Background
Prevalence and burden of tobacco smoking
Stop smoking interventions
Approved pharmacotherapies
Electronic cigarettes
Behavioural therapies
Exercise
Alternative therapies
Current clinical practice and recommendations
Canadian guidelines
Guidelines from international organizations
Objective and key questions
Stage 1: Overview of systematic reviews of stop smoking interventions
Stage 2: Updated systematic review on e-cigarette use for smoking cessation
Methods
Stage 1: Overview of systematic reviews of stop smoking interventions
Literature search
Eligibility criteria
“PICO” structured question element | Inclusion | Exclusion |
---|---|---|
Population | KQ1a/b: adults (≥ 18 years) who are current tobacco smokers (as defined by a given study/review) The overview of reviews will seek information on various population groups: • Fewer versus more quit attempts • Opportunistic versus individuals seeking treatment • Baseline level of nicotine dependence (e.g. using a validated scale or cigarettes per day as a proxy) • By demographic factors (age, SES, sex, ethnicity, LGBTQ+) • By comorbid conditions (e.g. mental illness, HIV infection, cardiovascular disease, COPD, obesity, substance use disorder) • By pregnancy status | ▪ Reviews exclusively in children/adolescents (i.e. under 18 years old) ▪ Studies that involve interventions targeted to adults other than the tobacco smoker (e.g. partners, healthcare providers) |
Intervention | KQ1a/b: interventions to promote abrupt (i.e. “all at once”) or gradual (reducing smoking to quit) tobacco smoking cessation that can be directly delivered or referred to by primary care practitioners and are available in Canadaa • Practitioner advice (of varying length/intensity, and by various provider types) o Very brief/minimal advice (as defined by a given review) o Brief advice (as defined by a given review) • Intensive individual counselling (of varying length, of varying number of sessions, and by various provider types) • Intensive group counselling (of varying length, of varying number of sessions, and by various provider types) • Self-help interventionsc(print-based or web/computer-based) • Internet or computer-based interventions with counselling/supportc • Telephone-based interventions (e.g. mobile phone-based, quit lines/help lines) with counselling/support c • Nicotine receptor partial agonists (varenicline and cytisined) • Bupropion • Nicotine replacement therapye(e.g. patch, gum, lozenge, mist, inhaler) • E-cigarettesf • Exercise interventions • “Alternative” therapies (e.g. acupuncture, acupressure, electrostimulation, hypnosis, St. John’s Wortd, S-adenosylmethionined) • Combinations of interventions Other interventions encountered in the literature will be assessed on a case-by-case basis in consultation with the WG. The overview of reviews will seek information on the effects of variations in the delivery of stop smoking interventions (e.g. dose, duration of intervention, number of session) | Interventions that cannot feasibly or readily be delivered or referred to by a wide variety of primary care practitioners: • Quit-to-win contests • Biomedical risk assessment • Aversive smoking (e.g. rapid smoking) • Incentivized cessation Reviews that focus solely on specialized behavioural counselling interventions (e.g. motivational interviewing, stage of change-based interventions).b Pharmacotherapies that are not approved by Health Canada as smoking cessation aids (e.g. clonidine, lobeline, anxiolytics, nortriptyline, opioid antagonists, silver acetate, rimonabant) or not available in Canada (e.g. Nicobrevin, Nicobloc, nicotine vaccines, mecamylamine) Broader public health interventions (e.g. mass media, taxation, packaging restrictions) Reviews on broad lifestyle interventions not specific to tobacco smoking behaviour and that do not attempt to isolate for the effect of our included interventions (when delivered as part of a multifaceted lifestyle intervention, for example) |
Comparator | KQ1a: ▪ Placebo ▪ No intervention ▪ Usual care ▪ Waitlist ▪ Minimal intervention KQ1b: ▪ Other intervention (e.g. head-to-head comparisons, comparisons of types or intensities of advice/counselling) ▪ Other combination of interventions ▪ The same intervention, but used to promote cessation by reducing smoking to quit as opposed to quitting abruptly or vice versa | |
Outcomes | Critical • Tobacco use abstinence (as defined in a given review) Important • Reduction in tobacco smoking frequency/quantity • Relapse (KQ1b only)g • Quality of life (using validated scales) • Adverse events (as defined in a given review) • Possible adverse outcomes: o Weight gain o Changes in emotional state (e.g. increases in anxiety, changes in mood, irritability) o Loss of social grouph | |
Timing of outcome assessment | For abstinence/relapse, and quality of life outcomes: ▪ Minimum 6 months from quit date (if reported) or from initiation of intervention (if quit date not specified) All other outcomes: Any point after initiation of intervention | |
Setting | ▪ Reviews in which some or all of the included studies are in settings that could serve as the primary point of contact for individuals to receive smoking cessation advice, including: • Family medicine clinics • Walk-in clinics • Smoking cessation clinics • Urgent care facilities • Emergency departments • Public health units • Pharmacies • Dental offices • Behavioural health/substance use treatment facilities (ambulatory or outpatient) • Telehealth • Academic research settings The effect of various settings may be examined | ▪ Reviews exclusively in settings not relevant to primary care including workplaces, schools, inpatient settings, and medical specialist settings ▪ Reviews in which > 50% of included studies took place in countries “high”, “medium”, or “low” on the Human Development Index http://hdr.undp.org/en/composite/HDI |
Study design | Systematici reviews Overviewsj of systematici reviews that include a network meta-analysis | • Primary studies • Editorials • Commentaries |
