-H, Random, 95% CI)4.33 [3.18, 5.89]

    5.2 Multiple sessions
62628Odds Ratio (M-H, Random, 95% CI)0.97 [0.74, 1.27]

 
Comparison 4. Sub-group: treatment intensity - Total exposure

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date84332Odds Ratio (M-H, Random, 95% CI)4.98 [1.79, 13.88]

    1.1 Duration 40 minutes to 2 hours
52979Odds Ratio (M-H, Random, 95% CI)5.63 [0.71, 44.43]

    1.2 Duration >2 to 4 hours
21102Odds Ratio (M-H, Random, 95% CI)4.70 [3.08, 7.16]

    1.3 Duration >4 hours
1251Odds Ratio (M-H, Random, 95% CI)3.76 [0.65, 21.65]

 2 Patient asked to make a follow-up appointment6Odds Ratio (M-H, Random, 95% CI)Totals not selected

    2.1 Duration 40 minutes to 2 hours
4Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    2.2 Duration >2 to 4 hours
2Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 3 Number of smokers counselled148531Odds Ratio (M-H, Random, 95% CI)2.28 [1.41, 3.67]

    3.1 Duration 40 minutes to 2 hours
84220Odds Ratio (M-H, Random, 95% CI)3.25 [1.67, 6.33]

    3.2 Duration >2 to 4 hours
32482Odds Ratio (M-H, Random, 95% CI)1.57 [0.86, 2.86]

    3.3 Duration >4 hours
31829Odds Ratio (M-H, Random, 95% CI)1.29 [0.99, 1.68]

 4 Number of smokers receiving self-help material94925Odds Ratio (M-H, Random, 95% CI)3.52 [1.56, 7.91]

    4.1 Duration 40 minutes to 2 hours
52192Odds Ratio (M-H, Random, 95% CI)3.16 [0.77, 13.07]

    4.2 Duration >2 to 4 hours
32482Odds Ratio (M-H, Random, 95% CI)3.54 [1.84, 6.83]

    4.3 Duration >4 hours
1251Odds Ratio (M-H, Random, 95% CI)21.82 [1.50, 317.23]

 5 Number of smokers receiving nicotine gum/replacement therapy95073Odds Ratio (M-H, Random, 95% CI)1.57 [0.72, 3.42]

    5.1 Duration 40 minutes to 2 hours
53164Odds Ratio (M-H, Random, 95% CI)2.33 [0.73, 7.43]

    5.2 Duration >2 to 4 hours
31334Odds Ratio (M-H, Random, 95% CI)0.87 [0.52, 1.45]

    5.3 Duration >4 hours
1575Odds Ratio (M-H, Random, 95% CI)1.14 [0.67, 1.95]

 
Comparison 5. Sub-group: mode of intervention delivery

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date8Odds Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 One-on-one
42353Odds Ratio (M-H, Random, 95% CI)7.52 [2.17, 26.12]

    1.2 Group sessions
84332Odds Ratio (M-H, Random, 95% CI)4.98 [1.79, 13.88]

 2 Patient asked to make a follow-up appointment7Odds Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 One-on-one
31135Odds Ratio (M-H, Random, 95% CI)3.60 [0.86, 15.08]

    2.2 Group sessions
62596Odds Ratio (M-H, Random, 95% CI)2.74 [1.06, 7.08]

 3 Number of smokers counselled14Odds Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 One-on-one
63762Odds Ratio (M-H, Random, 95% CI)2.76 [1.27, 6.01]

    3.2 Group sessions
127438Odds Ratio (M-H, Random, 95% CI)2.47 [1.41, 4.30]

 4 Number of smokers receiving self-help material9Odds Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 One-on-one
31451Odds Ratio (M-H, Random, 95% CI)6.09 [3.93, 9.44]

    4.2 Group sessions
84407Odds Ratio (M-H, Random, 95% CI)3.22 [1.36, 7.65]

 5 Number of smokers receiving nicotine gum/replacement therapy9Odds Ratio (IV, Random, 95% CI)Subtotals only

    5.1 One-on-one
2941Odds Ratio (IV, Random, 95% CI)0.88 [0.41, 1.87]

    5.2 Group sessions
84498Odds Ratio (IV, Random, 95% CI)1.65 [0.68, 4.01]

 
Comparison 6. Sub-group: behavioural change technique used

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date52997Odds Ratio (M-H, Random, 95% CI)4.19 [0.63, 28.09]

    1.1 Prompting
31939Odds Ratio (M-H, Random, 95% CI)6.99 [0.90, 54.02]

    1.2 Provide feedback
21058Odds Ratio (M-H, Random, 95% CI)1.76 [0.43, 7.17]

 2 Patient asked to make a follow-up appointment4Odds Ratio (M-H, Random, 95% CI)Totals not selected

    2.1 Prompting
1Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    2.2 Provide feedback
3Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 3 Number of smokers counselled84322Odds Ratio (M-H, Random, 95% CI)2.32 [1.13, 4.74]

