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1.  Estimating the probabilities of making a smoking quit attempt in Italy: stall in smoking cessation levels, 1986-2009 
BMC Public Health  2012;12:183.
Background
No data on annual smoking cessation probability (i.e., the probability of successfully quit in a given year) are available for Italy at a population level. Mathematical models typically used to estimate smoking cessation probabilities do not account for smoking relapse. In this paper, we developed a mathematical model to estimate annual quitting probabilities, taking into account smoking relapse and time since cessation.
Methods
We developed a dynamic model describing the evolution of current, former, and never smokers. We estimated probabilities of smoking cessation by fitting the model with observed smoking prevalence in Italy, 1986-2009.
Results
Annual cessation probabilities were higher than 5% only in elderly persons and in women aged < 30 years, while in adults aged 30-49 and 50-59 cessations were about 2% and 3-5%, respectively. Most of quit probabilities stalled from 1986 to 2009.
Conclusions
Over the last 20 years, cessation probabilities among Italian smokers, particularly for those aged 30-59 years, have been very low and stalled. Quitting in Italy is considered as a practicable strategy only by women in the age of pregnancy and by elderly persons, when it’s likely that symptoms of tobacco-related diseases have already appeared. In order to increase cessation probabilities, smoking cessation treatment policies (introducing total reimbursement of cessation treatments, with a further development of quitlines and smoking cessation services) should be empowered and a country-wide mass media campaign targeting smokers aged 30-59 years and focusing on promotion of quitting should be implemented.
doi:10.1186/1471-2458-12-183
PMCID: PMC3378462  PMID: 22410134
2.  Interplay of Genetic Risk Factors (CHRNA5-CHRNA3-CHRNB4) and Cessation Treatments in Smoking Cessation Success 
The American journal of psychiatry  2012;169(7):735-742.
Objective
Smoking is highly intractable and the genetic influences on cessation are unclear. Identifying the genetic factors affecting smoking cessation could elucidate the nature of tobacco dependence, enhance risk assessment, and support treatment algorithm development. This study tests whether variants in the nicotinic receptor gene cluster (CHRNA5-CHRNA3-CHRNB4) predict age of smoking cessation and relapse to smoking after a quit attempt.
Method
In a community-based, cross-sectional study (N=5,216) and a randomized comparative effectiveness smoking cessation trial (N=1,073), we used survival analyses and logistic regression to model relations between smoking cessation (self-reported quit age in a community study and point-prevalence abstinence at end-of-treatment in a clinical trial) and three common haplotypes in the CHRNA5-CHRNA3-CHRNB4 region defined by rs16969968 and rs680244.
Results
The genetic variants in the CHRNA5-CHRNA3-CHRNB4 region that predict nicotine dependence also predict a later age of smoking cessation in a community-based sample (X2=8.46, df=2, p=0.015). In the smoking cessation trial, these variants predict abstinence at end-of-treatment in individuals receiving placebo medication, but not amongst individuals receiving active medication. Genetic variants interact with treatment in affecting cessation success (X2=8.97, df=2, p=0.011).
Conclusions
Smokers with the high risk genetic variants have a three-fold increased likelihood of responding to pharmacologic cessation treatments, compared to smokers with the low risk genetic variants. The high-risk variants increase the risk of cessation failure, and this increased risk can be ameliorated by cessation pharmacotherapy. By identifying a high-risk genetic group with heightened response to smoking cessation pharmacotherapy, this work may support the development of personalized cessation treatments.
doi:10.1176/appi.ajp.2012.11101545
PMCID: PMC3433845  PMID: 22648373
3.  Smoking and Ethics: What Are the Duties of Oncologists? 
The Oncologist  2010;15(9):987-993.
The role oncologists play in combating the smoking epidemic is examined. The authors argue that quitting or abstaining from smoking, advocating for smoke-free environments in one's own community, and actively supporting one's international colleagues to do the same are duties of oncologists, grounded in both common sense and in the ethics of professionalism.
