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1.  Tobacco Company Efforts to Influence the Food and Drug Administration-Commissioned Institute of Medicine Report Clearing the Smoke: An Analysis of Documents Released through Litigation 
PLoS Medicine  2013;10(5):e1001450.
Stanton Glantz and colleagues investigate efforts by tobacco companies to influence Clearing the Smoke, a 2001 Institute of Medicine report on harm reduction tobacco products.
Please see later in the article for the Editors' Summary
Background
Spurred by the creation of potential modified risk tobacco products, the US Food and Drug Administration (FDA) commissioned the Institute of Medicine (IOM) to assess the science base for tobacco “harm reduction,” leading to the 2001 IOM report Clearing the Smoke. The objective of this study was to determine how the tobacco industry organized to try to influence the IOM committee that prepared the report.
Methods and Findings
We analyzed previously secret tobacco industry documents in the University of California, San Francisco Legacy Tobacco Documents Library, and IOM public access files. (A limitation of this method includes the fact that the tobacco companies have withheld some possibly relevant documents.) Tobacco companies considered the IOM report to have high-stakes regulatory implications. They developed and implemented strategies with consulting and legal firms to access the IOM proceedings. When the IOM study staff invited the companies to provide information on exposure and disease markers, clinical trial design for safety and efficacy, and implications for initiation and cessation, tobacco company lawyers, consultants, and in-house regulatory staff shaped presentations from company scientists. Although the available evidence does not permit drawing cause-and-effect conclusions, and the IOM may have come to the same conclusions without the influence of the tobacco industry, the companies were pleased with the final report, particularly the recommendations for a tiered claims system (with separate tiers for exposure and risk, which they believed would ease the process of qualifying for a claim) and license to sell products comparable to existing conventional cigarettes (“substantial equivalence”) without prior regulatory approval. Some principles from the IOM report, including elements of the substantial equivalence recommendation, appear in the 2009 Family Smoking Prevention and Tobacco Control Act.
Conclusions
Tobacco companies strategically interacted with the IOM to win several favored scientific and regulatory recommendations.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Up to half of tobacco users will die of cancer, lung disease, heart disease, stroke, or another tobacco-related disease. Cigarettes and other tobacco products cause disease because they expose their users to nicotine and numerous other toxic chemicals. Tobacco companies have been working to develop a “safe” cigarette for more than half a century. Initially, their attention focused on cigarettes that produced lower tar and nicotine yields in machine-smoking tests. These products were perceived as “safer” products by the public and scientists for many years, but it is now known that the use of low-yield cigarettes can actually expose smokers to higher levels of toxins than standard cigarettes. More recently, the tobacco companies have developed other products (for example, products that heat aerosols of nicotine, rather than burning the tobacco) that claim to reduce harm and the risk of tobacco-related disease, but they can only market these modified risk tobacco products in the US after obtaining Food and Drug Administration (FDA) approval. In 1999, the FDA commissioned the US Institute of Medicine (IOM, an influential source of independent expert advice on medical issues) to assess the science base for tobacco “harm reduction.” In 2001, the IOM published its report Clearing the Smoke: Assessing the Science Base for Tobacco Harm and Reduction, which, although controversial, set the tone for the development and regulation of tobacco products in the US, particularly those claiming to be less dangerous, in subsequent years.
Why Was This Study Done?
Tobacco companies have a long history of working to shape scientific discussions and agendas. For example, they have produced research results designed to “create controversy” about the dangers of smoking and secondhand smoke. In this study, the researchers investigate how tobacco companies organized to try to influence the IOM committee that prepared the Clearing the Smoke report on modified risk tobacco products by analyzing tobacco industry and IOM documents.
What Did the Researchers Do and Find?
The researchers searched the Legacy Tobacco Documents Library (a collection of internal tobacco industry documents released as a result of US litigation cases) for documents outlining how tobacco companies tried to influence the IOM Committee to Assess the Science Base for Tobacco Harm Reduction and created a timeline of events from the 1,000 or so documents they retrieved. They confirmed and supplemented this timeline using information in 80 files that detailed written interactions between the tobacco companies and the IOM committee, which they obtained through a public records access request. Analysis of these documents indicates that the tobacco companies considered the IOM report to have important regulatory implications, that they developed and implemented strategies with consulting and legal firms to access the IOM proceedings, and that tobacco company lawyers, consultants, and regulatory staff shaped presentations to the IOM committee by company scientists on various aspects of tobacco harm reduction products. The analysis also shows that tobacco companies were pleased with the final report, particularly its recommendation that tobacco products can be marketed with exposure or risk reduction claims provided the products substantially reduce exposure and provided the behavioral and health consequences of these products are determined in post-marketing surveillance and epidemiological studies (“tiered testing”) and its recommendation that, provided no claim of reduced exposure or risk is made, new products comparable to existing conventional cigarettes (“substantial equivalence”) can be marketed without prior regulatory approval.
What Do These Findings Mean?
These findings suggest that tobacco companies used their legal and regulatory staff to access the IOM committee that advised the FDA on modified risk tobacco products and that they used this access to deliver specific, carefully formulated messages designed to serve their business interests. Although these findings provide no evidence that the efforts of tobacco companies influenced the IOM committee in any way, they show that the companies were satisfied with the final IOM report and its recommendations, some of which have policy implications that continue to reverberate today. The researchers therefore call for the FDA and other regulatory bodies to remember that they are dealing with companies with a long history of intentionally misleading the public when assessing the information presented by tobacco companies as part of the regulatory process and to actively protect their public-health policies from the commercial interests of the tobacco industry.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001450.
This study is further discussed in a PLOS Medicine Perspective by Thomas Novotny
The World Health Organization provides information about the dangers of tobacco (in several languages); for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
A PLOS Medicine Research Article by Heide Weishaar and colleagues describes tobacco company efforts to undermine the Framework Convention on Tobacco Control, an international instrument for tobacco control
Wikipedia has a page on tobacco harm reduction (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The IOM report Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction is available to read online
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The University of California, San Francisco Center for Tobacco Control Research and Education is the focal point for University of California, San Francisco (UCSF) scientists in disciplines ranging from the molecular biology of nicotine addiction through political science who combine their efforts to eradicate the use of tobacco and tobacco-induced cancer and other diseases worldwide
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
doi:10.1371/journal.pmed.1001450
PMCID: PMC3665841  PMID: 23723740
2.  A Longitudinal Study of Medicaid Coverage for Tobacco Dependence Treatments in Massachusetts and Associated Decreases in Hospitalizations for Cardiovascular Disease 
PLoS Medicine  2010;7(12):e1000375.
Thomas Land and colleagues show that among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was followed by a substantial decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease.
Background
Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period.
Methods and Findings
Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%–70%) and 49% (95% confidence interval 6%–72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated.
Conclusions
Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Smoking is the leading preventable cause of death in the world. Globally, it is responsible for one in ten deaths among adults. In developed countries, the death toll is even higher—in the USA and the UK, for example, one in five deaths are caused by cigarette smoking. In the USA alone, where a fifth of adults smoke, smoking accounts for more than 400,000 deaths every year; globally, smoking causes 5 million deaths per year. On average, smokers die 14 years earlier than nonsmokers, and half of all long-term smokers will die prematurely because of a smoking-related disease. These diseases include lung cancer, other types of cancer, heart disease, stroke, and lung diseases such as chronic airway obstruction, bronchitis, and emphysema. And, for every smoker who dies from one of these smoking-related diseases, another 20 will develop at least one serious disease because of their addiction to tobacco.
Why Was This Study Done?
About half of US smokers try to quit each year but most of these attempts fail. Many experts believe that counseling and/or treatment with tobacco cessation medications such as nicotine replacement products help smokers to quit. In the USA, where health care is paid for through private or state health insurance, there is some evidence that insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence. However, smoking cessation treatment is poorly covered by US health insurance programs, largely because of uncertainty about the impact of such coverage on health care costs. It is unknown, for example, whether the introduction of publicly funded tobacco cessation benefits decreases claims for treatment for tobacco-related diseases. In this longitudinal study (a study that follows a group of individuals over a period of time), the researchers ask whether the adoption of comprehensive coverage of tobacco cessation medications by the Massachusetts Medicaid program (MassHealth) in July 2006 has affected claims for treatment for tobacco-related diseases. During its first two and half years, more than 75,000 MassHealth subscribers used the tobacco cessation medication benefit and smoking prevalence among subscribers declined by approximately 10% (38.3% to 28.8%).
What Did the Researchers Do and Find?
The researchers used MassHealth claims data and a statistical method called generalized estimating equations to compare the probability of hospitalization prior to the use of tobacco cessation medication benefit with the probability of hospitalization after benefit use among MassHealth subscribers. After adjusting for other factors that might have affected hospitalization such as influenza outbreaks and the implementation of the Massachusetts Smoke-Free Workplace Law in July 2004, there was a statistically significant annualized decline in hospital admissions for heart attack of 46% after use of the tobacco cessation medication benefit. That is, the calculated annual rate of admissions for heart attacks was 46% lower after use of the benefit than before among MassHealth beneficiaries. There was also a 49% annualized decline in admissions for coronary atherosclerosis, another smoking-related heart disease. There were no significant changes in hospitalization rates for lung diseases (including asthma, pneumonia, and chronic airway obstruction) or for seven other diagnostic groups.
What Do These Findings Mean?
These findings show that, among MassHealth subscribers, the use of a tobacco cessation medication benefit was followed by a significant decrease in claims for hospitalization for heart attack and for coronary atherosclerosis but not for other diseases. It does not, however, show that the reduced claims for hospitalization were associated with a reduction in smoking because smoking cessation was not recorded by MassHealth. Furthermore, it is possible that the people who used the tobacco cessation medication benefit shared other characteristics that reduced their chances of hospitalization for heart disease. For example, people using tobacco cessation medication might have been more likely to adhere to prescription schedules for medications such as statins that would also reduce their risk of heart disease. Finally, these findings might be unique to Massachusetts, so similar studies need to be undertaken in other states. Nevertheless, the results of this study suggest that, for low-income smokers, removing financial barriers to the use of smoking cessation medications has the potential to produce short-term decreases in the use of hospital services that will, hopefully, outweigh the costs of comprehensive tobacco cessation medication benefits.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000375.
The US Centers for Disease Control and Prevention Office on Smoking and Health has information on all aspects of smoking and health, including advice on how to quit
The UK National Health Service Choices Web site provides advice about quitting smoking; more advice on quitting is provided by Smokefree
The American Heart Association provides information on heart disease, including advice on how to quit smoking (in several languages)
Information about MassHealth is available, including information on smoking and tobacco use prevention
doi:10.1371/journal.pmed.1000375
PMCID: PMC3000429  PMID: 21170313
3.  Smoking Cessation Counseling Beliefs and Behaviors of Outpatient Oncology Providers 
The Oncologist  2012;17(3):455-462.
Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the “teachable moment” of cancer diagnosis to provide smoking cessation assistance. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.
Learning Objectives
After completing this course, the reader will be able to: Describe current smoking cessation assessment and counseling behaviors of outpatient oncology providers.Identify key barriers to providing smoking cessation services identified by oncology providers.Describe available resources for enhancing training in smoking cessation counseling.
This article is available for continuing medical education credit at CME.TheOncologist.com
Purpose.
Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the “teachable moment” of cancer diagnosis to provide smoking cessation assistance.
Providers and Methods.
Physicians and midlevel providers (n = 74) who provide outpatient oncology services completed an online survey regarding smoking cessation counseling behaviors, beliefs, and perceived barriers. Outpatient medical records for 120 breast, lung, head and neck, colon, prostate, and acute leukemia cancer patients were reviewed to assess current smoking cessation assessment and intervention documentation practices.
Results.
