NIHR Signal Group-based interventions may help teenagers stop smoking

Published on 30 January 2018

There is no single clear intervention that helps young people quit smoking in the UK, but this review shows that group counselling is one that may be effective.

Interventions included in this review were diverse, for example, computer or text-based, group or individual counselling. Drug treatments such as nicotine patches were included too. Although the review was large, including 41 trials involving more than 13,000 young people, most interventions were not shown to be effective. In contrast, about a third more of those taking part in group counselling quit smoking compared with controls.

Given the high cost to the NHS attributed to smoking-related illness and the uptake of smoking in teenage years, finding effective interventions for this age group is imperative. This review suggests that using group counselling as one tactic might be effective.

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Why was this study needed?

Smoking is the main cause of preventable disease and early death in England and is the main reason for the difference in healthy life expectancy between the most and least deprived people. Overall, 3% of UK youth aged 16 and under smoked at least one cigarette a day in 2014. This figure is down from 5% in 2010. These 2014 data also show that 18% of children under age 16 had tried smoking. Many smokers report that they started smoking as teenagers and peer pressure at this age is known to be an important factor in encouraging uptake.

It is estimated that smoking costs the NHS £1.5 billion a year, without taking into account other costs such as the cost of sickness benefits paid by the government, the costs to industry or to the individual or families of those who smoke.

Previous reviews had found that no single model of intervention could be recommended for young people. This review looked to update previous reviews with 15 new studies.  

What did this study do?

This review of tobacco cessation interventions looked at 41 studies involving 13,000 participants mostly aged under 20, in high-income countries. The majority were from the US, with only one from the UK.

Studies were included where young participants had smoked at least once a week, for at least six months. Participants were either individually randomised or randomised by group to interventions for smoking cessation compared with minimal therapy as a control. These included counselling in a group, individual counselling, computer-based interventions, text messaging or drug treatments, such as nicotine patches. Smoking status was assessed at least six months later.

There was wide variability between study types, and many did not use biochemical validation of cessation, leading to a risk of bias and reducing any confidence in the findings (graded low).

What did it find?

  • There was evidence that interventions involving group counselling, some peer-led, were effective at stopping smoking after at least six months follow-up, pooled relative risk (RR) 1.35 (95% confidence interval [CI] 1.03 to 1.77), 1,910 participants in nine trials. About 19 in every 100 adolescents in the counselling group managed to stop compared to 14 in every 100 in the minimal control groups.
  • Studies involving individual counselling as the intervention were not found to be effective, pooled RR 1.07 (95% CI 0.83 to 1.39).
  • Studies involving computer-based interventions, interventions using text messaging or computer-based with face-to-face counselling interventions were not found to be effective for young people.
  • The pooled outcomes of the drug-treatment interventions were also not found to be effective.

What does current guidance say on this issue?

NICE guidelines 2013 suggest smoking cessation services should be aimed at everyone who smokes or uses any other form of tobacco.

The 2013 guideline for all ages recommends that interventions proven effective to be implemented, including brief interventions, which involve opportunistic discussion and advice, with referral to more intense treatment when necessary. It is likely that some of these might still be effective at younger ages, so might also be considered.  Suggested individual interventions for adults can involve face-to-face meetings with a trained counsellor, drug treatment, self-help materials, telephone counselling.

What are the implications?

This review updates evidence on interventions for stopping smoking among young people.

Given that smoking in teenage years is a strong predictor for smoking in adulthood, stopping smoking in those who start at a young age is of great importance.

Interventions included in this review were some of those recommended by the NICE guidelines and some of these have been proven effective at older ages based on more trials. However only group counselling was found to be somewhat effective in this review and resulted in an extra five in 100 participants stopping. This adds to the call to adapt interventions to the ages and real-life triggers and pressures of smokers, such as peer group opinions and support.

Based on these results, no single intervention appeared better than in the control groups, though the researchers say that combined interventions with multiple delivery methods showed promise.

Citation and Funding

Fanshawe TR, Halliwell W, Lindson N, et al. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2017;11:CD003289.

