Nursing interventions for smoking cessation

  • Review
  • Intervention

Authors


Abstract

Background

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

Objectives

To determine the effectiveness of nursing-delivered smoking cessation interventions.

Search methods

We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.

Selection criteria

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

Data collection and analysis

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

Main results

Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

Authors' conclusions

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

Plain language summary

Does support and intervention from nurses help people to stop smoking?

Background

Most smokers want to quit, and may be helped by advice and support from healthcare professionals. Nurses are the largest healthcare workforce, and are involved in virtually all levels of health care. The main aim of this review was to determine if nursing-delivered interventions can help adult smokers to stop smoking.

Study characteristics

This review of clinical trials covered 49 studies in which nurses delivered a stop smoking intervention to smokers. More than 17,000 participants were included in the main analysis, including hospitalized adults and adults in the general community. The most recent search was conducted in June 2013. All studies reported whether or not participants had quit smoking at six months or longer.

Results and quality of evidence

This review found moderate quality evidence that advice and support from nurses could increase people's success in quitting smoking, especially in a hospital setting. There was moderate evidence which found similar advice and encouragement given by nurses at health checks or prevention activities seems to be less effective, but may still have some impact. Results were not consistent across all studies and in some cases there were not very many studies contributing to comparisons.

Laički sažetak

Da li podrška i postupci koje primjenjuju medicinske sestre pomažu ljudima prestati pušiti?

Dosadašnja saznanja

Većina pušača želi prestati pušiti, i zdravstveni radnici im mogu pomoći savjetom i podrškom . Medicinske sestre su najbrojniji zdravstveni radnici, i uključene su u gotovo sve razine zdravstvene zaštite. Glavni cilj ovog Cochrane sustavnog pregleda bio je utvrditi da li intervencije koje primjenjuju medicinske sestre mogu pomoći odraslome pušaču u prestanku pušenja.

Obilježja istraživanja

Ovaj Cochrane sustavni pregled kliničkih istraživanja obuhvatio je 49 studija u kojima medicinske sestre daju intervencije pušačima za prestanak pušenja. Više od 17 000 ispitanika bilo je uključeno u glavnu analizu, uključujući hospitalizirane odrasle osobe te odrasle u zajednici. Zadnje pretraživanje literature provedeno je u lipnju 2013. Sva istraživanja su opisala jesu li ili nisu ispitanici prestali pušiti u roku šest mjeseci ili duže.

Rezultati i kvaliteta dokaza

Ovaj sustavni pregled je pronašao dokaze umjerene kvalitete da savjet i podrška medicinske sestre može povećati uspjeh osoba u prestanku pušenja, pogotovo u bolnici. Bilo je umjerenih dokaza koji su pokazali da su slični savjeti i ohrabrenja koje daju medicinske sestre pri zdravstvenim pregledima ili pri aktivnostima prevencije manje učinkoviti, ali mogu imati neki utjecaj. Rezultati nisu bili dosljedni u svim istraživanjima i u nekim slučajevima nije bilo mnogo istraživanja koji pridonose zbirnoj analizi podataka.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Božena Armanda
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Streszczenie prostym językiem

Czy wsparcie oraz interwencje udzielane przez pielęgniarki mogą pomóc w rzucaniu palenia?

Wprowadzenie

Większość palaczy chce zerwać z nałogiem; pomocą dla nich mogą być porady i wsparcie udzielane przez pracowników opieki zdrowotnej. Pielęgniarki stanowią największą część personelu opieki zdrowotnej i pracują praktycznie na wszystkich jej poziomach. Głównym celem tego przeglądu było określenie czy interwencje prowadzone przez pielęgniarki mogą pomóc dorosłym palaczom w rzuceniu palenia.

Zakwalifikowane badania

Niniejszy przegląd objął 49 badań klinicznych, w których pielęgniarki prowadziły interwencje antytytoniowe. Główną analizą objęto ponad 17 tys. dorosłych uczestników badań - hospitalizowanych oraz z populacji ogólnej. Ostatnie przeszukanie baz danych wykonano w czerwcu 2013 r. We wszystkich badaniach analizowano zaprzestanie palenia po upływie co najmniej sześciu miesięcy.

Wyniki i jakość danych

Niniejszy przegląd dostarczył umiarkowanej jakości danych świadczących, że porady i wsparcie udzielane przez pielęgniarki mogą zwiększyć szanse na rzucenie palenia, zwłaszcza w warunkach szpitalnych. Również umiarkowanej jakości dane wskazują, że podobne rady i zachęty ze strony pielęgniarek udzielane w trakcie rutynowych badań kontrolnych lub działań profilaktycznych są prawdopodobnie mniej skuteczne, ale jednak mogą mieć jakiś wpływ. Wyniki nie były jednorodne we wszystkich badaniach, a niektóre porównania były analizowane w nielicznych badaniach.

Uwagi do tłumaczenia

Tłumaczenie: Bartlomiej Matulewicz, Redakcja: Łukasz Strzeszyński

Laienverständliche Zusammenfassung

Kann eine pflegerische Unterstützung und Intervention Menschen dabei helfen, mit dem Rauchen aufzuhören?

Hintergrund

Die meisten Raucher wollen aufhören zu rauchen und können dabei durch Beratung und Unterstützung von medizinischem Fachpersonal Hilfe erhalten. Pflegende sind die größte Berufsgruppe im Gesundheitswesen und nahezu auf allen Ebenen der Gesundheitsversorgung beteiligt. Das Hauptziel dieses Reviews war es zu untersuchen, ob Interventionen von Pflegenden erwachsenen Rauchern dabei helfen können, mit dem Rauchen aufzuhören.

Studienmerkmale

Dieser Review klinischer Studien beinhaltet 49 Studien, in denen Pflegende für Raucher eine Intervention zur Raucherentwöhnung angeboten haben. Mehr als 17.000 erwachsene Teilnehmer aus stationären Einrichtungen oder dem gemeindenahen Umfeld wurden in die Hauptanalyse eingeschlossen. Die letzte Literaturrecherche wurde im Juni 2013 durchgeführt. Alle Studien berichteten, ob die Teilnehmer nach sechs Monaten oder später mit dem Rauchen aufgehört hatten.

Ergebnisse und Qualität der Evidenz

Dieser Review hat Evidenz moderater Qualität dafür gefunden, dass Beratung und Unterstützung durch Pflegende eine erfolgreiche Raucherentwöhnung, insbesondere im Krankenhaus, begünstigen könnte. Es gab Evidenz moderater Qualität dafür, dass vergleichbare Beratung und Motivation durch Pflegende bei Gesundheitsuntersuchungen oder Vorsorgemaßnahmen anscheinend weniger wirksam sind, aber dennoch einen gewissen Einfluss haben. Die Ergebnisse waren über die Studien hinweg nicht einheitlich und einigen Vergleichen lag nur eine geringe Anzahl von Studien zugrunde.

Anmerkungen zur Übersetzung

C. Richter, J. Abraham, freigegeben durch Cochrane Deutschland.

Резюме на простом языке

Помогает ли поддержка и помощь, получаемая от медсестёр, бросить курить?

Актуальность

Большинство курильщиков хотят бросить курить, им могут помочь в этом советы и поддержка работников здравоохранения. Медицинские сёстры составляют большинство медицинских работников, они востребованы практически на всех уровнях обеспечения охраны здоровья. Главной целью этого обзора было определить, могут ли вмешательства, проводимые медсёстрами, помочь курильщикам бросить курить.

Характеристика исследований

Этот обзор клинических испытаний включил 49 исследований, в которых медсёстры проводили мероприятия / вмешательства с курильщиками по отказу от курения. В основной анализ были включены более 17000 участников: как госпитализированных взрослых лиц, так и не госпитализированных участников. Наиболее недавнее исследование было проведено в июне 2013 года. Во всех исследованиях сообщалось, отказались ли участники от курения или нет в течение шести месяцев или дольше.

Результаты и качество доказательств

В этом обзоре были найдены доказательства среднего качества, что советы и поддержка медсестёр могут увеличивать успех в отказе от курения, особенно в госпитальных условиях. Были найдены доказательства среднего качества, что подобные советы и воодушевление, предоставляемые медсёстрами во время обычных проверок состояния здоровья или во время профилактических мероприятий, оказываются менее эффективными, но, они, тем не менее, могут оказывать некоторое воздействие. Результаты не были согласующимися (последовательными) от исследования к исследованию, и было не очень много исследований, которые внесли вклад в сравнения.

Заметки по переводу

Перевод: Нижник Яков Петрович. Редактирование: Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Cochrane Russia - Кокрейн Россия (филиал Северного Кокрейновского Центра на базе Казанского федерального университета). По вопросам, связанным с этим переводом, пожалуйста, обращайтесь к нам по адресу: cochrane.russia.kpfu@gmail.com; cochranerussia@kpfu.ru

Summary of findings(Explanation)

Summary of findings for the main comparison. Nursing interventions for smoking cessation
  1. 1 Control group quit rate based on average across all included studies
    2 Sensitivity analyses excluding studies at high or unclear risk of bias did not significantly alter the effect size
    3 Unexplained statistical heterogeneity present
    4 Total number of events < 300, confidence intervals include a significant effect and no effect

Nursing interventions for smoking cessation
Patient or population: adult smokers
Settings: any
Intervention: cessation interventions delivered by nurses
OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed riskCorresponding risk
Control Nursing interventions
Smoking cessation at longest follow up (high and low intensity)
Follow-up: 6+ months
115 per 1000 1 144 per 1000
(134 to 156)
RR 1.26
(1.17 to 1.36)
17629
(35 studies)
⊕⊕⊕⊝
moderate 2,3
Pooled results from the below two subgroups
Smoking cessation at longest follow-up - High intensity intervention
Follow-up: 6+ months
137 per 1000 1 172 per 1000
(160 to 186)
RR 1.26
(1.17 to 1.36)
13613
(28 studies)
⊕⊕⊕⊝
moderate 2,3
High intensity = initial contact > 10 minutes, additional materials (e.g. manuals) and/or strategies other than simple leaflets, additional follow-up visits
Smoking cessation at longest follow-up - Low intensity intervention
Follow-up: 6+ months
51 per 1000 1 64 per 1000
(50 to 82)
RR 1.27
(0.99 to 1.62)
4016
(7 studies)
⊕⊕⊕⊝
moderate 2,4
Low intensity = advice provided (with or without a leaflet) during single consultation lasting 10 minutes or less with up to one follow-up visit
*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; RR: Risk 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.

Background

Tobacco-related deaths and disabilities are on the increase worldwide because of continued use of tobacco (mainly cigarettes). Tobacco use has reached epidemic proportions in many developing countries, while steady use continues in industrialized nations like the United States (The Tobacco Atlas 2012; CDC 2012). The following two factors may help to reduce the prevalence of cigarette smoking. According to the Centers for Disease Control, 68.8% of adult smokers in the USA want to quit and millions have attempted to quit (CDC 2011), with 70% of smokers visiting a healthcare professional each year (AHRQ 2008). Nurses, representing the largest number of healthcare providers worldwide, are involved in the majority of these visits and therefore, have the potential for a profound effect on the reduction of tobacco use (Youdan 2005).

Systematic reviews (e.g. Stead 2013) have confirmed the effectiveness of advice from physicians to stop smoking. The Agency for Health Care Research and Quality Clinical Practice Guideline (AHRQ 2008) lists nurses as one of the many providers from whom advice to stop smoking could increase quit rates, but identifies the effectiveness of advice to quit smoking given by clinicians other than physicians (including nurses) as an area requiring further research. The American Nurses Association (ANA 2012) wrote that nurses have tremendous potential to implement smoking cessation interventions effectively and advance tobacco use reduction goals proposed by Healthy People 2010, and noted that nurses must be equipped to assist with smoking cessation, prevent tobacco use, and promote strategies to decrease exposure to second-hand smoke. The American Nurses Association/American Nurses Foundation promotes the mission of Tobacco-Free Nurses to the nation’s registered nurses through its constituent associations, members, and organizational affiliates (ANA 2012).

A review of nursing's specific role in smoking cessation is essential if the profession is to endorse the International Council of Nurses (ICN) call to encourage nurses to "...integrate tobacco use prevention and cessation ... as part of their regular nursing practice" (ICN 2012).

The aim of this review is to examine and summarize randomized clinical trials where nurses provided smoking cessation interventions. The review therefore focuses on the nurse as the intervention provider, rather than on a particular type of intervention. Smoking cessation interventions targeting pregnant women are not included here, because of the particular circumstances and motivations among this population. Interventions for pregnant smokers have been reviewed elsewhere (Lumley 2009; Coleman 2012).

Objectives

The primary objective of this review was to determine the effectiveness of nursing-delivered interventions on smoking behaviour in adults. A priori study hypotheses were that nursing-delivered smoking cessation interventions:
(i) are more effective than no intervention;
(ii) are more effective if the intervention is more intensive;
(iii) differ in effectiveness with health state and setting of the participants;
(iv) are more effective if they include follow-ups;
(v) are more effective if they include aids that demonstrate the pathophysiological effect of smoking.

Methods

Criteria for considering studies for this review

Types of studies

Inclusion criteria for studies were:
(i) they had to have at least two treatment groups;
(ii) allocation to treatment groups must have been stated to be 'random'.
Studies that used historical controls were excluded.

Types of participants

Participants were adult smokers, 18 years and older, of either gender and recruited in any type of healthcare or other setting. The only exceptions were studies that had exclusively recruited pregnant women. Trials in which 'recent quitters' were classified as smokers were included, but sensitivity analyses were performed to determine whether they differed from trials that excluded such individuals.

Types of interventions

Nursing intervention was defined as the provision of advice, counselling, and/or strategies to help people quit smoking. The review includes cessation studies that compared usual care with an intervention, brief advice with a more intensive smoking cessation intervention or different types of interventions. Studies of smoking cessation interventions as a part of multifactorial lifestyle counselling or rehabilitation were included only if it was possible to discern the specific nature and timing of the intervention, and to extract data on the outcomes for those who were smokers at baseline. Advice was defined as verbal instructions from the nurse to 'stop smoking' whether or not information was provided about the harmful effects of smoking. Interventions were grouped into low and high intensity for comparison. Low intensity was defined as trials where advice was provided (with or without a leaflet) during a single consultation lasting 10 minutes or less with up to one follow-up visit. High intensity was defined as trials where the initial contact lasted more than 10 minutes, there were additional materials (e.g. manuals) and/or strategies other than simple leaflets, and usually participants had more than one follow-up contact. Studies where participants were randomized to receive advice versus advice plus some form of nicotine replacement therapy (NRT) were excluded, since these were primarily comparisons of the effectiveness of NRT rather than nursing interventions. These are covered in a separate review (Stead 2012).

Types of outcome measures

The principal outcome was smoking cessation rather than a reduction in withdrawal symptoms or a reduction in the number of cigarettes smoked. Trials had to report follow-up of at least six months for inclusion in the review. We excluded trials which did not include data on smoking cessation rates. We used the strictest available criteria to define abstinence in each study, e.g. sustained cessation rather than point prevalence. Where biochemical validation was used, only participants meeting the biochemical criteria for cessation were regarded as abstainers. Participants lost to follow-up were regarded as continuing smokers (in intention-to-treat analyses).