Language | ▪ English ▪ French | |
Dates of publications | 2008 to present |
“PICO” structured question element | Inclusion | Exclusion |
---|---|---|
Population | Adults (≥ 18 years) who are current tobacco smokers (as defined by a given study/review) The overview of reviews will seek information on various population groups: • Fewer versus more quit attempts • Opportunistic versus individuals seeking treatment • Baseline level of nicotine dependence (e.g. using a validated scale or cigarettes per day as a proxy) • By demographic factors (age, SES, sex, ethnicity, LGBTQ+) • By comorbid conditions (e.g. mental illness, HIV infection, cardiovascular disease, COPD, obesity, substance use disorder) • By pregnancy status | ▪ Reviews exclusively in children/adolescents (i.e. under 18 years old) ▪ Studies that involve interventions targeted to adults other than the tobacco smoker (e.g. partners, healthcare providers) |
Intervention | Interventions to promote abrupt (i.e. “all at once”) or gradual (reducing smoking to quit) tobacco smoking cessation that can be directly delivered or referred to by primary care practitioners and are available in Canadaa We will seek reviews which specifically examine the effectiveness of behavioural change techniques or cluster of techniques (e.g. explaining the consequences of smoking, strengthening ex-tobacco smoker identity, explaining the importance of abrupt cessation) which may be used as a component of the following behavioural change interventions: • Practitioner advice (of varying length/intensity, and by various provider types) o Very brief/minimal advice (as defined by a given review) o Brief advice (as defined by a given review) • Intensive individual counselling (of varying length, of varying number of sessions, and by various provider types) • Intensive group counselling (of varying length, of varying number of sessions, and by various provider types) • Self-help interventionsb (print-based or web/computer-based) • Internet or computer-based interventions with counselling/supportb • Telephone-based interventions (e.g. mobile phone-based, quit lines/help lines) with counselling/supportb • Combinations of interventions Behavioural change techniques delivered as part of other behavioural change interventions (i.e. other than those listed above) will be assessed on a case-by-case basis in consultation with the working group. We will seek information on intervention characteristics which may moderate the effectiveness of behavioural change techniques (e.g. duration of intervention, number of sessions) | Reviews which intend to examine behavioural change interventions rather than behavioural change techniques. |
Comparator | ▪ No intervention ▪ Usual care ▪ Waitlist ▪ Minimal intervention Behavioural change techniques or cluster of techniques delivered as part of: ▪ Other behavioural change intervention (e.g. head-to-head comparisons, comparisons of types or intensities of advice/counselling) ▪ Other combination of behavioural change interventions ▪ The same behavioural change intervention, but used to promote cessation by reducing smoking to quit as opposed to quitting abruptly or vice versa | |
Outcomes | Critical • Tobacco use abstinence (as defined in a given review) Important • Reduction in tobacco smoking frequency/quantity • Relapse (only when the comparator is an active intervention)c • Quality of life (using validated scales) • Adverse events (as defined in a given review) • Possible adverse outcomes: o Weight gain o Changes in emotional state (e.g. increases in anxiety, changes in mood, irritability) o Loss of social groupd | |
Timing of outcome assessment | For abstinence/relapse, and quality of life outcomes: ▪ Minimum 6 months from quit date (if reported) or from initiation of intervention (if quit date not specified) All other outcomes: Any point after initiation of intervention | |
Setting | Settings that could serve as the primary point of contact for individuals to receive smoking cessation advice, including: • Family medicine clinics • Walk-in clinics • Smoking cessation clinics • Urgent care facilities • Emergency departments • Public health units • Pharmacies • Dental offices • Behavioural health/substance use treatment facilities (ambulatory or outpatient) • Telehealth • Academic research settings Reviews in other settings (e.g. inpatient or specialist medical settings) will be assessed on a case-by-case basis in consultation with the working group The effect of various settings may be examined | ▪ Reviews in which > 50% of included studies took place in countries “high”, “medium”, or “low” on the Human Development Index http://hdr.undp.org/en/composite/HDI |
Study design | Systematice reviews Overviews6 of systematice reviews that include a network meta-analysis | • Primary studies • Editorials • Commentaries |
Language | ▪ English ▪ French | |
Dates of publications | 2008 to present |
Study selection
Data mapping and overlap detection
Quality assessment of systematic reviews
Data extraction and management
Subgroup analysis
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Fewer versus more quit attempts (specific groupings will depend on what is found in the literature)
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Opportunistic versus individuals seeking treatment
-
Baseline level of nicotine dependence (e.g. using a validated scale or cigarettes per day as a proxy)
-
By demographic factors (age, SES, sex, ethnicity, LGBTQ+)
-
By comorbid conditions (e.g. mental illness, HIV infection, cardiovascular disease, COPD, obesity, substance use disorder)
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By pregnancy status
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Dose, type, duration, number of sessions
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Specific forms of an intervention (e.g. yoga as a form of exercise)
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KQ1a/b: behavioural change technique (e.g. providing information on consequences of smoking, explaining the importance of abrupt cessation, receiving prompt commitment from the patient)