Providers reported commonly assessing smoking in new patients (82.4% frequently or always), but rates declined at subsequent visits for both current smokers and recent quitters. Rates of advising patients to quit smoking were also high (86.5% frequently or always), but <30% of providers reported frequently or always providing intervention to smoking patients (e.g., nicotine replacement therapy or other medications, self-help materials, and/or referrals). Only 30% of providers reported that they frequently or always followed up with patients to assess progress with quitting. Few providers (18.1%) reported high levels of confidence in their ability to counsel smoking patients. Patients' lack of motivation was identified as the most important barrier to smoking cessation.
Conclusions.
Although beliefs about providing cessation services to smoking patients were generally positive, few providers reported commonly providing interventions beyond advice to quit. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.
doi:10.1634/theoncologist.2011-0350
PMCID: PMC3316932  PMID: 22334454
Smoking cessation; Clinical oncology; Health care providers; Cancer
4.  Burden of Total and Cause-Specific Mortality Related to Tobacco Smoking among Adults Aged ≥45 Years in Asia: A Pooled Analysis of 21 Cohorts 
PLoS Medicine  2014;11(4):e1001631.
Wei Zheng and colleagues quantify the burden of tobacco-smoking-related deaths for adults in Asia.
Please see later in the article for the Editors' Summary
Background
Tobacco smoking is a major risk factor for many diseases. We sought to quantify the burden of tobacco-smoking-related deaths in Asia, in parts of which men's smoking prevalence is among the world's highest.
Methods and Findings
We performed pooled analyses of data from 1,049,929 participants in 21 cohorts in Asia to quantify the risks of total and cause-specific mortality associated with tobacco smoking using adjusted hazard ratios and their 95% confidence intervals. We then estimated smoking-related deaths among adults aged ≥45 y in 2004 in Bangladesh, India, mainland China, Japan, Republic of Korea, Singapore, and Taiwan—accounting for ∼71% of Asia's total population. An approximately 1.44-fold (95% CI = 1.37–1.51) and 1.48-fold (1.38–1.58) elevated risk of death from any cause was found in male and female ever-smokers, respectively. In 2004, active tobacco smoking accounted for approximately 15.8% (95% CI = 14.3%–17.2%) and 3.3% (2.6%–4.0%) of deaths, respectively, in men and women aged ≥45 y in the seven countries/regions combined, with a total number of estimated deaths of ∼1,575,500 (95% CI = 1,398,000–1,744,700). Among men, approximately 11.4%, 30.5%, and 19.8% of deaths due to cardiovascular diseases, cancer, and respiratory diseases, respectively, were attributable to tobacco smoking. Corresponding proportions for East Asian women were 3.7%, 4.6%, and 1.7%, respectively. The strongest association with tobacco smoking was found for lung cancer: a 3- to 4-fold elevated risk, accounting for 60.5% and 16.7% of lung cancer deaths, respectively, in Asian men and East Asian women aged ≥45 y.
Conclusions
Tobacco smoking is associated with a substantially elevated risk of mortality, accounting for approximately 2 million deaths in adults aged ≥45 y throughout Asia in 2004. It is likely that smoking-related deaths in Asia will continue to rise over the next few decades if no effective smoking control programs are implemented.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, more than 5 million smokers die from tobacco-related diseases. Tobacco smoking is a major risk factor for cardiovascular disease (conditions that affect the heart and the circulation), respiratory disease (conditions that affect breathing), lung cancer, and several other types of cancer. All told, tobacco smoking kills up to half its users. The ongoing global “epidemic” of tobacco smoking and tobacco-related diseases initially affected people living in the US and other Western countries, where the prevalence of smoking (the proportion of the population that smokes) in men began to rise in the early 1900s, peaking in the 1960s. A similar epidemic occurred in women about 40 years later. Smoking-related deaths began to increase in the second half of the 20th century, and by the 1990s, tobacco smoking accounted for a third of all deaths and about half of cancer deaths among men in the US and other Western countries. More recently, increased awareness of the risks of smoking and the introduction of various tobacco control measures has led to a steady decline in tobacco use and in smoking-related diseases in many developed countries.
Why Was This Study Done?
Unfortunately, less well-developed tobacco control programs, inadequate public awareness of smoking risks, and tobacco company marketing have recently led to sharp increases in the prevalence of smoking in many low- and middle-income countries, particularly in Asia. More than 50% of men in many Asian countries are now smokers, about twice the prevalence in many Western countries, and more women in some Asian countries are smoking than previously. More than half of the world's billion smokers now live in Asia. However, little is known about the burden of tobacco-related mortality (deaths) in this region. In this study, the researchers quantify the risk of total and cause-specific mortality associated with tobacco use among adults aged 45 years or older by undertaking a pooled statistical analysis of data collected from 21 Asian cohorts (groups) about their smoking history and health.
What Did the Researchers Do and Find?
For their study, the researchers used data from more than 1 million participants enrolled in studies undertaken in Bangladesh, India, mainland China, Japan, the Republic of Korea, Singapore, and Taiwan (which together account for 71% of Asia's total population). Smoking prevalences among male and female participants were 65.1% and 7.1%, respectively. Compared with never-smokers, ever-smokers had a higher risk of death from any cause in pooled analyses of all the cohorts (adjusted hazard ratios [HRs] of 1.44 and 1.48 for men and women, respectively; an adjusted HR indicates how often an event occurs in one group compared to another group after adjustment for other characteristics that affect an individual's risk of the event). Compared with never smoking, ever smoking was associated with a higher risk of death due to cardiovascular disease, cancer (particularly lung cancer), and respiratory disease among Asian men and among East Asian women. Moreover, the researchers estimate that, in the countries included in this study, tobacco smoking accounted for 15.8% of all deaths among men and 3.3% of deaths among women in 2004—a total of about 1.5 million deaths, which scales up to 2 million deaths for the population of the whole of Asia. Notably, in 2004, tobacco smoking accounted for 60.5% of lung-cancer deaths among Asian men and 16.7% of lung-cancer deaths among East Asian women.
What Do These Findings Mean?
These findings provide strong evidence that tobacco smoking is associated with a substantially raised risk of death among adults aged 45 years or older throughout Asia. The association between smoking and mortality risk in Asia reported here is weaker than that previously reported for Western countries, possibly because widespread tobacco smoking started several decades later in most Asian countries than in Europe and North America and the deleterious effects of smoking take some years to become evident. The researchers note that certain limitations of their analysis are likely to affect the accuracy of its findings. For example, because no data were available to estimate the impact of secondhand smoke, the estimate of deaths attributable to smoking is likely to be an underestimate. However, the finding that nearly 45% of the global deaths from active tobacco smoking occur in Asia highlights the urgent need to implement comprehensive tobacco control programs in Asia to reduce the burden of tobacco-related disease.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001631.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about the WHO Framework Convention on Tobacco Control, an international instrument for tobacco control that came into force in February 2005 and requires parties to implement a set of core tobacco control provisions including legislation to ban tobacco advertising and to increase tobacco taxes; its 2013 report on the global tobacco epidemic is available
The US Centers for Disease Control and Prevention provides detailed information about all aspects of smoking and tobacco use
The UK National Health Services Choices website provides information about the health risks associated with smoking
MedlinePlus has links to further information about the dangers of smoking (in English and Spanish)
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
doi:10.1371/journal.pmed.1001631
PMCID: PMC3995657  PMID: 24756146
5.  The Brazil SimSmoke Policy Simulation Model: The Effect of Strong Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths in a Middle Income Nation 
PLoS Medicine  2012;9(11):e1001336.
David Levy and colleagues use the SimSmoke model to estimate the effect of Brazil's recent stronger tobacco control policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have.
Background
Brazil has reduced its smoking rate by about 50% in the last 20 y. During that time period, strong tobacco control policies were implemented. This paper estimates the effect of these stricter policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have.
Methods and Findings
The model was developed using the SimSmoke tobacco control policy model. Using policy, population, and smoking data for Brazil, the model assesses the effect on premature deaths of cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs, and youth access restrictions. We estimate the effect of past policies relative to a counterfactual of policies kept to 1989 levels, and the effect of stricter future policies. Male and female smoking prevalence in Brazil have fallen by about half since 1989, which represents a 46% (lower and upper bounds: 28%–66%) relative reduction compared to the 2010 prevalence under the counterfactual scenario of policies held to 1989 levels. Almost half of that 46% reduction is explained by price increases, 14% by smoke-free air laws, 14% by marketing restrictions, 8% by health warnings, 6% by mass media campaigns, and 10% by cessation treatment programs. As a result of the past policies, a total of almost 420,000 (260,000–715,000) deaths had been averted by 2010, increasing to almost 7 million (4.5 million–10.3 million) deaths projected by 2050. Comparing future implementation of a set of stricter policies to a scenario with 2010 policies held constant, smoking prevalence by 2050 could be reduced by another 39% (29%–54%), and 1.3 million (0.9 million–2.0 million) out of 9 million future premature deaths could be averted.
Conclusions
Brazil provides one of the outstanding public health success stories in reducing deaths due to smoking, and serves as a model for other low and middle income nations. However, a set of stricter policies could further reduce smoking and save many additional lives.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Tobacco kills up to half its users—more than 5 million smokers die every year from tobacco-related causes. It also kills more than half a million non-smokers annually who have been exposed to second-hand smoke. If current trends continue, annual tobacco-related deaths could increase to more than 8 million by 2030. In response to this global tobacco epidemic, the World Health Organization has developed an international instrument for tobacco control called the Framework Convention on Tobacco Control (FCTC). Since it came into force in February 2005, 176 countries have become parties to the FCTC. As such, they agree to implement comprehensive bans on tobacco advertizing, promotion, and sponsorship; to ban misleading and deceptive terms on tobacco packaging; to protect people from exposure to cigarette smoke in public spaces and indoor workplaces; to implement tax policies aimed at reducing tobacco consumption; and to combat illicit trade in tobacco products.
Why Was This Study Done?
Brazil has played a pioneering role in providing support for tobacco control measures in low and middle income countries. It introduced its first cigarette-specific tax in 1990 and, in 1996, it placed the first warnings on cigarette packages and introduced smoke-free air laws. Many of these measures have subsequently been strengthened. Over the same period, the prevalence of smoking among adults (the proportion of the population that smokes) has halved in Brazil, falling from 34.8% in 1989 to 18.5% in 2008. But did the introduction of tobacco control policies contribute to this decline, and if so, which were the most effective policies? In this study, the researchers use a computational model called the SimSmoke tobacco control policy model to investigate this question and to examine the possible effect of introducing additional control policies consistent with the FCTC, which Brazil has been a party to since 2006.
What Did the Researchers Do and Find?
The researchers developed Brazil SimSmoke by incorporating policy, population, and smoking data for Brazil into the SimSmoke simulation model; Brazil SimSmoke estimates smoking prevalence and smoking-attributable deaths from 1989 forwards. They then compared smoking prevalences and smoking-attributable deaths estimated by Brazil SimSmoke for 2010 with and without the inclusion of the tobacco control policies that were introduced between 1989 and 2010. The model estimated that the smoking prevalence in Brazil in 2010 was reduced by 46% by the introduction of tobacco control measures. Almost half of this reduction was explained by price increases, 14% by smoke-free laws, 14% by marketing restrictions, 8% by health warnings, 6% by anti-smoking media campaigns, and 10% by cessation treatment programs. Moreover, as a result of past policies, the model estimated that almost 420,000 tobacco-related deaths had been averted by 2010 and that almost 7 million deaths will have been averted by 2050. Finally, using the model to compare the effects of a scenario that includes stricter policies (for example, an increase in tobacco tax) with a scenario that includes the 2010 policies only, indicated that stricter control policies would reduce the estimated smoking prevalence by an extra 39% between 2010 and 2050 and avert about 1.3 million additional premature deaths.
What Do These Findings Mean?
