术前戒烟干预
2010/09/14
摘要
背景：吸烟者出现术后并发症的风险会显著增加。术前吸烟干预治疗可有效减少术后并发症的发生率，因此手术可能为患者戒烟提供一个契机。
目的：本综述旨在评价术前戒烟干预治疗对围手术期戒烟情况和术后12个月内戒烟情况的影响，及其对术后并发症的影响。
检索策略：对在Cochrane烟草成瘾组注册的研究进行检索，采用自由词和关键词（手术或麻醉）。同时使用烟草和手术相关关键词，在MEDLINE、EMBASE和CINAHL数据库中进行检索。检索截止期为2010年4月。
选择标准：入选标准包括有术前吸烟者参与、试验中采用了戒烟干预治疗措施，并对术前和术后长期的戒断率和/或术后并发症进行研究的随机对照试验。
数据收集和分析：作者对研究进行独立评价，以验证研究是否符合标准。对于结果，作者之间进行讨论形成共识。
主要结果：有1156人参与的8项试验符合本研究的入选标准。其中一项研究未将戒烟作为研究结果。2项研究进行多区段试验，术前至少进行6个月的面对面戒烟咨询。6项研究中给予了简化干预治疗。7项研究中，对部分或所有参与者推荐或给予尼古丁替代治疗（NRT）。6项研究显示，围手术期戒烟率增加，其中一项存在统计学显著差异。亚组分析显示，强化和简化的戒烟干预治疗能显著增加围手术期戒烟率：集合风险比分别为10.76 (95% CI：4.55～25.46；2项试验)和1.61 (95% CI 1.12～2.33；7项试验)。若分别集合强化治疗和简化治疗，仅强化治疗对长期戒烟率有显著影响（风险比：2.96；95% CI：1.57～5.55，2项研究）。5项试验研究戒烟干预治疗对术后并发症发生率的影响。出现任一并发症的集合风险比为0.70 (95% CI：0.56～0.88)，出现伤口并发症的集合风险比为0.70 (95% CI：0.51～0.95)。探索性亚组分析显示强化治疗对于任一并发症（风险比：0.42；95% CI：0.27～0.65）和伤口并发症的发生率（风险比：0.31；95% CI：0.16～0.62）具有显著影响。对于简化治疗，疗效无统计学差异，但在可信区间内并不排除对任一并发症（风险比：0.96；95% CI：0.74～ 1.25）和伤口并发症（风险比：0.99；95%CI：0.70～1.40）发生率存在临床有效性。
结论：术前戒烟治疗包括采用NRT戒烟，能增加短期戒断率，减少术后并发症。最佳的术前戒烟治疗强度尚不清楚。基于间接比较和来自于2项小型试验的证据，术前4～8周开始的戒烟干预治疗，包括每周咨询、使用NRT，更有可能对术后并发症的发生率和术后长期戒烟率产生影响。
（林江涛 审校）
Cochrane Database Syst Rev. 2010 Jul 7;7:CD002294.
Interventions for preoperative smoking cessation
Thomsen T, Villebro N, Møller AM.
Department of Anaesthesiology, Herlev University Hospital, Herlev Ringvej 75, Herlev, Denmark, 2730.
Abstract
BACKGROUND: Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions.
OBJECTIVES: The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively and on the incidence of postoperative complications.
SEARCH STRATEGY: The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) or (operation) or (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search April 2010.
SELECTION CRITERIA: Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking and/or the incidence of postoperative complications.
DATA COLLECTION AND ANALYSIS: The authors independently assessed studies to determine eligibility. Results were discussed between the authors.
MAIN RESULTS: Eight trials enrolling a total of 1156 people met the inclusion criteria. One of these did not report cessation as an outcome. Two trials initiated multisession face to face counselling at least 6 weeks before surgery whilst six used a brief intervention. Nicotine replacement therapy (NRT) was offered or recommended to some or all participants in seven trials. Six trials detected significantly increased smoking cessation at the time of surgery, and one approached significance. Subgroup analyses showed that both intensive and brief intervention significantly increased smoking cessation at the time of surgery; pooled RR 10.76 (95% confidence interval (CI) 4.55 to 25.46, two trials) and RR 1.41 (95% CI 1.22 to 1.63, five trials) respectively. Four trials evaluating the effect on long-term smoking cessation found a significant effect; pooled RR 1.61 (95% CI 1.12 to 2.33). However, when pooling intensive and brief interventions separately, only intensive intervention retained a significant effect on long-term smoking cessation; RR 2.96 (95% CI 1.57 to 5.55, two trials).Five trials examined the effect of smoking intervention on postoperative complications. Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for developing any complication; and 0.70 (95% CI 0.51 to 0.95) for wound complications. Exploratory subgroup analyses showed a significant effect of intensive intervention on any complications; RR 0.42 (95% CI 0.27 to 0.65) and on wound complications RR 0.31 (95% CI 0.16 to 0.62). For brief interventions the effect was not statistically significant but CIs do not rule out a clinically significant effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication, RR 0.99 (95%CI 0.70 to 1.40) for wound complications.
AUTHORS’ CONCLUSIONS: There is evidence that preoperative smoking interventions including NRT increase short-term smoking cessation and may reduce postoperative morbidity. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling, and use NRT are more likely to have an impact on complications and on long-term smoking cessation.
Cochrane Database Syst Rev. 2010 Jul 7;7:CD002294.