Search methods for identification of studies

We searched the Tobacco Addiction Review Group Specialized Register for trials (most recent search June 2013). This Register includes trials located from systematic searches of MEDLINE, EMBASE and PsycINFO and handsearching of specialist journals, conference proceedings, and reference lists of previous trials and overviews. At the time of the search the Register included the results of searches of the Cochrane Central Register of Controlled trials (CENTRAL), 2013, Issue 6 ; MEDLINE (via OVID) to update 20130607; EMBASE (via OVID) to week 201324; PsycINFO (via OVID) to update 20130610. See the Tobbaco Addiction Group module in The Cochrane Library for full search strategies and list of other resources searched. We checked all trials with 'nurse*' or 'nursing' or 'health visitor' in the title, abstract, or keywords for relevance. See Appendix 1 for the search strategy. We also searched the Cumulative Index to Nursing and Allied Health Literature (CINAHL) on OVID for 'nursing' and 'smoking cessation' from 1983 to June 2013.

Data collection and analysis

Selection of studies

One review author screened titles and abstracts. Where there was uncertainty, we requested the full text. Two review authors checked the full text of articles flagged for inclusion, with discrepancies resolved via discussion or by referral to a third review author.

Data extraction and management

The authors extracted data from the published reports independently. Disagreements were resolved by referral to a third person. For each trial, the following data were extracted: (i) author(s) and year; (ii) country of origin, study setting, and design; (iii) number and characteristics of participants and definition of 'smoker'; (iv) description of the intervention and designation of its intensity (high or low); and (v) outcomes and biochemical validation.

Assessment of risk of bias in included studies

We used the Cochrane 'Risk of bias' tool to assess bias in four domains:

  • random sequence generation (a potential source of selection bias);

  • allocation concealment (also a potential source of selection bias);

  • incomplete outcome data (attrition bias);

  • other biases.

We did not judge the trials on the basis of blinding, as we tested behavioural interventions where blinding of participants and providers is not possible.

We judged each included study to be at high, unclear, or low risk of bias in each of the above domains according to the guidelines in the Cochrane Handbook.

Measures of treatment effect

We use the risk ratio (RR) for summarizing individual trial outcomes and for the estimate of the pooled effect. Where we judged a group of studies to be sufficiently clinically and statistically homogeneous we used the Mantel-Haenszel fixed-effect method (Greenland 1985) to calculate a weighted average of the risk ratios of the individual trials, with 95% confidence intervals.

Dealing with missing data

In trials where the details of the methodology were unclear or where the results were expressed in a form that did not allow for extraction of key data, we approached the original investigators for additional information. We treated participants lost to follow-up as continuing smokers. We excluded from totals only those participants who died before follow-up or were known to have moved to an untraceable address.

Assessment of heterogeneity

To assess statistical heterogeneity between trials we used the I² statistic (Higgins 2003). This measures the percentage of total variation across studies due to heterogeneity rather than to chance. Values of I² over 75% indicate a considerable level of heterogeneity (Chapter 8, Cochrane Handbook).

Results

Description of studies

Included studies

Forty-nine trials met the inclusion criteria, of which seven were new for this update (Duffy 2006; Aveyard 2007; Jiang 2007; Wood 2008; Meysman 2010; Cossette 2011; Chan 2012). Longer-term follow-up was reported for two trials (Hilberink 2005; Hanssen 2007) and the data they contributed to the meta-analysis were updated. Trials were of nursing interventions for smoking cessation for adults who used tobacco (primarily cigarettes), published between 1987 and 2012. One trial (Sanders 1989a; Sanders 1989b) had two parts with randomization at each stage, so is treated here as two separate studies, making a total of 50 studies in the Characteristics of included studies table. Thirty-five studies contributed to the primary meta-analysis that compared a nursing intervention to a usual care or minimal intervention control. Eleven studies included a comparison between two nursing interventions, involving different components or different numbers of contacts. Six studies did not contribute to a meta-analysis and their results are described separately. Sample sizes of studies contributing to a meta-analysis ranged from 25 to 2700 but were typically between 150 and 500.

Seventeen trials took place in the USA, ten in the UK, four in Canada, and two each in Australia, China, Denmark, Japan, The Netherlands, Norway and Spain. One trial was reported from Belgium, South Korea and Sweden. One multicenter study was conducted in multiple European countries.

Twenty trials intervened with hospitalized participants (Taylor 1990; Rigotti 1994; DeBusk 1994; Allen 1996; Carlsson 1997; Miller 1997; Lewis 1998; Feeney 2001; Bolman 2002; Hajek 2002, Quist-Paulsen 2003; Froelicher 2004; Hasuo 2004; Chouinard 2005; Hennrikus 2005; Nagle 2005; Hanssen 2007; Wood 2008; Meysman 2010; Cossette 2011). One trial (Rice 1994) recruited hospitalized participants, but with follow-up after discharge. Twenty-four studies recruited from primary care or outpatient clinics (Janz 1987; Sanders 1989a/Sanders 1989b; Risser 1990; Vetter 1990; Nebot 1992; Hollis 1993; OXCHECK 1994; Family Heart 1994; Tonnesen 1996; Campbell 1998; Lancaster 1999; Steptoe 1999; Canga 2000; Aveyard 2003; Ratner 2004; Tonnesen 2006; Kim 2005; Hilberink 2005; Duffy 2006; Sanz-Pozo 2006; Aveyard 2007; Jiang 2007; Wood 2008; Chan 2012). In some trials, the recruitment took place during a clinic visit whilst in others the invitation to enrol was made by letter. One study (Terazawa 2001) recruited employees during a workplace health check, two enrolled community-based adults motivated to make a quit attempt (Davies 1992; Alterman 2001), one recruited mothers taking their child to a pediatric clinic (Curry 2003) and one recruited people being visited by a home healthcare nurse (Borrelli 2005).

Fifteen of the studies focused on adults with diagnosed cardiovascular health problems (Taylor 1990; DeBusk 1994; Family Heart 1994; Rice 1994; Rigotti 1994; Allen 1996; Carlsson 1997; Miller 1997; Campbell 1998; Feeney 2001; Bolman 2002; Hajek 2002; Jiang 2007; Cossette 2011; Chan 2012 (subgroup with cardiovascular disease)); two studies were with participants with respiratory diseases (Tonnesen 1996; Tonnesen 2006) and one with participants with diabetes (Canga 2000). One study recruited participants either with diagnosed cardiovascular health problems or judged to be at high risk of developing heart disease (Wood 2008). Two studies recruited surgical patients: Ratner 2004 recruited people attending a surgical pre-admission clinic and Meysman 2010 recruited people admitted to surgical wards. One study recruited head and neck cancer patients at four medical centres (Duffy 2006).

All studies included adults 18 years and older who used some form of tobacco. Allen 1996, Curry 2003 and Froelicher 2004 studied women only, and Terazawa 2001 men only. The definition of tobacco use varied and in some cases included recent quitters.

Seven of the studies examined a smoking cessation intervention as a component of multiple risk factor reduction interventions in adults with cardiovascular disease (DeBusk 1994; Allen 1996; Carlsson 1997; Campbell 1998; Hanssen 2007; Jiang 2007; Wood 2008). In four studies, the smoking cessation component was clearly defined, of high intensity, and independently measurable (DeBusk 1994; Allen 1996; Carlsson 1997; Jiang 2007), whereas in the remaining three the smoking component was less clearly specified (Campbell 1998; Hanssen 2007; Wood 2008).

Thirty-five studies with a total of over 17,000 participants contributed to the main comparison of nursing intervention versus control. We classified 28 as high intensity on the basis of the planned intervention, although in some cases implementation may have been incomplete. In seven, we classified the intervention as low intensity (Janz 1987; Vetter 1990; Davies 1992; Nebot 1992; Tonnesen 1996; Aveyard 2003; Nagle 2005). All of these were conducted in outpatient, primary care or community settings. One further study (Hajek 2002) may be considered as a comparison between a low intensity intervention and usual care. Participants in the usual care control group received systematic brief advice and self-help materials from the same nurses who provided the intervention. Unlike the other trials in the low intensity subgroup, this trial was conducted amongst inpatients with cardiovascular disease. Since the control group received a form of nursing intervention, we primarily classified the trial as a comparison of two intensities of nursing intervention. But since other studies had usual care groups that may have received advice from other healthcare professionals, we also report the sensitivity of the main analysis results to including it there as a low intensity nursing intervention compared to usual care control.

Hajek 2002 and ten other studies contributed to a second group comparing two interventions involving a nursing intervention. Three of these tested additional components as part of a session: demonstration of carbon monoxide (CO) levels to increase motivation to quit (Sanders 1989b); CO and spirometry feedback (Risser 1990); and CO feedback plus additional materials and an offer to find a support buddy (Hajek 2002). Five involved additional counselling sessions from a nurse (Alterman 2001; Feeney 2001; Tonnesen 2006; Aveyard 2007; Jiang 2007). One other study compared two interventions with a usual-care control (Miller 1997). The minimal intervention condition included a counselling session and one telephone call after discharge from hospital. In the intensive condition, participants received three additional telephone calls, and those who relapsed were offered further face-to-face meetings, and nicotine replacement therapy if needed. We classified both interventions as intensive in the main meta-analysis, but compared the intensive and minimal conditions in a separate analysis of the effect of additional follow-up. Chouinard 2005 also assessed the effect of additional telephone support as an adjunct to an inpatient counselling session, so is pooled in a subgroup with Miller 1997. We included in the same subgroup a study that tested additional telephone follow-up as a relapse prevention intervention for people who had inpatient counselling (Hasuo 2004).

Five studies (Family Heart 1994; OXCHECK 1994; Campbell 1998; Steptoe 1999; Wood 2008) were not included in any meta-analysis and do not have results displayed graphically because their designs did not allow appropriate outcome data to be extracted. The first part of a two-stage intervention study is also included here (Sanders 1989a); the second part (Sanders 1989b) is included in one of the meta-analyses. These six studies are discussed separately in the results.

We determined whether the nurses delivering the intervention were providing it alongside clinical duties that were not smoking-related, were working in health promotion roles, or were employed specifically as project nurses. Of the high intensity intervention studies, 12 used nurses for whom the intervention was a core component of their role (Hollis 1993; DeBusk 1994; Allen 1996; Carlsson 1997; Terazawa 2001; Quist-Paulsen 2003; Froelicher 2004; Duffy 2006; Aveyard 2007; Meysman 2010; Cossette 2011; Chan 2012). In nine studies the intervention was delivered by a nurse specifically employed by the project (Taylor 1990; Rice 1994; Rigotti 1994; Miller 1997; Lewis 1998; Canga 2000; Hennrikus 2005; Hanssen 2007; Jiang 2007). In four of these, the same nurse provided all the interventions (Rigotti 1994; Lewis 1998; Canga 2000; Jiang 2007). One study (Kim 2005) employed retired nurses who were trained to provide a brief intervention using the '5 As' framework. In only four studies were intensive interventions intended to be delivered by nurses for whom it was not a core task (Lancaster 1999; Bolman 2002; Curry 2003; Sanz-Pozo 2006). Most of the low intensity interventions were delivered by primary care or outpatient clinic nurses. One low-intensity inpatient intervention was delivered by a clinical nurse specialist (Nagle 2005).

Follow-up periods for reinforcement and outcome measurements varied across studies, with a tendency for limited reinforcement and shorter follow-up periods in the older studies. All trials had some contact with participants in the first three months of follow-up for restatement of the intervention and/or point prevalence data collection. Five of the studies had less than one year final outcome data collection (Janz 1987; Vetter 1990; Davies 1992; Lewis 1998; Canga 2000). The rest had follow-up at one year or beyond. Outcome used for the meta-analysis was the longest follow-up (six months and beyond), with the exception of Hanssen 2007 in which 12-month data were used in preference over 18-month data. The outcome in this study was point prevalence abstinence and the 18-month data were judged to be too conservative due to a rise in abstinent participants in the control group. There was no evidence from a subgroup analysis that the differences in length of follow-up explained any of the heterogeneity in study results.

A brief description of the main components of each intervention is provided in the 'Characteristics of included studies' table.

Excluded studies

Fifty-four studies that we had identified as potentially relevant based on title and abstract were excluded upon screening the full text. These are listed in the Characteristics of excluded studies table along with the reason for exclusion for each. The most common reasons for exclusion were: study design (not a randomized clinical trial); less than six months follow-up; multicomponent studies with insufficient detail on smoking intervention/outcome; and studies in which the impact of the nursing intervention was confounded by additional pharmacological or behavioural treatment that was not provided to the control arm.

Risk of bias in included studies

As seen in Figure 1, the majority of studies were judged to be at low or unclear risk of selection bias (random sequence generation and allocation concealment) and attrition bias (loss to follow-up).

Figure 1.

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

Allocation

Twenty-four studies provided details of a method of random sequence generation judged to be at low risk of bias, and a further 20 studies did not report how the sequence was generated and were hence rated as unclear in this domain. Five studies were judged to be at high risk based on their reported methods of random sequence generation: Bolman 2002 was a cluster-randomized study in which some hospitals picked their allocation; in Curry 2003 participants drew a coloured ball from a bag; Davies 1992 allocated based on order of attendance; Hollis 1993 randomized participants based on health record number; and Sanders 1989a/Sanders 1989b randomized participants based on day of attendance. In addition to these five studies, three further studies in which providers rather than participants were randomized were judged to be at high risk of selection bias: Hilberink 2005 reported that self selection at practice level may have affected the results; in Janz 1987 allocation was determined by clinic session; and in Nebot 1992 the providers were also responsible for allocating participants, rendering allocation concealment impossible. A sensitivity analysis including only the results of studies judged to be at low risk of selection bias did not alter the main conclusions.

Incomplete outcome data

Twenty-seven studies that reported minimal to moderate loss to follow-up and accounted for all participants in their reporting were judged to be at low risk of attrition bias. A further 19 studies did not provide sufficient detail with which to judge likelihood of attrition bias and hence were rated as 'unclear' in this domain. Four studies were judged to be at high risk of attrition bias: in Feeney 2001, 79% of usual-care participants were not followed up; OXCHECK 1994 stated that their methods of accounting for missing participants may have overestimated the effect; in Sanders 1989a/Sanders 1989b only a subsample of participants from the control group was followed up; and in Steptoe 1999 overall drop-out rates were high and varied between intervention and control groups.

Other potential sources of bias

Definitions of abstinence ranged from single point prevalence to sustained abstinence (multiple point prevalence with self report of no slips or relapses). In one study (Miller 1997) we used validated abstinence at one year rather than continuous self-reported abstinence because only the former outcome was reported for disease diagnosis subgroups. Validation of smoking behaviour using biochemical analysis of body fluids (e.g. cotinine or thiocyanate) was reported in 15 (47%) of the 31 studies in the primary meta-analysis. Expired CO was used for validation in another six (24%) of the trials. One study tested CO levels only amongst people followed up in person (Curry 2003). Five others used some validation but did not report rates based on biochemical validation of every self-reported quitter (Nebot 1992; Rice 1994; Miller 1997; Froelicher 2004; Borrelli 2005). Six studies (23%) did not use any biochemical validation and relied on self-reported smoking cessation at a single follow-up (Janz 1987; Allen 1996; Carlsson 1997; Bolman 2002; Hilberink 2005; Hanssen 2007), though two of these warned participants that samples might be requested for testing (i.e. 'bogus pipeline'). Where both self-reported and validated quitting were reported, the level of misreporting or failure to provide a sample is typically similar across intervention and control groups. One study, however, reported differential validation failure rates so that the significant differences based on self report were not found for validated abstinence (Hennrikus 2005); this study was judged to be at high risk of other bias.

Almost all the trials used convenience rather than randomly selected samples. Only one of the studies (Vetter 1990) did not let participants know initially that they were going to be part of a smoking cessation study. In most of the research, the basis for sample size was not specified a priori, nor was a retrospective power analysis conducted. Most studies did not report 'refusal to participate' rates.

