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Meta-Analysis
. 2015 Jul 6;2015(7):CD006886.
doi: 10.1002/14651858.CD006886.pub2.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

Jürgen Barth  1 , Tiffany Jacob, Ioana Daha, Julia A Critchley
Affiliations
Meta-Analysis

Psychosocial interventions for smoking cessation in patients with coronary heart disease

Jürgen Barth et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.

Objectives: This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.

Search methods: The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.

Selection criteria: Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.

Data collection and analysis: Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).

Main results: We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).

Authors' conclusions: Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

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Conflict of interest statement

None known.

Figures

1
1
Flow chart of study selection
2
2
Funnel plot of comparison: 1 Initial analysis: Efficacy of psychosocial interventions on abstinence (6 to 12 months; all trials), outcome: 1.1 Abstinence 6 to 12 months (ITT preferred over completer).
3
3
Funnel plot of comparison: 2 Efficacy of psychosocial interventions on abstinence (6 to 12 months; all trials), outcome: 2.1 Abstinence 6 to 12 months (ITT preferred over completer).
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
5
5
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Initial analysis: Efficacy of psychosocial interventions on abstinence all trials, Outcome 1 Abstinence 6 to 12 months (ITT preferred over completer).
2.1
2.1. Analysis
Comparison 2 Efficacy of psychosocial interventions on abstinence without outliers, Outcome 1 Abstinence 6 to 12 months (ITT preferred over completer).
3.1
3.1. Analysis
Comparison 3 Forest plot: Stratified analysis by risk of bias indicators, Outcome 1 Abstinence 6 to 12 months.
3.2
3.2. Analysis
Comparison 3 Forest plot: Stratified analysis by risk of bias indicators, Outcome 2 Abstinence 6 to 12 months.
3.3
3.3. Analysis
Comparison 3 Forest plot: Stratified analysis by risk of bias indicators, Outcome 3 Abstinence 6 to 12 months.
3.4
3.4. Analysis
Comparison 3 Forest plot: Stratified analysis by risk of bias indicators, Outcome 4 Abstinence at 6 to 12 months.
4.1
4.1. Analysis
Comparison 4 Forest plot: Stratified analysis by type of intervention (6 to 12 months), Outcome 1 Abstinence 6 to 12 months BEHAVIORAL THERAPY.
4.2
4.2. Analysis
Comparison 4 Forest plot: Stratified analysis by type of intervention (6 to 12 months), Outcome 2 Abstinence 6 to 12 months TELEPHONE SUPPORT.
4.3
4.3. Analysis
Comparison 4 Forest plot: Stratified analysis by type of intervention (6 to 12 months), Outcome 3 Abstinence 6 to 12 months SELF HELP MATERIALS.
4.4
4.4. Analysis
Comparison 4 Forest plot: Stratified analysis by type of intervention (6 to 12 months), Outcome 4 Abstinence 6 to 12 months Specific vs. Multi‐Risk‐Factor Intervention.
5.1
5.1. Analysis
Comparison 5 Sensitivity analysis brief / intense intervention (6 to 12 months), Outcome 1 Abstinence 6 to 12 months all studies.
6.1
6.1. Analysis
Comparison 6 Forest plot: Efficacy of psychosocial interventions on long‐term abstinence, Outcome 1 Abstinence more than 12 months (completer only).
6.2
6.2. Analysis
Comparison 6 Forest plot: Efficacy of psychosocial interventions on long‐term abstinence, Outcome 2 Abstinence more than 12 months (ITT only).
See this image and copyright information in PMC

Update of

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    1. Yorio J, Viswanathan S, See R, Uchal L, McWhorter JA, Spencer N, Murphy S, Khera A, Lemos JA, McGuire DK. The effect of a disease management algorithm and dedicated postacute coronary syndrome clinic on achievement of guideline compliance: results from the parkland acute coronary event treatment study. Journal of Investigative Medicine 2008;56(1):15‐25. - PubMed
Zwisler 2005 {published data only}
    1. Zwisler AD, Schou L, Soja AM, Bronnum‐Hansen H, Gluud C, Iversen L, Sigurd B, Madsen M, Fischer‐Hansen J, Danrehab group. A randomized clinical trial of hospital‐based, comprehensive cardiac rehabilitation versus usual care for patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease (the DANREHAB trial)‐‐design, intervention, and population. American heart journal 2005;150(5):899. - PubMed

References to studies awaiting assessment

Becker 2003 {published data only}
    1. Becker BM, Bock BC, Partridge RA. Smoking cessation interventions in the emergency department for smokers with chest pain. Acadademic Emergency Medicine 2003;10(5):507.
Boulay 2001 {published data only}
    1. Boulay P, Prud'Homme D. Risk factor management after short‐term versus long‐term cardiac rehabilitation program. Coronary Health Care 2001;5(3):133‐40.
Enriquez‐Puga 2001 {published data only}
    1. Enriquez‐Puga A, Khunti K. Secondary prevention of coronary heart disease in primary care. Journal of Clinical Governance 2001;9(4):211‐22.
Puente‐Silva 1989 {published data only}
    1. Puente‐Silva FG, Cicero R, Gonzalez E, Ocampo A. Comparative study of four programs for smoking cessation among chronic cardiorespiratory patients [Estudio comparativo de cuatro programas para el abandono del tabaquismo en pacientes cronicos cardiorespiratorios]. Revista Intercontinental de Psicologia y Educacion 1989;2(3):113‐31.

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