These findings indicate that the introduction of tobacco control policies has been a critical factor in the rapid decline in smoking prevalence in Brazil over the past 20 years. They also suggest that the introduction of stricter policies that are fully consistent with the FCTC has the potential to reduce the prevalence of smoking further and save many additional lives. Although the reduction in smoking prevalence in Brazil between 1989 and 2010 predicted by the Brazil SimSmoke model is close to the recorded reduction over that period, these findings need to be interpreted with caution because of the many assumptions incorporated in the model. Moreover, the accuracy of the model's predictions depends on the accuracy of the data fed into it, some of which was obtained from other countries and may not accurately reflect the situation in Brazil. Importantly, however, these findings show that, even for a middle income nation, reducing tobacco use is a “winnable battle” that carries huge dividends in terms of reducing illness and death without requiring unlimited resources.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001336.
The World Health Organization provides information about the dangers of tobacco (in several languages), about the Framework Convention on Tobacco Control, and about tobacco control in Brazil
The Framework Convention Alliance provides more information about the FCTC
The Brazilian National Cancer Institute (INCA) provides information on tobacco control policies in Brazil; additional information about tobacco control laws in Brazil is available on the Tobacco Control Laws interactive website, which provides information about tobacco control legislation worldwide
More information on the SimSmoke model of tobacco control policies is available in document or slideshow form
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
doi:10.1371/journal.pmed.1001336
PMCID: PMC3491001  PMID: 23139643
6.  Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
Objective
The objective of this evidence-based analysis was to determine the effectiveness and cost-effectiveness of smoking cessation interventions in the management of chronic obstructive pulmonary disease (COPD).
Clinical Need: Condition and Target Population
Tobacco smoking is the main risk factor for COPD. It is estimated that 50% of older smokers develop COPD and more than 80% of COPD-associated morbidity is attributed to tobacco smoking. According to the Canadian Community Health Survey, 38.5% of Ontarians who smoke have COPD. In patients with a significant history of smoking, COPD is usually present with symptoms of progressive dyspnea (shortness of breath), cough, and sputum production. Patients with COPD who smoke have a particularly high level of nicotine dependence, and about 30.4% to 43% of patients with moderate to severe COPD continue to smoke. Despite the severe symptoms that COPD patients suffer, the majority of patients with COPD are unable to quit smoking on their own; each year only about 1% of smokers succeed in quitting on their own initiative.
Technology
Smoking cessation is the process of discontinuing the practice of inhaling a smoked substance. Smoking cessation can help to slow or halt the progression of COPD. Smoking cessation programs mainly target tobacco smoking, but may also encompass other substances that can be difficult to stop smoking due to the development of strong physical addictions or psychological dependencies resulting from their habitual use.
Smoking cessation strategies include both pharmacological and nonpharmacological (behavioural or psychosocial) approaches. The basic components of smoking cessation interventions include simple advice, written self-help materials, individual and group behavioural support, telephone quit lines, nicotine replacement therapy (NRT), and antidepressants. As nicotine addiction is a chronic, relapsing condition that usually requires several attempts to overcome, cessation support is often tailored to individual needs, while recognizing that in general, the more intensive the support, the greater the chance of success. Success at quitting smoking decreases in relation to:
a lack of motivation to quit,
a history of smoking more than a pack of cigarettes a day for more than 10 years,
a lack of social support, such as from family and friends, and
the presence of mental health disorders (such as depression).
Research Question
What are the effectiveness and cost-effectiveness of smoking cessation interventions compared with usual care for patients with COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on June 24, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations (1950 to June Week 3 2010), EMBASE (1980 to 2010 Week 24), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, and the Centre for Reviews and Dissemination for studies published between 1950 and June 2010. A single reviewer reviewed the abstracts and obtained full-text articles for those studies meeting the eligibility criteria. Reference lists were also examined for any additional relevant studies not identified through the search. Data were extracted using a standardized data abstraction form.
Inclusion Criteria
English-language, full reports from 1950 to week 3 of June, 2010;
either randomized controlled trials (RCTs), systematic reviews and meta-analyses, or non-RCTs with controls;
a proven diagnosis of COPD;
adult patients (≥ 18 years);
a smoking cessation intervention that comprised at least one of the treatment arms;
≥ 6 months’ abstinence as an outcome; and
patients followed for ≥ 6 months.
Exclusion Criteria
case reports
case series
Outcomes of Interest
≥ 6 months’ abstinence
Quality of Evidence
The quality of each included study was assessed taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Nine RCTs were identified from the literature search. The sample sizes ranged from 74 to 5,887 participants. A total of 8,291 participants were included in the nine studies. The mean age of the patients in the studies ranged from 54 to 64 years. The majority of studies used the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD staging criteria to stage the disease in study subjects. Studies included patients with mild COPD (2 studies), mild-moderate COPD (3 studies), moderate–severe COPD (1 study) and severe–very severe COPD (1 study). One study included persons at risk of COPD in addition to those with mild, moderate, or severe COPD, and 1 study did not define the stages of COPD. The individual quality of the studies was high. Smoking cessation interventions varied across studies and included counselling or pharmacotherapy or a combination of both. Two studies were delivered in a hospital setting, whereas the remaining 7 studies were delivered in an outpatient setting. All studies reported a usual care group or a placebo-controlled group (for the drug-only trials). The follow-up periods ranged from 6 months to 5 years. Due to excessive clinical heterogeneity in the interventions, studies were first grouped into categories of similar interventions; statistical pooling was subsequently performed, where appropriate. When possible, pooled estimates using relative risks for abstinence rates with 95% confidence intervals were calculated. The remaining studies were reported separately.
Abstinence Rates
Table ES1 provides a summary of the pooled estimates for abstinence, at longest follow-up, from the trials included in this review. It also shows the respective GRADE qualities of evidence.
Summary of Results*
Abbreviations: CI, confidence interval; NRT, nicotine replacement therapy.
Statistically significant (P < 0.05).
One trial used in this comparison had 2 treatment arms each examining a different antidepressant.
Conclusions
Based on a moderate quality of evidence, compared with usual care, abstinence rates are significantly higher in COPD patients receiving intensive counselling or a combination of intensive counselling and NRT.
Based on limited and moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving NRT compared with placebo.
Based on a moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving the antidepressant bupropion compared to placebo.
PMCID: PMC3384371  PMID: 23074432
7.  The Effect of Tobacco Control Measures during a Period of Rising Cardiovascular Disease Risk in India: A Mathematical Model of Myocardial Infarction and Stroke 
PLoS Medicine  2013;10(7):e1001480.
In this paper from Basu and colleagues, a simulation of tobacco control and pharmacological interventions to prevent cardiovascular disease mortality in India predicted that Smokefree laws and increased tobacco taxation are likely to be the most effective measures to avert future cardiovascular deaths in India.
Please see later in the article for the Editors' Summary
Background
We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.
Methods and Findings
A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model's results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%–34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.
Conclusions
Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Cardiovascular diseases (CVDs) are conditions that affect the heart and/or the circulation. In coronary heart disease, for example, narrowing of the heart's blood vessels by fatty deposits slows the blood supply to the heart and may eventually cause a heart attack (myocardial infarction). Stroke, by contrast, is a CVD in which the blood supply to the brain is interrupted. CVD has been a major cause of illness and death in high-income countries for many years, but the burden of CVD is now rapidly rising in low- and middle-income countries. Indeed, worldwide, three-quarters of all deaths from heart disease and stroke occur in low- and middle-income countries. Smoking, high blood pressure (hypertension), high blood cholesterol (hyperlipidemia), diabetes, obesity, and physical inactivity all increase an individual's risk of developing CVD. Prevention strategies and treatments for CVD include lifestyle changes (for example, smoking cessation) and taking drugs that lower blood pressure (antihypertensive drugs) or blood cholesterol levels (statins) or thin the blood (aspirin).
Why Was This Study Done?
Because tobacco use is a key risk factor for CVD and for several other noncommunicable diseases, the World Health Organization has developed an international instrument for tobacco control called the Framework Convention on Tobacco Control (FCTC). Parties to the FCTC (currently 176 countries) agree to implement a set of core tobacco control provisions including legislation to ban tobacco advertising and to increase tobacco taxes. But will tobacco control measures reduce the burden of CVD effectively in low- and middle-income countries as other risk factors for CVD are becoming more common? In this mathematical modeling study, the researchers investigated this question by simulating the effects of tobacco control measures and pharmacological strategies for preventing CVD on CVD deaths in India. Notably, many of the core FCTC provisions remain poorly implemented or unenforced in India even though it became a party to the convention in 2005. Moreover, experts predict that, over the next decade, this middle-income country will contribute more than any other nation to the global increase in CVD deaths.
What Did the Researchers Do and Find?
The researchers developed a microsimulation model (a computer model that operates at the level of individuals) to quantify the likely effects of various tobacco control measures and pharmacological therapies on deaths from myocardial infarction and stroke in India between 2013 and 2022. They incorporated population-representative data from India on risk factors that affect myocardial infarction and stroke mortality and on tobacco use and exposure to secondhand smoke into their model. They then simulated the effects of five tobacco control measures—smoke-free legislation, tobacco taxation, provision of brief cessation advice by health care providers, mass media campaigns, and advertising bans—and increased access to aspirin, antihypertensive drugs, and statins on deaths from myocardial infarction and stroke. Smoke-free legislation and tobacco taxation are likely to be the most effective strategies for reducing myocardial infarction and stroke deaths over the next decade, according to the model, and the effects of these strategies are likely to be substantially larger than those achieved by drug therapies under current health system conditions. If the effects of smoke-free legislation and tobacco taxation are additive, the model predicts that these two measures alone could avert about 9 million deaths, that is, a quarter of the expected deaths from myocardial infarction and stroke in India over the next 10 years, and that a combination of tobacco control policies and pharmacological interventions could avert up to a third of these deaths.
What Do These Findings Mean?
These findings suggest that the implementation of smoke-free laws and the introduction of increased tobacco taxes in India would yield substantial and rapid health benefits by averting future CVD deaths. The accuracy of these findings is likely to be affected by the many assumptions included in the mathematical model and by the quality of the data fed into it. Importantly, however, these finding suggest that, despite the rise in other CVD risk factors such as hypertension and hyperlipidemia, tobacco control is likely to be a highly effective strategy for the reduction of CVD deaths over the next decade in India and probably in other low- and middle-income countries. Policymakers in these countries should, therefore, work towards fuller and faster implementation of the core FCTC provisions to boost their efforts to reduce deaths from CVD.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001480.
The American Heart Association provides information on all aspects of cardiovascular disease; its website includes personal stories about heart attacks and stroke
The US Centers for Disease Control and Prevention has information on heart disease and on stroke (in English and Spanish
The UK National Health Service Choices website provides information about cardiovascular disease and stroke
MedlinePlus provides links to other sources of information on heart diseases, vascular diseases, and stroke (in English and Spanish)
The World Health Organization provides information (in several languages) about the dangers of tobacco, about the Framework Convention on Tobacco Control, and about noncommunicable diseases; its Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle- income countries reduce illness and death caused by CVD and other noncommunicable diseases
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, supported by the US National Cancer Institute and other US agencies, offers online tools and resources to help people quit smoking
doi:10.1371/journal.pmed.1001480
PMCID: PMC3706364  PMID: 23874160
8.  Population-Based Smoking Cessation Strategies 
Executive Summary
Objective
The objective of this report was to provide the Ministry of Health Promotion (MHP) with a summary of existing evidence-based reviews of the clinical and economic outcomes of population-based smoking cessation strategies.
Background
Tobacco use is the leading cause of preventable disease and death in Ontario, linked to approximately 13,000 avoidable premature deaths annually – the vast majority of these are attributable to cancer, cardiovascular disease, and chronic obstructive lung disease. (1) In Ontario, tobacco related health care costs amount to $6.1 billion annually, or about $502 per person (including non-smokers) and account for 1.4% of the provincial domestic product. (2) In 2007, there were approximately 1.7 to 1.9 million smokers in Ontario with two-thirds of these intending to quit in the next six months and one-third wanting to quit within 30 days. (3) In 2007/2008, Ontario invested $15 million in cessation programs, services and training. (4) In June 2009, the Ministry of Health Promotion (MHP) requested that MAS provide a summary of the evidence base surrounding population-based smoking cessation strategies.