This project was funded by the NIHR who fund the Cochrane Tobacco Addiction Group through a Cochrane Infrastructure Award.

Bibliography

Grimshaw GM, Stanton A. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2006;(4):CD003289.

NICE. Stop smoking services: key priorities. PH10. London: National Institute for Health and Care Excellence; 2013.

NICE. Stop smoking services: public health needs and practice. PH10. London: National Institute for Health and Care Excellence; 2013.

NICE. Stop smoking services: recommendations. PH10. London: National Institute for Health and Care Excellence; 2013.

Why was this study needed?

Smoking is the main cause of preventable disease and early death in England and is the main reason for the difference in healthy life expectancy between the most and least deprived people. Overall, 3% of UK youth aged 16 and under smoked at least one cigarette a day in 2014. This figure is down from 5% in 2010. These 2014 data also show that 18% of children under age 16 had tried smoking. Many smokers report that they started smoking as teenagers and peer pressure at this age is known to be an important factor in encouraging uptake.

It is estimated that smoking costs the NHS £1.5 billion a year, without taking into account other costs such as the cost of sickness benefits paid by the government, the costs to industry or to the individual or families of those who smoke.

Previous reviews had found that no single model of intervention could be recommended for young people. This review looked to update previous reviews with 15 new studies.  

What did this study do?

This review of tobacco cessation interventions looked at 41 studies involving 13,000 participants mostly aged under 20, in high-income countries. The majority were from the US, with only one from the UK.

Studies were included where young participants had smoked at least once a week, for at least six months. Participants were either individually randomised or randomised by group to interventions for smoking cessation compared with minimal therapy as a control. These included counselling in a group, individual counselling, computer-based interventions, text messaging or drug treatments, such as nicotine patches. Smoking status was assessed at least six months later.

There was wide variability between study types, and many did not use biochemical validation of cessation, leading to a risk of bias and reducing any confidence in the findings (graded low).

What did it find?

  • There was evidence that interventions involving group counselling, some peer-led, were effective at stopping smoking after at least six months follow-up, pooled relative risk (RR) 1.35 (95% confidence interval [CI] 1.03 to 1.77), 1,910 participants in nine trials. About 19 in every 100 adolescents in the counselling group managed to stop compared to 14 in every 100 in the minimal control groups.
  • Studies involving individual counselling as the intervention were not found to be effective, pooled RR 1.07 (95% CI 0.83 to 1.39).
  • Studies involving computer-based interventions, interventions using text messaging or computer-based with face-to-face counselling interventions were not found to be effective for young people.
  • The pooled outcomes of the drug-treatment interventions were also not found to be effective.

What does current guidance say on this issue?

NICE guidelines 2013 suggest smoking cessation services should be aimed at everyone who smokes or uses any other form of tobacco.

The 2013 guideline for all ages recommends that interventions proven effective to be implemented, including brief interventions, which involve opportunistic discussion and advice, with referral to more intense treatment when necessary. It is likely that some of these might still be effective at younger ages, so might also be considered.  Suggested individual interventions for adults can involve face-to-face meetings with a trained counsellor, drug treatment, self-help materials, telephone counselling.

What are the implications?

This review updates evidence on interventions for stopping smoking among young people.

Given that smoking in teenage years is a strong predictor for smoking in adulthood, stopping smoking in those who start at a young age is of great importance.

Interventions included in this review were some of those recommended by the NICE guidelines and some of these have been proven effective at older ages based on more trials. However only group counselling was found to be somewhat effective in this review and resulted in an extra five in 100 participants stopping. This adds to the call to adapt interventions to the ages and real-life triggers and pressures of smokers, such as peer group opinions and support.

Based on these results, no single intervention appeared better than in the control groups, though the researchers say that combined interventions with multiple delivery methods showed promise.

Citation and Funding

Fanshawe TR, Halliwell W, Lindson N, et al. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2017;11:CD003289.

