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The American Journal of Managed Care November 2015
Community Pharmacy Automatic Refill Program Improves Adherence to Maintenance Therapy and Reduces Wasted Medication
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Physician Response to Patient Request for Unnecessary Care
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Anticoagulation in Atrial Fibrillation: Impact of Mental Illness
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Will Preoperative Smoking Cessation Programs Generate Long-Term Cessation? A Systematic Review and Meta-Analysis
Nicholas L. Berlin, MD, MPH; Christina Cutter, MD, MSc; and Catherine Battaglia, PhD, RN

Will Preoperative Smoking Cessation Programs Generate Long-Term Cessation? A Systematic Review and Meta-Analysis

Nicholas L. Berlin, MD, MPH; Christina Cutter, MD, MSc; and Catherine Battaglia, PhD, RN
This review demonstrates the long-term (≥12 months) efficacy of preoperative smoking cessation programs, providing further support for incorporation of smoking cessation programs into presurgical clinics.

Objectives: The aim of this review was to examine published randomized controlled trials (RCTs) and quasi-experimental studies that evaluate the association between preoperative smoking cessation programs and long-term smoking cessation at a minimum of 6 months, postoperatively.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review was performed utilizing MEDLINE, EMBASE, CINAHL, PSYCHinfo, and COCHRANE databases. All eligible studies of smoking-cessation interventions initiated preoperatively, with cessation measured at a minimum of 6 months postoperatively, were identified. The effect of cessation interventions at 12 months postoperatively in RCTs was evaluated through meta-analyses using Mantel-Haenszel risk ratios (RRs) and 95% CIs. A fixed effects model was conducted initially; however, due to heterogeneity in study characteristics and patient cohorts, a more conservative random effects model was also performed.

Results: Four RCTs and 4 quasi-experimental studies were included. Two RCTs demonstrated an association between interventions and cessation at 12 months, and the quasi-experimental studies showed cessation rates of 48% to 56% at 12 months, postoperatively. In a fixed effects model, interventions were associated with a greater likelihood of cessation at 12 months (RR, 1.50; 95% CI, 1.05-2.15; P = .02), although this effect was not statistically significant after applying a random effects model (RR, 1.61; 95% CI, 0.88-2.96; P = .12).

Conclusions: The literature suggests that preoperative smoking cessation programs will likely precipitate long-term (≥12 months) cessation. Additional studies should identify approaches that optimize preoperative cessation programs in the promotion of short-term, and long-term cessation.

Am J Manag Care. 2015;21(11):e623-e631
Take-Away Points
This systematic review and meta-analysis of 4 randomized controlled trials and 4 quasi-experimental studies supports the long-term (≥12 months) efficacy of preoperative smoking cessation programs.
  • The efficacy and cost-effectiveness of smoking cessation programs in the context of presurgical clinics in the United States is understudied.
  • Nurse-driven cessation programs may optimize the effect of preoperative cessation intervention; however, further trials are needed to elucidate optimal approaches to preoperative cessation programs.
Tobacco use is the leading cause of preventable death not only in the United States, but worldwide.1 Each year, 5 million deaths are attributed to tobacco use, with projections suggesting that by 2020, tobacco will kill more people than any single disease pathology—an annual mortality increase to 8 million by 2030.1-3 Further, smokers die on average 10 years earlier than their nonsmoking counterparts.1,4 These are particularly troubling trends in the context of plateaued progress in smoking cessation rates since 1990.3

Diseases associated with tobacco use include, though are not limited to, cancer, cardiovascular disease, respiratory disease, and both ischemic and embolic events. In the United States alone, the economic cost and healthcare expenditure associated with tobacco use is estimated at $97 billion and $96 billion, respectively.1 In a paradigm emphasizing cost reduction in healthcare provision, tobacco use should be a prime target for behavioral intervention to generate cost savings.