Project Scope
The MAS and the MHP agreed that the project would consist of a clinical and economic summary of the evidence surrounding nine population-based strategies for smoking cessation including:
Mass media interventions
Telephone counselling
Post-secondary smoking cessation programs (colleges/universities)
Community-wide stop-smoking contests (i.e. Quit and Win)
Community interventions
Physician advice to quit
Nursing interventions for smoking cessation
Hospital-based interventions for smoking cessation
Pharmacotherapies for smoking cessation, specifically:
Nicotine replacement therapies
Antidepressants
Anxiolytic drugs
Opioid antagonists
Clonidine
Nicotine receptor partial agonists
Reviews examining interventions for Cut Down to Quit (CDTQ) or harm reduction were not included in this review. In addition, reviews examining individual-level smoking cessation strategies (i.e. self-help interventions, counselling, etc.), web-based smoking cessation interventions, and smoking cessation strategies for special population groups outside of those identified from reviews included in this analysis were excluded from the scope. Information on cessation programs or strategies in other provinces or an evaluation of current population-based programs in Ontario was also not included in the scope.
Status in Ontario
In 2005, the McGuinty government launched the Smoke-Free Ontario Strategy, focusing on initiatives aimed at young people to encourage them not to smoke, protection from exposure to second-hand smoke, and programs to help smokers quit. There are currently many smoking cessation programs funded across the province and in 2007/2008, Ontario invested $15 million in cessation programs, services and training. Ontario Health Insurance Plan (OHIP) fee codes for physician advice to quit also exist.
Evidence-Based Analysis
Research Question
What are the efficacy and cost-effectiveness of the selected population-based strategies for smoking cessation?
Literature Search
A preliminary scan of Medline was conducted to identify major systematic reviews, meta-analyses, and health technology assessments (HTAs) in the area of smoking cessation. Based on the availability of a number of Cochrane Reviews on the topic of smoking cessation, a more systematic search of the literature was not conducted. For the economic analysis, a literature search was conducted of relevant databases for recently published article reviews, HTAs, and Cochrane Reviews of the nine identified population-based smoking cessation strategies. This analysis is limited as it is a summary of existing reviews and not a systematic review.
Outcomes of Interest
The primary outcome of interest for the clinical summary was abstinence from smoking at 6 months follow up; additional outcomes were examined where available. The primary outcomes of interest for the economic analysis were cost-effectiveness ratios.
Summary of Findings
The evidence suggests that pharmacotherapy, physician advice to quit, nursing interventions, hospital-based interventions, and proactive telephone counselling are effective and cost-effective in the short-term.
There is poor quality data around other population-based smoking cessation strategies including mass media campaigns, community interventions, quit and win contests, access to ‘quitlines’, and interventions for university and college campuses, making evaluation of their effectiveness and cost-effectiveness difficult.
Based on pooled summary estimates of effect and safety data, the most effective strategies are varenicline, buproprion, and nicotine replacement therapies, followed by physician advice to quit and nursing interventions (in non-hospitalized smokers without cardiovascular disease).
PMCID: PMC3377580  PMID: 23074386
9.  Tobacco Industry Manipulation of Tobacco Excise and Tobacco Advertising Policies in the Czech Republic: An Analysis of Tobacco Industry Documents 
PLoS Medicine  2012;9(6):e1001248.
Risako Shirane and colleagues examined the the Legacy Tobacco Documents Library and found evidence of transnational tobacco company influence over tobacco advertising and excise policy in the Czech Republic, a country with one of the poorest tobacco control records in Europe.
Background
The Czech Republic has one of the poorest tobacco control records in Europe. This paper examines transnational tobacco companies' (TTCs') efforts to influence policy there, paying particular attention to excise policies, as high taxes are one of the most effective means of reducing tobacco consumption, and tax structures are an important aspect of TTC competitiveness.
Methods and Findings
TTC documents dating from 1989 to 2004/5 were retrieved from the Legacy Tobacco Documents Library website, analysed using a socio-historical approach, and triangulated with key informant interviews and secondary data. The documents demonstrate significant industry influence over tobacco control policy. Philip Morris (PM) ignored, overturned, and weakened various attempts to restrict tobacco advertising, promoting voluntary approaches as an alternative to binding legislation. PM and British American Tobacco (BAT) lobbied separately on tobacco tax structures, each seeking to implement the structure that benefitted its own brand portfolio over that of its competitors, and enjoying success in turn. On excise levels, the different companies took a far more collaborative approach, seeking to keep tobacco taxes low and specifically to prevent any large tax increases. Collective lobbying, using a variety of arguments, was successful in delaying the tax increases required via European Union accession. Contrary to industry arguments, data show that cigarettes became more affordable post-accession and that TTCs have taken advantage of low excise duties by raising prices. Interview data suggest that TTCs enjoy high-level political support and continue to actively attempt to influence policy.
Conclusion
There is clear evidence of past and ongoing TTC influence over tobacco advertising and excise policy. We conclude that this helps explain the country's weak tobacco control record. The findings suggest there is significant scope for tobacco tax increases in the Czech Republic and that large (rather than small, incremental) increases are most effective in reducing smoking.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 5 million people die from tobacco-related diseases and, if current trends continue, annual tobacco-related deaths will increase to 10 million by 2030. Faced with this global tobacco epidemic, national and international bodies have drawn up conventions and directives designed to control tobacco. For example, European Union (EU) Directives on tobacco control call for member states to ban tobacco advertising, promotion, and sponsorship and to adopt taxation policies (for example, high levels of tobacco excise tax) aimed at reducing tobacco consumption. Within the EU, implementation of tobacco control policies varies widely but the Czech Republic, which was formed in 1993 when Czechoslovakia split following the 1989 collapse of communism, has a particularly poor record. The Czech Republic, which joined the EU in 2004, is the only EU Member State not to have ratified the World Health Organization's Framework Convention on Tobacco Control, which entered into force in 2005, and its tobacco control policies were the fourth least effective in Europe in 2010.
Why Was This Study Done?
During the communist era, state-run tobacco monopolies controlled the supply of cigarettes and other tobacco products in Czechoslovakia. Privatization of these monopolies began in 1991 and several transnational tobacco companies (TTCs)—in particular, Philip Morris and British American Tobacco—entered the tobacco market in what was to become the Czech Republic. In this socio-historical study, which aims to improve understanding of both effective tobacco excise policy and the ways in which TTCs seek to influence policy in emerging markets, the researchers analyze publically available internal TTC documents and interview key informants to examine efforts made by TTCs to influence tobacco advertising and tobacco excise tax policies in the Czech Republic. A socio-historical study examines the interactions between individuals and groups in a historical context.
What Did the Researchers Do and Find?
The researchers analyzed 511 documents (dated 1989 onwards) in the Legacy Tobacco Documents Library website (a collection of internal tobacco industry documents released through US litigation cases) that mentioned tobacco control policies in the Czech Republic. They also analyzed information obtained from sources such as tobacco industry journals and data obtained in 2010 in interviews with key Czech informants (including a tobacco industry representative and a politician). The researchers' analysis of the industry documents indicates that Philip Morris ignored, overturned, and weakened attempts to restrict tobacco advertising and promoted voluntary approaches as an alternative to binding legislation. Importantly, while the internal documents show that Philip Morris lobbied for a specific excise tax (a fixed amount of tax per cigarette, a tax structure that favors the expensive brands that Philip Morris mainly markets), the European strategy employed at that time by British American Tobacco was to lobby for a mixed excise structure that combined an “ad valorem” tax (a tax levied as a proportion of price) and a specific tax, an approach that favors a mixed portfolio of tobacco brands. By contrast, the documents show that TTCs collaborated in trying to keep tobacco taxes low and in trying to prevent any large tax increases. This collective lobbying successfully delayed the tobacco tax increases required as a condition of the Czech Republic's accession to the EU. Finally, the interview data suggest that TTCs had high-level political support in the Czech Republic and continue actively to attempt to influence policy.
What Do These Findings Mean?
These findings provide clear evidence that Philip Morris and British American Tobacco (the two TTCs that have dominated the Czech market since privatization of the tobacco industry) have significantly influenced tobacco advertising and excise policy in the Czech Republic since 1989. The findings, which also suggest that this influence is ongoing, help to explain the Czech Republic's poor tobacco control record, which was reflected in a fall in the real price of cigarettes between 1990 and 2000. More generally, this study provides valuable insight into how TTCs might try to influence policy in other emerging markets. Improvements in global tobacco control, the researchers conclude, will be possible only if efforts are made to protect tobacco control policies from the vested interests of the tobacco industry, a principle enshrined in the WHO Framework Convention on Tobacco control, and if public and political attitudes to the industry shift.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001248.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about its Framework Convention on Tobacco Control
For information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
The Framework Convention Alliance more information about the FCTC
Details of European Union legislation on excise duty applied to manufactured tobacco and on the manufacture, presentation and sale of tobacco products are available (in several languages)
The Legacy Tobacco Documents Library is a searchable public database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking and not start again
doi:10.1371/journal.pmed.1001248
PMCID: PMC3383744  PMID: 22745606
10.  Smoking Cessation: An Integral Part of Lung Cancer Treatment 
Oncology  2010;78(5-6):289-301.
Lung cancer is the leading cause of cancer death in the US. About 50% of lung cancer patients are current smokers at the time of diagnosis and up to 83% continue to smoke after diagnosis. A recent study suggests that people who continue to smoke after a diagnosis of early-stage lung cancer almost double their risk of dying. Despite a growing body of evidence that continued smoking by patients after a lung cancer diagnosis is linked with less effective treatment and a poorer prognosis, the belief prevails that treating tobacco dependence is useless. With improved cancer treatments and survival rates, smoking cessation among lung cancer patients has become increasingly important. There is a pressing need to clarify the role of smoking cessation in the care of lung cancer patients.
Objective
This paper will report on the benefits of smoking cessation for lung cancer patients and the elements of smoking cessation treatment, with consideration of tailoring to the needs of lung cancer patients.
Results
Given the significant benefits of smoking cessation and that tobacco dependence remains a challenge for many lung cancer patients, cancer care providers need to offer full support and intensive treatment with a smoking cessation program that is tailored to lung cancer patients’ specific needs.
Conclusion
A tobacco dependence treatment plan for lung cancer patients is provided.
doi:10.1159/000319937
PMCID: PMC2945268  PMID: 20699622
Lung cancer; Tobacco dependence; Older smokers
11.  Tobacco Use in the Oncology Setting: Advancing Clinical Practice and Research 
While tobacco is a well-established causal agent for many human cancers, less emphasis has been placed on translating this evidence by evaluating the effects of continued tobacco use after a cancer diagnosis. A broad assessment of the effects of continued tobacco use demonstrates that tobacco increases cancer treatment toxicity, recurrence, second primary tumors, and mortality in cancer patients. Few studies report the potential benefits of cessation after a cancer diagnosis, but data suggest improved treatment outcomes in cancer patients who quit smoking. Improving tobacco cessation treatment efficacy and access to cessation support has been sparsely researched in the oncology setting compared with the general population; however, cancer patients are receptive to standard evidence based tobacco cessation guidelines. Several studies demonstrate moderate tobacco cessation success in cancer patients using the general principles of evidence based tobacco cessation support. Several systems level issues and research efforts are needed to standardize tobacco use definitions, increase access to tobacco cessation support, improve tobacco cessation efficacy, understand the time dependent effects of tobacco and cessation on cancer biology, and realize the potential benefits of tobacco cessation for cancer patients.
doi:10.1158/1055-9965.EPI-13-0896
PMCID: PMC3893715  PMID: 24420982
12.  Practice Patterns and Perceptions of Thoracic Oncology Providers on Tobacco Use and Cessation in Cancer Patients 
Introduction
Tobacco use is associated with poor outcomes in cancer patients, but there is little information on the practice patterns or perceptions of tobacco use and smoking cessation by oncology providers.
