Tobacco Translating evidence and policy into clinical practice
Dr Leonie Brose
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Outline Evidence Translation Current policy Current
practice
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The design-evaluation cycle Treatment concept/ innovation
Evaluation Implementation Evaluation 3 Randomised trials
Quasi-experiments Efficacy Service monitoring Effectiveness
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Smoking cessation efficacy: Brief advice 4 Stead et al 2013,
Cochrane Relative risks (95% Confidence interval): VBA: 1.66 (1.42
to 1.94) More extensive advice: 1.84 (1.60 to 2.13) Interpretation:
Assuming unassisted quit rate of 2 - 3%, brief physician advice can
increase quitting by a further 1 - 3% (42 to 113% of 3% = 1-3%)
Aveyard et al 2012, Addiction Advice increased quit attempts by 24%
(95% CI: 16-33%) Offering behavioural support increased quit
attempts by 117% (95% CI: 52-210%) Offering prescription increased
quit attempts by 68% (95%CI: 48-89%)
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Efficacy: Medication 5 Figure: Stead et al 2012, Cahill et al
2012, Cochrane reviews Compared with placebo Cahill et al, 2013,
Review of medication reviews All those shown in figure and
bupropion superior to placebo Bupropion equal to single NRT
Combination NRT and varenicline superior to single NRT
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Efficacy: Behavioural support 6 Strong evidence base Individual
vs brief advice (Lancaster & Stead, 2005) Group vs self-help
(Stead & Lancaster, 2009) Treat intervention with caution,
evidence weak or inconsistent Internet vs nothing (Civljak et al,
2013) Text messaging vs control messages (Whittaker et al, 2012)
Written materials: N=15,117 (Lancaster & Stead, 2005)
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The design-evaluation cycle Treatment concept/ innovation
Evaluation Implementation Evaluation 7 Randomised trials
Quasi-experiments Efficacy Service monitoring Effectiveness
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NHS Stop Smoking Services in England Available for any smoker
making a quit attempt Set up in 1999/2000, world first Deliver
behavioural support and medication to support quit attempt Various
settings: Home, primary care, pharmacy, specialist clinics,
workplace Medication options: none, single or combination NRT,
varenicline, rarely: bupropion, combinations of medications Support
options: one-to-one support, groups, sometimes couple or family
Increase chance of quitting 4-fold compared with no support
(Ferguson et al, 2005)
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126,890 treatment episodes in 24 services Assessed association
between intervention characteristics and 4- week CO-verified
success rates adjusting for key smoking and demographic
characteristics 9 Major independent predictors of success were:
Specialist treatment rather than primary care Group rather than
one-to-one Use of varenicline or combination NRT rather than single
NRT Major independent predictors of success were: Specialist
treatment rather than primary care Group rather than one-to-one Use
of varenicline or combination NRT rather than single NRT
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Clinical Effectiveness Medication Interpretation: If Odds ratio
(green line) above 1 and Confidence Interval (blue bar) does not
cross 1, we are confident that this option increases the odds of
quitting compared with the other option.
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Clinical Effectiveness Support Type
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Clinical Effectiveness Setting
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Outline Evidence Translation Current policy Current
practice
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1.Intervention Development 2. Feasibility & Piloting 3.
Evaluation (e.g. RCT, effectiveness, cost- effectiveness) 4.
Evidence 5. Dissemination of findings (produce unbiased, usable
report; ensure full publication accessible) 6. Evidence synthesis
(e.g. systematic review) 8. Treatment manuals 9. Training 10.
Clinical Practice (intervention/ care delivered by health care
professionals, systems, organisations) 11. Receipt of
evidence-based intervention/care by individual(s) 12. Enactment of
targeted behaviour change by individual 13. Desired health outcomes
7. Evidence-based recommendations/ guidelines. Policy (?) Based on
MRC guidance (Craig et al. 2008) and Chalmers & Glasziou (2009)
Translating evidence into practice (Lorencatto, 2013)
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One example of training
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Very brief advice training trailer 16 www.ncsct.co.uk/vba
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Theoretical domains and questions for investigating
implementation of evidence-based guidelines (Michie et al, 2005)
DomainQuestions (examples) KnowledgeDo they know about the
guideline? SkillsDo they know how to do x? Social/professional role
and identity What is the purpose of the guidelines? What do they
think about the credibility of the source? Beliefs about
capabilities (self- efficacy) How difficult or easy is it for them
to do x? How confident are they that they can do x despite the
difficulties? Beliefs about consequencesWhat do they think will
happen if they do not do x? Motivation and goalsHow much do they
feel they need to do x? Memory, attention and decision processes
Will they remember to do x? How? How much attention will they have
to pay to do x? Environmental context and resources Are there
competing tasks and time constraints? Are the necessary resources
available? Social influences (Norms)To what extent do social
influences facilitate or hinder x? EmotionDoes doing x evoke an
emotional response?Does emotion affect x? Behavioural regulationAre
there procedures or ways of working that encourage x? Nature of the
behavioursWho needs to do what differently when, where, how, how
often and with whom?
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Outline Evidence Translation Current policy Current
practice
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19 Department of Health (1999) Smoking Kills
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Tobacco Control Plan 2010 Aspirations: Reduce smoking
prevalence by end of 2015 -In adults to 18.5% 2010: 21%, 2012: 19%
-Among 15 year olds to 12% 2010: 15%, 2012: 10% -In pregnancy at
time of delivery to 11% 2010: 12% Strands 1.Stopping promotion of
tobacco 2.Making Tobacco less affordable 3.Effective regulation of
tobacco products 4.Helping tobacco users to quit 5.Reducing
exposure to second-hand smoke 6.Effective communications for
tobacco control
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National Institute of Health and Care Excellence (NICE)
Pathway
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Policy/Practice Guidance on Commissioning Delivery Data
recording Statistics on Services Clients Support Outcomes
Self-reported and CO-verified abstinence 4 weeks after quit
date
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Outline Obtaining evidence and current evidence Translation of
evidence to practice Current policy Current practice
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24 Relative success rates of quit attempts in England
Significantly better than no aid adjusting for confounding
variables, p