Effects of interventions

See: Summary of findings for the main comparison Nursing interventions for smoking cessation

Effects of intervention versus control/usual care

Smokers offered advice by a nursing professional had an increased likelihood of quitting compared to smokers without intervention, with evidence of only moderate statistical heterogeneity between the results of the 35 studies contributing to this comparison (I² = 50%). Heterogeneity was marginally more apparent in the subgroup of 28 high-intensity trials (I² = 54%). There was one trial with a significant negative effect for treatment (Rice 1994) and two with particularly large positive effects (Canga 2000; Terazawa 2001). Pooling all 35 studies using a fixed-effect model gave a risk ratio (RR) of 1.29 with a 95% confidence interval (CI) 1.20 to 1.39 at the longest follow-up (Figure 2, Analysis 1.1). Because of the heterogeneity we tested the sensitivity to pooling the studies using a random-effects model. This did not materially alter the estimated effect size or greatly widen the confidence intervals (RR 1.32, 95% CI 1.17 to 1.49). A sensitivity analysis excluding the three outlying trials widened the CIs but did not alter the point estimate whilst greatly reducing statistical heterogeneity not attributable to chance in the high intensity subgroup (I² = 7%).

Figure 2.

Trials of nursing intervention versus control grouped by intensity of intervention. Outcome: Smoking cessation at longest follow-up.

We also tested the sensitivity of these results to excluding studies that did not validate all reports of abstinence, limiting the analysis to studies judged to be at low risk of selection bias and excluding studies with less than 12 months follow-up. None of these altered the estimates to any great extent, although confidence intervals became wider due to the smaller number of studies. Excluding one study (Bolman 2002) for which we were not able to enter the numbers of quitters directly did not alter the results.

Some participants in Taylor 1990 had been encouraged to use nicotine replacement therapy (NRT). Exclusion of these people did not alter the significant effect of the intervention in this study. In Miller 1997 more people in the intervention conditions than the control used NRT (44% of intensive and 39% of minimal intervention versus 29% of control). People who were prescribed NRT had lower quit rates than those who were not, but the relative differences in quit rates between the usual-care and intervention groups were similar for the subgroups that did and did not use NRT. However, because of the different rates of use of NRT, it is probable that the increased use of NRT contributed to the effects of the nursing intervention. Use of NRT was also encouraged as part of the Canga 2000 intervention, with 17% of the intervention group accepting a prescription, and as part of the Duffy 2006 intervention, although at six months similar percentages in the intervention and control group had used NRT over the course of the study.

Effect of intervention intensity

We detected no evidence from our indirect comparison between subgroups that the trials we classified as using higher intensity interventions had larger treatment effects. In this update of the review the point estimate for the pooled effect of the seven lower-intensity trials is effectively the same as for the 28 of higher intensity, although for the low-intensity group the confidence interval does not exclude 1 (high-intensity subgroup RR 1.26, 95% CI 1.17 to 1.36; low-intensity subgroup RR 1.27, 95% CI 0.99 to 1.62). In a sensitivity analysis we included Hajek 2002, a study for which we were uncertain over the classification of the control group (as noted above in the Description of studies section), in the low-intensity subgroup. Including this study in the low-intensity subgroup further reduces the point estimate and there was no evidence of a treatment effect (RR 1.09, 95% CI 0.92 to 1.29). Compared to the other trials in the low-intensity subgroup, the Hajek trial was conducted amongst hospitalized participants with cardiovascular disease and the overall quit rates were high. The large number of events gave this trial a high weight in the meta-analysis.

The distinction between low- and high-intensity subgroups was based on our categorization of the intended intervention. Low levels of implementation were particularly noted in the trial reports for Lancaster 1999, Bolman 2002 and Curry 2003, so we tested the effect of moving them from the high- to the low-intensity subgroup. This reduced the point estimate of effect in the low-intensity subgroup and increased it in the high-intensity one. If these three studies and Hajek 2002 are included in the low-intensity subgroup, the pooled estimate of effect is small and non-significant (RR 1.09, 95% CI 0.96 to 1.25, Analysis 4.1). We also assessed the sensitivity of the results to using additional participants in the control group for Aveyard 2003 (see Characteristics of included studies for details). This reduced the size of the effect in the low-intensity subgroup but did not alter our conclusions.

Effects of differing health states and client settings

Trials in hospitals recruited participants with health problems, but some trials specifically recruited those with cardiovascular disease, and amongst these, some interventions addressed multiple risks whilst most only addressed smoking. Trials in primary care generally did not select participants with a particular health problem. We combined setting and disease diagnosis in one set of subgroups (Analysis 2.1).
Five trials that included a smoking cessation intervention from a nurse as part of cardiac rehabilitation showed a significant pooled effect on smoking (RR 1.35, 95% CI 1.14 to 1.59). Four of these (Allen 1996; Carlsson 1997; Hanssen 2007; Jiang 2007) did not use biochemical validation of quitting, and in the fifth (DeBusk 1994) we were unable to confirm the proportion of drop-outs with the study authors.
There was moderate heterogeneity (I² = 50%) amongst seven trials in hospitalized smokers with cardiovascular disease, due to the strong intervention effect in one of the seven trials (Taylor 1990). The estimated RR was 1.29 (95% CI 1.14 to 1.45) and the effect remained significant if Taylor 1990 was excluded or if a random-effects model was used. A sensitivity analysis of the effect of including Hajek 2002 in this category increased the heterogeneity (I² = 60%), and the pooled effect was just significant whether a fixed-effect or a random-effects model was used (Analysis 5.1). Excluding Taylor 1990 again removed heterogeneity but the pooled effect was then small and not significant (RR 1.1, 95% CI 0.99 to 1.26, analysis not shown).
Amongst the six trials in non-cardiac hospitalized smokers the risk ratio was small and the confidence interval did not exclude no effect (RR 1.09, 95% CI 0.94 to 1.28). We included in this subgroup one trial that began the intervention in a pre-admission clinic for elective surgery patients (Ratner 2004).
Heterogeneity was high (I² = 94%) between two trials of interventions delivered to non-hospitalized adults with cardiovascular disease,(Rice 1994; Chan 2012;). Subgroup analysis in Rice 1994, however, suggested that smokers who had experienced cardiovascular bypass surgery were more likely to quit, and these participants were over-represented in the control group who received advice to quit but no structured intervention.
Pooling 15 trials of cessation interventions for other non-hospitalized adults showed an increase in the success rates (RR 1.81, 95% CI 1.48 to 2.22). A sensitivity analysis testing the effect of excluding those trials (Janz 1987; Vetter 1990; Curry 2003; Hilberink 2005) where a combination of a nursing intervention and advice from a physician was used did not substantially alter this.

Higher versus lower intensity interventions

Effects of physiological feedback

Two trials (Sanders 1989b; Risser 1990) that evaluated the effect of physiological feedback as an adjunct to a nursing intervention failed to detect an effect at maximum follow-up (Analysis 3.1.1).

Effects of other components at a single contact

One trial in hospitalized smokers with cardiovascular disease (Hajek 2002) failed to detect a significant benefit of additional support from a nurse giving additional written materials, a written quiz, an offer of a support buddy, and carbon monoxide measurement compared to controls receiving brief advice and a self-help booklet (RR 0.91, 95% CI 0.73 to 1.13, Analysis 3.1.2).

Effects of additional telephone support

There was weak evidence from pooling three trials that additional telephone support increased cessation, as the lower limit of the confidence interval was at the boundary of no effect (RR 1.25, 95% CI 1.00 to 1.56; Analysis 3.2.1).

Effects of additional face-to-face sessions

One trial of additional support from an alcohol and drug assessment unit nurse for people admitted to a coronary care unit (Feeney 2001) showed a very significant benefit for the intervention. The cessation rate among the controls, however, was very low (1/97), and there were a large number of drop-outs, particularly from the control group. This could have underestimated the control group quit rate. In another trial (Alterman 2001), offering four nurse sessions rather than one as an adjunct to nicotine patch showed no benefit, with the control group having a significantly higher quit rate (RR 0.43, 95% CI 0.21 to 0.89, Analysis 3.2.3). No explanation was offered for the lower than expected quit rates in the intervention group.

Effects of additional face-to-face sessions and telephone support

Pooled results from three trials did not show an effect of providing additional clinic sessions and telephone support to participants (RR 0.92, 95% CI 0.65 to 1.31, Analysis 3.2.4).

Results of studies not included in the meta-analysis

We identified six studies (Sanders 1989a; Family Heart 1994; OXCHECK 1994; Campbell 1998; Steptoe 1999; Wood 2008) in which nurses intervened with primary care patients. All except Sanders 1989a addressed multiple cardiovascular risk factors, and all except Campbell 1998 and Wood 2008 targeted healthy people. Campbell 1998 recruited participants with coronary heart disease. Wood 2008 recruited general practice patients deemed to be at high risk of cardiovascular disease, and also recruited hospitalized participants with established coronary heart disease. Although they met the main inclusion criteria, in five of the trials the design did not allow for data extraction for meta-analysis in a comparable format to other studies. In the other (Sanders 1989a) only a random sample of the control group was followed up. We therefore discuss these trials separately.

Sanders 1989a, in which smokers visiting their family doctor were asked to make an appointment for cardiovascular health screening, reported that only 25.9% of the patients made and kept such an appointment. The percentage that had quit at one month and at one year and reported last smoking before the one-month follow-up was higher both in the attenders (4.7%) and the non-attenders (3.3%) than in the usual-care controls (0.9%). This suggests that the invitation to make an appointment for health screening could have been an anti-smoking intervention in itself, and that the additional effect of the structured nursing intervention was small.

We do not have comparable data for OXCHECK 1994, which used similar health checks, because the households had been randomized to be offered the health check in different years. The authors compared the proportions of smokers in the intervention group who claimed to have stopped smoking in the previous year to patients attending for their one-year follow-up, and to controls attending for their first health check. They found no difference in the proportions that reported stopping smoking in the previous year.

The Family Heart 1994 study offered nurse-led cardiovascular screening for men aged 40 to 59 and for their partners, with smoking cessation as one of the recommended lifestyle changes. Cigarette smokers were invited to attend up to three further visits. Smoking prevalence was lower amongst those who returned for the one-year follow up than amongst the control group screened at one year. This difference was reduced if non-returners were assumed to have continued to smoke, and if CO-validated quitting was used. In that case there was a reduction of only about one percentage point, with weak evidence of a true reduction.

Campbell 1998 invited people with a diagnosis of coronary heart disease to nurse-run clinics promoting medical and lifestyle aspects of secondary prevention. There was no significant effect on smoking cessation. At one year the decline in smoking prevalence was greater in the control group than in the intervention group. Four-year follow-up did not alter the effect of a lack of benefit.

Steptoe 1999 recruited people at increased risk of coronary heart disease for a multi-component intervention. The quit rate amongst smokers followed up after one year was not significantly higher in the intervention group (9.4%, 95% CI -9.6 to 28.3), and there was greater loss to follow-up of smokers in the intervention group.

Wood 2008 recruited people with established or increased risk of coronary heart disease for a multicomponent lifestyle intervention, coordinated by nurses. The authors report results separately for those participants recruited in hospital and those recruited in general practice. For coronary patients recruited in hospital who had smoked within one month at baseline, abstinence at one year favoured the intervention group (58% versus 47%), but the difference was not significant (P = 0.06). For participants at high risk of coronary heart disease recruited in general practice the prevalence of smoking fell from baseline but did not differ between conditions.

Discussion

Summary of main results

The results of this meta-analysis support a modest but positive effect for smoking cessation intervention by nurses, but with caution about the effects that can be expected if interventions are very brief or cannot be consistently delivered (see Summary of findings for the main comparison). A structured smoking cessation intervention delivered by a nurse was more effective than usual care on smoking abstinence at six months or longer from the start of treatment. The direction of effect was consistent in different intensities of intervention, in different settings, and in smokers with and without tobacco-related illnesses. In a subgroup of low-intensity studies the confidence interval did not exclude no effect, but the point estimate was effectively the same as that in the larger group of high-intensity studies. There was also some evidence of statistical heterogeneity, although this was attributable to a very small number of outlying studies. In the one study (Rice 1994) that showed a statistically significantly higher quit rate in a control group, participants had been advised to quit and the control group included a significantly larger proportion of people who had had coronary artery bypass graft surgery. A multivariate analysis of one-year follow-up data in this study revealed that a quitter was significantly more likely to be less than 48 years, male, to have had individualized versus group or no cessation instruction, and to have had a high degree of perceived threat relative to their health state.

Overall completeness and applicability of evidence

Overall, these meta-analysis findings need to be interpreted carefully in light of the methodological limitations of both the review and the clinical trials. In terms of the review, it is possible that there was a publication selection bias due to using only tabulated data derived from published works (Stewart 1993). Data from the unpublished and/or missed studies could have shown more or less favourable results, though a funnel plot for the main comparison did not suggest the presence of reporting bias. Secondly, the results of a meta-analysis (based on the findings of many small trials) should be viewed with caution even when the combined effect is statistically significant (LeLorier 1997). In this analysis one study (Miller 1997) contributes 21% of the weight to the primary analysis, while the next largest contributes 11% of the weight. Finding statistical heterogeneity between the relative incidence of cessation in different studies limits any assumption that interventions in any clinical setting and with any type of participant are equally effective.

A difference among the studies that may have contributed to the differences in outcome was baseline cigarette use. There was an inverse relationship between number of cigarettes smoked per day and success in quitting; the more addicted the individuals, the more difficult it was for them to quit. Studies that recruited a higher proportion of lighter smokers or that included recent quitters could have achieved better results. Interestingly, the studies in the meta-analysis that reported the highest cigarette use rates had the weakest effect for the intervention (Davies 1992; Rice 1994). Although some trials included recent quitters in their recruitment, there was no evidence that these trials had different results.

The findings of this review, and in particular the estimated size of the treatment effect, have remained remarkably stable since its initial publication. In 1999. fifteen studies contributed to the main analysis, with a pooled risk ratio of 1.30 (95% CI 1.16 to 1.44). Further studies have more than doubled the number of participants and thus narrowed the CIs but have had little impact on the point estimate

Effectiveness by intervention characteristics and population

The effect estimates are similar for high- and low-intensity smoking cessation interventions by nurses, as was found in a review of physicians' advice (Stead 2013). Presumably, the more components added to the intervention the more intensive the intervention; however, assessing the contribution of factors such as total contact time, number of contacts, and content of the intervention was difficult. Our distinction between high and low intensity based on the length of initial contact and number of planned follow-ups may not have accurately distinguished among the key elements that could have contributed to greater efficacy. We found that the nature of the smoking cessation interventions differed from advice alone, to more intensive interventions with multiple components, and that the description of what constituted 'advice only' varied. In most trials, advice was given with an emphasis on 'stopping smoking' because of some existing health problem. To make most interventions more intensive, verbal advice was supplemented with a variety of counselling messages, including benefits and barriers to cessation (e.g. Taylor 1990) and effective coping strategies (e.g. Allen 1996). Manuals and printed self-help materials were also added to many interventions along with repeated follow-up (Hollis 1993; Miller 1997). In some studies, the proposed intervention was not delivered consistently to all participants. In recent updates the evidence for the benefit of a low-intensity intervention has become weaker than that for a more intensive intervention, and the estimated effect is sensitive to the inclusion of one additional study (Hajek 2002) and to the classification of intensity of three studies. Almost all the intensive interventions were delivered by either dedicated project staff or nurses with a health promotion role. Most studies in which the intensive intervention was intended to be delivered by a nurse with other roles reported problems in delivering the intervention consistently. None showed a statistically significant benefit for the intervention. We found no studies of brief opportunistic advice that were directly analogous to the low-intensity interventions used in physician advice trials (Stead 2013).

