1. Moving Cochrane evidence into practice: past, present & future
Nicola Lindson-Hawley & Jamie Hartmann-Boyce
Managing Editors
Cochrane Tobacco Addiction Group
Nuffield Department of Primary Care Health Sciences
University of Oxford
@cochraneTAG
9th June 2016
UKNSCC 2016
London, UK

2. What we will cover 01 What is Cochrane 02
What is the Cochrane Tobacco Addiction Group (CTAG) 03
The impact of CTAG 04
How to use and interpret Cochrane evidence 05
Where should CTAG focus their efforts in future? 06
How should we disseminate to our users?

3. Cochrane Organisation named after Archie Cochrane
Chalmers, Chalmers and Enkin built on Archie’s work - summarised all the RCT data relating to the care of pregnant women
Published as ‘Effective Care in Pregnancy and Childbirth’ (Keirse, Grant et al. 1989)
Revolutionised perinatal care and led to the formation of the Cochrane Collaboration in 1993
Archie believed that there wasn’t enough evidence to justify most clinical practice and championed the use of randomised controlled trials

4. Cochrane
WHAT?
Gathers and combines the best evidence from research to determine the benefits and risks of treatments/interventions
HOW?
By systematically reviewing the available evidence, with strong emphasis on quality assessment
WHY?
To help healthcare providers, patients, carers, researchers, funders, policy makers, guideline developers improve their knowledge and make decisions

5. Cochrane Protocol => Review => Update
53 topic specific Review Groups, including TAG
Worldwide- based in over 100 countries
Not-for-profit- largely government funded

6. Tobacco Addiction Group (CTAG)
Founded by GPs working in the Department of Public Health at the University of Oxford (C.Silagy, T.Lancaster, G.Fowler)
The group carried out one of the first trials of nicotine patches in primary care
They met Iain Chalmers, who was establishing Cochrane, and carried out a prototype review of NRT for smoking cessation
Established CTAG in 1996, making 2016 our 20th anniversary

7. Tobacco Addiction Group (CTAG)
@cochraneTAG
Tobacco Addiction Group (CTAG)
Main focus on interventions for tobacco use & prevention
Manage approx. 90 reviews & 350 authors
Based at the University of Oxford in the Primary Care Department
Funded by the National Institute for Health Research (NIHR)
Jamie Hartmann-Boyce
Managing Editor
Paul Aveyard
Editor, University of Oxford
Lindsay Stead
Information Specialist
John Hughes
Editor, University of Vermont
Tim Lancaster
Co-ordinating Editor
Nicola Lindson-Hawley
Managing Editor
Robert West
Editor, University College London

8. CTAG’s aims To inform tobacco control policy internationally
to inform research in tobacco control, and help ensure new research is focussed on important unanswered questions
to contribute to reducing tobacco use

9. Example review: NRT Updated 10 times! Influencing healthcare guidance
Influencing treatment availability
Adapts to usage methods
Studies increase, effect size stays stable

10. Recent evidence: e-cigarettes
It is important that TAG reviews move with the times
The recent publication of the first version of our e-cigarette review was an example of this (McRobbie et al. 2014)
Highlighted the lack of high quality research in the area- only 2 RCTs met the inclusion criteria!
Received publicity worldwide, following press release & news briefing at the Science Media Centre in London, UK
Due for update this year!

11. Using and interpreting systematic reviews

12. In this session we’ll cover….
Sources of evidence
How to access systematic reviews via the Cochrane Library
How to interpret systematic reviews (key features)
Quiz

13. Where do you look for information?
Aims and structure of a Cochrane Review
There are three main reasons why systematic reviews are useful:
first, they are efficient, bringing together the whole body of research answering a specific question, and saving readers the time and expertise required to locate, appraise and interpret the results.
secondly, unlike a single study, a systematic review can help us explore the differences between studies, identifying those factors that influence the effect of an intervention.
thirdly, they aim to be reliable, presenting an unbiased, comprehensive picture of the available evidence, that can then be used to support decisions in health care, in policy, or to identify areas where future research may be needed. Traditional narrative reviews have not had this advantage – it’s often not clear how the evidence was selected for inclusion in reviews – perhaps only studies conducted in the last five years, only studies published in English, only studies conducted in large US teaching hospitals, or only studies that agree with the author’s opinion.