    3.1 Prompting
42171Odds Ratio (M-H, Random, 95% CI)3.27 [1.23, 8.68]

    3.2 Provide feedback
42151Odds Ratio (M-H, Random, 95% CI)1.67 [0.99, 2.85]

 4 Number of smokers receiving self-help material52011Odds Ratio (M-H, Random, 95% CI)2.51 [0.74, 8.58]

    4.1 Prompting
2435Odds Ratio (M-H, Random, 95% CI)1.48 [0.64, 3.42]

    4.2 Provide feedback
31576Odds Ratio (M-H, Random, 95% CI)4.33 [0.51, 36.60]

 5 Number of smokers receiving nicotine gum/replacement therapy41526Odds Ratio (M-H, Fixed, 95% CI)1.05 [0.76, 1.45]

    5.1 Provide feedback
21091Odds Ratio (M-H, Fixed, 95% CI)1.00 [0.71, 1.41]

    5.2 Prompting
2435Odds Ratio (M-H, Fixed, 95% CI)1.47 [0.57, 3.76]

 
Comparison 7. Sub-group: type of professional being trained

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date84332Odds Ratio (M-H, Random, 95% CI)4.98 [1.79, 13.88]

    1.1 Doctor
62878Odds Ratio (M-H, Random, 95% CI)6.35 [2.49, 16.19]

    1.2 Dentist
1647Odds Ratio (M-H, Random, 95% CI)6.43 [1.91, 21.56]

    1.3 Healthcare worker
1807Odds Ratio (M-H, Random, 95% CI)1.19 [0.74, 1.91]

 2 Patient asked to make a follow-up appointment7Odds Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 Doctor
73114Odds Ratio (M-H, Random, 95% CI)3.34 [1.18, 9.46]

    2.2 Healthcare worker
1807Odds Ratio (M-H, Random, 95% CI)1.06 [0.73, 1.54]

 3 Number of smokers counselled1410916Odds Ratio (IV, Random, 95% CI)2.05 [1.38, 3.05]

    3.1 Doctor
127592Odds Ratio (IV, Random, 95% CI)2.09 [1.25, 3.49]

    3.2 Dentist
1647Odds Ratio (IV, Random, 95% CI)4.33 [2.64, 7.10]

    3.3 Healthcare worker
42677Odds Ratio (IV, Random, 95% CI)1.55 [0.99, 2.42]

 4 Number of smokers receiving self-help material9Odds Ratio (IV, Random, 95% CI)Subtotals only

    4.1 Doctor
94925Odds Ratio (IV, Random, 95% CI)3.51 [1.57, 7.85]

    4.2 Healthcare worker
1807Odds Ratio (IV, Random, 95% CI)1.07 [0.73, 1.55]

 5 Number of smokers receiving nicotine gum/replacement therapy9Odds Ratio (IV, Random, 95% CI)Subtotals only

    5.1 Doctor
84581Odds Ratio (IV, Random, 95% CI)1.44 [0.63, 3.30]

    5.2 Healthcare worker
31583Odds Ratio (IV, Random, 95% CI)1.27 [0.64, 2.53]

 
Comparison 8. Sub-group: length of follow-up

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date8Odds Ratio (IV, Random, 95% CI)Subtotals only

    1.1 From 6 months up to and including 9 months
31939Odds Ratio (IV, Random, 95% CI)7.02 [0.98, 50.34]

    1.2 From greater than 9 months up to and including 12 months
74129Odds Ratio (IV, Random, 95% CI)5.67 [1.96, 16.42]

 2 Patient asked to make a follow-up appointment73114Odds Ratio (IV, Random, 95% CI)3.34 [1.19, 9.34]

    2.1 From 6 months up to and including 9 months
2721Odds Ratio (IV, Random, 95% CI)3.82 [0.48, 30.51]

    2.2 From greater than 9 months up to and including 12 months
52393Odds Ratio (IV, Random, 95% CI)3.10 [0.98, 9.75]

 3 Number of smokers counselled14Odds Ratio (IV, Random, 95% CI)Subtotals only

    3.1 From 6 months up to and including 9 months
63752Odds Ratio (IV, Random, 95% CI)3.13 [1.38, 7.09]

    3.2 From greater than 9 months up to and including 12 months
106575Odds Ratio (IV, Random, 95% CI)2.50 [1.34, 4.64]

    3.3 From greater than 12 months up to 24 months
21235Odds Ratio (IV, Random, 95% CI)1.30 [0.91, 1.86]

 4 Number of smokers receiving self-help material94925Odds Ratio (IV, Random, 95% CI)3.51 [1.57, 7.85]

    4.1 From 6 months up to and including 9 months
2721Odds Ratio (IV, Random, 95% CI)2.59 [0.22, 30.56]

    4.2 From greater than 9 months up to and including 12 months
63972Odds Ratio (IV, Random, 95% CI)4.42 [1.53, 12.70]

    4.3 From greater than 12 months up to 24 months
1232Odds Ratio (IV, Random, 95% CI)1.88 [0.80, 4.42]

 5 Number of smokers receiving nicotine gum/replacement therapy95073Odds Ratio (IV, Random, 95% CI)1.57 [0.72, 3.41]

    5.1 From 6 months up to and including 9 months
2695Odds Ratio (IV, Random, 95% CI)2.27 [0.75, 6.85]

    5.2 From greater than 9 months up to and including 12 months
64146Odds Ratio (IV, Random, 95% CI)1.44 [0.54, 3.81]

    5.3 From greater than 12 months up to 24 months
1232Odds Ratio (IV, Random, 95% CI)1.43 [0.34, 5.99]

 
Comparison 9. Sub-group: risk of bias in the studies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Patient asked to set a quit date84332Odds Ratio (IV, Random, 95% CI)4.97 [1.85, 13.30]