This project was funded by the NIHR who fund the Cochrane Tobacco Addiction Group through a Cochrane Infrastructure Award.

Bibliography

Grimshaw GM, Stanton A. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2006;(4):CD003289.

NICE. Stop smoking services: key priorities. PH10. London: National Institute for Health and Care Excellence; 2013.

NICE. Stop smoking services: public health needs and practice. PH10. London: National Institute for Health and Care Excellence; 2013.

NICE. Stop smoking services: recommendations. PH10. London: National Institute for Health and Care Excellence; 2013.

Tobacco cessation interventions for young people

Published on 18 November 2017

Fanshawe, T. R.,Halliwell, W.,Lindson, N.,Aveyard, P.,Livingstone-Banks, J.,Hartmann-Boyce, J.

Cochrane Database Syst Rev Volume 11 , 2017

IncludedBACKGROUND: Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the update of a Cochrane Review first published in 2006. OBJECTIVES: To evaluate the effectiveness of strategies that help young people to stop smoking tobacco. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialized Register in June 2017. This includes reports for trials identified in CENTRAL, MEDLINE, Embase and PsyclNFO. SELECTION CRITERIA: We included individually and cluster-randomized controlled trials recruiting young people, aged under 20 years, who were regular tobacco smokers. We included any interventions for smoking cessation; these could include pharmacotherapy, psycho-social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months' follow-up among those who smoked at baseline. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility of candidate trials and extracted data. We evaluated included studies for risk of bias using standard Cochrane methodology and grouped them by intervention type and by the theoretical basis of the intervention. Where meta-analysis was appropriate, we estimated pooled risk ratios using a Mantel-Haenszel fixed-effect method, based on the quit rates at six months' follow-up. MAIN RESULTS: Forty-one trials involving more than 13,000 young people met our inclusion criteria (26 individually randomized controlled trials and 15 cluster-randomized trials). We judged the majority of studies to be at high or unclear risk of bias in at least one domain. Interventions were varied, with the majority adopting forms of individual or group counselling, with or without additional self-help materials to form complex interventions. Eight studies used primarily computer or messaging interventions, and four small studies used pharmacological interventions (nicotine patch or gum, or bupropion). There was evidence of an intervention effect for group counselling (9 studies, risk ratio (RR) 1.35, 95% confidence interval (CI) 1.03 to 1.77), but not for individual counselling (7 studies, RR 1.07, 95% CI 0.83 to 1.39), mixed delivery methods (8 studies, RR 1.26, 95% CI 0.95 to 1.66) or the computer or messaging interventions (pooled RRs between 0.79 and 1.18, 9 studies in total). There was no clear evidence for the effectiveness of pharmacological interventions, although confidence intervals were wide (nicotine replacement therapy 3 studies, RR 1.11, 95% CI 0.48 to 2.58; bupropion 1 study RR 1.49, 95% CI 0.55 to 4.02). No subgroup precluded the possibility of a clinically important effect. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions. Our certainty in the findings for all comparisons is low or very low, mainly because of the clinical heterogeneity of the interventions, imprecision in the effect size estimates, and issues with risk of bias. AUTHORS' CONCLUSIONS: There is limited evidence that either behavioural support or smoking cessation medication increases the proportion of young people that stop smoking in the long-term. Findings are most promising for group-based behavioural interventions, but evidence remains limited for all intervention types. There continues to be a need for well-designed, adequately powered, randomized controlled trials of interventions for this population of smokers.

Expert commentary

Smoking cessation interventions are not very effective among young people, and this is likely to reflect the speed at which dependence on nicotine can appear. New approaches are needed to help young people quit so that they do not compromise the health of others including any future children they may have themselves and, as they age, put their health at risk.

Nevertheless, smoking prevalence is falling among young people in the UK; thus other tobacco control elements may have been effective, perhaps chiefly by reducing uptake.

The impact of e-cigarettes requires further study in this age group.

Dr Rosemary Hiscock, Research Associate, UK Centre for Tobacco and Alcohol Studies, Department for Health, University of Bath