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Smoking Cessation: Treatment Intensity and Outcome in Randomized Clinical Trials
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The primary aim was to compare the effectiveness of smoking cessation interventions of different intensities in a clinical dental and a telephone setting in Sweden.

Methods: A total of 300 smokers were randomized to High or Low Intensity Treatment (HIT or LIT) at the Public Dental Service, County Council of Västmanland. Effectiveness (abstinence rate) was measured after 1yr (paper I) and 5-8yrs (paper III). A cost-effectiveness analysis was conducted, based on intervention costs, number of abstinent participants after 1yr, and a Markov modelling of future costs and health (in QALYs) consequences (paper II). In paper IV, 586 callers to the Swedish National Tobacco Quitline (SNTQ) were randomized to high-intensity proactive or low-intensity reactive service, and effectiveness was measured after 1 yr. Effectiveness measures were self-reported point prevalence, 6-month continuous abstinence, and sustained abstinence.

Results: Absolute quit rates were 7% higher with HIT than with LIT on all measures and increased by 8% from 1yr to 5-8yrs. Point prevalence was 23% vs. 16% (p=.11) after 1yr and 31% vs. 24% (p=.16) after 5-8yrs. Six-month continuous abstinence was 18% vs. 9% (p =.02) after 1yr and 26% vs.19% (p=.18) after 5-8yrs. Sustained abstinence was 12% vs. 5% (p =.03) after 5-8yrs. Nicotine dependence was a strong predictor for abstinence at 1yr and achieved abstinence at 1yr was a strong predictor for abstinence at long-term follow-up. The cost-effectiveness analysis showed that both HIT and LIT were cost-effective, and LIT was even cost-saving compared with doing nothing. HIT was more costly and more effective than LIT, and the cost of each extra QALY gained by HIT was 100,000SEK, which is considered very cost-effective in Sweden. Proactice and reactive services were equally effective at the SNTQ. Point prevalence was 27% and 6-month continuous abstinence was 21% after 1yr. Being smoke-free at baseline was the strongest predictor for abstinence at 1yr.

Conclusion: Support at high as well as low intensity in a clinical dental setting in Sweden and at the SNTQ was effective in achieving smoking cessation. Both high- and low-intensity interventions were very cost-effective in a clinical dental setting.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. , 131 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 945
Keyword [en]
RCT, cost-effectiveness, dental setting, quitline, long-term follow-up, proactive, reactive, tobacco
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-208972ISBN: 978-91-554-8791-1 (print)OAI: oai:DiVA.org:uu-208972DiVA: diva2:658729
Public defence
2013-12-05, Samlingssalen, Ingång 29, Västmanlands sjukhus Västerås, Västerås, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2013-11-14 Created: 2013-10-11 Last updated: 2014-01-23
List of papers
1. Comparison of a high and a low intensity smoking cessation intervention in a dentistry setting in Sweden: a randomized trial
Open this publication in new window or tab >>Comparison of a high and a low intensity smoking cessation intervention in a dentistry setting in Sweden: a randomized trial
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2009 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 9, 121- p.Article in journal (Refereed) Published
Abstract [en]

Background

Tobacco is still the number one life style risk factor for ill health and premature death and also one of the major contributors to oral problems and diseases. Dentistry may be a potential setting for several aspects of clinical public health interventions and there is a growing interest in several countries to develop tobacco cessation support in dentistry setting. The aim of the present study was to assess the relative effectiveness of a high intensity intervention compared with a low intensity intervention for smoking cessation support in a dental clinic setting.

Methods

300 smokers attending dental or general health care were randomly assigned to two arms and referred to the local dental clinic for smoking cessation support. One arm received support with low intensity treatment (LIT), whereas the other group was assigned to high intensity treatment (HIT) support. The main outcome measures included self-reported point prevalence and continuous abstinence (≥ 183 days) at the 12-month follow-up.

Results

Follow-up questionnaires were returned from 86% of the participants. People in the HIT-arm were twice as likely to report continuous abstinence compared with the LIT-arm (18% vs. 9%, p = 0.02). There was a difference (not significant) between the arms in point prevalence abstinence in favour of the HIT-protocol (23% vs. 16%). However, point prevalence cessation rates in the LIT-arm reporting additional support were relatively high (23%) compared with available data assessing abstinence in smokers trying to quit without professional support.