Learning Objectives
After completing this course, the reader will be able to: Act as a role model to promote patient and community health by abstaining from or quitting smoking and encouraging and assisting patients and colleagues to quit smoking.Assume more responsibility for advocating for smoke-free environments and policies that combat smoking-related health threats in the community.Actively support international policies and interventions that expand tobacco cessation and smoke-free environments.
This article is available for continuing medical education credit at CME.TheOncologist.com
The World Health Organization's 2009 report on the world's tobacco epidemic predicts that, unchecked, tobacco use will kill a billion people in this century. Oncologists have a special professional role to play in combating this epidemic. Based on two views of professionalism, this editorial argues that oncologists have three duties. First, oncologists should be role models. They should not smoke themselves and urge their colleagues to do the same. Second, oncologists must strongly advise their own patients to stop smoking and advocate for tobacco-free environments in their patients' communities. Third, oncologists have duties to their international colleagues. They should share their experience in combating tobacco use with them, encourage and assist them to quit smoking, and help them advocate for smoke-free environments. Further, oncologists should work to ratify the Framework Convention on Tobacco Control in their own country.
doi:10.1634/theoncologist.2010-0034
PMCID: PMC3228038  PMID: 20736299
Professional ethics; Tobacco smoking
4.  Financial incentives for smoking cessation in low-income smokers: study protocol for a randomized controlled trial 
Trials  2012;13:88.
Background
Tobacco smoking is the leading avoidable cause of death in high-income countries. The smoking-related disease burden is borne primarily by the least educated and least affluent groups. Thus, there is a need for effective smoking cessation interventions that reach to, and are effective in this group. Research suggests that modest financial incentives are not very effective in helping smokers quit. What is not known is whether large financial incentives can enhance longer-term (1 year) smoking cessation rates, outside clinical and workplace settings.
Trial design
A randomized, parallel groups, controlled trial.
Methods
Participants: Eight hundred low-income smokers in Switzerland (the less affluent third of the population, based on fiscal taxation).
Intervention: A smoking cessation program including: (a) financial incentives given during 6 months; and (b) Internet-based counseling. Financial rewards will be offered for biochemically verified smoking abstinence after 1, 2, and 3 weeks and 1, 3, and 6 months, for a maximum of 1,500 CHF (1,250 EUR, 1,500 USD) for those abstinent at all time-points. All participants, including controls, will receive Internet-based, individually-tailored, smoking cessation counseling and self-help booklets, but there will be no in-person or telephone counseling, and participants will not receive medications. The control group will not receive financial incentives.
Objective: To increase smoking cessation rates.
Outcome: Smoking abstinence after 6 and 18 months, not contradicted by biochemical tests. We will assess relapse after the end of the intervention, to test whether 6-month effects translate into sustained abstinence 12 months after the incentives are withdrawn.
Randomization: Will be done using sealed envelopes drawn by participants.
Blinding: Is not possible in this context.
Discussion
Smoking prevention policies and interventions have been least effective in the least educated, low-income groups. Combining financial incentives and Internet-based counseling is an innovative approach that, if proven acceptable and effective, could be later implemented on a large scale at a reasonable cost, decrease health disparities, and save many lives.
Trial registration
Current Controlled Trials ISRCTN04019434.
doi:10.1186/1745-6215-13-88
PMCID: PMC3526393  PMID: 22721577
Financial incentives; Smoking; Smoking cessation
5.  Attitudes to smoking cessation and triggers to relapse among Chinese male smokers 
BMC Public Health  2006;6:65.
Background
Smoking is related to many diseases, and the relapse to smoking after cessation in China is noticeable. We examined the attitudes of Chinese male smokers regarding smoking cessation and reasons for relapse.
Methods
We interviewed 201 male smokers in Hangzhou City, Zhejiang province, China who had tried to quit smoking at least once in order to identify reasons for quitting and situations triggering relapse.