Methods
An online survey of practices, perceptions, and barriers to tobacco assessment and cessation in cancer patients was conducted in members of the International Association for the Study of Lung Cancer (IASLC). Responses of physician level respondents were analyzed and reported.
Results
Responses from 1,507 IASLC members who completed the survey are reported representing 40.5% of IASLC members. Over 90% of physician respondents believe current smoking affects outcome and that cessation should be a standard part of clinical care. At the initial patient visit, 90% ask patients about tobacco use, 79% ask patients if they will quit, 81% advise patients to stop tobacco use, but only 40% discuss medication options, 39% actively provide cessation assistance, and fewer yet address tobacco at follow-up. Dominant barriers to physician cessation effort are pessimism regarding their ability to help patients stop using tobacco (58%) and concerns about patient resistance to treatment (67%). Only 33% report themselves adequately trained to provide cessation interventions.
Discussion
Physicians who care for lung cancer patients recognize the importance of tobacco cessation as a necessary part of clinical care, but many still do not routinely provide assistance to their patients. Increasing tobacco cessation will require increased assessment and cessation at diagnosis and during follow-up, increased clinician education, and improved tobacco cessation methods.
doi:10.1097/JTO.0b013e318288dc96
PMCID: PMC3628367  PMID: 23529191
smoking; tobacco; survey; thoracic; oncologists; cancer; cessation
13.  “Efforts to Reprioritise the Agenda” in China: British American Tobacco's Efforts to Influence Public Policy on Secondhand Smoke in China 
PLoS Medicine  2008;5(12):e251.
Background
Each year, 540 million Chinese are exposed to secondhand smoke (SHS), resulting in more than 100,000 deaths. Smoke-free policies have been demonstrated to decrease overall cigarette consumption, encourage smokers to quit, and protect the health of nonsmokers. However, restrictions on smoking in China remain limited and ineffective. Internal tobacco industry documents show that transnational tobacco companies (TTCs) have pursued a multifaceted strategy for undermining the adoption of restrictions on smoking in many countries.
Methods and Findings
To understand company activities in China related to SHS, we analyzed British American Tobacco's (BAT's) internal corporate documents produced in response to litigation against the major cigarette manufacturers to understand company activities in China related to SHS. BAT has carried out an extensive strategy to undermine the health policy agenda on SHS in China by attempting to divert public attention from SHS issues towards liver disease prevention, pushing the so-called “resocialisation of smoking” accommodation principles, and providing “training” for industry, public officials, and the media based on BAT's corporate agenda that SHS is an insignificant contributor to the larger issue of air pollution.
Conclusions
The public health community in China should be aware of the tactics previously used by TTCs, including efforts by the tobacco industry to co-opt prominent Chinese benevolent organizations, when seeking to enact stronger restrictions on smoking in public places.
Monique Muggli and colleagues study British American Tobacco (BAT) internal documents and find that from the mid 1990s BAT pursued a strategy aimed at influencing the public debate on secondhand smoke in China.
Editors' Summary
Background.
Each year, about one million people die in China from tobacco-caused diseases, including cancer, heart disease, and lung disease. Although most of these deaths occur among smokers—300 million people smoke in China, accounting for one-third of the global “consumption” of cigarettes—more than 100,000 deaths from tobacco-related causes occur annually among the 540 million Chinese people who are exposed to secondhand smoke. Tobacco smoke contains 4,000 known chemicals, 69 of which are known or probable carcinogens, and, when it is produced in enclosed spaces, both smokers and nonsmokers are exposed to its harmful effects. The only effective way to reduce tobacco smoke exposure indoors to acceptable levels is to implement 100% smoke-free environments—ventilation, filtration, and the provision of segregated areas for smokers and nonsmokers are insufficient. Importantly, as well as protecting nonsmokers from secondhand smoke, the implementation of smoke-free public places also reduces the number of cigarettes smoked among continuing smokers, increases the likelihood of smokers quitting, and reduces the chances of young people taking up smoking.
Why Was This Study Done?
Article 8 of the World Health Organization's Framework Convention on Tobacco Control (FCTC; an international public-health treaty that seeks to reduce tobacco-caused death and disease) calls on countries party to the treaty to protect their citizens from secondhand smoke exposure. China became a party to the FCTC in 2005 but restrictions on smoking in public places in China remain limited and ineffective. Previous analyses of internal tobacco industry documents have revealed that transnational tobacco companies (TTCs) have used a multifaceted approach to undermine the adoption of restrictions on smoking in many countries. TTCs have been shown to influence media coverage of secondhand smoke issues and to promote ineffective ventilation and separate smoking and nonsmoking areas in restaurants, bars, and hotels (so-called “resocalization of smoking” accommodation principles) with the aim of undermining smoke-free legislation. In addition, TTCs have created organizations interested in non-tobacco-related diseases to draw attention away from the public-health implications of secondhand smoke. In this study, the researchers ask whether TTCs have used a similar approach to undermine the adoption of restrictions on smoking in China, one of the most coveted cigarette markets in the world by the major TTCs.
What Did the Researchers Do and Find?
The researchers analyzed internal corporate documents produced by British American Tobacco (BAT; the predominant TTC in China) in response to litigation against major cigarette manufacturers stored in document depositories in Minnesota, USA and Guildford, UK. Among these documents, they found evidence that BAT had attempted to divert attention from secondhand smoke issues toward liver disease prevention by funding the Beijing Liver Foundation (BFL) from its inception in 1997 until at least 2002 (the most recent year that BAT's corporate records are available for public review). The researchers also found evidence that BAT had promoted “resocialization of smoking” accommodation principles as a “route to avoid smoking bans” and pushed ventilation and air filtration in airports and in establishments serving food and drink. Finally, the researchers found evidence that BAT had sought to “present the message that ‘tobacco smoke is just one of the sources of air polution [sic] and a very insignificant one compared with other pollutants'” through presentations given to the Chinese tobacco industry and media seminars aimed at Chinese journalists.
What Do These Findings Mean?
These findings indicate that, beginning in the mid 1990s and continuing until at least 2002, BAT has followed an intensive, multi-pronged strategy designed to undermine the health policy agenda on secondhand smoke in China. Given their findings, the researchers suggest that BFL and other charitable organizations in China must be wary of accepting tobacco money and that measures must be taken to improve the transparency and accountability of these and other public organizations. To meet FCTC obligations under Article 5.3 (industry interference), policy makers in China, they suggest, must be made aware of how BAT and other TTCs have repeatedly sought to influence health policy in China by focusing attention toward the adoption of ineffective air filtration and ventilation systems in hospitality venues rather than the implementation of 100% smoke-free environments. Finally, Chinese policy makers and the media need to be better informed about BAT's long-standing attempts to communicate misleading messages to them about the health effects of secondhand smoke.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050251.
The World Health Organization's Regional Office for the Western Pacific provides smoking statistics for China and other countries in the region
The World Health Organization provides information on the health problems associated with secondhand smoke, about its Tobacco Free Initiative (available in several languages), and about the Framework Convention on Tobacco Control (also available in several languages)
MedlinePlus provides links to information about the dangers of secondhand smoke (available in English and Spanish)
The UK National Health Service Smokefree Web site provides information about the advantages of giving up smoking, how to give up smoking, and the dangers associated with secondhand smoke
British American Tobacco documents stored in the Minnesota and Guildford Depositories, including those analyzed in this study, can be searched through the British American Tobacco Documents Archive
doi:10.1371/journal.pmed.0050251
PMCID: PMC2605899  PMID: 19108603
14.  Representation and Misrepresentation of Scientific Evidence in Contemporary Tobacco Regulation: A Review of Tobacco Industry Submissions to the UK Government Consultation on Standardised Packaging 
PLoS Medicine  2014;11(3):e1001629.
Selda Ulucanlar and colleagues analyze submissions by two tobacco companies to the UK government consultation on standardized packaging.
Please see later in the article for the Editors' Summary
Background
Standardised packaging (SP) of tobacco products is an innovative tobacco control measure opposed by transnational tobacco companies (TTCs) whose responses to the UK government's public consultation on SP argued that evidence was inadequate to support implementing the measure. The government's initial decision, announced 11 months after the consultation closed, was to wait for ‘more evidence’, but four months later a second ‘independent review’ was launched. In view of the centrality of evidence to debates over SP and TTCs' history of denying harms and manufacturing uncertainty about scientific evidence, we analysed their submissions to examine how they used evidence to oppose SP.
Methods and Findings
We purposively selected and analysed two TTC submissions using a verification-oriented cross-documentary method to ascertain how published studies were used and interpretive analysis with a constructivist grounded theory approach to examine the conceptual significance of TTC critiques. The companies' overall argument was that the SP evidence base was seriously flawed and did not warrant the introduction of SP. However, this argument was underpinned by three complementary techniques that misrepresented the evidence base. First, published studies were repeatedly misquoted, distorting the main messages. Second, ‘mimicked scientific critique’ was used to undermine evidence; this form of critique insisted on methodological perfection, rejected methodological pluralism, adopted a litigation (not scientific) model, and was not rigorous. Third, TTCs engaged in ‘evidential landscaping’, promoting a parallel evidence base to deflect attention from SP and excluding company-held evidence relevant to SP. The study's sample was limited to sub-sections of two out of four submissions, but leaked industry documents suggest at least one other company used a similar approach.
Conclusions
The TTCs' claim that SP will not lead to public health benefits is largely without foundation. The tools of Better Regulation, particularly stakeholder consultation, provide an opportunity for highly resourced corporations to slow, weaken, or prevent public health policies.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 6 million people die from tobacco-related diseases and, if current trends continue, annual tobacco-related deaths will increase to more than 8 million by 2030. To reduce this loss of life, national and international bodies have drawn up various conventions and directives designed to implement tobacco control measures such as the adoption of taxation policies aimed at reducing tobacco consumption and bans on tobacco advertising, promotion, and sponsorship. One innovative but largely unused tobacco control measure is standardised packaging of tobacco products. Standardised packaging aims to prevent the use of packaging as a marketing tool by removing all brand imagery and text (other than name) and by introducing packs of a standard shape and colour that include prominent pictorial health warnings. Standardised packaging was first suggested as a tobacco control measure in 1986 but has been consistently opposed by the tobacco industry.
Why Was This Study Done?
The UK is currently considering standardised packaging of tobacco products. In the UK, Better Regulation guidance obliges officials to seek the views of stakeholders, including corporations, on the government's cost and benefit estimates of regulatory measures such as standardised packaging and on the evidence underlying these estimates. In response to a public consultation about standardised packaging in July 2013, which considered submissions from several transnational tobacco companies (TTCs), the UK government announced that it would wait for the results of the standardised packaging legislation that Australia adopted in December 2012 before making its final decision about this tobacco control measure. Parliamentary debates and media statements have suggested that doubt over the adequacy of the evidence was the main reason for this ‘wait and see’ decision. Notably, TTCs have a history of manufacturing uncertainty about the scientific evidence related to the harms of tobacco. Given the centrality of evidence to the debate about standardised packaging, in this study, the researchers analyse submissions made by two TTCs, British American Tobacco (BAT) and Japan Tobacco International (JTI), to the first UK consultation on standardised packaging (a second review is currently underway and will report shortly) to examine how TTCs used evidence to oppose standardised packaging.
What Did the Researchers Do and Find?
