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QUESTION: What is the effectiveness of smoking cessation interventions delivered by nurses?
Studies were identified by searching the Cochrane Tobacco Addiction Review Group specialised register (which includes studies identified from Medline, EMBASE/Excerpta Medica, and PsycLIT, and by handsearches of specialist journals, conference proceedings, and bibliographies) using the terms nurse or health visitor. CINAHL was also searched from 1983 using the terms nursing, smoking cessation, and intervention.
Randomised trials were selected if they evaluated the effectiveness of nursing smoking cessation interventions (defined as provision of advice or other information and strategies to help patients to stop smoking) for adults; had ≥2 treatment groups; and had ≥6 months of follow up. Studies were excluded if the sample included pregnant women, if they compared advice alone with advice plus nicotine replacement therapy, or if no outcome data were provided on smoking cessation rates.
Data were extracted on study setting and design, sample size, definition of a “smoker,” description of the intervention and its intensity, outcomes, and biochemical validation. Main outcome was smoking cessation, defined using the strictest available criteria for abstinence (eg, sustained cessation rather than point prevalence). Studies were assessed for quality and rated for efforts to control for selection bias.
19 studies met the selection criteria; 17 involved patients from hospitals or primary care settings and 18 involved adults with diagnosed health problems. 14 studies reported smoking cessation validated by biochemical analysis of body fluids or expired carbon monoxide. Meta-analysis included 15 studies (n=7912) and was done on an intention to treat basis. At longest follow up, patients who received advice from a nurse were more likely to stop smoking than those who received usual care (table).
Nursing interventions (primarily advice to stop smoking) increase smoking cessation rates among adults.
Rice and Stead's review of 19 articles and their conclusions provide intriguing information about smoking cessation counselling approaches delivered by nurses. They indicate that healthcare providers have an important role in developing and implementing smoking cessation interventions. They also contend that healthcare providers need to include smoking risk assessment for every patient. Finally, they recommend that additional research is needed on the systematic use of nurse delivered smoking cessation interventions. Because nurses are often the gatekeepers for people entering the healthcare system, they could easily incorporate smoking risk assessments.1
Other areas need to be considered when evaluating the conclusions of this review. These interpretations were made based upon 19 studies. Although this is a respectable number compared with other meta-analyses, it means that many of the subanalyses were based on only a small number of trials. This is a potential problem because some of the results of these subanalyses differ somewhat from those of the larger reviews. For example, a smoking cessation intervention as part of a multifactorial intervention was effective for patients with cardiovascular disease (3 studies) whereas the smoking cessation intervention alone was not effective for these or other patients admitted to hospital. Only 1 study included patients with cardiovascular disease who were not in hospital and reported a statistically significant relative risk and a barely significant risk difference.
Sources of funding: National Health Service Research & Development Programme, UK; American Heart Association, USA.
For correspondence: Professor V H Rice, College of Nursing, Wayne State University, 5557 Cass Avenue, Detroit, MI 48202, USA. Fax +1 313 577 5777.
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