    1.1 Up to and including 2 domains
74129Odds Ratio (IV, Random, 95% CI)5.67 [1.96, 16.42]

    1.2 From 3 to 5 domains
1203Odds Ratio (IV, Random, 95% CI)1.68 [0.31, 9.00]

 2 Patient asked to make a follow-up appointment73114Odds Ratio (IV, Random, 95% CI)3.34 [1.19, 9.34]

    2.1 Up to and including 2 domains
62911Odds Ratio (IV, Random, 95% CI)3.79 [1.14, 12.55]

    2.2 From 3 to 5 domains
1203Odds Ratio (IV, Random, 95% CI)1.68 [0.69, 4.06]

 3 Number of smokers counselled148531Odds Ratio (IV, Random, 95% CI)2.28 [1.41, 3.67]

    3.1 Up to and including 2 domains
117804Odds Ratio (IV, Random, 95% CI)2.32 [1.34, 4.02]

    3.2 From 3 to 5 domains
2435Odds Ratio (IV, Random, 95% CI)1.64 [0.87, 3.10]

    3.3 From 6 to 8 domains
1292Odds Ratio (IV, Random, 95% CI)3.42 [1.61, 7.28]

 4 Number of smokers receiving self-help material95157Odds Ratio (IV, Random, 95% CI)3.26 [1.57, 6.77]

    4.1 Up to and including 2 domains
84722Odds Ratio (IV, Random, 95% CI)4.08 [1.75, 9.55]

    4.2 From 3 to 5 domains
2435Odds Ratio (IV, Random, 95% CI)1.48 [0.64, 3.42]

 5 Number of smokers receiving nicotine gum/replacement therapy95073Odds Ratio (IV, Random, 95% CI)1.57 [0.72, 3.41]

    5.1 Up to and including 2 domains
64146Odds Ratio (IV, Random, 95% CI)1.44 [0.54, 3.81]

    5.2 From 3 to 5 domains
2435Odds Ratio (IV, Random, 95% CI)1.47 [0.57, 3.76]

    5.3 From 6 to 8 domains
1492Odds Ratio (IV, Random, 95% CI)3.53 [0.95, 13.09]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. MEDLINE search strategy

1 RANDOMIZED-CONTROLLED-TRIAL.pt. (223948)
2 CONTROLLED-CLINICAL-TRIAL.pt. (38083)
3 CLINICAL-TRIAL.pt. (265615)
4 Meta analysis.pt. (29188)
5 exp Clinical Trial/ (457811)
6 Random-Allocation/ (38507)
7 randomized-controlled trials/ (69081)
8 double-blind-method/ (68631)
9 single-blind-method/ (13151)
10 placebos/ (12338)
11 Research-Design/ (43437)
12 ((clin$ adj$ trial$) or placebo$ or random$).ti,ab. (530665)
13 ((singl$ or doubl$ or trebl$ or tripl$) adj5 (blind$ or mask$)).ti,ab. (67270)
14 (volunteer$ or prospectiv$).ti,ab. (340629)
15 exp Follow-Up-Studies/ (269958)
16 exp Retrospective-Studies/ (314812)
17 exp Prospective-Studies/ (233927)
18 exp Evaluation-Studies/ or Program-Evaluation.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] (187044)
19 exp Cross-Sectional-Studies/ (115024)
20 exp Behavior-therapy/ (25130)
21 exp Health-Promotion/ (34021)
22 exp Community-Health-Services/ (246874)
23 exp Health-Education/ (69098)
24 exp Health-Behavior/ (59981)
25 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 (1995011)
26 smoking cessation.mp. or exp Smoking Cessation/ (17529)
27 "Tobacco-Use-Cessation"/ (545)
28 "Tobacco-Use-Disorder"/ (5569)
29 Tobacco-Smokeless/ (1457)
30 exp Tobacco-Smoke-Pollution/ (6538)
31 exp Tobacco-/ (13929)
32 exp Nicotine-/ (10241)
33 ((quit$ or stop$ or ceas$ or giv$) adj5 smoking).ti,ab. (6469)
34 exp Smoking/pc, th [Prevention & Control, Therapy] (8740)
35 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 [A category smoking terms] (50315)
36 1 or 2 or 3 [Likely CT design terms; RCTs, CCTs, Clinical trials] (384162)
37 (animals not humans).sh. [used with 'not' to exclude animal studies for each subset] (1521160)
38 (35 and 36) not 37 [Set 1: A smoking terms, likely CT design terms, human only] (3290)
39 Education, Premedical/ (192)
40 exp Education, Professional/ (102079)
41 exp Inservice Training/ (13162)
42 Physician's Practice Patterns/ (30147)
43 Dentist's Practice Patterns/ (1382)
44 exp Delivery of Health Care/ (479118)
45 exp Comprehensive Health Care/ (120957)
46 Critical Pathways/ (3744)
47 Disease Management/ (8035)
48 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 (622105)
49 (training or trained).ti,ab. (152010)
50 48 not 49 [MeSH without training text terms] (575357)
51 38 and 49 [training text terms with smoking trials] (224)
52 38 and 50 [sensitive MeSH terms, no mention of training in text] (600)

Records retrieved by this strategy that matched records in the Tobacco Addiction Group Specialised Register were screened for potential relevance. Records not already in the Register were not checked because they would previously have been retrieved during regular searches, and excluded for not being reports of controlled trials or other potentially eligible evaluations of tobacco control interventions.

 

Appendix 2. Glossary of tobacco-specific terms


TermDefinition

AbstinenceA period of being quit, i.e. stopping the use of cigarettes or other tobacco products, May be defined in various ways; see also:
point prevalence abstinence; prolonged abstinence; continuous/sustained abstinence

Biochemical verificationAlso called 'biochemical validation' or 'biochemical confirmation':
A procedure for checking a tobacco user's report that he or she has not smoked or used tobacco. It can be measured by testing levels of nicotine or cotinine or other chemicals in blood, urine, or saliva, or by measuring levels of carbon monoxide in exhaled breath or in blood.