In two studies in the low-intensity category (Janz 1987; Vetter 1990), advice from a physician was also part of the intervention and this almost certainly contributed to the overall effect. The most highly weighted study in the high-intensity subgroup (Miller 1997) produced only relatively modest results. This was due in part to the effect of the minimal treatment condition that had just one follow-up telephone call. However, using just the high-intensity condition in the analysis did not materially alter the pooled estimate.

One study (Miller 1997) provided data on the effect of the same intervention in smokers with different types of illness and showed a greater effect in cardiovascular patients. In these individuals the intervention increased the 12-month quit rate from 24% to 31%, which just reached statistical significance. In other types of patients, the rates were increased from 18.5% to 21%, an effect that did not reach statistical significance. In this study participants were eligible if they had smoked any tobacco in the month prior to hospitalization, but were excluded if they had no intention of quitting (although they were also excluded if they wanted to quit on their own). These criteria may have contributed to the relatively high quit rates achieved. Also, a higher proportion of participants in the intensive treatment arm than in the minimal or usual care intervention arms were prescribed nicotine replacement therapy (NRT). However, the intervention was also effective in those not prescribed NRT. Those given NRT were heavier smokers (with higher levels of addiction) who achieved lower cessation rates than those who did not use NRT.

This suggests that nursing professionals may have an important 'window of opportunity' to intervene with patients in the hospital setting, or at least to introduce the notion of not resuming tobacco use on hospital discharge. The size of the effect may be dependent on the reason for hospitalization. The additional telephone support, with the possibility of another counselling session for people who relapsed after discharge, seemed to contribute to more favourable outcomes in the intensive intervention used by Miller 1997, although pooled results from three studies testing the addition of telephone counselling and further face-to-face contact did not detect an effect. A separate Cochrane review of the efficacy of interventions for hospitalized patients has been recently updated (Rigotti 2012), and this supports the efficacy of interventions for this patient group, but only when the interventions included post-discharge support for at least one month.

Providing additional physiological feedback in the form of spirometry and demonstrated carbon monoxide level as an adjunct to nursing intervention did not appear to have an effect. Three studies in primary care or outpatient settings used this approach (Sanders 1989b; Risser 1990; Hollis 1993). It was also used as part of the enhanced intervention in a study with hospitalized patients (Hajek 2002).

The identification of an effect for a nurse-mediated intervention in smokers who were not hospitalized is based on 15 studies. The largest study (Hollis 1993) increased the quit rate from 2% in those who received only advice from a physician to 4% when a nurse delivered one of three additional interventions, including a video, written materials, and a follow-up telephone call. Control group quit rates were less than 10% in almost all these studies, and more typically between 4% and 8%. The risk ratio in this group of studies (1.8) was a little higher than in some subgroups, but because of the low background quit rate the proportion of participants likely to become long-term quitters as a result of a nursing intervention in these settings is likely to be small. However, because of the large number of people who could be reached by nursing, the effect would be important.

The evidence is not strong for an effect of nurse counselling about smoking cessation when it is provided as part of a health check. It may be unrealistic to expect a benefit from this type of intervention. Two studies that invited smokers to make an appointment with a nurse for counselling (Lancaster 1999; Aveyard 2003) also had relatively poor results. In both cases the uptake of the intervention was reported to be poor, with participants reluctant to schedule visits.

Combined efforts of many types of healthcare professionals are likely to be required. The US Public Health Service clinical practice guideline 'Treating Tobacco Use and Dependence' (AHRQ 2008) used logistic regression to estimate efficacy for interventions delivered by different types of providers. Their analysis did not distinguish among the non-physician medical healthcare providers, so that dentists, health counsellors, and pharmacists were included with nurses. The guideline concluded that these providers were effective (Table 15, OR 1.7, 95% CI 1.3 to 2.1). They also concluded that interventions by multiple clinician types were more effective (Table 16, OR 2.5, 95% CI 1.9 to 23.4). Although it was recognized that there could be confounding between the number of providers and the overall intensity of the intervention, the findings confirmed that a nursing intervention that reinforces or complements advice from physicians and/or other healthcare providers is likely to be an important component in helping smokers to quit.

Authors' conclusions

Implications for practice

The results of this review indicate the potential benefits of interventions given by nurses to their patients. The challenge remains to incorporate smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice to quit along with reinforcement and follow-up. Nicotine replacement therapy has been shown to improve quit rates when used in conjunction with counselling for behavioural change and should be considered an important adjunct, but not a replacement for nursing interventions (Stead 2012). The evidence suggests that brief interventions from nurses who combine smoking cessation work with other duties are less effective than longer interventions with multiple contacts, delivered by nurses with a role in health promotion or cardiac rehabilitation.

Implications for research

Further studies of nursing interventions are warranted, with more careful consideration of sample size, participant selection, refusals, drop-outs, long-term follow-up, and biochemical verification. Additionally, controlled studies are needed that carefully examine the effects of 'brief advice by nursing' as this type of professional counselling may more accurately reflect the current standard of care. Work is now required to systematize interventions so that more rigorous comparisons can be made between studies. None of the trials reviewed was a replication study; this is a very important method to strengthen the science, and should be encouraged.

Acknowledgements

Nicky Cullum and Tim Coleman for their helpful peer review comments on the original version of this review. Hitomi Kobayasha, a doctoral student, for assistance with Japanese translation of a study.

Data and analyses

Download statistical data

Comparison 1. All nursing intervention vs control trials, grouped by intensity of intervention
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Smoking cessation at longest follow-up3517604Risk Ratio (M-H, Fixed, 95% CI)1.29 [1.20, 1.39]
1.1 High intensity intervention2813588Risk Ratio (M-H, Fixed, 95% CI)1.29 [1.20, 1.40]
1.2 Low intensity intervention74016Risk Ratio (M-H, Fixed, 95% CI)1.27 [0.99, 1.62]
Analysis 1.1.

Comparison 1 All nursing intervention vs control trials, grouped by intensity of intervention, Outcome 1 Smoking cessation at longest follow-up.

Comparison 2. All nursing intervention vs control trials, grouped by setting and population
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Smoking cessation at longest follow-up34 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 Smoking intervention as part of multifactorial intervention in patients with cardiovascular disease5553Risk Ratio (M-H, Fixed, 95% CI)1.35 [1.14, 1.59]
1.2 Smoking intervention alone in hospitalized smokers with a cardiovascular disease72278Risk Ratio (M-H, Fixed, 95% CI)1.29 [1.14, 1.45]
1.3 Smoking intervention alone in other hospitalized smokers64759Risk Ratio (M-H, Fixed, 95% CI)1.09 [0.94, 1.28]
1.4 Smoking intervention alone in non-hospitalized smokers with a cardiovascular disease22090Risk Ratio (M-H, Fixed, 95% CI)0.99 [0.73, 1.34]
1.5 Smoking intervention alone in other non-hospitalized smokers157799Risk Ratio (M-H, Fixed, 95% CI)1.81 [1.48, 2.22]
Analysis 2.1.

Comparison 2 All nursing intervention vs control trials, grouped by setting and population, Outcome 1 Smoking cessation at longest follow-up.

Comparison 3. Effect of additional strategies: Higher versus lower intensity
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Additional components at single contact. Smoking cessation at longest follow-up3 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 Demonstration of CO levels1751Risk Ratio (M-H, Fixed, 95% CI)1.06 [0.55, 2.02]
1.2 Demonstration of spirometry and CO measurement190Risk Ratio (M-H, Fixed, 95% CI)0.33 [0.10, 1.15]
1.3 Additional support including CO reading, materials1505Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.73, 1.13]
2 Additional contacts. Smoking cessation at longest follow-up8 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2.1 Additional telephone support31220Risk Ratio (M-H, Fixed, 95% CI)1.25 [1.00, 1.56]
2.2 Self-help manual, additional telephone support1189Risk Ratio (M-H, Fixed, 95% CI)32.68 [4.55, 234.56]
2.3 Three additional sessions1157Risk Ratio (M-H, Fixed, 95% CI)0.43 [0.21, 0.89]
2.4 Additional face-to-face and telephone support31335Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.65, 1.31]
Analysis 3.1.

Comparison 3 Effect of additional strategies: Higher versus lower intensity, Outcome 1 Additional components at single contact. Smoking cessation at longest follow-up.

Analysis 3.2.

Comparison 3 Effect of additional strategies: Higher versus lower intensity, Outcome 2 Additional contacts. Smoking cessation at longest follow-up.

Comparison 4. Sensitivity analysis by intensity, including Hajek 2002, with Lancaster, Bolman, Curry as low intensity
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Smoking cessation at longest follow-up3417615Risk Ratio (M-H, Fixed, 95% CI)1.24 [1.15, 1.33]
1.1 High intensity intervention2311559Risk Ratio (M-H, Fixed, 95% CI)1.30 [1.20, 1.42]
1.2 Low intensity intervention116056Risk Ratio (M-H, Fixed, 95% CI)1.09 [0.96, 1.25]
Analysis 4.1.

Comparison 4 Sensitivity analysis by intensity, including Hajek 2002, with Lancaster, Bolman, Curry as low intensity, Outcome 1 Smoking cessation at longest follow-up.

Comparison 5. Sensitivity analysis by setting and population, including Hajek 2002
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Smoking cessation at longest follow-up9 Risk Ratio (M-H, Random, 95% CI)Subtotals only
1.1 Smoking intervention alone in hospitalized smokers with a cardiovascular disease94127Risk Ratio (M-H, Random, 95% CI)1.20 [1.02, 1.42]
Analysis 5.1.

Comparison 5 Sensitivity analysis by setting and population, including Hajek 2002, Outcome 1 Smoking cessation at longest follow-up.

Appendices

Appendix 1. Register search strategy

Run using Cochrane Register of Studies (CRS) software

#1 (nurse* or nursing):TI,AB,XKY,MH,EMT,KY
#2 (health visitor*):TI,AB,XKY,MH,EMT,KY
#3 #1 OR #2

XKY, MH, EMT, KY are keyword fields. XKY field includes indexing terms added for the use of the tobacco addiction group.

Appendix 2. Glossary of 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
TarThe toxic chemicals found in cigarettes. In solid form, it is the brown, tacky residue visible in a cigarette filter and deposited in the lungs of smokers.
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

DateEventDescription
14 June 2013New citation required but conclusions have not changedConclusions unchanged.
14 June 2013New search has been performedSearches updated. Seven new included studies, and new data (longer follow-up) added for two already included studies.

History

Protocol first published: Issue 3, 1998
Review first published: Issue 3, 1999

DateEventDescription
22 June 2011AmendedAdditional table converted to appendix to correct pdf format
29 October 2008AmendedConverted to new review format.
21 October 2007New citation required and minor changesUpdated for issue 1 2008 with 12 new studies included; no major changes to results. The conclusions did not change.
14 September 2003New citation required and conclusions have changedUpdated for issue 1 2004 with 7 new studies. Conclusions now give more emphasis to possible differences between high and low intensity interventions. 
14 October 2001New citation required and minor changesUpdated for issue 3 2001 with 3 new studies. The conclusions did not change substantially. 

Contributions of authors

VHR extracted data and wrote the review. LS conducted searches, extracted data and assisted in drafting the review. Both authors contribute to review updates. JHB contributed to the 2013 update, extracting data and assisting in updating the text.

Declarations of interest

V.H. Rice was the principal investigator in one of the studies included in this review.

Sources of support

Internal sources

  • Wayne State University College of Nursing, Adult Health & Administration, USA.

  • Department of Primary Health Care, Oxford University, UK.

External sources

  • American Heart Association, USA.

  • NHS Research & Development Programme, UK.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Allen 1996

MethodsCountry: USA (Maryland)
Recruitment setting: hospital inpatients. Intervention: Prior to hospital discharge and 2 weeks post-discharge
Participants116 women post-CABG. 25 smokers amongst them. Smoker defined by use of cigs in 6 months before admission.
Nurses provided intervention as part of their core role.
Interventions1. Multiple risk factor intervention, self-efficacy programme: 3 sessions with nurse using AHA Active Partnership Program and a follow-up call
2. Usual care (standard discharge teaching and physical therapy instructions)
Intensity: High
OutcomesAbstinence at 12m ('current use')
Validation: none
NotesData on number of quitters derived from percentages. Likely to include some who stopped prior to intervention.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Consenting patients were randomly assigned to receive special intervention or usual care by using a computerized schema that achieved a balanced allocation."
Allocation concealment (selection bias)Low risk"The nurse obtaining study consent and the participants were unaware of the group assignment at the time consent was obtained and baseline data were collected."
Incomplete outcome data (attrition bias)
All outcomes
Low riskSimilar number lost to follow-up in both arms; drop-outs counted as smokers.

Alterman 2001

MethodsCountry: USA
Recruitment setting: community volunteers, motivated to quit, cessation clinic
Participants160 smokers (≥ 1 pack/day) in relevant arms
InterventionsAll received nicotine patch 21mg 8 weeks incl weaning
Medium Intensity: 4 sessions over 9 weeks, 15 - 20 mins, advice and education from nurse practitioner
Low Intensity: single 30-min session with nurse, 3 videos
OutcomesAbstinence at 12m, not defined
Validation: CO < 9 ppm, urine cotinine < 50 ng/ml
NotesNo control group so not in main analysis.
High intensity intervention not included in review.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Urn randomization"
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low riskRate of drop-out similar in both groups; drop-outs counted as smokers. Authors give 77 as ITT denominator for medium intensity group. N randomized of 80 used in meta-analysis.

Aveyard 2003

MethodsCountry: UK
Recruitment setting: 65 general practices, invitation by letter
Participants831 current smokers in relevant arms, volunteers but not selected by motivation (> 80% precontemplators)
Intervention from practice nurses with 2 days training in Pro-Change system
Interventions1. In addition to tailored self help in 2., asked to make appointment to see practice nurse. Single postal reminder if no response. Up to 3 visits, at time of letters. Reinforced use of manual.
2. Self-help manual based on Transtheoretical model, maximum of 3 letters generated by expert system. No face-to-face contact.
Intensity: Low
(Standard S-H control and telephone counselling arms not used in review.)
OutcomesAbstinence at 12m, self-reported sustained for 6m
Validation: saliva cotinine < 14.2 ng/ml
NotesLow uptake of nurse component, 20% attended 1st visit, 6% 2nd and 2% 3rd, also more withdrawals (20%).
Nursing arm discontinued part way through recruitment. We use only the Manual (control) group recruited during 4-arm section of trial (3/418, data from author website www.publichealth.bham.ac.uk/berg/pdf/Addiction2003.pdf, compared to 15/683 for Manual group across the entire trial). This increases apparent benefit of nurse intervention. A sensitivity analysis did not alter any findings from the meta-analysis.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Minimization was used to allocate individuals to arms to balance three predictors of smoking cessation success... Questionnaires were read optically and the data transferred automatically to the Access database that performed the minimization and controlled the contacts."
Allocation concealment (selection bias)Low risk"There was no reason and no way that the clerical assistant running the database could alter the questionnaire reading schedule."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskHighest withdrawal rate in nursing group (20%). Participants with missing data counted as smokers.