In the primary care setting, patients present to their primary care physician with multiple complaints at a majority of appointments; therefore, integration of preventative protocols may continuously prove more challenging. Alternate strategies should be explored; perioperative care presents a unique opportunity in both patient capture and incentivization.

It is estimated that approximately 10 million tobacco smokers undergo surgical intervention in the United States each year.5-7 Moreover, surgery precipitates spontaneous uptake of risk-reducing health behaviors8—it is a documented “teachable moment” for smoking cessation.9 Studies suggest that preoperative smoking cessation interventions can increase postoperative abstinence by up to 60%,10 with each additional week of cessation producing an improved cumulative effect.11 Surgeons, anesthesiologists, nurses, and other presurgical staff should seize this opportunity, not only to improve surgical outcomes, but also to promote smoking cessation.

After adjusting for demographic characteristics and baseline cigarette consumption, patients who have undergone continuous cessation for longer periods (≥3 months) are more likely to be continuously abstinent at approximately 2 years12—this highlights the importance of assessing long-term cessation. Additionally, despite a robust foundation of literature discussing the effectiveness of perioperative care as a teachable moment for smoking cessation at 3 months, few studies examine the effect at periods longer than 3 months.13

Two systematic reviews conducted in 2008 and 2010 to evaluate the impact of preoperative smoking cessation programs solicited the need for additional studies to more fully assess the impact of preoperative smoking cessation interventions on long-term abstinence.13,14 This systematic review and meta-analysis sought to evaluate the current literature with regard to the impact of preoperative smoking cessation programs on long-term cessation beyond 6 months postoperatively.

Search Strategy

Two authors (NLB and CMC) independently conducted a literature search using: 1) Ovid MEDLINE, 2) Ovid EMBASE, 3) EBSCO CINAHL, 4) Ovid PSYCHinfo, and 5) the COCHRANE Database of Systematic Reviews, Database of Abstracts and Review of Effects, and Central Register of Controlled Trials for studies published prior to July 19, 2013.

The authors searched Ovid MEDLINE with the following search strategy: first, they performed a search including the Medical Subject Heading (MeSH) terms and Boolean connectors, “smoking cessation” (exploded and focused) OR “tobacco use cessation” (exploded and focused) AND “” OR “perioperative care” (exploded) OR “perioperative period” (exploded) OR “anesthesia” (exploded) with an additional limit to the English language. This produced 208 articles. Similar search strategies were applied to the Ovid EMBASE (344 articles), EBSCO CINAHL (148 articles), and Cochrane databases (66 articles). The authors also searched Ovid PSYCHinfo with the MeSH term, key words, and Boolean connectors, “smoking cessation” (expanded and focused) AND “surgery” or “surgical patients,” which produced 20 articles.

Study Selection, Inclusion and Exclusion Criteria

After duplicates were removed, the authors independently screened the 506 remaining abstracts against the following inclusion and exclusion criteria defined a priori (Figure 1). Studies that met eligibility for inclusion employed a smoking cessation intervention begun preoperatively with a primary or secondary outcome of smoking cessation. In addition, only prospective interventional studies, including randomized controlled trials (RCTs) or quasi-experimental study designs, were considered for inclusion to improve the specificity of patient information reported, as well as to evaluate a prospectively designed cessation intervention. The remaining studies were excluded if smoking cessation was not measured at a minimum of 6 months postoperatively, if the sample included patients not undergoing surgery, or if the intervention failed to include a behavioral component of the smoking cessation program. The inclusion of an individualized behavioral component in smoking cessation programs, such as motivational interviewing, has been shown to assist with smoking cessation.15

Two authors (NLB and CMC) independently reviewed potentially eligible studies and selected relevant studies for inclusion in this review. All disagreements were resolved through discussion between the 2 authors until consensus was achieved. Of the 506 articles initially identified, the authors excluded 341 upon review of titles and abstracts; among the 165 remaining articles, 157 were excluded upon full review of the article against the exclusion criteria. The 2 most common reasons for exclusion were: 1) failure to meet study design inclusion criteria and 2) no smoking cessation intervention was performed.