BupropionA pharmaceutical drug originally developed as an antidepressant, but now also licensed for smoking cessation; trade names Zyban, Wellbutrin (when prescribed as an antidepressant)

Carbon monoxide (CO)A colourless, odourless highly poisonous gas found in tobacco smoke and in the lungs of people who have recently smoked, or (in smaller amounts) in people who have been exposed to tobacco smoke. May be used for biochemical verification of abstinence.

CessationAlso called 'quitting'
The goal of treatment to help people achieve abstinence from smoking or other tobacco use, also used to describe the process of changing the behaviour

Continuous abstinenceAlso called 'sustained abstinence'
A measure of cessation often used in clinical trials involving avoidance of all tobacco use since the quit day until the time the assessment is made. The definition occasionally allows for lapses. This is the most rigorous measure of abstinence

'Cold Turkey'Quitting abruptly, and/or quitting without behavioural or pharmaceutical support.

CravingA very intense urge or desire [to smoke].
See: Shiffman et al 'Recommendations for the assessment of tobacco craving and withdrawal in smoking cessation trials'
Nicotine & Tobacco Research 2004: 6(4): 599-614

DopamineA neurotransmitter in the brain which regulates mood, attention, pleasure, reward, motivation and movement

EfficacyAlso called 'treatment effect' or 'effect size':
The difference in outcome between the experimental and control groups

Harm reductionStrategies to reduce harm caused by continued tobacco/nicotine use, such as reducing the number of cigarettes smoked, or switching to different brands or products, e.g. potentially reduced exposure products (PREPs), smokeless tobacco.

Lapse/slipTerms sometimes used for a return to tobacco use after a period of abstinence. A lapse or slip might be defined as a puff or two on a cigarette. This may proceed to relapse, or abstinence may be regained. Some definitions of continuous, sustained or prolonged abstinence require complete abstinence, but some allow for a limited number or duration of slips. People who lapse are very likely to relapse, but some treatments may have their effect by helping people recover from a lapse.

nAChR[neural nicotinic acetylcholine receptors]: Areas in the brain which are thought to respond to nicotine, forming the basis of nicotine addiction by stimulating the overflow of dopamine

NicotineAn alkaloid derived from tobacco, responsible for the psychoactive and addictive effects of smoking.

Nicotine Replacement Therapy (NRT)A smoking cessation treatment in which nicotine from tobacco is replaced for a limited period by pharmaceutical nicotine. This reduces the craving and withdrawal experienced during the initial period of abstinence while users are learning to be tobacco-free The nicotine dose can be taken through the skin, using patches, by inhaling a spray, or by mouth using gum or lozenges.

OutcomeOften used to describe the result being measured in trials that is of relevance to the review. For example smoking cessation is the outcome used in reviews of ways to help smokers quit. The exact outcome in terms of the definition of abstinence and the length of time that has elapsed since the quit attempt was made may vary from trial to trial.

PharmacotherapyA treatment using pharmaceutical drugs, e.g. NRT, bupropion

Point prevalence abstinence (PPA)A measure of cessation based on behaviour at a particular point in time, or during a relatively brief specified period, e.g. 24 hours, 7 days. It may include a mixture of recent and long-term quitters. cf. prolonged abstinence, continuous abstinence

Prolonged abstinenceA measure of cessation which typically allows a 'grace period' following the quit date (usually of about two weeks), to allow for slips/lapses during the first few days when the effect of treatment may still be emerging.
See: Hughes et al 'Measures of abstinence in clinical trials: issues and recommendations'; Nicotine & Tobacco Research, 2003: 5 (1); 13-25

RelapseA return to regular smoking after a period of abstinence

Secondhand smokeAlso called passive smoking or environmental tobacco smoke [ETS]
A mixture of smoke exhaled by smokers and smoke released from smouldering cigarettes, cigars, pipes, bidis, etc. The smoke mixture contains gases and particulates, including nicotine, carcinogens and toxins.

Self-efficacyThe belief that one will be able to change one's behaviour, e.g. to quit smoking

SPC [Summary of Product Characteristics]Advice from the manufacturers of a drug, agreed with the relevant licensing authority, to enable health professionals to prescribe and use the treatment safely and effectively.

TaperingA gradual decrease in dose at the end of treatment, as an alternative to abruptly stopping treatment

TitrationA technique of dosing at low levels at the beginning of treatment, and gradually increasing to full dose over a few days, to allow the body to get used to the drug. It is designed to limit side effects.

WithdrawalA variety of behavioural, affective, cognitive and physiological symptoms, usually transient, which occur after use of an addictive drug is reduced or stopped.
See: Shiffman et al 'Recommendations for the assessment of tobacco craving and withdrawal in smoking cessation trials'
Nicotine & Tobacco Research 2004: 6(4): 599-614



 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 13 April 2012.


DateEventDescription

5 December 2013AmendedCorrection to Summary of Findings Table (confidence interval for continuous abstinence)



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 2, 1996
Review first published: Issue 2, 1996


DateEventDescription

30 March 2012New search has been performedSeven new studies added; SOF table, meta-analyses and summary of individual study effectiveness table added.

30 March 2012New citation required and conclusions have changedStructure of review changed, body of text updated and re-written; Conclusions changed.

4 August 2008AmendedConverted to new review format

31 May 2000New citation required and conclusions have changedSubstantive amendment



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Kristin Carson updated the protocol, reviewed the literature, identified studies for inclusion, extracted data, entered and analysed data and updated the text of the manuscript.