Aveyard 2007

Methods

Country: UK

Recruitment: Patients from 26 GP practices; 92% volunteers in response to mailing

Participants925 smokers
51% women, av. age 43, 50% smoked 11 - 20 cpd
Interventions from practice nurses trained to give NHS smoking cessation support and manage NRT
Interventions

Both interventions included 8 wks 16 mg nicotine patch
1. Basic support; 1 visit (20 - 40 mins) before quit attempt, phone call on TQD, visits/
phone calls at 7 - 14 days and at 21 - 28 days (10 - 20 mins)
2. Weekly support; as 1. plus additional call at 10 days and visits at 14 and 21 days

Intensity: High (for both groups)

OutcomesAbstinence at 12m (sustained at 1, 4, 12, 26 wks)
Validation: CO < 10ppm at treatment visits, saliva cotinine < 15 ng/ml at follow-ups
NotesNew for 2013 update. Both conditions included nurse support; Included in analysis of effects of additional strategies only.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"A random number sequence and sealed number envelopes were generated by a statistician."
Allocation concealment (selection bias)Low risk"Nurses opened the envelopes in sequence following eligibility assessment and consent."
Incomplete outcome data (attrition bias)
All outcomes
Low risk288 (31%) lost to follow-up, similar across groups, included in ITT analysis

Bolman 2002

MethodsCountry: Netherlands
Recruitment setting: cardiac ward patients in 11 hospitals
Participants789 smokers who had smoked in previous week.
Nurses had 2 hours training and delivered intervention alongside normal duties
Interventions1. Cardiologist advice on ward and 1st check-up, GP notified, nurse provided stage of change-based counselling and provided a self-help cessation manual and a brochure on smoking and CHD. Nurse assessed smoking behaviour, addiction, motivation, addressed pros and cons, barriers and self efficacy, encouraged a quit date.
2. Usual care (nurses on control wards intended to be blind to status)
Intensity: High (but not consistently delivered)
OutcomesAbstinence at 12m (no smoking since hospital discharge)
Validation: none ('bogus pipeline')
NotesProcess analysis indicated some implementation failure.
Due to cluster-randomization there were baseline differences between intervention and control participants. Raw numbers quit are misleading. Regression analyses suggest no significant effect on continuous abstinence at 12m, so numbers quit in intervention group in meta-analysis adjusted to approximate the odds ratio and confidence interval from regression analysis.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High risk"The design was partially randomized: 4 of the 11 hospitals selected the experimental condition themselves... while the remaining 7 hospitals were randomly assigned." (Exclusion of the four hospitals who selected condition did not change results.) Baseline differences between intervention and control participants due to cluster randomization.
Allocation concealment (selection bias)High riskSee above
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskParticipants lost to follow-up counted as smokers with the exception of 25 deaths, 38 refusals, and 64 missing baseline data which were excluded from analysis denominator. Significantly more loss to follow-up in intervention group.
Other biasHigh risk 

Borrelli 2005

MethodsCountry: USA
Recruitment/setting: Home healthcare nursing service
Participants278 smoking patients of home healthcare nurses, not selected by motivation
54% F, av.age 57, av.cpd 21
Home healthcare nurses trained to deliver intervention during usual visits
Interventions1. Motivational enhancement. 3 x 20 - 30-min sessions during nursing visits. 5-min follow-up call.
2. Standard care control based on 5As model, single 5 - 15-min session with brief support at subsequent nursing visits, consistent with guidelines.
Intensity: High
OutcomesAbstinence at 12m (no smoking since 6m assessment)
Validation: CO < 10 ppm obtained for 60%, informant report also used
NotesNurses treated an average of 4 participants (range 1 - 13). Within-nurse correlation low, so multilevel models not reported.
39 deaths and 5 who quit before intervention excluded from denominators. Included in high intensity subgroup. Control intervention was more than usual care.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskCluster-randomized by nurse, method of sequence generation not specified.
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low risk70.5% retention rate; similar number of drop-outs in both groups. Unclear if denominators used in published article include all lost to follow-up; denominators for meta-analysis generated from data provided elsewhere in article.

Campbell 1998

MethodsCountry: UK (Scotland)
Recruitment setting: GP (Family Practice)
Intervention: within 3m of enrolment
ParticipantsApprox 200 smokers amongst 1343 patients with CVD diagnosis
Interventions1. Multiple risk factor intervention, at least one 45-min counselling session plus follow-up visits
2. Usual care
OutcomesAbstinence at 12m
Validation: none
NotesNot included in meta-analysis. Data presented as odds ratio for non-smoking
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"We used random numbers tables to centrally randomise patients (by individual after stratification for age, sex, and practice)."
Allocation concealment (selection bias)Low riskEligibility and randomization determined centrally
Incomplete outcome data (attrition bias)
All outcomes
Low risk7% missing data at final follow-up; counted as smokers. Similar numbers in both groups.

Canga 2000

MethodsCountry: USA
Recruitment: 15 primary care centres, 2 hospitals
Intervention: After enrolment
Participants280 smokers with diabetes (incl 16 recent quitters)
Intervention delivered by a single research nurse
Interventions1. Individual counselling based on NCI physician manual: 40 min, follow up with phone call, 2 further visits, letter.
2. Usual care
Intensity: High
OutcomesAbstinence at 6m for >5m.
Validation: urine cotinine
NotesNRT offered to 105 of intervention group but only accepted by 25. No reported use in control group. Quit rate for NRT user subgroup not stated.
6 in int and 4 in control failed/refused validation
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Subjects were randomly assigned to experimental or control groups using a computer-generated allocation method."
Allocation concealment (selection bias)Unclear riskSealed envelope used but not specified to be numbered and opaque.
Incomplete outcome data (attrition bias)
All outcomes
Low riskVery low drop-out rate: one loss to follow-up and one death. Loss to follow-up counted as smoker.
Other biasUnclear risk"Although the same nurse conducted all interviews and follow-up examinations with the potential for some degree of observer bias, the high incidence cessation ratio is very difficult to explain only on that basis."

Carlsson 1997

MethodsCountry: Sweden
Recruitment setting: Hospital CCU. Intervention at home 4 weeks after discharge.
Participants168 survivors of AMI. 67 smokers amongst them defined as present smoker by questionnaire.
Intervention delivered by a trained nurse rehabilitator
Interventions1. Multiple risk factor intervention in secondary prevention unit, 1½ hrs smoking cessation component as part of 9 hours group/ individual counselling. 4 visits to nurse during 9m.
2. Usual care, follow-up by general practitioners
Intensity: High
OutcomesAbstinence at 12m
Validation: none
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot specified
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNumber and proportion of lost to follow-up not specified; all participants missing data counted as smokers.

Chan 2012

Methods

Country: Hong Kong

Recruitment setting: Cardiac outpatient clinics at 10 major hospitals

Participants

1860 Chinese cardiac patients smoking ⋝ 1 cig in past week. 91% men, av.age 58, av.cpd 12. Excluded from study if "too clinically ill."

Intervention delivered by trained nurse counsellors.

Interventions

1. Intervention: At baseline, 30-min individual face-to-face counselling matched to stage of readiness to quit. At 1 wk and 1m: telephone calls from nurse counsellor, re-assessment of stage and counselling to suit that stage, avg. phone call length 15 mins.

2. Control: 15-min, individual face-to-face counselling on healthy diet from nurse counsellor at baseline.

Pharmacotherapy: No smoking cessation drugs provided, but stage-matched medication counselling on NRT was discussed with intervention participants "if deemed appropriate".

Intensity: High

Outcomes

7d PP at 12m (30d PP at 12m and 3 and 6m outcomes also reported)

Validation: CO ≤ 8 ppm, urinary cotinine < 100 ng/ml

Notes

New for 2013 update

Validated rates used in MA; only about 25% of people self-reporting abstinence were validated.

Participants in intervention group had higher stage of readiness to quit smoking than in the control group. Adjusted OR provided in text (unadjusted OR 1.35, 95% CI 0.91 to 2.00; adjusted OR 1.26, 95% CI 0.85 to 1.87); numbers used in MA are unadjusted.

No contamination observed

54% intervention received all counselling

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"The allocation sequence was generated sequentially by the project co-ordinator based on simple random sampling procedure using MS Excel."
Allocation concealment (selection bias)Low risk"serially numbered sealed and opaque envelope"
Incomplete outcome data (attrition bias)
All outcomes
Low riskSimilar rates of follow-up in both groups at 12m (85.5% intervention and 84.3% control). "No statistically significant difference was found between the two groups." ITT analysis conducted, 25 who died during study removed from denominators.
Other biasUnclear risk"Some cardiac out-patient clinics provided rehabilitation programmes which included health talks or brief advice on smoking cessation as their usual or standard care (but no stage-matched counselling). It is plausible that our intervention might overlap with the usual standard care which patients from the control group received. As brief intervention in an out-patient setting is effective, the usual care might have biased the effect towards null."

Chouinard 2005

MethodsCountry: Canada
Recruitment setting: Inpatients with cardiovascular disease (MI, angina, CHF) or PVD, unselected by motivation
Participants168 past-month smokers.
Av.age 56
Intervention delivered by a research nurse
Interventions1. Counselling by research nurse (1x, 10-60 mins, av. 40 min, based on Transtheoretical Model, included component to enhance social support from a significant family member), 23% used pharmacotherapy.
2. As 1, plus telephone follow-up, 6 calls over 2m post-discharge, 29% used pharmacotherapy
3. Control: cessation advice, 11% used pharmacotherapy.
OutcomesAbstinence at 6m (sustained at 2m and 6m)
Validation: Urine cotinine or CO
NotesTwo interventions combined versus control in high intensity subgroup. 1 versus 2 used in higher versus lower comparison.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Cluster randomization was used... by first randomly assigning individuals to predetermined clusters of three to six subjects. The group assignment was then randomly assigned to each of these clusters."
Allocation concealment (selection bias)Low risk"Individuals not familiar with the study were in charge of the randomization procedure, which included inserting the information into envelopes that were sealed and would be opened by the investigator only at the time of treatment."
Incomplete outcome data (attrition bias)
All outcomes
Low risk4 deaths and 3 not meeting follow-up criteria excluded from meta-analysis; all other drop-outs and those lost to follow-up counted as smokers; similar numbers in all arms.

Cossette 2011

Methods

Country: Canada

Recruitment setting: all smokers admitted to 1 specialized cardiac hospital were asked to participate by the study nurse. Willing to quit

Participants

40 current daily smokers, 40% women, av age 57,

Intervention delivered by nurse specializing in smoking cessation

Interventions

1. Intervention: usual care during hospitalization consisting of 1 or more sessions with the study nurse. Follow-up: 6 phone calls by study nurse at wk 1, 2, 3, 4, 8, 12 and then if needed additional phone calls could be arranged between 3 and 6m post-discharge. At wk 3 appointment with the study nurse if asked by participant.

2. Control: usual care during hospitalization consisting of 1 or more sessions with the study nurse, referral to a national quitline or a community centre for smoking cessation

Pharmacotherapy: NRT, bupropion or varenicline were suggested during hospitalization and follow-up

Intensity: High

Outcomes

Abstinence: self-reported abstinence at 6m

Validation: only for one participant

NotesNew for 2013 update. Included in analysis 3.2 only (additional contact) as all participants received nurse counselling in hospital.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot specified, but generated by a centre for randomized controlled trials
Allocation concealment (selection bias)Unclear riskOpaque sealed envelopes
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskMissing data similar in both groups and analyses are ITT, participants lost to follow-up considered smokers

Curry 2003

MethodsCountry: USA
Recruitment setting: mothers attending 4 paediatric clinics, unselected by motivation
Participants303 women (any smoking), 23% in precontemplation
av age 33, av cpd 12
Intervention delivered either by clinic nurses or a study interventionist. Nurses received 8 hours individual training in motivational interviewing
Interventions1. Clinician advice based on 5As (1 - 5 mins), Self-help materials targeted for mothers. Asked to meet a nurse or health educator who provided motivational interviewing during visit. Up to 3 phone calls over 3m.
2. No intervention
Intensity: High (but implementation incomplete)
OutcomesAbstinence at 12m (Sustained at 3m and 12m. PP also reported)
Validation: CO < 10 ppm, only for women followed up in person. Tabulated rates based on self report
NotesIntervention included physician advice. Not all participants received intervention. Based on counsellor records, 74% received face-to-face intervention, average length 13 mins, and 78% had at least 1 phone call. Nurses provided intervention as part of their normal duties.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskParticipants "determined their randomization group by choosing a Ping-Pong ball out of a brown paper bag. The bag contained several Ping-Pong balls that were either white or yellow, and the color of the selected ball indicated their study group."
Allocation concealment (selection bias)High riskSee above
Incomplete outcome data (attrition bias)
All outcomes
Low risk19% lost at final follow-up; counted as smokers. Similar numbers lost to follow-up in both groups.

Davies 1992

MethodsCountry: Canada
Recruitment setting: healthy adult community-based volunteers
Participants307 essentially healthy adult smokers of at least 5 cpd
Interventions1. 'Time To Quit' programme delivered by a student nurse trained in programme
2. Visit by same student nurse prior to receiving training
Intensity: Low
OutcomesAbstinence at 9m
Validation: Cotinine < 100n g/ML
NotesEffect of training and manuals on nurse intervention
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskEach participating nurse visited a control participant first, then received training. Authors state: "While the study protocol introduced an order bias, it was deliberately selected for practical reasons."
Allocation concealment (selection bias)High riskSee above
Incomplete outcome data (attrition bias)
All outcomes
Low riskParticipants lost to follow-up counted as smokers in outcome data (30 in experimental group, 20 in control group)

DeBusk 1994

MethodsCountry: USA (California)
Recruitment setting: inpatients with AMI at 5 hospitals
Participants131/293 intervention and 121/292 control participants were smokers as defined by any use of tobacco in 6m before admission.
Nurses provided intervention as part of their core role
Interventions1. Multiple risk factor intervention case-management system with smoking cessation, nutritional counselling, lipid-lowering therapy and exercise therapy. Smoking cessation: 2-min physician then nurse counselling with repeated telephone follow-ups x 8. NRT offered only to highly addicted participants who relapsed post-discharge.
2. Usual care including physician counselling. Group cessation programmes available for USD 50 (2% enrolled)
OutcomesAbstinence at 1yr (PP)
Validation: plasma cotinine < 10 ng/mL, or 11 - 15 ng/mL with expired CO < 10 ppm.
NotesNumber of quitters derived from smoking cessation rates based on number of baseline smokers - Author contacted for smoker drop-out rates.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Patients were randomly assigned using a computer program that achieved a balanced allocation to the two management conditions within each hospital."
Allocation concealment (selection bias)Low risk"Randomization was done centrally; nurses were notified of the assignments by telephone calls from the coordinating center staff."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskUnclear what percentage of smokers were lost to follow-up. "Among participants who did not relapse before death or dropout, censoring occurred at the last point at which they reported not smoking."

Duffy 2006

Methods

Country: USA

Recruitment setting: Head and neck cancer patients at 4 medical centres (1 university, 3 VA) who smoked

Participants

136 head and neck cancer patients who were current smokers or had quit smoking within the last 6m

84% men, av.age 57

Interventions

1. CBT workbook, 9 - 11 CBT sessions via telephone and pharmacologic management ‘as needed.’ Smokers offered NRT and/or bupropion. Nurses trained in CBT.

2. Usual care (referred based on participant’s needs, insurance, and ability to pay, given handout of resources)

Intensity: High

Outcomes

Smoking prevalence at 6m

Validation: none

Notes

New for 2013 update.

Subgroup from trial of head and neck cancer patients who smoked, were depressed, or were alcohol-dependent. Sex and age stats based on overall sample of 184 (not just smokers).