The researchers analysed sub-sections of two of the four TTC submissions (those submitted by BAT and JTI) made to the public consultation using verification-oriented cross-documentary analysis, which compared references made to published sources with the original sources to ascertain how these sources had been used, and interpretative analysis to examine the conceptual significance of TTC critiques of the evidence on standardised packaging. The researchers report that the companies' overall argument was that the evidence base in support of standardised packaging was seriously flawed and did not warrant the introduction of such packaging. The researchers identified three ways in which the TTC reports misrepresented the evidence base. First, the TTCs misquoted published studies, thereby distorting the main messages of these studies. For example, the TTCs sometimes omitted important qualifying information when quoting from published studies. Second, the TTCs undermined evidence by employing experts to review published studies for methodological rigor and value in ways that did not conform to normal scientific critique approaches (‘mimicked scientific critique’). So, for example, the experts considered each piece of evidence in isolation for its ability to support standardised packaging rather than considering the cumulative weight of the evidence. Finally, the TTCs engaged in ‘evidential landscaping’. That is, they promoted research that deflected attention from standardised packaging (for example, research into social explanations of smoking behaviour) and omitted internal industry research on the role of packaging in marketing.
What Do These Findings Mean?
These findings suggest that the TTC critique of the evidence in favour of standardised packaging that was presented to the UK public consultation on this tobacco control measure is highly misleading. However, because the researchers' analysis only considered subsections of the submissions from two TTCs, these findings may not be applicable to the other submissions or to other TTCs. Moreover, their analysis only considered the efforts made by TTCs to influence public health policy and not the effectiveness of these efforts. Nevertheless, these findings suggest that the claim of TTCs that standardised packaging will not lead to public health benefits is largely without foundation. More generally, these findings highlight the possibility that the tools of Better Regulation, particularly stakeholder consultation, provide an opportunity for wealthy corporations to slow, weaken, or prevent the implementation of public health policies.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001629.
The World Health Organization provides information about the dangers of tobacco (in several languages) and an article about first experiences with Australia's tobacco plain packaging law; for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report ‘Tobacco industry interference with tobacco control’
A UK parliamentary briefing on standardised packaging of tobacco products, a press release about the consultation, and a summary report of the consultation are available; the ideas behind the UK's Better Regulation guidance are described in a leaflet produced by the Better Regulation Task Force
Cancer Research UK (CRUK) has a web page with information on standardised packaging and includes videos
Wikipedia has a page on standardised packaging of tobacco products (note: Wikipedia is a free online encyclopaedia that anyone can edit; available in several languages)
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
TobaccoTactics.org, an online resource managed by the University of Bath, provides up-to-date information on the tobacco industry and the tactics it uses to influence tobacco regulation
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
doi:10.1371/journal.pmed.1001629
PMCID: PMC3965396  PMID: 24667150
15.  Self-reported tobacco smoking practices among medical students and their perceptions towards training about tobacco smoking in medical curricula: A cross-sectional, questionnaire survey in Malaysia, India, Pakistan, Nepal, and Bangladesh 
Background
Tobacco smoking issues in developing countries are usually taught non-systematically as and when the topic arose. The World Health Organisation and Global Health Professional Student Survey (GHPSS) have suggested introducing a separate integrated tobacco module into medical school curricula. Our aim was to assess medical students' tobacco smoking habits, their practices towards patients' smoking habits and attitude towards teaching about smoking in medical schools.
Methods
A cross-sectional questionnaire survey was carried out among final year undergraduate medical students in Malaysia, India, Nepal, Pakistan, and Bangladesh. An anonymous, self-administered questionnaire included items on demographic information, students' current practices about patients' tobacco smoking habits, their perception towards tobacco education in medical schools on a five point Likert scale. Questions about tobacco smoking habits were adapted from GHPSS questionnaire. An 'ever smoker' was defined as one who had smoked during lifetime, even if had tried a few puffs once or twice. 'Current smoker' was defined as those who had smoked tobacco product on one or more days in the preceding month of the survey. Descriptive statistics were calculated.
Results
Overall response rate was 81.6% (922/1130). Median age was 22 years while 50.7% were males and 48.2% were females. The overall prevalence of 'ever smokers' and 'current smokers' was 31.7% and 13.1% respectively. A majority (> 80%) of students asked the patients about their smoking habits during clinical postings/clerkships. Only a third of them did counselling, and assessed the patients' willingness to quit. Majority of the students agreed about doctors' role in tobacco control as being role models, competence in smoking cessation methods, counseling, and the need for training about tobacco cessation in medical schools. About 50% agreed that current curriculum teaches about tobacco smoking but not systematically and should be included as a separate module. Majority of the students indicated that topics about health effects, nicotine addiction and its treatment, counselling, prevention of relapse were important or very important in training about tobacco smoking.
Conclusion
Medical educators should consider revising medical curricula to improve training about tobacco smoking cessation in medical schools. Our results should be supported by surveys from other medical schools in developing countries of Asia.
doi:10.1186/1747-597X-5-29
PMCID: PMC2994841  PMID: 21080923
16.  The Effectiveness of Mobile-Health Technology-Based Health Behaviour Change or Disease Management Interventions for Health Care Consumers: A Systematic Review 
PLoS Medicine  2013;10(1):e1001362.
Caroline Free and colleagues systematically review a fast-moving field, that of the effectiveness of mobile technology interventions delivered to healthcare consumers, and conclude that high-quality, adequately powered trials of optimized interventions are required to evaluate effects on objective outcomes.
Background
Mobile technologies could be a powerful media for providing individual level support to health care consumers. We conducted a systematic review to assess the effectiveness of mobile technology interventions delivered to health care consumers.
Methods and Findings
We searched for all controlled trials of mobile technology-based health interventions delivered to health care consumers using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990–Sept 2010). Two authors extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and used random effects meta-analysis. We identified 75 trials. Fifty-nine trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviours. Nearly all trials were conducted in high-income countries. Four trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (>400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72–0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47–1.32]). In a second, a PDA based intervention increased scores for perceived self care agency in lung transplant patients. Two trials of health behaviour management had low risk of bias. The pooled effect of text messaging smoking cessation support on biochemically verified smoking cessation was (RR 2.16 [95% CI 1.77–2.62]). Interventions for other conditions showed suggestive benefits in some cases, but the results were not consistent. No evidence of publication bias was demonstrated on visual or statistical examination of the funnel plots for either disease management or health behaviours. To address the limitation of the older search, we also reviewed more recent literature.
Conclusions
Text messaging interventions increased adherence to ART and smoking cessation and should be considered for inclusion in services. Although there is suggestive evidence of benefit in some other areas, high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Every year, millions of people die from cardiovascular diseases (diseases of the heart and circulation), chronic obstructive pulmonary disease (a long-term lung disease), lung cancer, HIV infection, and diabetes. These diseases are increasingly important causes of mortality (death) in low- and middle-income countries and are responsible for nearly 40% of deaths in high-income countries. For all these diseases, individuals can adopt healthy behaviors that help prevent disease onset. For example, people can lower their risk of diabetes and cardiovascular disease by maintaining a healthy body weight, and, if they are smokers, they can reduce their risk of lung cancer and cardiovascular disease by giving up cigarettes. In addition, optimal treatment of existing diseases can reduce mortality and morbidity (illness). Thus, in people who are infected with HIV, antiretroviral therapy delays the progression of HIV infection and the onset of AIDS, and in people who have diabetes, good blood sugar control can prevent retinopathy (a type of blindness) and other serious complications of diabetes.
Why Was This Study Done?
Health-care providers need effective ways to encourage "health-care consumers" to make healthy lifestyle choices and to self-manage chronic diseases. The amount of information, encouragement and support that can be conveyed to individuals during face-to-face consultations or through traditional media such as leaflets is limited, but mobile technologies such as mobile phones and portable computers have the potential to transform the delivery of health messages. These increasingly popular technologies—more than two-thirds of the world's population now owns a mobile phone—can be used to deliver health messages to people anywhere and at the most relevant times. For example, smokers trying to quit smoking can be sent regular text messages to sustain their motivation, but can also use text messaging to request extra support when it is needed. But is "mHealth," the provision of health-related services using mobile communication technology, an effective way to deliver health messages to health-care consumers? In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers assess the effectiveness of mobile technology-based health behavior change interventions and disease management interventions delivered to health-care consumers.
What Did the Researchers Do and Find?
The researchers identified 75 controlled trials (studies that compare the outcomes of people who do and do not receive an intervention) of mobile technology-based health interventions delivered to health-care consumers that met their predefined criteria. Twenty-six trials investigated the use of mobile technologies to change health behaviors, 59 investigated their use in disease management, most were of low quality, and nearly all were undertaken in high-income countries. In one high-quality trial that used text messages to improve adherence to antiretroviral therapy among HIV-positive patients in Kenya, the intervention significantly reduced the patients’ viral load but did not significantly reduce mortality (the observed reduction in deaths may have happened by chance). In two high-quality UK trials, a smoking intervention based on text messaging (txt2stop) more than doubled biochemically verified smoking cessation. Other lower-quality trials indicated that using text messages to encourage physical activity improved diabetes control but had no effect on body weight. Combined diet and physical activity text messaging interventions also had no effect on weight, whereas interventions for other conditions showed suggestive benefits in some but not all cases.
What Do These Findings Mean?
These findings provide mixed evidence for the effectiveness of health intervention delivery to health-care consumers using mobile technologies. Moreover, they highlight the need for additional high-quality controlled trials of this mHealth application, particularly in low- and middle-income countries. Specifically, the demonstration that text messaging interventions increased adherence to antiretroviral therapy in a low-income setting and increased smoking cessation in a high-income setting provides some support for the inclusion of these two interventions in health-care services in similar settings. However, the effects of these two interventions need to be established in other settings and their cost-effectiveness needs to be measured before they are widely implemented. Finally, for other mobile technology–based interventions designed to change health behaviors or to improve self-management of chronic diseases, the results of this systematic review suggest that the interventions need to be optimized before further trials are undertaken to establish their clinical benefits.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001362.
A related PLOS Medicine Research Article by Free et al. investigates the ability of mHealth technologies to improve health-care service delivery processes
Wikipedia has a page on mHealth (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
mHealth: New horizons for health through mobile technologies is a global survey of mHealth prepared by the World Health Organization’s Global Observatory for eHealth (eHealth is health-care practice supported by electronic processes and communication)
The mHealth in Low-Resource Settings website, which is maintained by the Netherlands Royal Tropical Institute, provides information on the current use, potential, and limitations of mHealth in low-resource settings
More information about Txt2stop is available, the UK National Health Service Choices website provides an analysis of the Txt2stop trial and what its results mean, and the UK National Health Service Smokefree website provides a link to a Quit App for the iPhone
The US Centers for Disease Control and Prevention has launched a text messaging service that delivers regular health tips and alerts to mobile phones
doi:10.1371/journal.pmed.1001362
PMCID: PMC3548655  PMID: 23349621
17.  Smokers’ beliefs about the tobacco control potential of “a gene for smoking”: a focus group study 
BMC Public Health  2014;14(1):1218.
Background
Several genetic variations associated with nicotine dependence and lung cancer exist. Translating this knowledge into tobacco control policy relies on smokers’ perceptions of the implications of the research. This study explored smokers’ beliefs about the tobacco control uses for research examining genomics, smoking, and addiction.
Method
Smokers (N = 85) participated in one of thirteen focus groups and one interview, stratified by race (eight black, six white) and education (seven < Bachelor’s degree, seven ≥ Bachelor’s degree). Data were analyzed by two independent coders using standard analysis and validation techniques.
Results
Nearly all groups suggested using genetic information for youth-oriented tobacco prevention education. Beliefs about the effectiveness of such actions varied. Many participants believed that providing smokers personalized genetic testing results or informing them about the existence of a gene would not motivate people to quit. All smokers emphasized the need for improved smoking cessation treatment options. Using genomics research to develop gene therapies and personalized drug treatments were also mentioned, yet perceptions of such treatments were mixed. Whereas some participants viewed the possibility positively, others expressed concern about cost and access. Participants who were skeptical of the effectiveness of using genetic information for tobacco control noted that the harms of tobacco use are widely known and genetic information does not add much of a deterrent.