Marjolein Verbiest updated the protocol, reviewed the literature, identified studies for inclusion, extracted data and updated the text of the manuscript.

Mathilde Crone updated the protocol, identified studies for inclusion and updated the text of the manuscript.

Malcolm Brinn extracted data, entered and analysed data and updated the text of the manuscript.

Adrian Esterman updated the protocol, analysed data and updated the text of the manuscript.

Willem Assendelft assisted in updating the protocol and updating the text of the manuscript.

Brian Smith assisted in updating the protocol and updating the text of the manuscript.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • The Respiratory Medicine Unit, The Queen Elizabeth Hospital, Australia.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

RevMan version 5.1 was upgraded to version 5.1.2 during the review update, as such risk of bias domain categories were altered from 'yes', 'no' and 'unclear' to 'high risk', 'low risk' and 'unclear risk'.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Cohen (Dent) 1989 {published data only}
  • Cohen SJ, Stooky GK, Katz BP, Drook CA, Christen AG. Helping smokers quit: a randomized controlled trial with private practice dentists. J Am Dent Assoc 1989;118:41-5.
  • Cohen SJ, Stooky GK, Katz BP, Drook CA, Smith DM. Encouraging primary care physicians to help smokers quit. A randomised, controlled trial. Ann Intern Med 1989;110:648-52.
Cohen (Doc) 1989 {published data only}
  • Cohen SJ, Christen AG, Katz BP, Drook CA, Davis BJ, Smith DM, et al. Counseling medical and dental patients about cigarette smoking: the impact of nicotine gum and chart reminders. Am J Public Health 1987;77:313-316.
  • Cohen SJ, Stooky GK, Katz BP, Drook CA, Smith DM. Encouraging primary care physicians to help smokers quit. A randomised, controlled trial. Ann Intern Med 1989;110:648-52.
Cornuz 2002 {published data only}
  • Cornuz J, Humair JP, Seematter L, Stalder H, Pecoud A. A randomized controlled trial of resident training in smoking cessation using standardized patients. 11th World Conference on Tobacco or Health 6-11 August Chicago Abstract book. Chicago, Illinois, USA, 2000.
  • Cornuz J, Humair JP, Seematter L, Stoianov R, Melle GV, Stalder H, Pecoud A. Efficacy of resident training in smoking cessation: a randomized, controlled trial of a program based on application of behavioral theory and practice with standardized patients. Annals of Internal Medicine 2002;136:429-37.
  • Cornuz J, Humair JP, Seematter L, Stoianov R, van Melle G, Stalder H, Pecoud A. Summaries for Patients: Effect of a training program for resident physicians in improving success rate in helping patients quit smoking. Annals of Internal Medicine 2002;136(6):I-31.
  • Cornuz J, Zellweger JP, Mounoud C, Decrey H, Pecoud A, Burnand B. Smoking cessation counseling by residents in an outpatient clinic. Preventive Medicine 1997;26:292-6.
  • Humair J, Sadowski J, Zellweger J, Kuenzi B, Burkhalter A, Cornuz J. Dissemination of an effective smoking cessation training program for Swiss primary care physicians. Journal of General Internal Medicine 2005;20(Supplement 1):31.
  • Humair JP, Cornuz J. A new curriculum using active learning methods and standardized patients to train residents in smoking cessation. Journal of General Internal Medicine 2003;18:1023-7.
  • Pinget C, Martin E, Wasserfallen JB, Humair JP, Cornuz J. Cost-effectiveness analysis of a European primary-care physician training in smoking cessation counseling. European Journal of Cardiovascular Prevention and Rehabilitation 2007;14:451-5.
Cummings (Priv) 1989 {published data only}
  • Cummings SR, Richard RJ, Duncan CL, Hansen B, Vander Martin R, Gerber B, et al. Training physicians about smoking cessation: a controlled trial in private practice. Journal of General Internal Medicine 1989;4:482-9.
Cummings 1989 {published data only}
  • Cummings SR, Coates TJ, Richard RJ, Hansen B, Zahnd EG, Vander Martin R, et al. Training physicians in counseling about smoking cessation. A randomized trial of the "Quit for Life" program. Annals of Internal Medicine 1989;110:640-7.
Gordon 2010 {published and unpublished data}
  • Gordon JS, Albert DA, Andrews JA, Crews KM, Payne TJ, Severson HH. Tobacco cessation in public dental clinics: short-term outcomes. Society for Research on Nicotine and Tobacco 14th annual Meeting. Portland, Oregon, 2008 Feb 26- Mar 1.
  • Gordon JS, Andrews JA, Albert DA, Crews KM, Payne TJ, Severson HH. Tobacco Cessation via Public Dental Clinics: Results of a Randomized Trial. American Journal of Public Health 2010;100(7):1307-12.
Hymowitz 2007 {published data only}
  • Hymowitz N, Schwab J, Haddock CK, Burd KM, Pyle S. The Pediatric Residency Training on Tobacco Project: baseline findings from the resident tobacco survey and observed structured clinical examinations. Preventive Medicine 2004;39:507-16.
  • Hymowitz N, Schwab J, Haddock CK, Pyle S, Meshberg S. The Pediatric Resident Training on Tobacco Project: Interim Findings. Journal of the National Medical Association Feb 2006;92(8):190-203.
  • Hymowitz N, Schwab J, Haddock CK, Pyle S, Meshberg S. The pediatric residency training on tobacco project: baseline findings from the patient tobacco survey. Preventive Medicine 2005;41:159-66.