Intervention group offered NRT and/or bupropion – at 6m 21/74 in intervention group had used NRT and 14/62 in usual care group had used NRT.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMethod not specified
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll smokers lost to follow-up counted as smokers in final outcome data. From the total group of 184 randomized: 4% died, 12% lost to follow-up. "The loss to follow-up was evenly distributed between the two randomized groups."

Family Heart 1994

MethodsCountry: UK
Recruitment setting: Male general practice (family practice) patients aged 40 - 59 and partners, identified by household
Participants7460 male and 5012 female medical practice patients who reported ‘smoking’ on a questionnaire.
Interventions1. Screening for cardiovascular risk factors, risk-related lifestyle intervention during a single 1½ hr visit.
2. Delayed screening (at 1 year) for families in the same practice (internal control) and the paired practice (external control)
OutcomesSmoking prevalence at 1yr
Validation: CO
NotesNot included in meta-analysis because outcome not directly comparable with cessation studies. Smoking prevalence was lower in the intervention participants at 1yr than in either internal or external practice controls. But non-returners in the intervention group had a higher smoking prevalence at baseline than returners.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskRandomized by practice (one of a pair in each of 14 towns): "a pair of willing practices in each town with similar sociodemographic characteristics was randomized to either arm of the study." "Within each intervention practice, the list of men was randomly divided into two groups: intervention and an internal comparison group." Method of sequence generation not specified.
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk87% attended final follow-up; similar numbers lost in both groups. Those lost to follow-up significantly more likely to be smokers at start of study.

Feeney 2001

MethodsCountry: Australia
Recruitment/setting: CCU, single hospital
Participants198 smokers in previous week, unselected for motivation.
Interventions1. Stanford Heart Attack Staying Free programme. Review by Alcohol and Drug Assessment Unit (ADAU) physician. Self-help manual, high relapse risk patients counselled on coping strategies, audiotapes. On discharge ADAU nurse contacted weekly for 4 weeks and 2, 3, 12m.
2. Verbal and written didactic advice, video, review by ADAU nurse, supportive counselling and follow-up offered at 3, 6, 12m
OutcomesAbstinence at 12m, continuous and validated at 1m and 3m.
Validation: urine cotinine < 400 ng/ml at each ADAU clinic visit
NotesBoth intervention and control included a nursing component so not in main analysis.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"A random list of odd and even numbers was generated and a sequence of 200 sealed envelopes created."
Allocation concealment (selection bias)Low risk"With patient consent an envelope was opened and they were assigned to either programme."
Incomplete outcome data (attrition bias)
All outcomes
High riskOnly participants who attended basic ADAU follow-up programme assessed, so large number of drop-outs. More drop-outs in group 2 (79%) than group 1 (51%), so treating drop-outs as smokers may overestimate treatment effect. 9 deaths (4/5) excluded from denominator in analysis.

Froelicher 2004

MethodsCountry: USA
Recruitment/setting: Inpatients with CVD or PVD admitted to 10 hospitals
Participants277 female current smokers or recent quitters (smoked in month before admission), willing to make serious quit attempt at discharge.
Av. age 61, av.cpd 18 - 19
Intervention delivered by trained research nurses
Interventions1. As usual care + nurse-managed cessation and relapse prevention: 30 - 45 mins individual counselling predischarge with multimedia materials. Up to 5 phone calls (5 - 10 mins) at 2, 7, 21, 28, 90 days. Relapsers offered additional session.
2. Usual care; brief physician counselling, Self-help pamphlet, list of resources
Patch or gum offered to selected women after discharge who had relapsed and wanted to try to quit (pharmacotherapy used by 20% of intervention and 23% of control group).
Intensity: High
OutcomesAbstinence at 12m (7-day PP). (Also followed at 24m, 30m but validation not attempted)
Validation: Saliva cotinine < 14 ng/ml or family/friend verification
NotesNew for 2008/1 update
11 deaths at 12m, excluded from cessation denominators. 73% of participants reached at all 4 follow-ups
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Randomization was by random permuted blocks, stratified by hospital, with an equal chance of assignment to the usual-care group or the intervention group."
Allocation concealment (selection bias)Low riskCentralized randomization.
Incomplete outcome data (attrition bias)
All outcomes
Low risk20 participants (13 intervention; 7 control) lost to follow-up included in meta-analysis as smokers.11 deaths excluded from meta-analysis.

Hajek 2002

MethodsCountry: UK
Recruitment/setting: inpatients with MI or for CABG at 17 hospitals
Participants540 smokers or recent quitters (26%) who had not smoked in hospital and motivated to quit. 26 deaths, 9 moved address excluded from denominator in analysis
Intervention delivered by nurses alongside other duties
Interventions1. As control, + CO reading, booklet on smoking and cardiac recovery, written quiz, offer to find support buddy, commitment, reminder in notes. Implemented by cardiac nurses during routine work, est time 20mins.
2. Verbal advice, Smoking and Your Heart booklet
OutcomesAbstinence at 12m, sustained (no more than 5 cigs since enrolment and 7-day PP)
Validation: saliva cotinine < 20 ng/ml (CO used at 6 week follow-up and for visits at 12m)
NotesControl meets criteria for a low intensity intervention so not included in comparison 1, but included there and in inpatient CVD category in sensitivity analyses (Comparisons 4 and 5).
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskRandomization method not described
Allocation concealment (selection bias)Low riskNurses opened a "serially numbered, opaque, sealed envelope designating the patient's allocation."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo significant differences in numbers lost to follow-up or participants who had died or moved away. Those who had died or moved away excluded from outcome data; those lost to follow-up counted as smokers.

Hanssen 2007

MethodsCountry: Norway
Recruitment/setting: inpatients with AMI
Participants133 daily smokers amongst 288 participants. Not selected by motivation.
Demographics not given for smoking subgroup
Intervention delivered by research nurses
Interventions1. Structured but individualized telephone support addressing lifestyle issues including smoking, diet and exercise. Nurse-initiated calls at 1, 2, 3, 4, 6, 8,1 2, 24 weeks post-discharge. Smoking not explicitly addressed at each call. Reactive phone support line available 6 hrs/week
2. Usual care; outpatient visit at 6 - 8 weeks and primary care follow-up
Intensity: High
OutcomesPP abstinence at 6, 12 and 18m. Primary trial outcome was health-related quality of life
Validation: none
NotesNew for 2008/1 (6m data only). Longer-term data added 2013. 12m data now used in analyses as 18m data includes rise in abstinence in control group; given outcome is PPA using 18m data judged too conservative.
Smoking was part of a multicomponent intervention.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Computer generated list of random numbers."
Allocation concealment (selection bias)Unclear risk"Group allocation in sealed opaque envelopes prepared by the researcher." However, fewer control group participants raises possibility of selection bias.
Incomplete outcome data (attrition bias)
All outcomes
Low riskMore lost to follow-up in intervention group at all follow-up points; participants with missing data at final follow-up counted as smokers.

Hasuo 2004

MethodsCountry: Japan
Recruitment: Inpatients (all diagnoses)
Participants120 current smokers or recent quitters (smoked in past month) who intended to be quit on day of discharge
Diagnoses include cancer (n = 37), cardiac (n = 57)
Interventions1. Intervention: nurse counselling (3 x 20-min sessions). Telephone follow-up with focus on relapse prevention at 7, 21, 42 days (5-min/call)
2. Control: Same inpatient counselling but no follow-up contact
OutcomesAbstinence at 12m (not defined).
Validation: urinary cotinine
NotesNew for 2008/1
Both groups included inpatient counselling so not used in main comparison; effect of telephone follow-up. Intervention was intended to prevent relapse.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputerized randomization stratified by smoking status, FTND, and self-efficacy
Allocation concealment (selection bias)Low riskComputerized programme randomly assigned individual participants.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskMore control participants missing outcome data at 12m than intervention group (9 versus 5). MA denominators exclude 6 deaths, but include 8 who were still smoking on day of discharge. This gives marginally larger relative effect.

Hennrikus 2005

MethodsCountry: USA
Recruitment/setting: Inpatients (all diagnoses) admitted to 4 hospitals
Selected: Invited to participate.
Participants2095 current smokers (smoked in past week and considered self to be regular smoker for at least a month in past year)
Not selected by motivation; approx 10% in each group confident they could quit.
Av.age 47
Intervention delivered by research nurses
Interventions1. Brief advice: as control, plus labels in records to prompt advice from nurses and physicians.
2. Brief advice and counselling: As 1. plus 1 bedside (or phone) session using motivational interviewing and relapse prevention approaches and 3 to 6 calls (2 - 3 days, 1 wk, 2 - 3 wks, 1m, 6m)
3. Control: modified usual care: smoking cessation booklet in hospital (not used in meta-analysis)
Intensity: High
Pharmacotherapy not offered.
OutcomesAbstinence at 12m (7-day PP).
Validation: saliva cotinine < 15 ng/ml
NotesBrief advice and counselling regarded as nurse intervention, compared to Brief advice. Including Usual Care in control as well would marginally increase RR but not change conclusion of no effect.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Research assistants... randomized [participants] to one of three treatment conditions by looking up the next available group assignment on a list on which the three conditions were randomly ordered within blocks of 30 assignments."
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low risk78 deaths and ineligible (too ill) for follow-up excluded from denominators; all other participants missing data at final follow-up counted as smokers. Similar numbers lost to follow-up in all groups.
Other biasHigh riskHigh and differential levels of refusal to provide validation and of misreporting.

Hilberink 2005

MethodsCountry: Netherlands
Recruitment/setting: People with COPD identified by prescription and diagnosis codes in 43 general practices
Participants392 current smokers with COPD. Not selected for motivation, ˜ 50% willing to quit within 6m, different between groups
50% women, av.age 59
Parts of intervention delivered by practice nurses alongside other duties
Interventions1. SMOCC intervention: booklet for COPD population and video. Stage-based intervention: Precontemplators given information on advantages of quitting. Contemplators received self efficacy-enhancing intervention, discussion of barriers, info on NRT if dependent and further visit at 2 weeks. Preparers had visit to GP to schedule quit date and max 2 follow-ups, and max 3 phone calls from practice nurse/assistant.
2. Usual care
Intensity: High
OutcomesAbstinence at 6, 12m (PP)
Validation: Urine cotinine < 50 ng/mL at 12m
NotesFirst included in 2008. 1 year follow-up reported in Hilberink 2011 - data changed in 2013 update.
Only the telephone follow-up for people in preparation stage was explicitly provided by a nurse. Paper notes that practices differed in amount of tasks delegated to practice nurses.
Paper reports use of multilevel modelling. No adjustment to crude RR needed for clustering. Denominators exclude 2 deaths and those for whom follow-up not attempted
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Randomization took place on practice level." No information provided on sequence generation.
Allocation concealment (selection bias)High risk"Self-selection at practice level possibly affected the quit rate too."
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk5/48 practices dropped out after randomization, leading to an imbalance of numbers of participants. Drop-outs counted as smokers; deaths and participants for whom follow-up was not attempted at 6m excluded from outcome data.

Hollis 1993

MethodsCountry: USA (Portland, OR)
Recruitment: Internal medicine/family clinics
Participants2691 internal medicine/family clinic adults who reported being a smoker on a questionnaire.
Interventions1. Brief physician advice (30 sec and pamphlet from nurse)
2. Brief physician message plus nurse who promoted self-quit attempts - advice, CO feedback, 10-min video and manual (1 of 3 types) + follow-up call and materials
3. Brief physician advice plus nurse-promoted group programme - advice, CO, + video-ask to join group with schedule, coupon, etc., follow-up calls
4. Brief physician advice, and nurse-offered choice between self-directed and group-assisted quit - shown both types of materials.
Intensity: High
OutcomesAbstinence at 1yr (2 PP)
Validation: Saliva cotinine at 12m
NotesAll 3 nurse-mediated interventions compared with 1. Saliva samples only obtained for approx half of reported quitters. Compliance and confirmation rates did not differ between groups.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High risk"Two random digits contained in the patient's health record number were used to assign patients to one of ... four interventions."
Allocation concealment (selection bias)High riskSee above.
Incomplete outcome data (attrition bias)
All outcomes
Low riskSmoking status missing for 24% of participants at 12m; "response rates did not differ significantly across treatment groups." Non-respondents counted as smokers.

Janz 1987

MethodsCountry: USA (Michigan)
Recruitment setting: OP Dept Med Clinic (R.A.)
ParticipantsSmokers (≥ 5 cpd) attending clinics
Interventions1. Physician discussed personal susceptibility, self efficacy and concern, trained nurse counselled on problems and strategies.
2. As 1, and self-help manual 'Step-by-Step Quit Kit' + 1 telephone call
3. Usual Care control (from physicians not involved in study)
Intensity: Low
OutcomesAbstinence at 6m (self report by telephone)
Validation: none
Notes1 and 2 vs 3. Interventions included both physician and nurse components.
Data derived from graphs of percentages. Original data sought but not available.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Each clinic site was divided into half-day clinic units with each unit assigned to either experimental or control status....Smokers at the clinic on experimental half-days were further randomized into one of two experimental groups." Method of sequence generation not specified.
Allocation concealment (selection bias)High riskAllocation dependent on half-day clinic attended.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskUnclear if participants lost to follow-up counted as smokers. Total drop-out from baseline to 6m = 15.6%. "Drop-out rates did not vary significantly across study groups."

Jiang 2007

Methods

Country: China

Recruitment: Patients at two tertiary medical centres

Participants

71 people with CHD who had used tobacco within 6m before hospital admission (out of a larger sample of 167 CHD patients)

60% men, av.age 62

Interventions

1. Nurse-led cardiac rehabilitation programme (addressing medication adherence, diet, exercise, and smoking where relevant). Individual teaching in hospital followed by 12 wks individual support post-discharge from experienced cardiac nurse.

2. Usual care

Intensity: High

Outcomes

PP abstinence at 12m

Validation: no biochemical validation. Smoking status confirmed by family member.

Notes

New for 2013 update.

Demographic characteristics based on broader sample of 167, not broken down into smokers.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"computer-generalized random table"
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNumber of smokers lost to follow-up not specified. Participants lost to follow-up who had been smoking at baseline counted as smokers.

Kim 2005

MethodsCountry: South Korea
Recruitment/setting: Internal medicine outpatient department
Participants401 daily smokers, 65% willing to quit within 1m
92% M, av.age 52
InterventionsTest of 5As approach recommended by US AHCPR guideline. All participants Asked about smoking status and Advised to quit by physicians. Counsellors (retired nurses trained in cessation) Assessed willingness to quit, and enrolled and randomized participants.
1. Intervention: Counsellors provided Assist and Arrange components to participants willing to quit within 1m; set quit date, provided self-help materials, supplied cigarette substitute. Culturally specific for Koreans. Other participants given 4Rs
2. Control: Counsellors told participants to quit without further assistance.
OutcomesAbstinence at 5m
Validation: CO ≤ 7 ppm
NotesNew for 2008/1 update
Marginal to include because 5m follow-up and counsellors were retired nurses
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"We randomly assigned the study participants to either the intervention or the control group. This was consummated according to a random list determined by fixed randomization with an allocation ration of 1:1, a block size of 6 and 12 allocation strata."
Allocation concealment (selection bias)Low risk"The treatment assignments based on each of the 12 stratum were placed in sealed opaque envelopes which the counselors opened at the formal enrollment of the study participants."
Incomplete outcome data (attrition bias)
All outcomes
Low riskVery low loss to follow-up (7 out of 401). All lost to follow-up counted as smokers.
Other biasUnclear riskDifferential validation rates (58.3% intervention; 69.2% control).