Results
The most significant reported reasons for quitting included personal health (77.1%), the cost of cigarettes (53.7%), and family pressures to quit (29.9%). The most common factors triggering relapse were social situations (34.3%), feeling negative or down (13.4%) and times of being alone (8.4%).
Conclusion
Health and family concerns, personal factors, the influence of others and a lack of cessation resources were cited as salient factors concerning smoking cessation among male smokers in this study. Effective smoking control efforts in China will require attention to these influences if China is to curb its current smoking epidemic.
doi:10.1186/1471-2458-6-65
PMCID: PMC1431522  PMID: 16533411
6.  Simultaneous evaluation of abstinence and relapse using a Markov chain model in smokers enrolled in a two-year randomized trial 
Background
GEE and mixed models are powerful tools to compare treatment effects in longitudinal smoking cessation trials. However, they are not capable of assessing the relapse (from abstinent back to smoking) simultaneously with cessation, which can be studied by transition models.
Methods
We apply a first-order Markov chain model to analyze the transition of smoking status measured every 6 months in a 2-year randomized smoking cessation trial, and to identify what factors are associated with the transition from smoking to abstinent and from abstinent to smoking. Missing values due to non-response are assumed non-ignorable and handled by the selection modeling approach.
Results
Smokers receiving high-intensity disease management (HDM), of male gender, lower daily cigarette consumption, higher motivation and confidence to quit, and having serious attempts to quit were more likely to become abstinent (OR = 1.48, 1.66, 1.03, 1.15, 1.09 and 1.34, respectively) in the next 6 months. Among those who were abstinent, lower income and stronger nicotine dependence (OR = 1.72 for ≤ vs. > 40 K and OR = 1.75 for first cigarette ≤ vs. > 5 min) were more likely to have relapse in the next 6 months.
Conclusions
Markov chain models allow investigation of dynamic smoking-abstinence behavior and suggest that relapse is influenced by different factors than cessation. The knowledge of treatments and covariates in transitions in both directions may provide guidance for designing more effective interventions on smoking cessation and relapse prevention.
Trial Registration
clinicaltrials.gov identifier: NCT00440115
doi:10.1186/1471-2288-12-95
PMCID: PMC3599722  PMID: 22770436
7.  Cigarette smokers' intention to quit smoking in Dire Dawa town Ethiopia: an assessment using the Transtheoretical Model 
BMC Public Health  2010;10:320.
Background
Cessation of smoking reduces morbidity and mortality related to tobacco smoking. It is essential to explore the intention of individuals to quit smoking to design effective interventions. The objective of this study was to assess cigarette smokers' intention to quit smoking in Dire Dawa town using the Transtheoretical model.
Methods
From February 15 to 19, 2009, we conducted a community based cross-sectional study among 384 current cigarette smokers in Dire Dawa town east Ethiopia. Data was collected by trained personnel using a pretested structured questionnaire. The data was analyzed using SPSS version 16.0.
Results
Two hundred and nineteen (57%) smokers in the study area had the intention to quit cigarette smoking within the next six months and all the process of change had an increasing trend across the stages. Based on the Fragestrom test of nicotine dependence of cigarette, 35 (9.1%), 69 (18%) and 48(12.5%) were very high, high and medium dependent on nicotine respectively. For the majority 247(64.3%) of the respondents, the mean score of cons of smoking outweighs the pros score (negative decisional balance). Only 66(17.2%) had high self efficacy not to smoke in places and situations that can aggravate smoking.
Conclusions
Majority of the smokers had the intention to quit smoking. All the process of change had an increasing trend across the stages. Those who had no intention to quit smoking had high level of dependence on nicotine and low self efficacy. The pros of smoking were decreasing while the cons were increasing across the stages. Stage based interventions should be done to move the smokers from their current stage to an advanced stages of quitting cigarette smoking.