  • Hymowitz N, Schwab J, Haddock CK, Pyle S, Moore G, Meshberg S. The pediatric resident training on tobacco project: baseline findings from the Parent/Guardian Tobacco Survey. Preventive Medicine 2005;41:334-41.
  • Hymowitz N, Schwab JV, Haddock CK, Pyle SA, Schwab LM. The pediatric residency training on tobacco project: four-year resident outcome findings. Preventive Medicine 2007;45(6):481-90.
Joseph 2004 {published data only}
  • Joseph AM, Arikian NJ, An LC, Nugent SM, Sloan RJ, Pieper CF and the GIFT Research Group. Results of a Randomized Controlled Trial of Intervention to Implement Smoking Guidelines in Veterans Affairs Medical Centers. Medical Care 2004;42(11):1100-10.
Kottke 1989 {published data only}
  • Kottke TE, Brekke ML, Solberg LI, Hughes JR. A randomised controlled trial to increase smoking intervention by physicians. Doctors helping smokers, round 1. JAMA 1989;261:2101-6.
Lennox 1998 {published data only}
  • Lennox AS, Bain N, Taylor RJ, McKie L, Donnan PT, Groves J. Stages of Change training for opportunistic smoking intervention by the primary health care team. Part I: randomised controlled trial of the effect of training on patient smoking outcomes and health professional behaviour as recalled by patients. Health Educ J 1998;57:140-149.
Sinclair 1998 {published data only}
  • Sinclair HK, Bond CM, Lennox AS. The long-term learning effect of training in stage of change for smoking cessation: a three year follow up of community pharmacy staff's knowledge and attitudes. International Journal of Pharmacy Practice 1999;7:1-11.
  • Sinclair HK, Bond CM, Lennox AS, Silcock J, Winfield AJ, Donnan PT. Training pharmacists and pharmacy assistants in the stage-of-change model of smoking cessation: a randomised controlled trial in Scotland. Tob Control 1998;7:253-261.
Strecher 1991 {published data only}
  • Campbell EE, Lyles MF, Strecher VJ, Gonzalez JJ. Teaching smoking cessation counseling skills to resident physicians. Clin Res 1989;37:805A.
  • Campbell EE, Villagra VG, Rgers CS and Other Members of the North Carolina Primary Care Research Consortium. Teaching and promoting smoking cessation counseling in primary care residencies: description of a method. Teaching and Learning in Medicine 1991;3(1):20-7.
  • Strecher VJ, O'Malley MS, Villagra VG. Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial. J Gen Intern Med 1991;6:9-17.
Swartz 2002 {published and unpublished data}
  • Swartz S, Cowan T. A Randomized Trial of Academic Profiling increases provider tobacco intervention. Society for Research on Nicotine and Tobacco 12th Annual Meeting February 15-18, Orlando, Florida. Orlando, Florida, 2006.
  • Swartz S, Cowan T, Thompson D, Leighton A, Goldstein M, DePue J, Salem-Schatz S. A Randomized Trial of Academic Profiling to Increase Tobacco Interventions in Primary Care. Supplied by author.
  • Swartz S, Cowan T, Thompson D, Leighton A, Goldstein M, DePue J, Salem-Schatz S. Academic Detailing and Data Feedback to Increase Tobacco Treatment. Supplied by author.
  • Swartz SH, Cowan TM, DePue J, Goldstein G. Academic profiling of tobacco-related performance measures in primary care. Nicotine & Tobacco Research 2002;4(S1):S39-45. [DOI: 10.1080/14622200210128018]
Twardella 2007 {published data only}
  • Breitling LP, Twardella D, Raum E, Brenner H. Situational Temptation Scores and Smoking Cessation in General Care. Psychology of Addictive Behaviors 2009;23(2):362-7. [DOI: 10.1037/a0015715]
  • Salize HJ, Merkel S, Reinhard I, Twardella D, Mann K, Brenner J. Cost-effective primary care-based strategies to improve smoking cessation: more value for money. Archives of Internal Medicine 2009;169(3):230-5.
  • Twardella D, Brenner H. Effects of practitioner education, practitioner payment and reimbursement of patients' drug costs on smoking cessation in primary care: a cluster randomised trial. Tobacco Control 2007;16:15-21.
Unrod 2007 {published data only}
  • Unrod M, Smith M, Spring B, DePue J, Redd W, Winkel G. Randomized Controlled Trial of a Computer-Based, Tailored Intervention to Increase Smoking Cessation Counseling by Primary Care Physicians. Journal of General Internal Medicine 2007;22:478-84.
Wang 1994 {published data only}
  • Wang WD. Feasibility and effectiveness of a stages-of-change model in cigarette smoking cessation counseling. J Formos Med Assoc 1994;93:752-757.
Wilson 1988 {published data only}
  • Lindsay EA, Wilson DM, Best JA, Willms DG, Singer J, Gilbert JR, Taylor DW. A randomized trial of physician training for smoking cessation. Am J Health Promot 1989;3:11-8.
  • Wilson DM, Taylor DW, Gilbert JR, Best JA, Lindsay EA, Willms DG, Singer J. A randomized trial of a family physician intervention for smoking cessation. JAMA 1988;260:1570-4.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Albert 2006 {published data only}
  • Albert DA. Tobacco and the Dental Office: Encouraging Patients to Quit. http://ncth.confex.com/ncth/viewHandout.epl?uploadid=679 [accessed 17/03/2011].
  • Albert DA, Gordon J, Andrews J, Severson H, Ward A, Sadowsky D. Use of electronic continuing education in dental offices for tobacco cessation. Society for Research on Nicotine and Tobacco 12th Annual Meeting February 15-18, Orlando, Florida. 2006.
Allen 1998 {published data only}
  • Allen B, Pederson LL, Leonard EH. Effectiveness of physicians-in-training counseling for smoking cessation in African Americans. Journal of the National Medical Association 1998;90:597-604.
