Treating Tobacco Use and Dependence: 2008 Update

s obtained Abstracts reviewed for inclusion/exclusion criteria by literature reviewerss reviewed for inclusion/exclusion criteria by literature reviewers Update topics chosen by Panel Full copy of each accepted article read and independently coded by at least 3 literature reviewers Evidence tables created by literature reviewers Initial meta-analyses conducted Panel reviewed relevant literature and meta-analytic results Panel formed tentative conclusions, identified need for further analyses Additional literature reviews and meta-analyses conducted Panel reviewed updated evidence and made recommendations based on evidence Manuscript drafted and reviewed by Panel Additional manuscript drafts reviewed by Panel Manuscript draft reviewed by peer reviewers and the public Manuscript revised and reviewed by Panel Manuscript submitted to PHS Overview and Methods 21 comparative effectiveness. Most of these randomized trials, however, were conducted with individuals who proactively sought treatment and who volunteered to fulfill various research requirements. It is possible that these individuals were more highly motivated to quit smoking than the typical smoker encountered in a clinical practice setting. Thus, the percentage abstinent estimates supplied with the meta-analyses may overestimate the actual level of abstinence produced by some of the treatments in real-world settings. Analyses conducted for the previous Guideline editions, though, suggest that the treatment effect sizes (odds ratios or ORs) are relatively stable across individuals seeking treatment (“treatment seekers”) and those recruited via inclusive recruitment strategies (“all-comers”). Randomized controlled trials were exclusively used in meta-analyses. However, the Panel recognized that variations in study inclusion criteria sometimes were warranted. For instance, research on tobacco interventions in adolescents frequently assigns interventions on the basis of larger units, such as schools. These units, rather than individuals, were allowed to serve as units of analysis when analyzing interventions for adolescents. In such cases, studies were combined for inclusion in meta-analyses if the study satisfied other review criteria. A similar strategy was followed in the review of health systems research. In certain areas, research other than randomized clinical trials was evaluated and considered to inform Panel opinion and judgment, though not submitted to meta-analysis. This occurred with topics such as tobacco dependence treatment in specific populations, tailoring interventions, and cost-effectiveness of tobacco dependence treatment. Literature Review and Inclusion Criteria Approximately 8,700 articles were screened to identify evaluable literature. This figure includes approximately 2,700 articles added to the literature since publication of the 2000 Guideline. These articles were obtained through searches of 11 electronic databases and reviews of published abstracts and bibliographies. An article was deemed appropriate for meta-analysis if it met the criteria for inclusion established a priori by the Panel. These criteria were that the article: (a) reported the results of a randomized, placebo/comparison controlled trial of a tobacco use treatment intervention randomized on the patient level (except as noted above); (b) provided followup results at least 5 months after the quit date (except in the case of studies evaluating tobacco dependence treatments Treating Tobacco Use and Dependence: 2008 Update 22 for pregnant smokers); (c) was published in a peer-reviewed journal; (d) was published between January 1975 and June 2007; (e) was published in English; and (f) was one of the 11 topics chosen to be included in the 2008 update (see Table 1.1). It is important to note that the article-screening criteria were updated for the 2008 Guideline update. Additionally, articles were screened for relevance to safety, economic, or health systems issues. As a result of the original and update literature reviews, more than 300 articles were identified for possible inclusion in a meta-analysis, and more than 600 additional articles were examined in detail by the Panel. These latter articles were used in the formulation of Panel recommendations that were not supported by meta-analyses. The literature search for the update project was validated by comparing the results against a search conducted by the CDC and through review by the expert Panel. When individual authors published multiple articles meeting the metaanalytic inclusion criteria, the articles were screened to determine whether they contained unique data. When two articles reported data from the same group of subjects, both articles were reviewed to ensure that complete data were obtained. The data were treated as arising from a single study in meta-analyses. Preparation of Evidence Tables Two Guideline staff reviewers independently read and coded each article that met inclusion criteria. The reviewers coded the treatment characteristics that were used in data analyses (see Tables 6.1 and 6.2 in Chapter 6). The same general coding procedure employed during the 2000 Guideline process was employed during the update. When adjustments to the coding process were made, articles coded with the original process were re-coded to reflect the changed coding (e.g., more refined coding criteria were used for the coding of treatment intensity). A third reviewer then examined the coding of both reviewers and adjudicated any differences. Discrepancies that could not be resolved through this process were adjudicated by the project manager, Panel chair, and/or the Panel’s senior scientist. Finally, each article accepted for a meta-analysis had key fields reviewed by the project manager as a final quality check. The data then were compiled and used in relevant analyses and/or Panel deliberations. Analyses done for the 2000 Guideline revealed that intervention coding categories could be used reliably by independent raters.94 Overview and Methods