Lancaster 1999

MethodsCountry: UK
Recruitment setting: General practice, recruitment during a visit or by letter. Smokers who completed a questionnaire about smoking habits.
Participants497 smokers (av. cpd 17)
Interventions1. Physician advice (face-to-face or in a letter) and a leaflet
2. As 1, plus invitation to contact a trained practice nurse for more intensive tailored counselling. Up to 5 follow-up visits offered.
OutcomesAbstinence at 12m (sustained at 3m and 12m)
Validation: saliva cotinine at 3m and 12m
Notes2 vs 1. Only 30% took up offer of extended counselling. Included in high-intensity subgroup based on intended intervention but sensitivity analysis for effect of treating as low intensity
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"An independent statistical advisor performed randomization from computer-generated random numbers."
Allocation concealment (selection bias)Low risk"The allocations, in blocks of 20, were in sequential sealed, opaque envelopes opened by the research nurse at the time of recruitment."
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk75% completed follow-up survey at 12m; number in each group not specified. Subjects lost to follow-up counted as smokers.

Lewis 1998

MethodsCountry: USA
Recruitment setting: hospital inpatients (excluding some cardiac conditions)
Participants185 hospitalized adults; self-reported ‘regular use’ for at least 1 year.
Counselling intervention delivered by research nurse
Interventions1. Minimal care (MC): motivational message from physician to quit plus pamphlet
2. Counselling and nicotine patch (CAP).
3. Counselling and placebo patch (CPP).
In addition groups 2 and 3 received a motivational message and instructions on patch use from physician, 4 sessions of telephone counselling by nurse based on cognitive behavioural therapy and motivational interviewing.
Intensity: High
OutcomesAbstinence at 6m (7-day PP)
Validation: CO ≤ 10 ppm
NotesCompared 3 vs 1; Nurse counselling and placebo patch compared to minimal care to avoid confounding with effect of NRT.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"The patient was randomized... using a predetermined computer-generated randomization code."
Allocation concealment (selection bias)Low riskRandomization determined centrally
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskParticipants lost to follow-up counted as smokers; exact numbers lost to follow-up not specified.

Meysman 2010

MethodsSetting: Surgical wards in 4 Flemish hospitals
Recruitment: inpatient smokers on surgical wards
Participants358 adult smokers admitted for surgery; randomized to experimental (178) or control (180) groups. 63% men, mean age 43.2, 39% smoked > 20 CPD, 61% 10 - 20 CPD.
Motivation to quit not required.
Interventions

1. Brief nurse-led counselling session; SoC assessed, and appropriate advice given, i.e. precontemplators got risks of smoking and health gains after cessation, contemplators got barriers and pitfalls to quitting, + raising self efficacy, and preparers were either referred to a SC counsellor of agreed a SC plan with the nurse.
2. Standard booklet on smoking cessation

Level of intensity: High

OutcomesSelf-reported continuous abstinence on discharge and at 6m post-discharge.
Validation: None
Notes

New for 2013 update. Intervention delivered by qualified smoking cessation nurse.

4 in control group and 9 in experimental group used some form of pharmacological smoking cessation aid.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskParticipants stratified by SoC. Method of randomization not specified.
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskParticipants lost to follow-up counted as smokers, exact numbers not provided

Miller 1997

MethodsCountry: USA (California)
Recruitment setting: hospital inpatients
Participants1942 hospitalized smokers (any tobacco use in week prior to admission)
Counselling delivered by a research nurse
Interventions1. Intensive: 30-min inpatient counselling, video, workbook, relaxation tape + 4 phone calls after discharge
2. Minimal: 30-min counselling etc + 1 phone call
3. Usual Care
Intensity: High
OutcomesAbstinence at 12m (PP, sustained abstinence also reported, but not by disease subgroup)
Validation: plasma cotinine or family member collaboration at 12m
Notes1+2 vs 3 in main analysis - classifying both interventions as high intensity. Cardiovascular and other diagnoses separated in analysis by setting. 1 vs 2 in analysis of effect of additional telephone contact (sustained abstinence).
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMethod of sequence generation not specified
Allocation concealment (selection bias)Low risk"Nurses opened sealed envelopes in front of patients to determine patients' assignments."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDeaths excluded from MA denominator; all others lost to follow-up considered smokers; similar loss to follow-up across all groups (10%).

Nagle 2005

MethodsCountry: Australia
Recruitment/setting: Inpatients (all diagnoses) admitted to 1 teaching hospital (excluding intensive care units), invited to participate.
Participants1422 current smokers or quitters (including 331 who had quit in past 12m). Not selected by motivation.
40% men in intervention group, 33% men in controls
Main part of intervention delivered by specialist
Interventions1. Assessment and identification of smokers with the Smoking Cessation Clinical Pathway as chart reminder for ward nurses, Clinical Nurse Specialist provided 2 brief counselling sessions, offer of NRT, (3% provided) discharge letter.
2. Usual care and assessment of smoking status, no standardized clinical assessment.
Intensity: Low (borderline)
OutcomesAbstinence at 12m ( 7-day validated PP, continuous self-reported abstinence also given)
Validation: Saliva cotinine ≤ 15 ng/ml.
NotesNew for 2008/1 update
Study includes recent quitters; no difference in intervention effect. 85% of recent smokers received at least 1 counselling session, 38% received 2.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputerized. "Randomization was based on blocks of 20 patients being assigned to either control or intervention. Stratification into recent smoker and recent quitter categories occured prior to randomization."
Allocation concealment (selection bias)Low risk"Patients who reported smoking within the last 12 months were entered by the research assistant at the patient's bedside into the LAPSMOKE program on a laptop computer, which gave an immediate random allocation to either control or intervention that could not be changed."
Incomplete outcome data (attrition bias)
All outcomes
Low risk"At 12 months no difference for completed surveys or for loss to follow-up existed between the intervention group and the control group." 28 deaths at 12m excluded from denominator, all other participants missing data counted as smokers.

Nebot 1992

MethodsCountry: Spain
Recruitment: Primary Care Centre (participants not selected for motivation to quit)
Participants425 smokers (at least 1 cpd in past wk)
Interventions1. Physician advice
2. Physician advice and nicotine gum
3. Nurse counselling (up to 15 mins)
Intensity: Low
All received booklet and offer of follow-up visit or call.
OutcomesAbstinence at 12m (sustained at 2m and 12m)
Validation: 1/4 validated by expired CO at 2m.
Notes3 vs 1
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Each PCT was randomly allocated to perform the three different interventions successively. Each physician was assigned to a different intervention option every week, so that during that week they could not include any patient under an intervention option different from previously scheduled." Method of sequence generation not specified.
Allocation concealment (selection bias)High riskRandomization does not allow blinding of allocation.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk76/425 patients lost to follow-up; numbers lost to follow-up not broken down by group; those lost to follow-up at 2m not included in final analysis.

OXCHECK 1994

MethodsCountry: UK
Recruitment: People aged 35 - 64 in 5 urban general practices (family practice) who returned a baseline questionnaire
Participants11,090 general practice patients
Interventions1. Health check and risk factor counselling
2. Delayed intervention
OutcomesSmoking prevalence, and reported quitting in previous year
NotesNot included in meta-analysis because outcome not directly comparable with cessation studies.
When all intervention participants (including non-attenders) are compared to controls there was no significant difference in the proportion who had stopped smoking in previous year.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Patients were... randomized by household to be offered a health check during a specified year over the four year period... After a health check had been performed during the first two years of the study half the patients were randomly assigned to be re-examined annually." Method of sequence generation not specified.
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
High risk"We used values from the initial health check for non-attenders... The difference between controls and attenders will over-estimate the effectiveness of the health check because non-attenders are likely to have been less compliant with advice than attenders."

Quist-Paulsen 2003

MethodsCountry: Norway
Recruitment/setting: Inpatients admitted to cardiac ward of 1 general hospital, invited to participate
Participants240 current smokers (smoked daily before symptoms began).
Av. 15 cpd
Intervention delivered by 3 cardiac nurses
Interventions1. Intervention: Usual care plus 1 - 2 sessions with nurse using booklet focusing on fear arousal and relapse prevention. 5 telephone follow-ups at 2, 7, 21 days, 3m, 5m). Clinic visit to nurse at 6 wks. Gum or patch encouraged for subjects with strong urges to smoke in hospital.
2. Control: usual care (advice to quit + booklet)
Intensity: High
OutcomesAbstinence at 12m (PP)
Validation: urine cotinine < 2.0 mmol/mol creatinine
NotesNew for 2008/1 update.
Included in CVD subcategory
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Randomization was in blocks of varying sizes."
Allocation concealment (selection bias)Low risk"The nurses were given a serially numbered sealed envelope from a secretary who was otherwise uninvolved in the study."
Incomplete outcome data (attrition bias)
All outcomes
Low riskMeta-analysis does not include 5 deaths, 2 patients who had moved away and 10 post-randomization withdrawals due to change in diagnosis; all other losses to follow-up considered to be smoking (18 in intervention group, 4 in control group).

Ratner 2004

MethodsCountry: Canada
Recruitment: Patients having presurgical assessment
Participants237 smokers (past 7 days) awaiting elective surgery
52% women
Av. 12 cpd
Interventions1. Pre-admission clinic 15 min counselling from trained research nurse, materials, nicotine gum, quit kit, hotline number. Post-operative counselling in hospital. 9 follow-up calls over 16 wks.
2. Usual care
Intensity: High
OutcomesAbstinence at 12m (PP)
Validation: urine cotinine (NicoMeter)
NotesNew for 2008/1 update
Included in hospitalized patient subgroup for Comparison 2 although the initial intervention delivered pre-admission
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Computer-generated, randomly determined group allocation."
Allocation concealment (selection bias)Low riskNurses opened a "sealed envelope" after recruiting participants.
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll participants who withdrew or were lost to follow-up (28.7%) were counted as smokers. "There was no differential loss to follow-up at 12 months." 9 deaths at 12m excluded from denominators.

Rice 1994

MethodsCountry: USA (Michigan)
Recruitment: Previously hospitalized; self-referral or by provider
Participants255 smokers (≥10 cpd) with CVD
Interventions1. Smokeless (R) programme, individual delivery by nurse, 5 sessions
2. Same programme, 5 group sessions
3. Same programme, written self-help format
4. Usual care control
Intensity: High
OutcomesAbstinence at 12m.
Validation: saliva thiocyanate measured, but self report used as outcome.
Notes1+2+3 vs 4
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Subjects were initially stratified by the singularity elements of 1) sex, 2) smoking history and 3) a health factor, and then randomized to one of four intervention groups." Sequence generation through table of random numbers
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low risk8% did not provide data at final follow-up and counted as smokers in final analysis; 12 died before follow-up and were not included in final outcome figures.
Other biasUnclear riskDifferential non-participation by experimental group assignments

Rigotti 1994

MethodsCountry: USA (Boston)
Setting/ Recruitment: Cardiac surgery unit
Participants87 smokers (1+ pack of cigs in past 6m) scheduled for CABG.
Interventions1. 3 sessions behavioural model with video tape and face-to-face counselling by registered nurse
2. Usual care control
Intensity: High
OutcomesSustained abstinence at 12m
Validation: saliva cotinine < 20 ng/mL
NotesAbstinence rates include some smokers who had quit prior to surgery
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Patients were randomly assigned to control or intervention groups after surgery." Method not specified.
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low risk7 deaths not counted in final meta-analysis. No other participants lost to follow-up at 12m.

Risser 1990

MethodsCountry: USA
Setting: Nurse-staffed health promotion clinic
Participants90 smokers attending health promotion clinic for annual visit
Interventions1. 50-min session, self-help materials, offer of training and counselling programme.
2. as 1, plus 10-min personalized motivational intervention with spirometry, CO measurement and discussion of symptoms.
OutcomesAbstinence at 1yr (PP)
Validation: expired CO
NotesNot in main comparison: effect of additional components.
No group without intervention. (No true control group.)
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMethod not described
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk6/45 lost to follow-up in control group, 13/45 lost to follow-up in treatment group; counted as smokers in final analysis. "Although attrition was unevenly distributed in the two groups, the reasons for attrition were distributed similarly in both groups."

Sanders 1989a

MethodsCountry: UK
Setting: Primary care clinics (11)
Participants4210 primary care clinic attenders identified by questionnaire as smokers
Interventions1. Asked by doctor (following advice to quit) to make appointment with nurse for health check. Advice, discussion, leaflet and offer of follow-up by nursing
2. Usual care control
Intensity: Low
OutcomesSustained abstinence at 12m (self report of not smoking at 1m and 12m and gave date on which they last smoked as before the 1m follow-up)
Validation: urine cotinine
NotesOnly a sample of usual care group followed up so not appropriate to use data in main meta-analysis.
A significant effect of the intervention was apparent only for the sustained cessation outcome. 12m PP abstinence rates were 11.2% for intervention, 10% for control (NS).
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High risk"...smokers identified were intended to be allocated to a control or intervention group on a one to two basis according to day of attendance... The designation of specific days was itself randomized across weeks and practices..."
Allocation concealment (selection bias)High riskRandomized according to day of attendance. "Although the doctors were given a desktop card to remind them which were control days and which intervention, 120 patients were allocated to the wrong group and were excluded from further analysis."
Incomplete outcome data (attrition bias)
All outcomes
High riskOnly a random sample of the control group was followed up. Non-respondents counted as smokers. Response rate significantly higher in attenders (63.8% versus 54.4% in non-attenders and 56.5% in control).

Sanders 1989b

MethodsCountry: UK
Setting: Primary care clinics (11)
Participants751 smokers who attended a health check (having been randomly allocated to an intervention offering a health check - see Sanders 1989a)
Interventions1. Health check from a practice nurse; advice, leaflet and offer of follow-up
2. As 1, with demonstration of expired CO levels.
OutcomesSustained abstinence at 1 yr (self report of not smoking at 1m and 12m and who gave date on which they last smoked as before the 1m follow-up)
Validation: urine cotinine in a sample of participants indicated a relatively high deception rate.
Notes2 vs 1 for effect of CO demonstration as an adjunct to nurse advice.
This was part of same study as Sanders 1989a, and randomized a subgroup of participants in the main study
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskSee above (Sanders 1989a)
Allocation concealment (selection bias)High riskSee above
Incomplete outcome data (attrition bias)
All outcomes
High riskSee above

Sanz-Pozo 2006

MethodsCountry: Spain
Setting: Primary care clinic
Participants125 daily smokers attending clinic, motivated to make a quit attempt but not interested in using pharmacotherapy
Intervention 52% women, Control 62% women, av.age ˜ 40, av.cpd 19
Interventions1. Brief advice from doctor at recruitment, appointment with clinic nurse 7 days before TQD, on TQD, 1wk, 1m, 2m, 3m.
2. Brief advice only.
No pharmacotherapy
OutcomesSustained abstinence at 24m (from 12m)
Validation: CO < 8ppm
NotesNew for 2008/1
Control group rates also higher at 12m follow-up. Some baseline differences but logistic regression did not alter conclusion of no effect
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"The patients recruited were randomised, according to the clinic from which they came." Method not described
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskParticipants lost to follow-up counted as smokers. Participants in intervention group who did not complete all sessions may have been automatically classified as smokers - unclear what effect this may have had on results.

