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Cochrane Database of Systematic Reviews

Intervenciones para mejorar la adherencia a los fármacos para la dependencia del tabaco

Información

DOI:
https://doi.org/10.1002/14651858.CD009164.pub3Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 16 agosto 2019see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Tabaquismo

Copyright:
  1. Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Gareth J Hollands

    Correspondencia a: Behaviour and Health Research Unit, University of Cambridge, Cambridge, UK

    [email protected]

  • Felix Naughton

    School of Health Sciences, University of East Anglia, Norwich, UK

  • Amanda Farley

    Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK

  • Nicola Lindson

    Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

  • Paul Aveyard

    Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

Contributions of authors

Draft the protocol: all authors.

Develop the search strategy: GJH, NL.

Search for trials: GJH, NL, FN.

Obtain copies of trials: GJH, FN.

Select which studies to include: GJH, FN, NL.

Extract data from studies: GJH, FN.

Enter data into Review Manager 5: GJH, FN.

Carry out the analysis: GJH, FN.

Interpret the analysis: all authors.

Draft the final review: all authors.

Update the review: GJH.

Sources of support

Internal sources

  • University of Cambridge, UK.

    Computer use, database access

  • NIHR senior investigator, UK.

    Paul Aveyard is an NIHR senior investigator.

  • NIHR Oxford Biomedical Research Centre, UK.

    Paul Aveyard is supported by the NIHR Oxford Biomedical Research Centre.

  • NIHR Oxford CLAHRC, UK.

    Paul Aveyard is supported by NIHR Oxford CLAHRC.

  • NIHR Infrastructure funding, UK.

    The Cochrane Tobacco Addiction Group is funded by the NIHR. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

External sources

  • No sources of support supplied

Declarations of interest

GJH is an author of one of the studies included in the review (Marteau 2012).

FN declares no competing interests.

AF declares researcher‐led funding from Johnson and Johnson (Ethicon) being awarded to her institution.

NL is managing editor of the Cochrane Tobacco Addiction Group, although this is not deemed a conflict of interest.

PA is an author of one the studies included in the review (Marteau 2012). PA is also the co‐ordinating editor of the Cochrane Tobacco Addiction Group, although this is not deemed a conflict of interest.

Acknowledgements

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Tobacco Addiction Group. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service or the Department of Health. PA is also part‐funded by the NIHR Oxford Biomedical Research Centre (BRC).

The authors would like to thank Jonathan Livingstone‐Banks who ran searches of the Tobacco Addiction Group Specialized Register, Jamie Hartmann‐Boyce and all at the Cochrane Tobacco Addiction Group. We also greatly appreciate the input of the peer reviewers who have commented on this review throughout its development.

Version history

Published

Title

Stage

Authors

Version

2019 Aug 16

Interventions to increase adherence to medications for tobacco dependence

Review

Gareth J Hollands, Felix Naughton, Amanda Farley, Nicola Lindson, Paul Aveyard

https://doi.org/10.1002/14651858.CD009164.pub3

2015 Feb 23

Interventions to increase adherence to medications for tobacco dependence

Review

Gareth J Hollands, Máirtín S McDermott, Nicola Lindson‐Hawley, Florian Vogt, Amanda Farley, Paul Aveyard

https://doi.org/10.1002/14651858.CD009164.pub2

2011 Jun 15

Interventions to increase adherence to medications for tobacco dependence

Protocol

Gareth J Hollands, Florian Vogt, Máirtín McDermott, Amanda C Parsons, Paul Aveyard

https://doi.org/10.1002/14651858.CD009164

Differences between protocol and review

For the 2015 version of the review (Hollands 2015b), the criteria for eligible interventions was refined between the protocol and the review. The original primary intention of the review was to examine the effect of interventions to increase adherence where this was the clearly intended focus of those intervening. However, this primary intention was not adequately reflected in the original criteria. As such, a large number of studies of interventions that could in theory alter adherence but where this was not the researchers' intention would have been relevant for inclusion. Furthermore, this lack of clarity meant that most extant studies that featured any intervention in smokers would have to be examined at the full‐text screening stage because a clear focus on increasing adherence (which can typically be derived from the title and abstract screening process) was not necessary for consideration for inclusion.

For the current update, we made additional changes to the original protocol.