14. Evidence based medicine resource pyramid

15. Why systematic reviews?
efficient way to access the body of research
saves time required for searching
critical appraisal
interpretation of results
explore differences between studies
reliable basis for decision making
unbiased selection of relevant information
useful for health care, policy, future research
Aims and structure of a Cochrane Review
There are three main reasons why systematic reviews are useful:
first, they are efficient, bringing together the whole body of research answering a specific question, and saving readers the time and expertise required to locate, appraise and interpret the results.
secondly, unlike a single study, a systematic review can help us explore the differences between studies, identifying those factors that influence the effect of an intervention.
thirdly, they aim to be reliable, presenting an unbiased, comprehensive picture of the available evidence, that can then be used to support decisions in health care, in policy, or to identify areas where future research may be needed. Traditional narrative reviews have not had this advantage – it’s often not clear how the evidence was selected for inclusion in reviews – perhaps only studies conducted in the last five years, only studies published in English, only studies conducted in large US teaching hospitals, or only studies that agree with the author’s opinion.

16. Key components of a Cochrane review

17. Key stages of a systematic review
PROTOCOL
clearly stated objectives
pre-defined eligibility criteria
explicit, reproducible methodology
Search strategy
FULL REVIEW
systematic search
assessment of validity of included studies
systematic synthesis and presentation of findings
There are key features that should go into any systematic review, whether Cochrane or not:
first, a review should have clearly stated objectives, specifying the question to be answered, and determining what evidence will be sought.
the objectives should determine clear eligibility criteria, so that all the relevant evidence is identified, and clear, objective decisions can be made about which studies are included in or excluded from the review.
throughout the review, all the methods used should be explicit and transparent, so that in theory, someone could follow along, repeat what you’ve done, and come to the same conclusions, or at least see clearly where they might have made a different decision.
once the eligibility and methods are planned, there is a systematic search of the literature, to find all the relevant evidence.
the included studies are then carefully assessed, identifying those that might be at risk of bias or inaccurate results.
finally, the results of all those included studies are systematically reported, and a synthesis of their findings is presented.

18. All our reviews are published online in The Cochrane Library.
ASK: Has anyone accessed Cochrane reviews in the Library before?
The part of the library containing Cochrane reviews is called the Cochrane Database of Systematic Reviews. As of September 2012 it contained 5222 reviews and 2259 protocols for reviews in progress. The Library is published monthly, and currently has an impact factor of (2011).
On the Library homepage, you’ll also find editorials, special collections of reviews (e.g. around H1N1 flu, disaster relief following major natural disasters, etc.), podcasts and resources for your local journal club.
To find out more about what’s in the Library, explore the Learn menu.

19. Accessing a review on the Library

20. Participants P
Interventions I
Comparators C
Outcomes O
Study type S

21. What is a forest plot?
Graphical display of treatment effects from multiple randomized controlled trials. When these are combined, it’s called a meta-analysis.

22. Risk ratios (RR) in cessation reviews
events in intervention group/participants in intervention group
events in control group/participants in control group
For cessation, a risk ratio greater than 1 indicates that more people are quitting in the intervention condition. For example, the below data gives us an RR of 1.5. A risk ratio of 1 means as many people quit in the control group as in the intervention group.
Intervention quit
Intervention total
Control quit
Control total 15
100 10

23. Summary of findings tables
Summary of key information from review
Most important outcomes for someone making a decision

25. What is GRADE based on? Risk of bias
Quality of evidence in GRADE is based on 5 domains
Risk of bias
The degree to which review authors have judged each included study to be at risk of bias
A systematic under or overestimate of an effect due to selective publication of studies. This can happen when the results of a study are not reported. If, for example, studies that detect an effect are more likely to be published than those with negative results, the meta-analysis will be biased towards positive results.
Unexplained differences between the results of individual studies (heterogeneity). This can lead to uncertainty about the underlying effect.
Results can be downgraded because of indirectness if:
Head to head comparisons are not available
The population, intervention, comparator or outcome is different from the question the review is trying to address
Results are considered imprecise if:
The total number of events is small (usually less than 300)
The confidence intervals are wide
Inconsistency
Indirectness
Imprecision
Publication bias