Conclusion
Participants generated several possible tobacco control uses for genomics research findings. Our findings suggest that tobacco control experts should consult with smokers prior to implementing tobacco control measures. The potential public health benefits of genetics and genomics research related to tobacco use cannot be realized until communication strategies that are most likely to encourage and support tobacco avoidance decisions, and minimize mistrust and backlash, are identified.
doi:10.1186/1471-2458-14-1218
PMCID: PMC4258807  PMID: 25424390
Gene-environment interaction; Smoking cessation; Tobacco prevention; Health promotion; Personalized medicine; Tobacco control
18.  Transnational Tobacco Company Interests in Smokeless Tobacco in Europe: Analysis of Internal Industry Documents and Contemporary Industry Materials 
PLoS Medicine  2013;10(9):e1001506.
In light lobbying by transnational tobacco companies to remove the European Union ban on the sale of snus (a smokeless tobacco product), Silvy Peeters and Anna Gilmore explore the motivation behind tobacco companies' interests in smokeless tobacco products in Europe.
Please see later in the article for the Editors' Summary
Background
European Union (EU) legislation bans the sale of snus, a smokeless tobacco (SLT) which is considerably less harmful than smoking, in all EU countries other than Sweden. To inform the current review of this legislation, this paper aims to explore transnational tobacco company (TTC) interests in SLT and pure nicotine in Europe from the 1970s to the present, comparing them with TTCs' public claims of support for harm reduction.
Methods and Results
Internal tobacco industry documents (in total 416 documents dating from 1971 to 2009), obtained via searching the online Legacy Tobacco Documents Library, were analysed using a hermeneutic approach. This library comprises documents obtained via litigation in the US and does not include documents from Imperial Tobacco, Japan Tobacco International, or Swedish Match. To help overcome this limitation and provide more recent data, we triangulated our documentary findings with contemporary documentation including TTC investor presentations. The analysis demonstrates that British American Tobacco explored SLT opportunities in Europe from 1971 driven by regulatory threats and health concerns, both likely to impact cigarette sales negatively, and the potential to create a new form of tobacco use among those no longer interested in taking up smoking. Young people were a key target. TTCs did not, however, make SLT investments until 2002, a time when EU cigarette volumes started declining, smoke-free legislation was being introduced, and public health became interested in harm reduction. All TTCs have now invested in snus (and recently in pure nicotine), yet both early and recent snus test markets appear to have failed, and little evidence was found in TTCs' corporate materials that snus is central to their business strategy.
Conclusions
There is clear evidence that BAT's early interest in introducing SLT in Europe was based on the potential for creating an alternative form of tobacco use in light of declining cigarette sales and social restrictions on smoking, with young people a key target. We conclude that by investing in snus, and recently nicotine, TTCs have eliminated competition between cigarettes and lower-risk products, thus helping maintain the current market balance in favour of (highly profitable) cigarettes while ensuring TTCs' long-term future should cigarette sales decline further and profit margins be eroded.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 5 million people die from cancer, heart disease, and other tobacco-related diseases. In recent years, to reduce this growing loss of life, international and national bodies have drawn up various tobacco control conventions and directives. For example, the European Union (EU) Directives on tobacco control call for member states to ban tobacco advertising, promotion, and sponsorship and to adopt taxation policies aimed at reducing tobacco consumption. The 2001 EU Tobacco Products Directive also bans the sale of snus, a form of smokeless tobacco (SLT), in all EU countries except Sweden. Snus, which originated in Sweden in the early 19th century, is a moist tobacco product that is placed under the upper lip. Although snus is considerably less harmful than smoking, the sale of snus was banned in the EU in 1992 because of fears that it might cause cancer and was being marketed to young people. When Sweden joined the EU in 1994, exemption from the ban was made a condition of the membership treaty.
Why Was This Study Done?
Transnational tobacco companies (TTCs) have been investing in European snus manufacturers since 2002 and more recently in pure nicotine products, and it has been suggested that, faced with declining cigarette markets in Europe and elsewhere, TTCs are preparing for a “post-cigarette era”. Since 2008, TTCs have been lobbying EU member states and the European Commission to remove the ban on snus sales, arguing that public health would be improved if governments allowed potentially reduced-harm products like snus onto the market. At the end of 2012, however, the European Commission proposed that the ban on snus sales should be continued. Here, to help inform this controversial policy debate, the researchers explore the interest of TTCs in SLT and pure nicotine in Europe from the 1970s to the present by examining internal tobacco documents and compare these interests with public claims of support for harm reduction made by TTCs.
What Did the Researchers Do and Find?
By searching the Legacy Tobacco Documents Library (internal tobacco industry documents released following US litigation cases), the researchers identified 416 documents that detail the historical interest of TTCs in SLT and pure nicotine and their efforts to enter European markets, and to influence national and EU public-health policy. The researchers analyzed these documents using a “hermeneutic” approach—methodical reading and re-reading of the documents to identify themes and sub-themes. Finally, they used TTC investor presentations and other documents to confirm these themes and to provide recent data on TTC investment in SLT. British American Tobacco (BAT) explored the opportunities for marketing SLT products in Europe from 1971 onwards. This exploration was driven by regulatory threats and health concerns, both of which were likely to impact tobacco sales, and by the potential to create a new form of tobacco use among people no longer interested in taking up smoking. TTCs did not begin to invest in SLT, however, until 2002, a time when EU cigarette sale volumes started to decline, smoke-free legislation was being introduced, and tobacco harm reduction first became a major public-health issue. All the TTCs have now invested in snus even though snus test markets appear to have failed and even though there is little evidence in corporate materials that snus is central to the business strategy of TTCs.
What Do These Findings Mean?
These findings suggest that BAT's early interest in SLT in Europe was driven by business concerns and was based on the potential for creating an alternative form of tobacco use among people—particularly young people—who would no longer take up smoking because of health concerns. They also suggest that TTC investments in snus were defensive—by buying up snus manufacturers and more recently nicotine producers, TTCs have eliminated competition between cigarettes and lower-risk products, thereby helping to maintain the current market balance in favor of cigarettes while ensuring the long-term future of TTCs should cigarette sales decline further. Although these findings are limited by the possibility that some relevant documents may have been omitted from this analysis, they nevertheless raise the concern that, if TTC investment in SLT continues, competition between cigarettes and SLT will reduce the potential for harm reduction to benefit public health. Legalization of snus sales in the European Union may therefore have considerably less benefit than envisaged.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001506.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about the Framework Convention on Tobacco Control, an international treaty for tobacco control; for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
Details of European Union legislation on the manufacture, presentation, and sale of tobacco products is available (in several languages)
Wikipedia has pages on tobacco harm reduction and on snus (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The Legacy Tobacco Documents Library is a searchable public database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
TobaccoTactics.org, an online resource managed by the University of Bath, provides up-to-date information on the tobacco industry and their tactics to influence tobacco regulation
doi:10.1371/journal.pmed.1001506
PMCID: PMC3769209  PMID: 24058299
19.  Perceptions and Practices of Japanese Nurses Regarding Tobacco Intervention for Cancer Patients 
Journal of Epidemiology  2011;21(5):391-397.
Background
We investigated the perceptions and practices regarding tobacco intervention among nurses, as improvement of such practices is important for the management of patients who smoke.
Methods
Self-administered questionnaires were delivered by hospital administrative sections for nursing staff to 2676 nurses who were working in 3 cancer hospitals and 3 general hospitals. Of these, 2215 (82.8%) responded.
Results
Most nurses strongly agreed that cancer patients who had preoperative or early-clinical-stage cancer but continued to smoke should be offered a tobacco use intervention. In contrast, they felt less need to provide tobacco use intervention to patients with incurable cancer who smoked. Most nurses felt that although they assessed and documented the tobacco status of cancer patients, they were not successful in providing cessation advice, assessing patient readiness to quit, and providing individualized information on the harmful effects of tobacco use. In multivariate analysis, nurses who received instruction on smoking cessation programs during nursing school were more likely to give cessation advice (odds ratio, 1.61; 95% confidence interval, 1.15–2.26), assess readiness to quit (1.73, 1.09–2.75), and offer individualized explanations of the harmful effects of tobacco (1.94, 1.39–2.69), as compared with nurses who had not received such instruction.
Conclusions
The perceptions of Japanese nurses regarding tobacco intervention for cancer patients differed greatly by patient treatment status and prognosis. The findings highlight the importance of offering appropriate instruction on smoking cessation to students in nursing schools in Japan.
doi:10.2188/jea.JE20110008
PMCID: PMC3899439  PMID: 21821967
smoking cessation; intervention; nurses; perception
20.  Adult Mortality Attributable to Preventable Risk Factors for Non-Communicable Diseases and Injuries in Japan: A Comparative Risk Assessment 
PLoS Medicine  2012;9(1):e1001160.
Using a combination of published data and modeling, Nayu Ikeda and colleagues identify tobacco smoking and high blood pressure as major risk factors for death from noncommunicable diseases among adults in Japan.
Background
The population of Japan has achieved the longest life expectancy in the world. To further improve population health, consistent and comparative evidence on mortality attributable to preventable risk factors is necessary for setting priorities for health policies and programs. Although several past studies have quantified the impact of individual risk factors in Japan, to our knowledge no study has assessed and compared the effects of multiple modifiable risk factors for non-communicable diseases and injuries using a standard framework. We estimated the effects of 16 risk factors on cause-specific deaths and life expectancy in Japan.
Methods and Findings
We obtained data on risk factor exposures from the National Health and Nutrition Survey and epidemiological studies, data on the number of cause-specific deaths from vital records adjusted for ill-defined codes, and data on relative risks from epidemiological studies and meta-analyses. We applied a comparative risk assessment framework to estimate effects of excess risks on deaths and life expectancy at age 40 y. In 2007, tobacco smoking and high blood pressure accounted for 129,000 deaths (95% CI: 115,000–154,000) and 104,000 deaths (95% CI: 86,000–119,000), respectively, followed by physical inactivity (52,000 deaths, 95% CI: 47,000–58,000), high blood glucose (34,000 deaths, 95% CI: 26,000–43,000), high dietary salt intake (34,000 deaths, 95% CI: 27,000–39,000), and alcohol use (31,000 deaths, 95% CI: 28,000–35,000). In recent decades, cancer mortality attributable to tobacco smoking has increased in the elderly, while stroke mortality attributable to high blood pressure has declined. Life expectancy at age 40 y in 2007 would have been extended by 1.4 y for both sexes (men, 95% CI: 1.3–1.6; women, 95% CI: 1.2–1.7) if exposures to multiple cardiovascular risk factors had been reduced to their optimal levels as determined by a theoretical-minimum-risk exposure distribution.
Conclusions
Tobacco smoking and high blood pressure are the two major risk factors for adult mortality from non-communicable diseases and injuries in Japan. There is a large potential population health gain if multiple risk factors are jointly controlled.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Worldwide, a small number of modifiable risk factors are responsible for many premature or preventable deaths. For example, having high blood pressure (hypertension) increases a person's risk of developing life-threatening heart problems and stroke (cardiovascular disease). Similarly, having a high blood sugar level increases the risk of developing diabetes, a chronic (long-term) disease that can lead to cardiovascular problems and kidney failure, and half of all long-term tobacco smokers in Western populations will die prematurely from diseases related to smoking, such as lung cancer. Importantly, the five major risk factors for death globally—high blood pressure, tobacco use, high blood sugar, physical inactivity, and overweight and obesity—are all modifiable. That is, lifestyle changes and dietary changes such as exercising more, reducing salt intake, and increasing fruit and vegetable intake can reduce an individual's exposure to these risk factors and one's chances of premature death. Moreover, public health programs designed to reduce a population's exposure to modifiable risk factors should reduce preventable deaths in that population.
Why Was This Study Done?