背景：吸烟者出现术后并发症的风险会显著增加。术前吸烟干预治疗可有效减少术后并发症的发生率，因此手术可能为患者戒烟提供一个契机。
目的：本综述旨在评价术前戒烟干预治疗对围手术期戒烟情况和术后12个月内戒烟情况的影响，及其对术后并发症的影响。
检索策略：对在Cochrane烟草成瘾组注册的研究进行检索，采用自由词和关键词（手术或麻醉）。同时使用烟草和手术相关关键词，在MEDLINE、EMBASE和CINAHL数据库中进行检索。检索截止期为2010年4月。
选择标准：入选标准包括有术前吸烟者参与、试验中采用了戒烟干预治疗措施，并对术前和术后长期的戒断率和/或术后并发症进行研究的随机对照试验。
数据收集和分析：作者对研究进行独立评价，以验证研究是否符合标准。对于结果，作者之间进行讨论形成共识。
主要结果：有1156人参与的8项试验符合本研究的入选标准。其中一项研究未将戒烟作为研究结果。2项研究进行多区段试验，术前至少进行6个月的面对面戒烟咨询。6项研究中给予了简化干预治疗。7项研究中，对部分或所有参与者推荐或给予尼古丁替代治疗（NRT）。6项研究显示，围手术期戒烟率增加，其中一项存在统计学显著差异。亚组分析显示，强化和简化的戒烟干预治疗能显著增加围手术期戒烟率：集合风险比分别为10.76 (95% CI：4.55～25.46；2项试验)和1.61 (95% CI 1.12～2.33；7项试验)。若分别集合强化治疗和简化治疗，仅强化治疗对长期戒烟率有显著影响（风险比：2.96；95% CI：1.57～5.55，2项研究）。5项试验研究戒烟干预治疗对术后并发症发生率的影响。出现任一并发症的集合风险比为0.70 (95% CI：0.56～0.88)，出现伤口并发症的集合风险比为0.70 (95% CI：0.51～0.95)。探索性亚组分析显示强化治疗对于任一并发症（风险比：0.42；95% CI：0.27～0.65）和伤口并发症的发生率（风险比：0.31；95% CI：0.16～0.62）具有显著影响。对于简化治疗，疗效无统计学差异，但在可信区间内并不排除对任一并发症（风险比：0.96；95% CI：0.74～ 1.25）和伤口并发症（风险比：0.99；95%CI：0.70～1.40）发生率存在临床有效性。
结论：术前戒烟治疗包括采用NRT戒烟，能增加短期戒断率，减少术后并发症。最佳的术前戒烟治疗强度尚不清楚。基于间接比较和来自于2项小型试验的证据，术前4～8周开始的戒烟干预治疗，包括每周咨询、使用NRT，更有可能对术后并发症的发生率和术后长期戒烟率产生影响。
（林江涛 审校）
Cochrane Database Syst Rev. 2010 Jul 7;7:CD002294.
Interventions for preoperative smoking cessation
Thomsen T, Villebro N, Møller AM.
Department of Anaesthesiology, Herlev University Hospital, Herlev Ringvej 75, Herlev, Denmark, 2730.
Abstract
BACKGROUND: Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions.
OBJECTIVES: The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively and on the incidence of postoperative complications.
SEARCH STRATEGY: The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) or (operation) or (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search April 2010.
SELECTION CRITERIA: Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking and/or the incidence of postoperative complications.
DATA COLLECTION AND ANALYSIS: The authors independently assessed studies to determine eligibility. Results were discussed between the authors.
MAIN RESULTS: Eight trials enrolling a total of 1156 people met the inclusion criteria. One of these did not report cessation as an outcome. Two trials initiated multisession face to face counselling at least 6 weeks before surgery whilst six used a brief intervention. Nicotine replacement therapy (NRT) was offered or recommended to some or all participants in seven trials. Six trials detected significantly increased smoking cessation at the time of surgery, and one approached significance. Subgroup analyses showed that both intensive and brief intervention significantly increased smoking cessation at the time of surgery; pooled RR 10.76 (95% confidence interval (CI) 4.55 to 25.46, two trials) and RR 1.41 (95% CI 1.22 to 1.63, five trials) respectively. Four trials evaluating the effect on long-term smoking cessation found a significant effect; pooled RR 1.61 (95% CI 1.12 to 2.33). However, when pooling intensive and brief interventions separately, only intensive intervention retained a significant effect on long-term smoking cessation; RR 2.96 (95% CI 1.57 to 5.55, two trials).Five trials examined the effect of smoking intervention on postoperative complications. Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for developing any complication; and 0.70 (95% CI 0.51 to 0.95) for wound complications. Exploratory subgroup analyses showed a significant effect of intensive intervention on any complications; RR 0.42 (95% CI 0.27 to 0.65) and on wound complications RR 0.31 (95% CI 0.16 to 0.62). For brief interventions the effect was not statistically significant but CIs do not rule out a clinically significant effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication, RR 0.99 (95%CI 0.70 to 1.40) for wound complications.
AUTHORS’ CONCLUSIONS: There is evidence that preoperative smoking interventions including NRT increase short-term smoking cessation and may reduce postoperative morbidity. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling, and use NRT are more likely to have an impact on complications and on long-term smoking cessation.
Cochrane Database Syst Rev. 2010 Jul 7;7:CD002294.
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