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Family medicine clinics
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Walk-in clinics
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Smoking cessation clinics
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Urgent care facilities
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Emergency departments
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Public health units
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Pharmacies
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Dental offices
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Behavioural health/substance use treatment facilities (ambulatory or outpatient)
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Telehealth
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Academic research settings
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By industry funding status (subgroup and/or sensitivity analyses performed in eligible reviews will be sought)
Evidence synthesis
Discordance
Quality of the body of evidence
Stage 2: Updated systematic review on electronic cigarettes for smoking cessation
Literature search
Eligibility criteria
Inclusion | Exclusion | |
---|---|---|
Population | Adults (≥ 18 years) who are current tobacco smokers (as defined by a given study) | ▪ Studies exclusively in children/adolescents (i.e. under 18 years old) ▪ Studies that involve interventions targeted to adults other than the tobacco smoker (e.g. partners, healthcare providers) |
Intervention | • Nicotine or non-nicotine containing e-cigarettesa • Nicotine or non-nicotine containing e-cigarettes combined with other smoking cessation treatment (behaviour and/or pharmacological) | Studies exclusively examining short-term use of nicotine or non-nicotine containing e-cigarettes (i.e. < 1 week) |
Comparator | KQ2a: ▪ Non-nicotine containing e-cigarettes (i.e. placebo e-cigarettes) ▪ No intervention ▪ Usual/standard care ▪ Waitlist ▪ Minimal intervention KQ2b: • Alternative nicotine containing e-cigarettes (e.g. different generation e-cigarette or e-cigarette containing a different dose of nicotine) • Non-nicotine containing e-cigarettes • Other smoking cessation aids (e.g. nicotine replacement therapy) | Studies exclusively examining short-term use of nicotine or non-nicotine containing e-cigarettes (i.e. < 1 week) |
Outcomes | Critical • Tobacco use abstinence (as defined in the study) Important • Reduction in tobacco smoking frequency/quantity • Relapse (KQ2b only)b • Quality of life (using validated scales) • Adverse events (as defined in a given review) • Possible adverse outcomes: o Weight gain o Changes in emotional state (e.g. increases in anxiety, changes in mood, irritability) o Loss of social groupc | |
Timing of outcome assessment | For abstinence/relapse, and quality of life outcomes: Minimum 6 months from quit date (if reported) or from initiation of intervention (if quit date not specified) All other outcomes: • Any point after initiation of intervention | |
Setting | Settings that could serve as the primary point of contact for individuals to receive smoking cessation advice, including: Family medicine clinics Walk-in clinics • Smoking cessation clinics • Urgent care facilities • Emergency departments • Public health units • Pharmacies • Dental offices • Behavioural health/substance use treatment facilities (ambulatory or outpatient) • Telehealth • Academic research settings | ▪ Studies in settings not relevant to primary care including workplaces, schools, inpatient settings, and medical specialist settings ▪ Studies that take place in countries “high”, “medium”, or “low” on the Human Development Index http://hdr.undp.org/en/composite/HDI |
Study design | For benefits: • Randomized controlled trials For harms: • Randomized controlled trials • Non-randomized controlled trials • Comparative observational study designs (e.g. prospective and retrospective cohort studies, case-control studies) | For benefits: • Non-randomized controlled trials • Observational study designs For harms: • Non-comparative studies • Cross-sectional studies For benefits and harms: • Systematic reviews • Case reports, case series • Editorials • Commentaries |
Language | ▪ English ▪ French | |
Dates of publication | ▪ Date of last search of the review to present date |
Study selection and data extraction
Risk of bias assessment
Analysis
Meta-analysis
Sparse binary data and studies with zero events
Subgroup analysis
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Fewer versus more quit attempts (specific groupings will depend on what is found in the literature)
-
Opportunistic versus individuals seeking treatment
-
Baseline level of nicotine dependence (e.g. using a validated scale or cigarettes per day as a proxy)
-
By demographic factors (age, SES, sex, ethnicity, LGBTQ+)
-
By comorbid conditions (e.g. mental illness, HIV infection, cardiovascular disease, COPD, obesity, substance use disorder)
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By use of other substances (alcohol, cannabis, opioids)
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By pregnancy status
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By setting (e.g. family medicine clinics, walk-in clinics, urgent care facilities)
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Nicotine content (groupings will depend on what is found in the literature)
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Intensity of behavioural therapy (groupings will depend on what is found in the literature)
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Duration of e-cigarette usage as part of the intervention (groupings will depend on what is found in the literature)
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By type or generation of e-cigarette device
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By industry funding