Rather than including separate meta‐analyses combining each of continuous outcome data and dichotomous outcome data for a given outcome, we produced a single meta‐analysis that combined these using generic inverse variance methods. If a study reported both continuous and dichotomous outcomes that were similar in meeting other criteria, continuous data were used. In the previous version of the review, we had applied fixed‐effect models to our pooling of the data. This was in line with the protocol, in which we stated that we intended to group substantially similar studies. In practice, there was considerable methodological and clinical variance between studies, reflecting different characteristics of settings, participant groups, interventions and measures. As such, a random‐effects model was considered more appropriate.

We added formal coding of the focus of the content of the intervention, which while stated as an objective, had not been conducted for the previous version of this review. We coded studies by reference to two key factors: 1. focus on perceptions, practicalities, or both; 2. participant‐centred or clinician‐centred. This was then used as the basis for subgroup analyses to determine which types of interventions were most effective.

In the previous version of this review we proposed to assess the impact of using intention‐to‐treat data for adherence outcomes instead of using data for only those participants who remained engaged with treatment (the latter being our specified preferred approach). This was no longer considered necessary given justification for using the latter data, reflected in the two newly identified studies which both report adherence data for participants who remained engaged with treatment.

For risk of bias assessment, following guidance from the Cochrane Tobacco Addiction Group, we removed three domains (blinding of participants and personnel (performance bias); validity and reliability of outcome measures (other sources of bias); comparability of baseline characteristics (other sources of bias)). We followed guidance in Section 8.7 (Table 8.7a) of the Cochrane Handbook for Systematic Reviews of Interventions for deriving a summary risk of bias judgement from the domains that were assessed (Higgins 2011).

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Study flow diagram for the current review update (eight studies were included in the previous version of the review).
Figuras y tablas -
Figure 1

Study flow diagram for the current review update (eight studies were included in the previous version of the review).

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Medication adherence intervention plus standard care versus standard care alone, outcome: 1.1 Adherence (combined dichotomous and continuous).
Figuras y tablas -
Figure 3

Forest plot of comparison: 1 Medication adherence intervention plus standard care versus standard care alone, outcome: 1.1 Adherence (combined dichotomous and continuous).

Funnel plot of comparison: 1 Medication adherence intervention plus standard care versus standard care alone, outcome: 1.1 Adherence (combined dichotomous and continuous).
Figuras y tablas -
Figure 4

Funnel plot of comparison: 1 Medication adherence intervention plus standard care versus standard care alone, outcome: 1.1 Adherence (combined dichotomous and continuous).

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 1 Adherence (combined dichotomous and continuous).
Figuras y tablas -
Analysis 1.1

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 1 Adherence (combined dichotomous and continuous).

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 2 Adherence: intervention focus subgroups.
Figuras y tablas -
Analysis 1.2

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 2 Adherence: intervention focus subgroups.

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 3 Adherence: delivery approach subgroups.
Figuras y tablas -
Analysis 1.3

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 3 Adherence: delivery approach subgroups.

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 4 Adherence: combined focus and delivery subgroups.
Figuras y tablas -
Analysis 1.4

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 4 Adherence: combined focus and delivery subgroups.

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 5 Adherence: medication type subgroups.
Figuras y tablas -
Analysis 1.5

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 5 Adherence: medication type subgroups.

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 6 Dichotomous adherence data (for calculation purposes).
Figuras y tablas -
Analysis 1.6

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 6 Dichotomous adherence data (for calculation purposes).

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 7 Continuous adherence data (for calculation purposes).
Figuras y tablas -
Analysis 1.7

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 7 Continuous adherence data (for calculation purposes).

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 8 Short‐term smoking abstinence (< 6 months).
Figuras y tablas -
Analysis 1.8

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 8 Short‐term smoking abstinence (< 6 months).

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 9 Long‐term smoking abstinence (≥ 6 months).
Figuras y tablas -
Analysis 1.9

Comparison 1 Medication adherence intervention plus standard care versus standard care alone, Outcome 9 Long‐term smoking abstinence (≥ 6 months).