Data Extraction and Statistical Analysis

Two authors (NLB and CMC) extracted data independently; discrepancies were resolved through reexamination until consensus was achieved. Extracted data included study design, sample size, patient demographics, depression screening, preoperative assessment of alcohol intake, type of surgery, intervention duration, intervention start relative to operation date, cessation team, modes of contact, postoperative follow-up period, nicotine-replacement therapy (NRT) use, and the method of verifying cessation at 6, 9, and 12 months.

All statistical analyses were performed using RevMan5 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).16 Mantel-Haenszel risk ratios and 95% CIs assuming both fixed and random effects models were used for the meta-analysis. Heterogeneity was tested using the I2 statistic, with a value of less than 25% representing no heterogeneity; 25% to 49%, low heterogeneity; 50% to 74%, moderate heterogeneity; and 75% or more, high heterogeneity.17

Eight studies18-25 met full eligibility criteria and, consequently, were included in this review. The studies took place in an array of developed countries (including Australia,20 Canada,21 Sweden,22 Denmark,23,24 the United Kingdom,25 and the United States18,19), and all, except a single article,18 were published between 2000 and 2010, included academic and nonacademic facilities, and encompassed a broad range of surgical specialties. In total, 716 patients were included, of which 604 patients were involved in RCTs. The characteristics of the 8 included studies are summarized in Table 1.

Study Populations

There were similarities and differences in patient demographics comprising the study samples. Patient age was relatively consistent.20-24 Gender was not equally distributed between the studies; female constitution of the intervention groups ranged from 22%18 to 100%,23 with the latter attributable to the context of a breast cancer clinic.

In the RCTs, potential confounding and effect-modifying variables were measured and controlled. The study samples included a broad spectrum of surgery types, including general, orthopedic, vascular, breast, and thoracic, as well as obstetrics and gynecology. The effect of alcohol intake was controlled through exclusion criteria or randomization in 4 studies.21-24 Depression or depressive symptoms were measured and controlled through exclusion criteria or randomization in 4 studies.21-24 The Fagerstrom Test for Nicotine Dependence, a validated test26 of physiological dependence, was included in the baseline assessment of 5 studies.19,21-24

Intervention Characteristics

The specific intervention characteristics of the preoperative smoking cessation programs are summarized in Table 2. All smoking cessation interventions included a behavioral component, as well as follow-up of at least 6 months postoperatively. The intervention length ranged from a single 45- to 90-minute counseling session23 to 2 counseling sessions over the course of 6 months.25 The intervention was either “brief” (no extension into the post hospital discharge period) or “extended” (extension into the post hospital discharge period); 5 of the studies applied a brief intervention approach,18,20,23-25 and the remaining studies employed an extended approach.19,21,22

The cessation interventions began a minimum of 3 to 7 days23 to a maximum of 6 months25 preoperatively, and, most commonly, emphasized a theme of self-efficacy.19-24 Four of the reviewed studies utilized a nurse-driven approach19,21,22,24 and 1 study utilized an interactive computerized smoking cessation program.20 All but a single study20 employed a face-to-face method of contact during the intervention, with 3 studies also including phone contact.19,21,22 NRT was offered free of charge in 4 studies21-24 and was highly encouraged in 1 quasi-experimental study.19 Only 2 studies indicated the timing or length of the NRT: in 1 study,23 patients were given nicotine replacement 6 to 8 weeks prior to the operation, and in the other study,23 patients were given the therapy during the perioperative period of 2 days before the operation until 10 days postoperatively.

The verification method for smoking cessation at 6, 9, and 12 months postoperatively varied among the studies. Three studies utilized biochemical verification through measuring either expired carbon monoxide or urine cotinine,19,21,24 and the 5 remaining studies relied on self-reporting of smoking cessation behavior.

Effect of Cessation Program

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