Andrews 1999 {published data only}
  • Andrews JA, Severson HH, Lichtenstein E, Gordon JS, Barckley MF. Evaluation of a dental office tobacco cessation program: effects of smokeless tobacco use. Annals of Behavioral Medicine 1999;21(1):48-53.
Andrews 2001 {published data only}
Ballbe 2008 {published data only}
  • Ballbe M, Mondon S, Nieva G, Walther M, Salto E, Gual A. Evaluation of a training programme for health professionals on smoking cessation in hospitalized patients [Evaluacion de un programa de formacion de profesionales sanitarios sobre abordaje del tabaquismo en pacientes hospitalizados]. Adicciones 2008;20:125-30.
Bernstein 2009 {published data only}
  • Bernstein SL, Boudreaux ED, Cabral L, Cydulka RK, Schwegman D, Larkin GL, et al. Efficacy of a brief intervention to improve emergency physicians' smoking cessation counseling skills, knowledge, and attitudes. Substance Abuse 2009;30:158-81.
Bobo 1997 {published data only}
Campbell 1997 {published data only}
  • Campbell HS, Petty TL, Meadows LM, Simpson L, Jannett PA. Improving tobacco cessation services in rural dental offices - recruitment to a randomized controlled trial. Canadian Journal of Community Dentistry 1997;12(2):15-22.
Caplan 2011 {published data only}
  • Caplan L, Stout C, Blumenthal DS. Training physicians to do office-based smoking cessation increases adherence to PHS guidelines. Journal of Community Health 2011;36(2):238-43.
Carney 1995 {published data only}
  • Carney PA, Dietrich AJ, Freeman DH Jr, Mott LA. A standardized-patient assessment of a continuing medical education program to improve physicians' cancer-control clinical skills. Academic Medicine 1995;70(1):52-8.
Cockburn 1992 {published data only}
  • Cockburn J, Ruth D, Silagy C, Dobbin M, Reid Y, Scollo M, et al. Randomised trial of three approaches for marketing smoking cessation programmes to Australian general practitioners. BMJ 1992;304:691-4.
Depue 2002 {published data only}
  • Depue JD, Goldstein MG, Schilling A, Reiss P, Papandonatos G, Sciamanna C, et al. Dissemination of the AHCPR clinical practice guideline in community health centres. Tobacco Control 2002;11:329-35.
Dietrich 1992 {published data only}
  • Dietrich AJ, O'Connor GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention. A community practice randomised trial. British Medical Journal 1992;304(6828):687-91.
Dunkley 1997 {published data only}
  • Dunkley J. Training midwives to help pregnant women stop smoking. Nursing Times Jan 1997;93(5):1-3.
Etter 2000 {published data only}
Etter 2006 {published data only}
  • Etter JF. Impact of educational outreach visits on smoking cessation activities performed by specialist physicians: A randomized trial. Education for Heatlh 2006;19(2):155-65.
Giuntini 2001 {published data only}
  • Giuntini C, Barrueco M, Astbury C, Hider AE, Hogue SL. Involvement of healthcare professionals in a smoking cessation programme positively benefit attitudes towards smoking. Society for Research on Nicotine and Tobacco 3rd Europe Conference, Paris, 19-22 September. 2001.
Goldberg 1994 {published data only}
  • Goldberg DN, Hoffman AM, Farinha MF, Marder DC, Tinson-Mitchem L, Burton D, Smith EG. Physician delivery of smoking-cessation advice based on the stages-of-change model. American Journal of Preventive Medicine 1994;10:267-74.
Gordon 2005a {published data only}
  • Gordon JS, Andrews JA, Lichtenstein E, Severson HH. The impact of a brief tobacco-use cessation intervention in public health dental clinics. Journal of the American Dental Association 2005;136:179-86.
Gordon 2005b {published data only}
  • Gordon JS, Andrews JA, Lichtenstein E, Severson HH, Akers L. Disseminating a smokeless tobacco cessation intervention model to dental hygienists: A randomized comparison of personalized instruction and self-study methods. Health Psychology 2005;24:447-55.
Graham 2011 {published data only}
  • Graham GF. Nursing student training, perception, and behavior in tobacco cessation counseling: A randomized experimental study. Dissertation Abstracts International: Section B: The Sciences and Engineering 2011;71(7-B):4171.
Guo 2010 {published data only}
  • Guo FR, Hung LY, Chang CJ, Leung KK, Chen CY. The evaluation of a Taiwanese training program in smoking cessation and the trainees' adherence to a practice guideline. BMC Public Health 2010;10:77.
Haresaku 2010 {published data only}
  • Haresaku S, Hanioka T, Yamamoto M, Ojima M. Impact of a tobacco curriculum on smoking behavior and attitudes toward smoking in dental students in Japan: a three-year follow-up study. International Dental Journal 2010;60(2):99-105.
Keller 2000 {published data only}
  • Keller S, Donnerbanzhoff N, Kaluza G, Baum E, Basler HD. Improving physician-delivered counseling in a primary care setting: Lessons from a failed attempt. Education for Health 2000;13(3):387-97.
Kerr 2011 {published data only}
Leong 2008 {published data only}
  • Leong SL, Lewis PR, Curry WJ, Gingrich DL. Tobacco world: evaluation of a tobacco cessation training program for third-year medical students. Academic Medicine Oct 2008;83(10 Suppl):S25-8.
Lindsay 1997 {published data only}
  • Lindsay EA, Hymowitz N, Giffen C, Purcell T, Pomrehan P, Pechacek T. Tobacco control activities of primary-care physicians in the Community Intervention Trial for Smoking Cessation. COMMIT Research Group. Tobacco Control 1997;6(Suppl 2):S49-56.