Summary of findings for the main comparison. Interventions to increase adherence compared to standard care for improving adherence to medications for tobacco dependence and abstinence from smoking

Interventions to increase adherence compared to standard care for improving adherence to medications for tobacco dependence and abstinence from smoking

Patient or population: adult smokers
Settings: typically in‐person clinical settings (China, UK, USA)
Intervention: interventions to increase adherence through providing information and facilitating problem‐solving
Comparison: behavioural support for smoking cessation

Outcomes

Relative effect (95% CI)

Illustrative comparative risks (95% CI)

No of participants
(studies; comparisons)

Certainty of the evidence
(GRADE)

Assumed risk

Corresponding risk

Standard care

Intervention to increase adherence

Adherence to medications for tobacco dependence

SMD 0.10 (0.03 to 0.18)

Mean proportion of prescribed medication consumed over 28 days was 63.6%

Mean proportion of prescribed medication consumed over 28 days was 3.9% higher (95% CI 1.2% to 7.0% higher)

3655
(10 RCTs; 12 comparisons)

⊕⊕⊕⊝
Moderatea,b

Short‐term abstinence from smoking (< 6 months)

RR 1.08
(0.96 to 1.21)

357 people per 1000 achieve abstinence)

386 people per 1000 achieve abstinence

(95% CI 343 to 432)

1795
(5 RCTs; 5 comparisons)

⊕⊕⊝⊝
Lowa,b,c

Long‐term abstinence from smoking (≥ 6 months)

RR 1.16
(0.96 to 1.40)

203 people per 1000 achieve abstinence

236 per 1000 achieve abstinence

(95% CI 195 to 284)

3593
(5 RCTs; 7 comparisons)

⊕⊕⊝⊝
Lowa,b,c

The basis for the illustrative comparative risks is provided in Footnotesd. 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; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference.

GRADE Working Group grades of evidence

High certainty: current evidence provides a very good indication of the likely effect, and the likelihood that the actual effect will be substantially different is low.
Moderate certainty: current evidence provides a good indication of the likely effect, and the likelihood that the actual effect of the treatment will not be substantially different is moderate.
Low certainty: current evidence provides some indication of the likely effect, but the likelihood that the actual effect will be substantially different is high.
Very low certainty: current evidence does not provide a reliable indication of the likely effect, and the likelihood that the actual effect will be substantially different is very high.

aMost studies were at high or unclear risk of bias which lowers confidence in estimate of effect (risk of bias).
bWe did not downgrade due to indirectness as we judged the evidence specifically relating to the general population receiving an adherence intervention in addition to behavioural support for smoking cessation, compared to behavioural support alone, is moderate. However, our conclusions cannot be generalised to populations not receiving behavioural support or that are unlikely to adhere, or both.
cIncluded sufficient sample size for single adequately powered trial but 95% CI overlapped no effect and ranged from minimal harm to moderate benefit (imprecision).
dConcerning adherence outcomes for the comparison group, as the basis for an illustration of potential effect size on a more familiar metric, we used data from the largest included study that reported adherence as assessed by tablet counts (Marteau 2012). In this study, mean proportion of prescribed nicotine replacement therapy that was consumed at 28 days by the 'standard care' arm was 63.6% (SD 39.0%). Further explanation is provided in Data synthesis. Concerning abstinence outcomes for the comparison group, the percentage of observed events seen in the review's data (which derives from studies with characteristics as specified by the 'Summary of findings' table) was applied to 1000 total events.

Figuras y tablas -
Summary of findings for the main comparison. Interventions to increase adherence compared to standard care for improving adherence to medications for tobacco dependence and abstinence from smoking
Table 1. Brief descriptions of adherence interventions

Study

Brief description of specific intervention components intended to increase adherencea

Additional contact time relative to standard care?

Medication for which adherence was targeted

Intervention focused on perceptions, practicalities or both

Participant‐ or clinician‐centred intervention

Chan 2010

Added counselling contact time to standard behavioural support, focusing specifically on medication adherence

Yes

NRT

Practicalities

Participant

Chan 2011

Added counselling contact time to standard behavioural support, focusing specifically on medication adherence

Yes

NRT

Practicalities

Participant

Marteau 2012

Tailored and communicated about NRT dosage using a more potent rationale (genotype vs phenotype)

No

NRT

Perceptions

Clinician

Mooney 2005

Personalised feedback of questionnaire responses regarding medication

No

NRT

Perceptions

Participant

Mooney 2007

Personalised feedback of externally validated medication adherence

Yes

Bupropion

Practicalities

Participant

Nollen 2011

Added counselling contact time to standard behavioural support, focusing specifically on medication adherence

