Slide 1

Tobacco Translating evidence and policy into clinical practice Dr Leonie Brose

Slide 2

Outline Evidence Translation Current policy Current practice

Slide 3

The design-evaluation cycle Treatment concept/ innovation Evaluation Implementation Evaluation 3 Randomised trials Quasi-experiments Efficacy Service monitoring Effectiveness

Slide 4

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%)

Slide 5

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

Slide 6

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)

Slide 7

The design-evaluation cycle Treatment concept/ innovation Evaluation Implementation Evaluation 7 Randomised trials Quasi-experiments Efficacy Service monitoring Effectiveness

Slide 8

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)

Slide 9

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

Slide 10

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.

Slide 11

Clinical Effectiveness Support Type

Slide 12

Clinical Effectiveness Setting

Slide 13

Outline Evidence Translation Current policy Current practice

Slide 14

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)

Slide 15

One example of training

Slide 16

Very brief advice training trailer 16 www.ncsct.co.uk/vba

Slide 17

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?

Slide 18

Outline Evidence Translation Current policy Current practice

Slide 19

19 Department of Health (1999) Smoking Kills

Slide 20

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

Slide 21

National Institute of Health and Care Excellence (NICE) Pathway

Slide 22

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

Slide 23

Outline Obtaining evidence and current evidence Translation of evidence to practice Current policy Current practice

Slide 24

24 Relative success rates of quit attempts in England Significantly better than no aid adjusting for confounding variables, p