In 2000, the Japanese government initiated Health Japan 21, a ten-year national health promotion campaign designed to prevent premature death from non-communicable (noninfectious) diseases and injuries. This campaign set 59 goals to monitor and improve risk factor management in the Japanese population, which has one of the longest life expectancies at birth in the world (the life expectancy of a person born in Japan in 2009 was 83.1 years). Because the campaign's final evaluation revealed deterioration or no improvement on some of these goals, the Japanese government recently released new guidelines that stress the importance of simultaneously controlling multiple risk factors for chronic diseases. However, although several studies have quantified the impacts on life expectancy and cause-specific death of individual modifiable risk factors in Japan, the effects of multiple risk factors have not been assessed. In this study, the researchers use a “comparative risk assessment” framework to estimate the effects of 16 risk factors on cause-specific deaths and life expectancy in Japan. Comparative risk assessment estimates the number of deaths that would be prevented if current distributions of risk factor exposures were changed to hypothetical optimal distributions.
What Did the Researchers Do and Find?
The researchers obtained data on exposure to the selected risk factors from the 2007 Japanese National Health and Nutrition Survey and from epidemiological studies, and information on the number of deaths in 2007 from different diseases from official records. They used published studies to estimate how much each factor increases the risk of death from each disease and then used a mathematical formula to estimate the effects of the risk factors on the number of deaths in Japan and on life expectancy at age 40. In 2007, tobacco smoking and high blood pressure accounted for 129,000 and 104,000 deaths, respectively, in Japan. Physical inactivity accounted for 52,000 deaths, high blood glucose and high dietary salt intake accounted for 34,000 deaths each, and alcohol use for 31,000 deaths. Life expectancy at age 40 in 2007 would have been extended by 1.4 years for both sexes, the researchers estimate, if exposure to multiple cardiovascular risk factors had been reduced to calculated optimal distributions, or by 0.7 years if these risk factors had been reduced to the distributions defined by national guidelines and goals.
What Do These Findings Mean?
These findings identify tobacco smoking and high blood pressure as the major risk factors for death from non-communicable diseases among adults in Japan, a result consistent with previous findings from the US. They also indicate that simultaneous control of multiple risk factors has great potential for producing health gains among the Japanese population. Although the researchers focused on estimating the effect of these risk factors on mortality and did not include illness and disability in this study, these findings nevertheless identify two areas of public health policy that need to be strengthened to improve health, reduce death rates, and increase life expectancy among the Japanese population. First, they highlight the need to reduce tobacco smoking, particularly among men. Second and most importantly, these findings emphasize the need to improve ongoing programs designed to help people manage multiple cardiovascular risk factors, including high blood pressure.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001160.
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living
The World Health Report 2002—Reducing Risks, Promoting Healthy Life provides a global analysis of how healthy life expectancy could be increased
The American Heart Association and the American Cancer Society provide information on many important risk factors for noncommunicable diseases and include some personal stories about keeping healthy
Details about Health Japan 21 are provided by the Japanese Ministry of Health, Labour and Welfare. Further details about this campaign are available from the World Health Organization
MedlinePlus provides links to further resources on healthy living and on healthy aging (in English and Spanish)
doi:10.1371/journal.pmed.1001160
PMCID: PMC3265534  PMID: 22291576
21.  Addressing Tobacco Use in Patients With Cancer: A Survey of American Society of Clinical Oncology Members 
Journal of Oncology Practice  2013;9(5):258-262.
Among ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support.
Purpose:
Assessing tobacco use and providing cessation support is recommended by the American Society for Clinical Oncology (ASCO). The purpose of this study was to evaluate practice patterns and perceptions of tobacco use and barriers to providing cessation support for patients with cancer.
Methods:
In 2012, an online survey was sent to 18,502 full ASCO members asking about their practice patterns regarding tobacco assessment, cessation support, perceptions of tobacco use, and barriers to providing cessation support for patients with cancer. Responses from 1,197 ASCO members are reported.
Results:
At initial visit, most respondents routinely ask patients about tobacco use (90%), ask patients to quit (80%), and advise patients to stop using tobacco (84%). However, only 44% routinely discuss medication options with patients, and only 39% provide cessation support. Tobacco assessments decrease at follow-up assessments. Most respondents (87%) agree or strongly agree that smoking affects cancer outcomes, and 86% believe cessation should be a standard part of clinical cancer care. However, only 29% report adequate training in tobacco cessation interventions. Inability to get patients to quit (72%) and patient resistance to treatment (74%) are dominant barriers to cessation intervention, but only 8% describe cessation as a waste of time.
Conclusion:
Among ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support. Interventions are needed to increase access to tobacco cessation support for patients with cancer.
doi:10.1200/JOP.2013.001025
PMCID: PMC3770508  PMID: 23943904
22.  Tobacco harm reduction: an alternative cessation strategy for inveterate smokers 
According to the Centers for Disease Control and Prevention, about 45 million Americans continue to smoke, even after one of the most intense public health campaigns in history, now over 40 years old. Each year some 438,000 smokers die from smoking-related diseases, including lung and other cancers, cardiovascular disorders and pulmonary diseases.
Many smokers are unable – or at least unwilling – to achieve cessation through complete nicotine and tobacco abstinence; they continue smoking despite the very real and obvious adverse health consequences. Conventional smoking cessation policies and programs generally present smokers with two unpleasant alternatives: quit, or die.
A third approach to smoking cessation, tobacco harm reduction, involves the use of alternative sources of nicotine, including modern smokeless tobacco products. A substantial body of research, much of it produced over the past decade, establishes the scientific and medical foundation for tobacco harm reduction using smokeless tobacco products.
This report provides a description of traditional and modern smokeless tobacco products, and of the prevalence of their use in the United States and Sweden. It reviews the epidemiologic evidence for low health risks associated with smokeless use, both in absolute terms and in comparison to the much higher risks of smoking. The report also describes evidence that smokeless tobacco has served as an effective substitute for cigarettes among Swedish men, who consequently have among the lowest smoking-related mortality rates in the developed world. The report documents the fact that extensive misinformation about ST products is widely available from ostensibly reputable sources, including governmental health agencies and major health organizations.
The American Council on Science and Health believes that strong support of tobacco harm reduction is fully consistent with its mission to promote sound science in regulation and in public policy, and to assist consumers in distinguishing real health threats from spurious health claims. As this report documents, there is a strong scientific and medical foundation for tobacco harm reduction, and it shows great potential as a public health strategy to help millions of smokers.
doi:10.1186/1477-7517-3-37
PMCID: PMC1779270  PMID: 17184539
23.  Promoting smoking cessation during hospitalization for coronary artery disease 
BACKGROUND
Quitting smoking is the most effective intervention to reduce mortality in patients with coronary artery disease who smoke. Guidelines for the treatment of tobacco dependency recommend that health care institutions develop plans to support the consistent and effective identification and treatment of tobacco users. The University of Ottawa Heart Institute (Ottawa, Ontario) has implemented an institutional program to identify and treat all smokers admitted to the Institute.
OBJECTIVES
The objectives of the present paper are to describe core elements of this program and present data concerning its reach and effectiveness.
PROGRAM DESCRIPTION
The goal of the program is to increase the number of smokers who are abstinent from smoking six months after a coronary artery disease-related hospitalization. Core elements of the program include: documentation of smoking status at hospital admission; inclusion of cessation intervention on patient care maps; individualized, bedside counselling by a nurse counsellor; the appropriate and timely use of nicotine replacement therapy; automated telephone follow-up; referral to outpatient cessation resources; and training of medical residents and nursing staff. Program reach and effectiveness were measured over a one-year period.
RESULTS
Between April 2003 and March 2004, almost 1300 smokers were identified at admission, and 91% received intervention to help them quit smoking. At six-month follow-up, 44% were smoke-free.
CONCLUSIONS
Hospitalization for coronary artery disease provides an important opportunity to intervene with smokers when their motivation to quit is high. An institutional approach reinforces the importance of smoking cessation in this patient population and increases the rate of smoking cessation. Posthospitalization quit rates should be a benchmark of cardiac program performance.
PMCID: PMC2560518  PMID: 16835672
Coronary disease; Health care delivery; Prevention; Smoking
24.  Best practices for smoking cessation interventions in primary care 
BACKGROUND:
In Canada, smoking is the leading preventable cause of premature death. Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation. Because smoking is a chronic addiction, repeated, opportunity-based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. However, only a small minority of family physicians provide thorough smoking cessation counselling and less than one-half offer adjunct support to patients.
OBJECTIVE:
To identify the key steps family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients.
METHODS:
A multidisciplinary panel of health care practitioners involved with smoking cessation from across Canada was convened to discuss best practices derived from international guidelines, including those from the United States, Europe, and Australia, and other relevant literature. The panellists subsequently refined their findings in the form of the present article.
RESULTS:
The present paper outlines best practices for brief and effective counselling for, and treatment of, tobacco addiction. By adopting a simple series of questions, taking 30 s to 3 min to complete, health care professionals can initiate smoking cessation interventions. Integrating these strategies into daily practice provides opportunities to significantly improve the quality and duration of patients’ lives.
CONCLUSION:
Tobacco addiction is the most important preventable cause of morbidity and mortality in Canada. Family physicians, nurse practitioners and other front-line health care professionals are well positioned to influence and assist their patients in quitting, thereby reducing the burden on both personal health and the public health care system.
PMCID: PMC2734439  PMID: 19707607
Behavioural intervention; Smoking cessation; Tobacco
25.  Factors associated with smoking abstinence among smokers and recent-quitters with lung and head and neck cancer 
Introduction
Smoking cessation among cancer patients is critical for improving outcomes. Understanding factors associated with smoking abstinence after the diagnosis of cancer can provide direction to develop and test interventions to enhance cessation rates. The purpose of this study was to identify determinants of smoking outcomes among cancer patients.
Methods
Standardized questionnaires were used to collect data from 163 smokers or recent-quitters (quit ≤ 6 mo) at study entry of which 132 and 121 had data collected at 3 and 6-months. Biochemical verification was conducted with urinary cotinine and carbon monoxide. Descriptive statistics, Cronbach alpha coefficients, Pearson correlations, Fisher’s exact test, and multivariable logistic regression were used for analyses.
Results
Seven-day-point-prevalence-abstinence (PPA) rates were 90/132 (68%) at 3-months; 46/71 (65%) among lung and 44/61 (72%) among head and neck cancer patients, whereas 7-day-PPA rates were 74/121 (61%) at 6-months; 31/58 (53%) among lung and 43/63 (68%) among head and neck cancer patients. Continuous abstinence rates were 63/89 (71%) at 3-months; 32/45 (71%) among lung and 31/44 (70%) among head and neck cancer patients, whereas continuous abstinence rates were 46/89 (52%) at 6-months; 18/45 (40%) among lung and 28/44 (64%) among head and neck cancer patients. Lower cancer-related, psychological and nicotine withdrawal symptoms were associated with increased 7-D-PPA abstinence rates at 3 and 6 months in univariate models. In multivariable models, however, decreased craving was significantly related with 7-day-PPA at 3-months and decreased craving and increased self-efficacy were associated with 7-D-PPA at 6-months. Decreased craving was the only factor associated with continuous abstinence at 6-months.
Conclusions
Smoking outcomes among lung and head and neck cancer patients appear to have remained the same over the last two decades despite the availability of an increased number of pharmacotherapy options to treat tobacco dependence. Decreased craving and increased self-efficacy were the most consistent factors associated with improved smoking outcomes but symptom control may also play a role in optimal management. Use of combined, and/or higher doses of pharmacotherapy along with behavioral interventions that increase self-efficacy and manage symptoms may promote enhanced cessation rates.
doi:10.1016/j.lungcan.2011.10.005
PMCID: PMC3322288  PMID: 22093155
smoking cessation; tobacco dependence; lung cancer; head and neck cancer; smoking cessation interventions; symptom management; craving

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