Yes

Varenicline

Both

Clinician

Schlam 2018

Added contact time to standard behavioural support with: 1. medication adherence counselling; 2. automated reminder calls; 3. electronic monitoring counselling

Yes

NRT

1. Perceptions

2. Both

3. Practicalities

1. Participant

2. Clinician

3. Participant

Schmitz 2005

Personalised feedback of externally validated medication adherence

Yes

Bupropion

Practicalities

Participant

Smith 2013

Added counselling contact time to standard behavioural support, focusing specifically on medication adherence

Yes

NRT

Both

Participant

Tucker 2017

Added contact time to standard behavioural support with module focused on improving adherence to nicotine patch

Yes

NRT

Both

Participant

aFor further details see Characteristics of included studies table.

NRT: nicotine replacement therapy.

Figuras y tablas -
Table 1. Brief descriptions of adherence interventions
Comparison 1. Medication adherence intervention plus standard care versus standard care alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Adherence (combined dichotomous and continuous) Show forest plot

10

3655

Std. Mean Difference (Random, 95% CI)

0.10 [0.03, 0.18]

2 Adherence: intervention focus subgroups Show forest plot

10

3655

Std. Mean Difference (Random, 95% CI)

0.10 [0.03, 0.18]

2.1 Perceptions

3

839

Std. Mean Difference (Random, 95% CI)

0.10 [‐0.03, 0.24]

2.2 Practicalities

5

1752

Std. Mean Difference (Random, 95% CI)

0.21 [0.03, 0.38]

2.3 Both perceptions and practicalities

4

1064

Std. Mean Difference (Random, 95% CI)

0.04 [‐0.08, 0.16]

3 Adherence: delivery approach subgroups Show forest plot

10

3655

Std. Mean Difference (Random, 95% CI)

0.10 [0.03, 0.18]

3.1 Participant‐centred

8

2791

Std. Mean Difference (Random, 95% CI)

0.12 [0.02, 0.23]

3.2 Clinician‐centred

3

864

Std. Mean Difference (Random, 95% CI)

0.09 [‐0.05, 0.23]

4 Adherence: combined focus and delivery subgroups Show forest plot

10

3655

Std. Mean Difference (Random, 95% CI)

0.10 [0.03, 0.18]

4.1 Perceptions + participant

2

206

Std. Mean Difference (Random, 95% CI)

0.03 [‐0.25, 0.30]

4.2 Perceptions + clinician

1

633

Std. Mean Difference (Random, 95% CI)

0.13 [‐0.03, 0.29]

4.3 Practicalities + participant

5

1752

Std. Mean Difference (Random, 95% CI)

0.21 [0.03, 0.38]

4.4 Both + participant

2

833

Std. Mean Difference (Random, 95% CI)

0.08 [‐0.16, 0.32]

4.5 Both + clinician

2

231

Std. Mean Difference (Random, 95% CI)

‐0.01 [‐0.27, 0.24]

5 Adherence: medication type subgroups Show forest plot

10

3655

Std. Mean Difference (Random, 95% CI)

0.10 [0.03, 0.18]

5.1 Nicotine replacement therapy

7

3442

Std. Mean Difference (Random, 95% CI)

0.09 [0.02, 0.17]

5.2 Bupropion

2

152

Std. Mean Difference (Random, 95% CI)

0.58 [0.14, 1.01]

5.3 Varenicline

1

61

Std. Mean Difference (Random, 95% CI)

‐0.22 [‐0.73, 0.29]

6 Dichotomous adherence data (for calculation purposes) Show forest plot

6

1664

Odds Ratio (M‐H, Random, 95% CI)

1.53 [1.05, 2.21]

7 Continuous adherence data (for calculation purposes) Show forest plot

5

4604

Std. Mean Difference (IV, Random, 95% CI)

0.11 [0.03, 0.19]

8 Short‐term smoking abstinence (< 6 months) Show forest plot

5

1795

Risk Ratio (M‐H, Random, 95% CI)

1.08 [0.96, 1.21]

9 Long‐term smoking abstinence (≥ 6 months) Show forest plot

5

3593

Risk Ratio (M‐H, Random, 95% CI)

1.16 [0.96, 1.40]

Figuras y tablas -
Comparison 1. Medication adherence intervention plus standard care versus standard care alone