Conclusion

Screening for willingness to quit smoking within the health care system and offering smoking cessation support within dentistry may be an effective model for smoking cessation support in Sweden. The LIT approach is less expensive and time consuming and may be appropriate as a first treatment option, but should be integrated with other forms of available support in the community. The more extensive and expensive HIT-protocol should be offered to those who are unable to quit with the LIT approach in combination with other support.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-129000 (URN)10.1186/1471-2458-9-121 (DOI)000266934100001 ()
Available from: 2010-08-05 Created: 2010-08-05 Last updated: 2017-12-12Bibliographically approved
2. Comparison of the Cost-Effectiveness of a High- and a Low-Intensity Smoking Cessation Intervention in Sweden: A Randomized Trial
Open this publication in new window or tab >>Comparison of the Cost-Effectiveness of a High- and a Low-Intensity Smoking Cessation Intervention in Sweden: A Randomized Trial
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2013 (English)In: Nicotine & tobacco research, ISSN 1462-2203, E-ISSN 1469-994X, Vol. 15, no 9, 1519-1527 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To assess the relative cost-effectiveness of a high-intensity treatment (HIT) and a low-intensity treatment (LIT) for smoking cessation. Methods: The societal and health care perspective economic evaluation was based on the reported number of quitters at 12-month follow-up (point prevalence) from a randomized controlled trial of 2 smoking cessation programs in Sweden. Future disease-related costs (in Swedish honor [SEK] 2004; SEK7.35 = USD1) and health effects (in quality-adjusted life-years [QALYs]) were estimated via a Markov model comprising lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease including stroke with costs and QALYs discounted 3% annually. Results: HIT was more effective than LIT (23% vs. 16% quitters), but at a considerably higher intervention cost: SEK26,100 versus 9,100 per quitter. The model-estimated societal costs avoided did not balance the higher intervention costs, so the incremental cost-effectiveness ratio (ICER) amounted to SEK100,000 per QALY for HIT versus LIT. All sensitivity analyses indicated an ICER below SEK300,000 and that HIT is the preferred option if the decision maker willingness-to-pay exceeds SEK50,000 per QALY. Compared with no intervention, LIT was cost saving, whereas HIT was estimated at SEK8,400 per QALY. Conclusions: Compared with no smoking cessation program, it is a societal waste not to implement the LIT as it is estimated to result in lower societal costs. The incremental cost per QALY gained of SEK100,000 for HIT is considered very cost-effective in Sweden. Thus, if smoking cessation programs are judged in the same manner as other Swedish health care measures, the high-intensity program should be chosen before the low-cost program.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-207521 (URN)10.1093/ntr/ntt009 (DOI)000323191100006 ()
Available from: 2013-09-17 Created: 2013-09-16 Last updated: 2017-12-06Bibliographically approved
3. Long-term follow-up of a high- and a low-intensity smoking cessation intervention in a dental setting- a randomized trial
Open this publication in new window or tab >>Long-term follow-up of a high- and a low-intensity smoking cessation intervention in a dental setting- a randomized trial
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2013 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, 592- p.Article in journal (Refereed) Published
Abstract [en]

Background: Achieving lifelong tobacco abstinence is an important public health goal. Most studies use 1-year follow-ups, but little is known about how good these are as proxies for long-term and life-long abstinence. Also, intervention intensity is an important issue for development of efficient and cost-effective cessation treatment protocols. The study aims were to assess the long-term effectiveness of a high-and a low-intensity treatment (HIT and LIT) for smoking cessation and to analyze to what extent 12-month abstinence predicted long-term abstinence. Methods: 300 smokers attending dental or general health care were randomly assigned to HIT or LIT at the public dental clinic. Main outcome measures were self-reported point prevalence, continuous abstinence (>= 6 months), and sustained abstinence. The study was a follow-up after 5-8 years of a previously performed 12-month follow-up, both by postal questionnaires. Results: Response rate was 85% (n=241) of those still alive and living in Sweden. Abstinence rates were 8% higher in both programs at the long-term than at the 12-month follow-up. The difference of 7% between HIT and LIT had not change, being 31% vs. 24% for point prevalence and 26% vs. 19% for 6-month continuous abstinence, respectively. Significantly more participants in HIT (12%) than in LIT (5%) had been sustained abstinent (p=0.03). Logistic regression analyses showed that abstinence at 12-month follow-up was a strong predictor for abstinence at long-term follow-up. Conclusions: Abstinence at 12-month follow-up is a good predictor for long-term abstinence. The difference in outcome between HIT and LIT for smoking cessation remains at least 5-8 years after the intervention.

Keyword
Tobacco cessation, Treatment intensity, Public health, Health care, Questionnaire
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-204278 (URN)10.1186/1471-2458-13-592 (DOI)000320958000001 ()
Available from: 2013-07-30 Created: 2013-07-29 Last updated: 2017-12-06Bibliographically approved
4. Effectiveness of proactive and reactive services at the Swedish National Tobacco Quitline in a randomized trial
Open this publication in new window or tab >>Effectiveness of proactive and reactive services at the Swedish National Tobacco Quitline in a randomized trial
2014 (English)In: Tobacco Induced Diseases, ISSN 1617-9625, E-ISSN 1617-9625, Vol. 12, 9- p.Article in journal (Refereed) Published
National Category
Public Health, Global Health, Social Medicine and Epidemiology Substance Abuse
Identifiers
urn:nbn:se:uu:diva-209274 (URN)10.1186/1617-9625-12-9 (DOI)000338465600001 ()
Available from: 2013-10-16 Created: 2013-10-16 Last updated: 2017-12-06Bibliographically approved

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