doi:10.1186/1471-2458-10-320
PMCID: PMC2889871  PMID: 20529337
8.  Control Systems Engineering for Understanding and Optimizing Smoking Cessation Interventions* 
Cigarette smoking remains a major public health issue. Despite a variety of treatment options, existing intervention protocols intended to support attempts to quit smoking have low success rates. An emerging treatment framework, referred to as adaptive interventions in behavioral health, addresses the chronic, relapsing nature of behavioral health disorders by tailoring the composition and dosage of intervention components to an individual’s changing needs over time. An important component of a rapid and effective adaptive smoking intervention is an understanding of the behavior change relationships that govern smoking behavior and an understanding of intervention components’ dynamic effects on these behavioral relationships. As traditional behavior models are static in nature, they cannot act as an effective basis for adaptive intervention design. In this article, behavioral data collected daily in a smoking cessation clinical trial is used in development of a dynamical systems model that describes smoking behavior change during cessation as a self-regulatory process. Drawing from control engineering principles, empirical models of smoking behavior are constructed to reflect this behavioral mechanism and help elucidate the case for a control-oriented approach to smoking intervention design.
PMCID: PMC3868623  PMID: 24362946
9.  Does the duration of smoking cessation have an impact on hospital admission and health-related quality of life amongst COPD patients? 
Background
Lack of awareness among ex-smokers on the benefits of sustaining smoking cessation may be the main cause of their smoking relapse. This study explored health-related quality of life (HRQoL) and hospital admission amongst chronic obstructive pulmonary disease (COPD) patients according to the duration of smoking cessation.
Materials and methods
This study recruited COPD patients from a chest clinic who agreed to participate in a medication therapy-adherence program from January to June 2013. They were interviewed during their visits to obtain information regarding their smoking history and HRQoL. They were divided into three groups according to smoking status (sustained quitters, quit ≥5 years; quitters, quit <5 years; and smokers, smoking at least one cigarette/day). The effects of the duration of cessation on HRQoL and hospital admission were analyzed using a multinomial logistic model.
Results
A total of 117 participants with moderate COPD met the inclusion criteria, who were comprised of 41 sustained quitters, 40 quitters, and 36 smokers. Several features were similar across the groups. Most of them were married elderly men (aged >64 years) with low-to-middle level of education, who smoked more than 33 cigarettes per day and had high levels of adherence to the medication regimen. The results showed that sustained quitters were less likely to have respiratory symptoms (cough, phlegm and dyspnea) than smokers (odds ratio 0.02, confidence interval 0–0.12; P<0.001). The hospital admission rate per year was increased in quitters compared to smokers (odds ratio 4.5, confidence interval 1.91–10.59; P<0.005).
Conclusion
A longer duration of quitting smoking will increase the benefits to COPD patients, even if they experience increased episodic respiratory symptoms in the early period of the cessation. Thus, the findings of this study show the benefits of early smoking cessation.
doi:10.2147/COPD.S56637
PMCID: PMC4027923  PMID: 24868154
HRQoL; hospital admission and hospital stay; chronic obstructive pulmonary disease (COPD)
10.  Interventions for smoking cessation in hospitalised patients: a systematic review 
Thorax  2001;56(8):656-663.
BACKGROUND—An admission to hospital provides an opportunity to help people stop smoking. Individuals may be more open to help at a time of perceived vulnerability, and may find it easier to quit in an environment where smoking is restricted or prohibited. Providing smoking cessation services during hospitalisation may help more people to attempt and sustain an attempt to quit. The purpose of this paper is to systematically review the effectiveness of interventions for smoking cessation in hospitalised patients.
METHODS—We searched the Cochrane Tobacco Addiction Group register, CINAHL, and the Smoking and Health database for studies of interventions for smoking cessation in hospitalised patients. Randomised and quasi-randomised trials of behavioural, pharmacological, or multi-component interventions to help patients stop smoking conducted with hospitalised patients who were current smokers or recent quitters were included. Studies of patients admitted for psychiatric disorders or substance abuse, those that did not report abstinence rates, and those with follow up of less than 6 months were excluded. Two of the authors extracted data independently for each paper, with assistance from others.