Little 2009 {published data only}
Manfredi 2011 {published data only}
  • Manfredi C, Cho YI, Warnecke R, Saunders S, Sullivan M. Dissemination strategies to improve implementation of the PHS smoking cessation guideline in MCH public health clinics: experimental evaluation results and contextual factors. Health Education Research 2011;26(2):349-60.
Martin 2010 {published data only}
  • Martin BA, Bruskiewitz RH, Chewning BA. Effect of a tobacco cessation continuing professional education program on pharmacists' confidence, skills, and practice-change behaviors. Journal of the American Pharmacists Association Jan 2010;50(1):9-16.
Matten 2011 {published data only}
McEwen 2002 {published data only}
McEwen 2006 {published data only}
McIntosh 2004 {published data only}
  • McIntosh S, Ossip-Klein DJ, Hazel-Fernandez L, Spada J, McDonald PW, Klein JD. Recruitment of physician offices for an office-based adolescent smoking cessation study. Nicotine & Tobacco Research 2005;7(3):405-12.
McRobbie 2008 {published data only}
  • McRobbie H, Hajek P, Feder G, Eldridge S. A cluster-randomised controlled trial of a brief training session to facilitate general practitioner referral to smoking cessation treatment. Tobacco Control 2008;17:173-6.
Meyer 2008 {published data only}
Moore 2005 {published data only}
  • Moore E, Keerbs A. The impact of training medical assistants to provide smoking cessation counseling to an underserved patient population. Journal of Investigative Medicine 2005;53:S81.
Morgan 1996 {published data only}
Moss 2009 {published data only}
  • Moss DR, Cluss PA, Watt-Morse M, Pike F. Targeting pregnant and parental smokers: Long-term outcomes of a practice-based intervention. Nicotine & Tobacco Research 2009;11(3):278-85.
Ockene 1991 {published data only}
  • Ockene JK, Adams A, Pbert L, Luippold R, Hebert JR, Quirk M, Kalan K. The Physician-Delivered Smoking Intervention Project: factors that determine how much the physician intervenes with smokers. J Gen Intern Med 1994;9:379-84.
  • Ockene JK, Kristeller J, Goldberg R, Amick TL, Pekow PS, Hosmer D, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6:1-8.
Patwardhan 2010 {published data only}
  • Patwardhan P, Chewing B. Randomized controlled trial evaluating the effect of a multimodal training intervention on brief tobacco cessation counseling in community chain pharmacies. Journal of the American Pharmacists Association 2010;50(2):260.
Pereira 2006 {published data only}
  • Pereira BC, Stoebner-Dalbarre A, Gourgou S, Sancho-Garnier H, Rijnoveanu A, Slama K, et al. A cluster randomised controlled trial of a continuing education programme - Smoking cessation intervention. European Journal of Epidemiology 2006;21:99.
Prokhorov 2010 {published data only}
  • Prokhorov AV, Hudmon KS, Marani S, Foxhall L, Ford KH, Luca NS, et al. Engaging physicians and pharmacists in providing smoking cessation counseling. Archives of Internal Medicine 2010;170(18):1640-6.
Pronk 2006 {published data only}
  • Pronk NP, Havlicek D, Stafne E. Tobacco cessation interventions in dental networks: a practice-based evaluation of the impact of education on provider knowledge, referrals, and pharmacotherapy use. Preventing Chronic Disease 2006;3(3):A96. [PUBMED: PMC1637804]
Rankin 2010 {published data only}
Richmond 1998 {published data only}
  • Richmond R, Mendelsohn C, Kehoe L. Family physicians' utilization of a brief smoking cessation program following reinforcement contact after training: A randomized trial. Prev Med 1998;27:77-83.
Roche 1996 {published data only}
  • Roche AM, Eccleston P, Sanson Fisher RW. Teaching smoking cessation skills to senior medical students - a block-randomized controlled trial of 4 different approaches. Prev Med 1996;25:251-8.
Royce 1995 {published data only}
Russos 1999 {published data only}
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Schmelz 2010 {published data only}
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Schnoll 2003 {published data only}
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Secker Walker 1992 {published data only}
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Sheffer 2009 {published data only}
Sheffer 2011 {published data only}
Sohn 2010 {published data only}
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Steinemann 2005 {published data only}
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Stolz 2012 {published data only}
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Targhetta 2011 {published data only}
Von Garnier 2010 {published data only}
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Additional references

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Albert 2004
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Cummings 1989b
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References to other published versions of this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Lancaster 2000
  • Lancaster T, Fowler G. Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews 2000, Issue 3. [DOI: 10.1002/14651858.CD000214]
Lancaster 2008
  • Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 3. [DOI: 10.1002/14651858.CD000214]
Silagy 1994
  • Silagy C, Lancaster T, Gray S, Fowler G. Effectiveness of training health professionals to provide smoking cessation interventions: systematic review of randomised controlled trials. Quality in Health Care 1994;3:193-198.