CANCER PREVENTION INSTITUTE OF CANADA

Last updated: 15-Jan-2007

Summary

The logic model reproduced at the head of this section provided a convenient framework for organizing the interventions reviewed in this section of the report. The task that remains is to summarize the results, so that the various approaches are prioritized according to relative effectiveness as indicated by high quality research studies. This summary will use the same three categories as a framework, namely interventions to reduce initiation rates, interventions to increase cessation rates, and interventions to reduce ETS exposure. Inevitably, there are various kinds of overlap between the categories.

The proposed evaluation grid attempts to capture two criteria at the same time: effectiveness and strength of evidence. There are three meta-categories:

1. interventions of proven effectiveness with strong evidence
2. interventions of promising effectiveness with moderate or mixed evidence
3. interventions of no or low effectiveness and / or with insufficient evidence

The effectiveness test relates mostly to actual decreases in smoking (or exposure to second-hand smoke) rather than “softer” targets such as expanded knowledge about the harmful effects of smoking or increased intentions to quit. The evidence test places a high premium on support from multiple RCTs as reviewed by groups such as the Cochrane Collaboration, though other valid research modalities also play a significant role.

It is now commonplace to recommend integrated approaches to health promotion across a wide range of risk factors, chronic diseases and interventions. Although the evidence from controlled trials of community-wide, multi-component programs has been disappointing, the circumstantial evidence, for instance, of California’s success with a state-wide tobacco control campaign and Florida’s experience with reduced youth smoking, continues to motivate the development of such comprehensive strategies at regional and local levels. Such a commitment, however, does not answer critical questions about selecting, prioritizing and staging the component interventions. What is required in every jurisdiction, including B.C., is to seek and select interventions that will maximize the overall impact on the desired outcomes as efficiently as possible.

Interventions to Reduce Initiation Rates

1. Interventions of proven effectiveness with strong evidence

• Increased taxation on tobacco products (this may be the single most effective intervention).

• Control of activities promoting tobacco consumption (e.g. advertising, power wall displays, sponsorship of sporting events, smoking in movies).

2. Interventions of promising effectiveness with moderate or mixed evidence

• School curricular programs focusing on social influence training.

• Smoke-free school policies.

• Multi-component community programs (e.g., school plus media efforts).

• Controlling tobacco sales to minors (effectiveness is very dependent on enforcement).

• Encouragements to not attend movies which glamorize smoking.

• Encouragements to create smoke-free homes.

3. Interventions of no or low effectiveness and / or with insufficient evidence

• School curricula based on methods other than social influence training.

Interventions to Increase Cessation Rates

1. Interventions of proven effectiveness with strong evidence

• Increased taxation on tobacco products (this may be the single most effective intervention, including with pregnant women).

• Consumer utilization of nicotine replacement therapy (over-the-counter).

• Sustained encouragements to physicians to treat smoking.

• Intensive counselling, including group therapy. Youth cessation can be one effective target.

• Regular clinical use of all forms of nicotine replacement therapy (NRT), plus the antidepressant bupropion. Aboriginal smoking cessation may be one effective target for NRT.

• High- and low-intensity counselling of pregnant women who smoke.

• For the mentally ill, drug treatment, combined with group work (in the case of schizophrenic patients) or individual cognitive-behavioural therapy (in the case of depression).

• Cessation advice in the context of an adverse health event, particularly when combined with NRT.

2. Interventions of promising effectiveness with moderate or mixed evidence

• Counter-advertising and other forms of media advocacy (if well-designed).

• Ensuring that insurance and / or public reimbursement plans cover patient costs (for counselling and any drugs).

• Ensuring that clinicians are compensated for counselling time.

• Second-line drug treatment using notriptyline or clonidine.

• Proactive telephone support (especially involving multiple contacts) and partner support (especially when parallel enhancement program is in place).

• Self-help materials (especially when personalized and combined with other interventions).

• Workplace smoking cessation campaigns (the key factor is the employee participation rate).

• Workplace smoking bans and poster campaigns.

• NRTs with pregnant women who smoke.

• Cessation help-lines, particularly if there are multiple pro-active contacts.

3. Interventions of no or low effectiveness and / or with insufficient evidence

• Basic encouragements to physicians to treat smoking.

• Use of serotonin selective reuptake inhibitors, anxiolytics and lobeline.

• Televised “how to quit” programs.

• Quit competitions and workplace incentives.

• Partner support with pregnant women who smoke.

• Basic information distributed about pregnancy and smoking.

• Motivational interviewing with adolescent psychiatric patients.

• Web based cessation programs (insufficient evidence).

Interventions to Reduce ETS Exposure (Especially in Children)

1. Interventions of proven effectiveness with strong evidence

• None.

2. Interventions of promising effectiveness with moderate or mixed evidence

• Intensive counselling to reduce ETS exposure, especially identifying parents in healthcare settings.

• Legislating smoking bans in public places.

3. Interventions of no or low effectiveness and / or with insufficient evidence

• Assertive requests to refrain from smoking in public places.

• Community-based interventions to reduce ETS exposure (other than bans).

• Brief advice to carers to reduce ETS exposure.

• Legislating smoking bans in mental health settings.