不同疾病处理水平对戒烟的影响：随机试验
2009/06/24
背景：吸烟是一种慢性、复发性疾病，但在初级卫生保健机构中重视不够。
目的：比较单纯采用药物治疗的吸烟者与合并采用包括咨询、咨询反馈在内的其它中或高强度疾病处理方案的吸烟者戒烟率的差异。
设计：随机临床试验从2004年6月-2007年12月。
地点：50个乡村初级卫生保健机构。
对象：750名每天吸烟超过10支的受试者。
干预措施：单独药物治疗组250人，药物加中等强度疾病处理方案（最多2次电话咨询；n = 249）、药物加高强度疾病处理方案（最多6次电话咨询通话；n = 251）。干预措施每6个月给予1次，持续2年。所有受试者给予免费药物治疗。接受中等或高强度疾病处理方案的受试对象，其咨询后的进展报告都会传真给医生。
检测：检测24个月后自述的戒烟率（主要结果）以及全程戒烟分析（0-24个月）、药物使用情况、与医生对吸烟问题的讨论情况（次要结果）。让不了解治疗分组情况的辅助研究人员对结果进行评价。
结果：几组间药物使用情况类似，在第一、二、三、四个治疗周期中，药物使用率分别为63.8％（473/741）、40.9％（302/739）、23.9％（175/732）、24.7％（179/726）。给定时间点与医生会面的受试者中，37.5%～59.5%自述与医生讨论戒烟相关问题，这在各治疗组间未见显著性差异。戒烟率在整个研究过程中都不断增加，全程分析显示，高强度疾病处理方案组的戒烟率显著高于中等强度组（OR为1.43；95% CI, 1.00-2.03 ），而且联合治疗组高于单纯药物治疗组（OR为1.47；95％CI, 1.08-2.00）。24个月后自述戒烟者比例在高强度和中等强度疾病处理方案组分别为27.9%（68/244）和23.5%（56/238）（OR为 1.33；95％CI, 0.88-2.02），药物单独治疗组为23.0%（56/244）（与联合治疗相比OR为 1.12；95％CI, 0.78－1.61）。
局限性：药物治疗作用不能与免费提供药物这个因素分开。而且仅有58％自述戒烟的患者达到了有效戒烟。
结论：吸烟者试图通过反复药物辅助治疗，以达到戒烟的目的，从而使戒烟率逐步增加。虽然组间24个月后的戒烟率无显著差异，但对24个月治疗进行全程分析显示，高强度疾病处理方案与戒烟率增加相关。
结论：吸烟者试图通过反复药物辅助治疗，以达到戒烟的目的，从而使戒烟率逐步增加。虽然组间24个月后的戒烟率无显著差异，但对24个月治疗进行全程分析显示，高强度疾病处理方案与戒烟率增加相关。
（刘国梁 审校）
Ellerbeck EF, et al. Ann Intern Med. 2009 Apr 7;150(7):437-46.
Effect of varying levels of disease management on smoking cessation: a randomized trial.
BACKGROUND: Cigarette smoking is a chronic, relapsing illness that is inadequately addressed in primary care practice.
OBJECTIVE: To compare cessation rates among smokers who receive pharmacotherapy alone or combined with either moderate- or high-intensity disease management that includes counseling and provider feedback.
DESIGN: Randomized clinical trial from June 2004 to December 2007.
SETTING: 50 rural primary care practices.
PARTICIPANTS: 750 persons who smoke more than 10 cigarettes per day.
INTERVENTION: Pharmacotherapy alone (n = 250), pharmacotherapy supplemented with up to 2 counseling calls (moderate-intensity disease management) (n = 249), or pharmacotherapy supplemented with up to 6 counseling calls (high-intensity disease management) (n = 251). Interventions were offered every 6 months for 2 years. All participants were offered free pharmacotherapy. Moderate-intensity and high-intensity disease management recipients had postcounseling progress reports faxed to their physicians.
MEASUREMENTS: Self-reported, point-prevalence smoking abstinence at 24 months (primary outcome) and overall (0 to 24 months) analyses of smoking abstinence, utilization of pharmacotherapy, and discussions about smoking with physicians (secondary outcomes). Research assistants who were blinded to treatment assignment conducted outcome assessments.
RESULTS: Pharmacotherapy utilization was similar across treatment groups, with 473 of 741 (63.8%), 302 of 739 (40.9%), 175 of 732 (23.9%), and 179 of 726 (24.7%) participants requesting pharmacotherapy during the first, second, third, and fourth 6-month treatment cycles, respectively. Of participants who saw a physician during any given treatment cycle, 37.5% to 59.5% reported that they had discussed smoking cessation with their physician; this did not differ across the treatment groups. Abstinence rates increased throughout the study, and overall (0 to 24 months) analyses demonstrated higher abstinence among the high-intensity disease management group than the moderate-intensity disease management group (odds ratio [OR], 1.43 [95% CI, 1.00 to 2.03) and among the combined disease management groups than the pharmacotherapy-alone group (OR, 1.47 [CI, 1.08 to 2.00]). Self-reported abstinence at 24 months was 68 of 244 (27.9%) and 56 of 238 (23.5%) participants in the high- and moderate-intensity disease management groups, respectively (OR, 1.33 [CI, 0.88 to 2.02]), and 56 of 244 (23.0%) participants in the pharmacotherapy-alone group (OR, 1.12 [CI, 0.78 to 1.61] for combined disease management vs. pharmacotherapy alone).
LIMITATION: The effect of pharmacotherapy management cannot be separated from the provision of free pharmacotherapy, and cessation was validated in only 58% of self-reported quitters. CONCLUSION: Smokers are willing to make repeated pharmacotherapy-assisted quit attempts, leading to progressively greater smoking abstinence. Although point-prevalence abstinence did not differ at 24 months, analyses that incorporated assessments across the full 24 months of treatment suggest that higher-intensity disease management is associated with increased abstinence.
PRIMARY FUNDING SOURCE: National Cancer Institute.
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COPD患者中的戒烟干预：随机试验的网络荟萃分析
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在住院的年轻精神病患者中戒烟动机访谈对精神活性药物使用情况的影响