Steptoe 1999

MethodsCountry: UK
Setting: Primary care clinics (20)
Participants404 smokers (from total of 883 people with modifiable CVD risk factors)
Interventions1. Behavioural counselling using stages of change approach. 2 - 3 20-min sessions + 1 - 2 phone contacts. NRT used if appropriate.
2. Usual care
OutcomesSustained abstinence at 12m (4m and 12m)
Validation: saliva cotinine
NotesNot included in meta-analysis. Used practice-based analysis.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"cluster randomized" using the "minimisation technique to balance groups for the Jarman score of social deprivation, ratio of patient to practice nurse hours per week, and fundholding status." Sequence generation method not specified.
Allocation concealment (selection bias)Unclear riskMethod of allocation not specified.
Incomplete outcome data (attrition bias)
All outcomes
High risk"Participants who smoked... tended to drop out more in the intervention than control groups." Overall drop-out rates high.

Taylor 1990

MethodsCountry: USA (California)
Recruitment setting: Hospital (patients with AMI)
Randomization: Random numbers in sealed envelopes
Participants173 smokers following AMI. Smoker defined as any use of tobacco.
Interventions1. Nurse counselling on self efficacy, benefits and risks, + manual coping with high risk situations. Further telephone counselling as needed up to 6m.
2. Usual care control
Intensity: High
OutcomesAbstinence at 12m
Validation: serum thiocyanate < 110 nmol/L, expired CO < 10 ppm
NotesNurses averaged 3½ hours/participant including phone contact
Slightly higher loss to follow-up in control group. Nicotine gum was prescribed to 5 participants.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"A random list of odd and even numbers was generated"
Allocation concealment (selection bias)Low risk"a sequence of numbers sealed in envelopes was created...the nurse assessing the intervention called the nurse coordinator who opened the next envelope to determine the condition to which the patient would be assigned"
Incomplete outcome data (attrition bias)
All outcomes
Low riskParticipants missing data counted as smokers. 14/86 patients in intervention group and 29/87 patients in control group missing data at 12m follow-up.

Terazawa 2001

MethodsCountry: Japan
Recruitment setting: Workplace annual health check
Participants228 male smokers, Av age 39, av cpd 23
Interventions1. 15 - 20-min stage-matched counselling by trained nurses. 4 follow-up calls for those willing to set a quit date. 1 wk after intervention, 3 - 4 days , 1m, 3m after cessation
2. Usual care
OutcomesSustained abstinence at 12m (> 6m, validated at 6m and 12m)
Validation: CO, urine
Notes25 from intervention group set quit date.
More intervention group in preparation/contemplation II subgroups at baseline; 17 vs 7.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMethod of sequence generation not specified.
Allocation concealment (selection bias)Low risk"Randomly divided into two groups before contact with subject. Participants' employee ID numbers were used for assignment."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo loss to follow-up reported in either group.

Tonnesen 1996

MethodsCountry: Denmark
Recruitment setting: outpatient chest clinic
Participants507 smokers of < 10 cpd or of > 10 cpd who had refused a trial of nicotine replacement. age 20 - 70 yrs
Intervention delivered by clinic nurses given 8-hr training and 3 problem-solving meetings
Interventions1. Motivational approach, 5 mins of benefits/risks, brochures on hazards and how to quit. 4 - 6 wks letter sent
2. Control - questionnaire and CO measurement. No advice to stop smoking.
Intensity: Low
OutcomesSustained abstinence at 1 yr (stopped during intervention and no reported smoking during year)
Validation: CO < 10 ppm
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMethod not described
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk12% lost to follow-up and counted as smokers; numbers lost in each group not specified.

Tonnesen 2006

MethodsCountry: Denmark
Recruitment setting: 7 outpatient chest clinics
Participants370 smokers of > 1 cpd with COPD
52% women, av. age 61, av.cpd 20
InterventionsFactorial trial. Nicotine sublingual tablet and placebo arms collapsed in MA
1. High support: 7 x 20 - 30-min clinic visits (0, 2, 4, 8, 12 wks, 6m, 12m) and 5 x 10-min phone calls (1, 6, 10 wks , 4½m. 9m), total contact time 4½ hrs.
2. Low support: 4 clinic visits (0, 2 wks, 6m, 12m) and 6 phone calls (1, 4, 6, 9, 12 wks, 9m), total time 2½ hrs
OutcomesSustained abstinence at 12m (validated at all visits from wk 2, PP also reported)
Validation: CO < 10 ppm
NotesNot in main comparison; compares different intensities of nurse counselling
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Patients were allocated to one of the four treatment groups using a block randomization list at each center."
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk82/370 participants lost to follow-up and counted as smokers. "One potential bias may have been the large early dropout of failures from the study. Consequently, these patients were not exposed to the possible effect of more intensive support."

Vetter 1990

MethodsCountry: UK (Wales)
Recruitment setting: general practice (family practice)
Participants226 smokers aged 60+ in general practice who completed a health questionnaire. Unselected by motivation to quit.
Interventions1. Letter asking participant to visit doctor who advised on importance of stopping smoking, opportunity to see practice nurse who gave advice on lifestyle factors concentrating on quitting smoking
2. No contact, completed questionnaire only
Intensity: Low
OutcomesAbstinence at 6m (PP)
Validation: expired CO (cut-off point not stated)
NotesIntervention included nursing and physician advice
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMethod not described
Allocation concealment (selection bias)Unclear riskNot specified
Incomplete outcome data (attrition bias)
All outcomes
Low risk10% lost to follow-up in intervention group; 9% lost to follow-up in treatment group. Participants lost to follow-up counted as smokers.

Wood 2008

  1. a

    CABG = Coronary Artery Bypass Graft; CCU = Coronary Care Unit; CHD = coronary heart disease; CHF = congestive heart failure; CO = carbon monoxide; COPD = AHCPR = Agency for Health Care Policy and Research; Chronic Obstructive Pulmonary Disease; cpd = cigarettes per day; CVD = cardiovascular disease; FTND: Fagerstrom Test for Nicotine Dependence; ITT = intention-to-treat; m =month(s); (A)MI = (Acute) Myocardial Infarction; NRT = nicotine replacement therapy; NS: not statistically significant; PP = point prevalence; PVD = peripheral vascular disease; SMOCC = Smoking cessation for patients with COPD in general practice; SoC= stage of change (precontemplation, contemplation, preparation, action); TQD = target quit date

Methods

Country: (multicentre) France, Italy, Poland, Spain, Sweden, UK, Netherlands, Denmark

Recruitment setting: hospitals and general practices

Participants2554 smokers who were patients at participating GP practices (at high risk of developing CHD) or hospitals (with established CHD). Demographics not reported.
Interventions

1. Nurse co-ordinated lifestyle intervention. Includes nurse counselling (at least 8 weekly sessions) covering smoking cessation where participants were self-reported smokers at baseline.

2. Usual care (not specified)

Outcomes

Abstinence at 12m (definition not provided)

Validation: CO < 6 ppm

Notes

New for 2013.

Subset of participants from larger study which included smokers and non-smokers. N provided above is smokers followed up at 12m, larger study had 5405 participants. Baseline n smoking not clear, study does not contribute to meta-analysis.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMethod not described
Allocation concealment (selection bias)Unclear riskCluster-randomized, method of allocation concealment not specified
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot specified for subgroup of smokers at baseline, not clear how smoking status of those smokers lost to follow-up was reported.

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Aertsen-Van Der Kuip 2006Abstract only, 3m follow-up.
Andrews 2007Cluster-randomized trial with only 2 community clusters and baseline differences between participants. Nurse-led counselling confounded with NRT availability and personal contact from a community health worker for the duration of the trial.
Avanzini 2011Not a randomized trial, uses matched controls
Bredie 2011Only 3m follow-up.
Browning 2000Not a randomized trial, uses historical control.
Brunner-Frandsen 2012Comparison of nurse-delivered counselling with more intensive smoking cessation therapy. Intensive therapy confounded additional nurse-delivered telephone support with specialist counselling and pharmacotherapy.
Cabezas 2011Both nurses and/or physicians provided intervention.
Carlsson 1998Describes 5 studies, only 1 reporting smoking cessation is included in review separately (Carlsson 1997).
Caslin 2006Abstract only, insufficient information for inclusion. Study of nurse intervention for smoking cessation in hospitalized inpatients.
Chan 2005Pilot study of intervention directed at non-smoking mothers with smoking partners; follow-up < 6m.
Chan 2008Intervention directed at non-smoking mothers with smoking partners.
Efraimsson 2008Less than 6m follow-up.
Fletcher 1987Number of quitters after 6m not stated. (Total of 20 participants)
French 2007Not RCT. Control and intervention ran sequentially. Study of a nurse-delivered home-visiting programme to prevent post-partum relapse.
Fritz 2008Adolescent smokers
Galvin 2001Only 3m follow up. (Total of 42 participants)
Gies 2008Only 3m follow-up. Non-random assignment to nurse intervention and control. Randomly compared 1 and 4 phone follow-ups.
Griebel 1998Maximum follow-up was 6 wks post-hospital discharge.
Haddock 1997No long-term follow-up. Randomization unclear.
Hall 2007Follow-up < 6m
Heath 2012Not randomized, evaluation.
Hjalmarson 2007Not randomized, intervention allocated by treatment site.
Jansink 2013Originally listed as ongoing study, now completed. Lifestyle intervention for Type 2 diabetes, smoking prevalence and smoking cessation results not reported.
Jelley 1995Not RCT. Control and intervention ran sequentially.
Johnson 1999Not RCT. No equivalent study groups, intervention allocated according to cardiac unit of admission.
Johnson 2000Population and intervention not within scope. Recruited women who had stopped smoking during pregnancy for a relapse prevention intervention.
Katz 2012Not randomized; pre/post design.
Kendrick 1995Intervention in pregnant smokers. See Lumley 2009.
Koelewijn-van Loon 2009Signficant baseline difference in smoking behaviour between intervention and control group. Data provided does not specify number quit in relation to those smoking at baseline.
Kotz 2009Effects of nurse intervention (counselling) confounded with pharmacotherapy (nortriptyline)
Lakerveld 2010Abstract only, insufficient detail provided for inclusion.
Lifrak 1997Four advice sessions with a nurse practitioner compared with a more intensive intervention of 16 weekly therapy sessions. All also received nicotine patch therapy.
McHugh 2001Multiple risk factor intervention with shared care. Cannot evaluate effect of nursing.
Meulepas 2007Cluster-randomized trial of intervention in people with COPD. Effect of nurse counselling confounded with effect of (GP initiated) COPD support service.
O'Connor 1992Intervention in pregnant smokers. See Lumley 2009.
Persson 2006Study of nurse-counselling for smoking cessation in general practice patients with diabetes. Practices assigned to intervention or control; practice assignment not randomized.
Planer 2011Study of bupropion, both intervention and control groups received nurse support.
Pozen 1977Intervention in post-MI patients. Only 1m follow-up, and number of smokers at baseline not described.
Reeve 2000Follow-up < 6m.
Reid 2003Stepped care intervention from nurse counsellor confounded with nicotine patch therapy (no evidence of effect of the combination).
Rigotti 1997Intervention not given by a nurse.
Smith 2009Compares physician + nurse advice with nurse-initiated counselling only
Stanislaw 1994Follow-up < 6m.
Sun 2000Follow-up < 6m.
Targhetta 2011Trial of training of medical staff, including nurses
Van Elderen 1994Multicomponent intervention, smoking cessation element not clear.
Van Zuilen 2011Study of multifactoral lifestyle intervention for people with chronic kidney disease. Unable to extract data on baseline smokers only; insufficient detail on nature of stop smoking intervention to include.
Wadland 1999Not randomized. The 2 groups were recruited by different means and given different interventions, both of which included telephone counselling by nurses or counsellors.
Wadland 2001Follow-up < 6m (90 days). Nurses and counsellors provided telephone-based intervention.
Wewers 1994Follow up < 6m.
Wewers 2009Intervention led by lay health advisors (managed by nurses, but nurses never had contact with participants).
Wilson 2008Planned sample size of 303 not reached, only 91 participants randomized between 3 conditions. Adherence to interventions (5 hrs of individual or group support) was very low. No participants achieved complete cessation.
Woollard 1995No data presented on number of smokers or quitting.
Zakrisson 2011Evaluation of nurse-led interdisciplinary intervention that involved physicians, as well.

Characteristics of ongoing studies [ordered by study ID]

Berndt 2012

Trial name or titleSmoking cessation among patients with coronary heart disease: effectiveness of two intensive counselling methods for smoking cessation and relapse prevention in persons with coronary heart disease
Methods3-arm cross-over cluster-randomized trial, cross-over randomization at ward level
Participants625 patients at 8 cardiac wards in the Netherlands smoking ≥ 5 cpd prior to admission
Interventions

1. Telephone counselling (trained counsellors from Dutch Centre for Tobacco Control)

2. Face-to-face counselling (provided by cardiac nurses)

3. Usual care

All participants offered NRT. Referral by nurses.

OutcomesContinued and 7-day point prevalence abstinence, cost, and health outcomes at 6 and 12m.
Starting dateOctober 2009
Contact informationNadine Berndt (nadine.berndt@ou.nl)
Notes

Dutch Trial Register NTR2144

Funded by Dutch Organisation for Health Research and Development (ZonMw)

Duffy 2012

Trial name or titleTobacco Tactics website for operating engineers (BCBSM-OE)
Methodscluster-randomized trial
Participants100 participants attending a training session provided by the Operating Engineers Local 324 Education Center, smoked in past month
Interventions

1. Tobacco Tactics web-based intervention including websites, medications, and nurse counselling

2. National quitline (1-800-QUIT-NOW)

Outcomes7-day point prevalence abstinence at 6m
Starting dateJanuary 2010
Contact informationSonia A Duffy (bump@umich.edu)
Notes

Clinicaltrials.gov NCT01124110

Funded by National Cancer Institute, Blue Cross Blue Shield of Michigan Foundation, Department of Veterans Affairs, National Institutes of Nursing Research 

Smit 2010

Trial name or titleThe PAS study: a randomized controlled trial evaluating the effectiveness of a web-based multiple tailored smoking cessation programme and tailored counselling by practice nurses
MethodsRandomized, parallel
ParticipantsAdult smokers willing to quit within 6 months with internet access
Interventions

Participants recruited by practice nurses and asked to sign up for PAS via PAS website. Once signed up to PAS, randomized into 3 groups:

1. Multiple computerized tailoring and tailored counselling by a practice nurse

2. Multiple computerized tailoring

3. Usual care

OutcomesContinued and point prevalence abstinence, quit attempt, measured at baseline, 6 wks, 6 and 12 months. Biochemically verified at 12 months.
Starting dateApril 2009
Contact informationE.S. Smit (es.smit@gvo.unimaas.nl)
Notes

Dutch Trial Register NTR1351

Funded by KWF Kankerbestrijding

Zwar 2010

Trial name or titleQuit in General Practice: a cluster randomised trial of enhanced in-practice support for smoking cessation
Methods3-arm, parallel, cluster-randomized. Outcome assessors blind to allocation.
Participants2250 daily or weekly smokers 18 or older presenting to GP practices in Australia (30 in each arm)
Interventions

1. Quit with practice nurse (flexible options to suit participant, including up to 4 face-to-face sessions with practice nurse using 5As approach, referral to quitline, support in use of pharmacotherapy)

2. Refferal to quitline

3. GP usual care

Participants in all 3 groups encouraged to use pharmacotherapy

OutcomesSustained and point prevalence abstinence at 3 and 12 months, cost-effectiveness analysis
Starting dateJuly 2009
Contact informationNicholas Zwar (n.zwar@unsw.edu.au)
Notes

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12609001040257

Funded by Australian Government National Health and Medical Research Council (NHMRC)

Ancillary