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      Tobacco cessation interventions for young people

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          Abstract

          Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the update of a Cochrane Review first published in 2006. To evaluate the effectiveness of strategies that help young people to stop smoking tobacco. We searched the Cochrane Tobacco Addiction Group's Specialized Register in June 2017. This includes reports for trials identified in CENTRAL, MEDLINE, Embase and PsyclNFO. We included individually and cluster‐randomized controlled trials recruiting young people, aged under 20 years, who were regular tobacco smokers. We included any interventions for smoking cessation; these could include pharmacotherapy, psycho‐social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months' follow‐up among those who smoked at baseline. Two review authors independently assessed the eligibility of candidate trials and extracted data. We evaluated included studies for risk of bias using standard Cochrane methodology and grouped them by intervention type and by the theoretical basis of the intervention. Where meta‐analysis was appropriate, we estimated pooled risk ratios using a Mantel‐Haenszel fixed‐effect method, based on the quit rates at six months' follow‐up. Forty‐one trials involving more than 13,000 young people met our inclusion criteria (26 individually randomized controlled trials and 15 cluster‐randomized trials). We judged the majority of studies to be at high or unclear risk of bias in at least one domain. Interventions were varied, with the majority adopting forms of individual or group counselling, with or without additional self‐help materials to form complex interventions. Eight studies used primarily computer or messaging interventions, and four small studies used pharmacological interventions (nicotine patch or gum, or bupropion). There was evidence of an intervention effect for group counselling (9 studies, risk ratio (RR) 1.35, 95% confidence interval (CI) 1.03 to 1.77), but not for individual counselling (7 studies, RR 1.07, 95% CI 0.83 to 1.39), mixed delivery methods (8 studies, RR 1.26, 95% CI 0.95 to 1.66) or the computer or messaging interventions (pooled RRs between 0.79 and 1.18, 9 studies in total). There was no clear evidence for the effectiveness of pharmacological interventions, although confidence intervals were wide (nicotine replacement therapy 3 studies, RR 1.11, 95% CI 0.48 to 2.58; bupropion 1 study RR 1.49, 95% CI 0.55 to 4.02). No subgroup precluded the possibility of a clinically important effect. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions. Our certainty in the findings for all comparisons is low or very low, mainly because of the clinical heterogeneity of the interventions, imprecision in the effect size estimates, and issues with risk of bias. There is limited evidence that either behavioural support or smoking cessation medication increases the proportion of young people that stop smoking in the long‐term. Findings are most promising for group‐based behavioural interventions, but evidence remains limited for all intervention types. There continues to be a need for well‐designed, adequately powered, randomized controlled trials of interventions for this population of smokers. Background Worldwide, between 80,000 and 100,000 young people start smoking every day. Many adolescent tobacco programmes focus on preventing teenagers from starting to smoke, but some programmes have been aimed at helping those teenagers who are already smoking to quit. We set out to investigate whether these programmes can help young people quit smoking for six months or longer. Searches are up to date as of June 2017. Study characteristics We identified 41 studies (around 13,000 participants) that researched ways of helping teenagers to quit smoking. These studies were of mixed quality and looked at various methods for stopping smoking, including one‐to‐one counselling, counselling as part of a group, methods using computers or text messaging, or a combination of these. Four studies used drug treatments such as nicotine patches. Most studies recruited participants from schools, and 29 of the studies were carried out in North America. Key results Although some programmes showed promise, especially those that used group counselling and those that combined a variety of approaches, there was no strong evidence that any particular method was effective in helping young people to stop smoking. Trials differed in how they measured whether a person had quit smoking, and many trials did not have enough participants for us to be confident about wider application of the results. Medications such as nicotine replacement and bupropion were not shown to be successful with adolescents, and some adverse events were reported, although these events were generally mild and findings were based on studies with small numbers of participants. Based on these findings we cannot currently identify a programme for helping adolescents to stop smoking that is more successful than trying to stop unaided. Quality of the evidence The quality of evidence was low or very low for all of the outcomes in this review. This is because of issues with the quality of some of the studies, the small number of studies and participants for some outcomes, and the differences between the studies.

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          Most cited references 204

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          Measures of abstinence in clinical trials: issues and recommendations.

          A workgroup formed by the Society for Research on Nicotine and Tobacco reviewed the literature on abstinence measures used in trials of smoking cessation interventions. We recommend that trials report multiple measures of abstinence. However, at a minimum we recommend that trial: (a) report prolonged abstinence (i.e., sustained abstinence after an initial period in which smoking is not counted as a failure) as the preferred measure, plus point prevalence as a secondary measure; (b) use 7 consecutive days of smoking or smoking on > or = 1 day of 2 consecutive weeks to define treatment failure; (c) include non-cigarette tobacco use, but not nicotine medications in definitions of failure; and (d) report results from survival analysis to describe outcomes more fully. Trials of smokers willing to set a quit date should tie all follow-ups to the quit date and report 6- and/or 12-month abstinence rates. For these trials, we recommend an initial 2-week grace period for prolonged abstinence definitions; however, the period may vary, depending on the presumed mechanism of the treatment. Trials of smokers who may not be currently trying to quit should tie follow-up to the initiation of the intervention and should report a prolonged abstinence measure of > or = 6-month duration and point prevalence rates at 6- and 12-month follow-ups. The grace period for these trials will depend on the time necessary for treatment dissemination, which will vary depending on the treatment, setting, and population. Trials that use short-term follow-ups ( or = 4 weeks. We again recommend a 2-week grace period; however, that period can vary.
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            Cigarette smoking and depression: tests of causal linkages using a longitudinal birth cohort.

            Research on the comorbidity between cigarette smoking and major depression has not elucidated the pathways by which smoking is associated with depression. To examine the causal relationships between smoking and depression via fixed-effects regression and structural equation modelling. Data were gathered on nicotine-dependence symptoms and depressive symptoms in early adulthood using a birth cohort of over 1000 individuals. Adjustment for confounding factors revealed persistent significant (P<0.05) associations between nicotine-dependence symptoms and depressive symptoms. Structural equation modelling suggested that the best-fitting causal model was one in which nicotine dependence led to increased risk of depression. The findings suggest that the comorbidity between smoking and depression arises from two routes; the first involving common or correlated risk factors and the second a direct path in which smoking increases the risk of depression. This evidence is consistent with the conclusion that there is a cause and effect relationship between smoking and depression in which cigarette smoking increases the risk of symptoms of depression.
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              Individual behavioural counselling for smoking cessation.

              Individual counselling from a smoking cessation specialist may help smokers to make a successful attempt to stop smoking.
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                Author and article information

                Journal
                Cochrane Database of Systematic Reviews
                Wiley
                14651858
                November 17 2017
                Affiliations
                [1 ]University of Oxford; Nuffield Department of Primary Care Health Sciences; Oxford UK
                Article
                10.1002/14651858.CD003289.pub6
                6486118
                29148565
                © 2017
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