Comparative effectiveness research featured at February's MRC

At the February Medicine Research Conference, two faculty members who also serve as researchers at the Center for Health Services Research in Primary Care at the Durham VA, addressed the comparative effectiveness of smoking cessations programs. Comparative effectiveness research is designed to inform healthcare decisions by helping providers choose appropriate treatment options for patients. The presentations, by Jennifer Gierisch, PhD, MPH, and Lori Bastian, MD, covered  two kinds of comparative research: research that synthesizes evidence from existing trials, and research that conducts trials to obtain new evidence about comparative effectiveness between two or more treatments.

Smoking cessation treatments

Jennifer Gierisch, PhD, MPH, assistant professor of medicine, gave a talk titled “Comparative Effectiveness of Smoking Cessation Treatments for Patients with Depression.” Gierisch, who earned her degrees from the University of North Carolina-Chapel Hill, conduced a meta-analysis of smoking cessation interventions among patients with a history of depression or significant depressive symptoms.. Gierisch began her talk by reminding the audience that 19% of Americans smoke, and tobacco use is the nation’s greatest cause of morbidity and mortality. Half of smokers will die from their addiction, and smokers with depression have harder time quitting and are more likely to relapse. Although evidenced-based best practices exist for smoking cessation, including treatment with some antidepressants, nicotine replacement therapy, and behavior counseling, it is unclear how effective those strategies are for smokers who also have a history of depression or currently suffered from depression. Gierisch conducted a review of the literature that compared smoking cessation interventions in adults with depression. She found 16 unique trials that dealt with this issue, but only 6 trials that used depression status as inclusion criteria. Data from the remaining 10 studies included in this review were from subgroup analysis of smoking cessation trials that recruited general populations of smokers. Results showed that nicotine replacement therapy (NRT) and behavior mood management had small positive effects on six month rates of smoking cessation. Subgroup analysis suggests smoking cessation may be more likely when behavioral mood management was used in combination with nicotine replacement therapy or antidepressants; however, this contrast was not statistically significant. Participants receiving antidepressants in combination with behavioral counseling were not more likely to quit smoking compared to participants receiving behavioral counseling only. Based on the available evidence, healthcare providers should consider encouraging their patients with depression who smoke to seek smoking cessation services that include both nicotine replacement therapy and behavioral mood management therapy. “I do believe patients with depression should be offered smoking cessation treatment,” said Gierisch. “Targeting both depressive symptoms and smoking will be beneficial.”

Smoking cessation interventions

Lori Bastian, MD, MPH, associate professor of medicine and interim chief of the Division of General Internal Medicine, shared her trial findings in a lecture titled “Comparative effectiveness trial of family-supported smoking cessation intervention versus standard telephone counseling for chronically ill veterans.” The  recently completed trial studied smoking cessation among a chronically ill veteran  population who seek care at the VA. Bastian said that less than 5% of veterans get treated at VA smoking cessation clinics, so she and her team looked at telephone-delivered interventions as a way to foster cessation and make it “as easy as possible for patients to quit.” Previous studies have shown that a patient’s environment (Do they live with smokers? Do they have supportive family and friends?) impacted their motivation to stop smoking. Thus, Bastian and her team developed a family-supported telephone-based intervention that taught veterans how to maximize positive support and minimize negative messages from their families. The trial compared five sessions of standard telephone counseling or enhanced telephone counseling which contained all the elements of standard counseling but also emphasized family support strategies. All participants were offered a choice of nicotine replacement therapy as well. . In total, the study involved 471 veterans with an average age of 69. The vets could identify one family member or friend in their life who could support their decision to quit. The veterans also suffered from cancer, diabetes, COPD, and hypertension. Smoking cessation rates among those randomized to the enhanced family support intervention were no better than those with standard care (22% each after 12 months of treatment). “I’m looking at this positively,” Bastian said. “We got 1 in 5 of these chronically ill veterans to quits smoking and sustain that.” Bastian said that she would currently recommend the standard telephone therapy to healthcare providers.