26. The blue square represents the point estimate for the effect.
In this example, studies are divided into subgroups based on the type of NRT.
The size of the square is dependent on the size of the study. Bullen 2010 has 969 participants; Rose
Results based on trials - element of chance
Each point estimate displayed with a confidence interval (CI)
CIs represented by the ends of the lines for individual studies and by the horizontal edges of the diamonds for pooled estimates.
95% CIs provide an estimated range of values within which the true effect is 95% certain to lie.
Each line represents an individual study (or intervention versus control comparison)
Diamonds show a pooled estimate, or the combined result from all of the studies. Here, there are pooled estimates for studies in each subgroup and for studies overall. This pooled estimate represents the result of the meta-analysis.
The vertical line is known as the line of no effect.
For our cessation reviews, if the point estimate is on the right side of the line, more people receiving the intervention quit than people in the control group. If the point estimate is on the left side of the line, more people quit in the control group than in the intervention group.
If the confidence interval crosses this central line, the effect is not statistically significant, meaning it is possible that the intervention and the control do not have different effects.
The blue square represents the point estimate for the effect.
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 11

27. Quiz Get into small groups You have time to discuss
You’ll be asked to share your answers after each question

28. Q1 How many of these studies have a statistically significant result?
none
One
Two
Three or more Q1
All of the studies have confidence intervals that cross the line of no effect (1), so their results aren’t statistically significant.

29. Q2
In four studies, the point estimate is to the left of the line of no effect
In how many studies did more people quit in the control group than in the treatment group?
None
Two
Four
Seven

30. Q3 What risk ratio would you expect to see for this result? a) 0.5
b) 1.0
c) 1.5
Intervention quit
Intervention total
Control quit
Control total 10
100 20
The risk ratio is less than one, because more people quit in the control group than in the intervention group

31. Q4. What are the PICOs? P I C O S P I C O S Participants Interventions
Comparators C
Outcomes O
Study type S
Individuals who smoke P
Cytisine I
Placebo C
Continuous abstinence at longest follow-up O
Randomized controlled trials S

32. Why was the evidence downgraded?
(can choose more than one answer)
Risk of bias
Inconsistency
Indirectness
Imprecision
Publication bias
The interventions being tested varied considerably. In addition, there was some evidence from a funnel plot to suggest smaller studies that did not detect significant results had not been published.

33. Cochrane TAG’s anniversary project
AIMS
Raise awareness of the group, and what we have achieved so far
Identify areas where further research is needed in the areas of tobacco control & smoking cessation by involving our stakeholders
Identify specific goals for Cochrane TAG
Funded by the NIHR School for Primary Care Research

34. Cochrane TAG’s anniversary project Stage 1: Identifying uncertainties survey
Asked anyone with an interest in tobacco to share the questions they would still like to see answered by tobacco control research

35. Cochrane TAG’s anniversary project Stage 2: Ranking uncertainties survey
Unanswered questions (uncertainties) were separated into 15 research categories, with each category consisting of questions.
278 from the 1st survey contacted and asked to rank the 15 research categories in order of their importance. They were then asked to rank the questions in their top 3
175 people completed the whole survey (63% of those invited)
3. Mental health & other substance abuse
1. E-cigarettes
2. Addressing inequalities

36. Cochrane TAG’s anniversary project Stage 3: Prioritisation Workshop
17th June we are holding a 1-day workshop with 50 of our stakeholders
Discussion of where CTAG should focus its future efforts and ways to disseminate our findings
The findings of the project will be written up, with our priorities & aims for the future, and published
We will begin to work on the priorities before the end of the year and will continue to do so into the future

37. Any questions?

38. Workshop
Get into small groups (3-5) – choose a scribe who will feed back from each
First 10 minutes: identify gaps in the tobacco control evidence base (see survey results if you need a steer)
Second 10 minutes: Discuss the best ways Cochrane can get information to you
Final 10 minutes: Feedback and discussion

39. How to find out more or contact us
Visit our website:
Tweet us: @cochraneTAG
us:
Call us: +44 (0)