System change interventions for smoking cessation

Dennis Thomas; Michael J Abramson; Billie Bonevski; Johnson George

doi:10.1002/14651858.CD010742.pub2

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Summary of findings for the main comparison. System change interventions for tobacco control

System change interventions for tobacco control (primary cessation outcome)
Patient or population: Smokers Settings: Any healthcare delivery setting Intervention: System change
Outcomes*	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
Cessation outcome Self‐reported/verified abstinence Follow‐up: 6 to 24 months	7142 (4 studies)	⊕⊝⊝⊝ very low^1,2	2 of the 4 studies significantly favoured the intervention. Mixed effect and low quality evidence preclude drawing conclusions
NB. Illustrative comparative risks and relative effects columns have been removed, as only narrative syntheses were conducted due to the presence of significant heterogeneity among studies.
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.
¹Self‐reported abstinence was verified only in one study, and one study reported higher dropout rate in one group. ²High clinical heterogeneity among included studies; outcomes are measured at different time points, and in different settings.

Summary of findings for the main comparison. System change interventions for tobacco control

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Summary of findings 2. System change interventions for tobacco control

System change interventions for tobacco control (secondary outcomes)
Patient or population: Smokers Settings: Any healthcare delivery setting Intervention: System change
Outcomes*	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
Provision of cessation counselling Proportion of smokers counselled to quit	10,949 (4 studies)	⊕⊕⊝⊝ low^1,2,3	3 of the 4 studies significantly favoured the intervention. The low quality of the evidence precludes drawing conclusions
Asking about tobacco use Proportion of smokers asked about tobacco use	2615 (3 studies)*	⊕⊕⊝⊝ low^1,3	2 of the 3 studies significantly favoured the intervention. The low quality of the evidence precludes drawing conclusions
Provision of cessation advice Proportion of smokers advised to quit	3003 (3 studies)*	⊕⊕⊝⊝ low^1,3	2 of the 3 studies significantly favoured the intervention. The low quality of the evidence precludes drawing conclusions
Quitline referral Proportion of smokers referred to quitline	3006 (3 studies)*	⊕⊝⊝⊝ very low^1,3	All 3 studies significantly favoured the intervention. However, the low quality of the evidence precludes drawing conclusions
Quitline enrolment Proportion of smokers enrolled in quitline	1191 (2 studies)*	⊕⊝⊝⊝ very low^1,3	Both studies significantly favoured the intervention. However, the low quality of the evidence precludes drawing conclusions
Prescription of NRT or other pharmacotherapy Proportion of smokers received NRT prescription	2615 (2 studies)	⊕⊕⊝⊝ low^1,3	Of the 2 studies, 1 significantly favoured the intervention. Mixed effect and low‐quality evidence preclude drawing conclusions
NB. Illustrative comparative risks and relative effects columns have been removed, as only narrative syntheses were conducted due to the presence of significant heterogeneity among studies *We have not included data from one study as the data were collected as counts (no denominator)
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.
¹Included studies had high risk of detection bias. ²Large difference in effect size between studies. ³High clinical heterogeneity among included studies; different settings, providers and intervention.

Summary of findings 2. System change interventions for tobacco control

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Table 1. Components of interventions in included studies

	Identification/ documentation of smoking status	Smoking cessation Training/ resources/feedback to providers	Dedicated staff to support cessation activities	Policies to improve access to cessation interventions	Free smoking cessation treatment from the organization	Reimburse clinicians for providing smoking cessation support
Cabezas 2011	Yes	Yes	No	No	Yes	No
Gordon 2010	Yes	Yes	No	No	Yes	No
Joseph 2004	Yes	Yes	No	Yes	Yes	No
Little 2009	Yes	Yes	No	Yes	Yes	No
Patwardhan 2012	Yes	Yes	No	Yes	Yes	No
Rothemich 2010	Yes	Yes	No	Yes	Yes	No
Winickoff 2013	Yes	Yes	No	Yes	Yes	No

Table 1. Components of interventions in included studies

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Table 2. Summary of secondary outcomes

Study	Asking about tobacco use	Documentation of smoking status	Advice to quit	Counselling to quit	Initiation of NRT or other pharmacotherapy	Quitline referral	Quitline enrolment
Cabezas 2011	Not assessed	Not assessed	Not assessed	Not assessed	Not assessed	Not assessed	Not assessed
Gordon 2010	Not assessed	Not assessed	Not assessed	Not assessed	Not assessed	Not assessed	Not assessed
Joseph 2004	No difference between groups (76.0% vs 74.3%; P = 0.71)	Favoured intervention (60.7% vs 67.0%; P < 0.001)	Not assessed	No difference between groups (73.9% vs 71.8%; P = 0.60)	No difference between groups (14.7% vs 18.0%; P = 0.38)	Not assessed	Not assessed
Little 2009	Not assessed	Not assessed	Not assessed	Favoured intervention (69% vs 3%; P < 0.01)	Not assessed	Not assessed	Not assessed
Patwardhan 2012*	Favoured intervention (636 vs 5; P < 0.001)	Not assessed	Favoured intervention (25 vs 3; P < 0.01)	Not assessed	Not assessed	Favoured intervention (240 vs 85; P = 0.02)	Favoured intervention (81 vs 8; P < 0.001)
Rothemich 2010	Not assessed	Not assessed	No difference between groups (58.2% vs 55.3%; P = 0.39).	Favoured intervention (34.4% vs 27.7%; P = 0.001)	Not assessed	Favoured intervention (21.4% vs 8.7%; P < 0.001)	Not assessed
Winickoff 2013	Favoured intervention (59.4% vs 32.6%; P < 0.001)	Not assessed	Favoured intervention (50.5% vs 26.9%; P < 0.001).	Favoured intervention (54.7% vs 19.2%; P < 0.001)	Favoured intervention (18.5% vs 2.4%; P < 0.001)	Favoured intervention (37.2% vs 9.3%; P < 0.001)	Favoured intervention (4.1% vs 1.1%; P < 0.01)
*data collected as counts (no denominator)

Table 2. Summary of secondary outcomes

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