RESULTS—Intensive intervention (inpatient contact plus follow up for at least 1 month) was associated with a significantly higher cessation rate compared with controls (Peto odds ratio (OR) 1.82,95% CI 1.49 to 2.22). Any contact during hospitalisation followed by minimal follow up failed to detect a statistically significant effect on cessation rate, but did not rule out a 30% increase in smoking cessation (Peto OR 1.09, 95% CI 0.91 to 1.31). There was insufficient evidence to judge the effect of interventions delivered only during the hospital stay. Although the interventions increased quit rates irrespective of whether nicotine replacement therapy (NRT) was used, the results for NRT were compatible with other data indicating that it increases quit rates. There was no strong evidence that clinical diagnosis affected the likelihood of quitting.
CONCLUSIONS—High intensity behavioural interventions that include at least 1 month of follow up contact are effective in promoting smoking cessation in hospitalised patients.


doi:10.1136/thorax.56.8.656
PMCID: PMC1746121  PMID: 11462070
11.  Successful smoking cessation with electronic cigarettes in smokers with a documented history of recurring relapses: a case series 
Introduction
Smoking cessation programs are useful in helping smokers to quit, but smoking is a very difficult addiction to break and the need for novel and effective approaches to smoking cessation interventions is unquestionable. The E-cigarette is a battery-powered electronic nicotine delivery device that may help smokers to remain abstinent during their quit attempt. We report for the first time objective measures of smoking cessation in smokers who experimented with the E-cigarette.
Case presentation
Three Caucasian smokers (two men aged 47 and 65 years and one woman aged 38 years) with a documented history of recurring relapses were able to quit and to remain abstinent for at least six months after taking up an E-cigarette.
Conclusions
This is the first time that objective measures of smoking cessation are reported for smokers who quit successfully after using an E-cigarette. This was accomplished in smokers who repeatedly failed in previous attempts with professional smoking cessation assistance using the usual nicotine dependence treatments and smoking cessation counselling.
doi:10.1186/1752-1947-5-585
PMCID: PMC3276453  PMID: 22185668
12.  Promotion of smoking cessation in developing countries: a framework for urgent public health interventions 
Thorax  2004;59(7):623-630.
The rapid rise in smoking in many developing countries will have devastating consequences; by 2030 the developing world is expected to have 7 million deaths annually from tobacco use. Many smokers express a desire to quit, but they often fail because they are addicted to tobacco. Although a number of cessation aids are now available in the developed world, their applicability and affordability in developing countries is less clear. Successful interventions will require many stakeholder groups to take action at the local, national, and international levels. We discuss smoking cessation as a means of reducing disease burden, examine factors that may limit the promotion of smoking cessation in developing countries, and propose a framework for public health action. This framework should comprise intervention with healthcare professionals, strengthening national commitment, development of a model for developing countries, changing the social acceptability of smoking, strengthening community participation, integration of smoking cessation with other healthcare services, specifying the role of healthcare professionals, development of guidelines, mobilisation of the business community, provision of financial incentives, establishing population specific smoking cessation services, increased collaboration between countries, and development of international initiatives.
doi:10.1136/thx.2003.018820
PMCID: PMC1747072  PMID: 15223875
13.  Cigarette smoking and attitudes toward quitting among black patients. 
A sample of 1,388 black patients attending the medical clinic of a general public hospital were interviewed regarding smoking habits and attitudes toward quitting. Current smokers constituted 30% of respondents of both sexes, and approximately half of the sample were ex-smokers. Rates of current smoking were lower, and cessation rates higher, among older individuals and men. Two thirds of current smokers expressed a desire to quit, and of those an equal proportion wanted to participate in a formal cessation program. A majority of smokers reported attempting to quit on their own, and most had made more than one attempt. Given the large burden from cigarette-related disease in the black population, and the current absence of effective primary prevention efforts, smoking intervention in the clinical setting will remain an important obligation of health providers caring for black patients. This article demonstrates moderately high smoking prevalence rates of black individuals already under care for chronic illness, and a concomitant high level of desire to quit. The absence of effective programs appears to be the obstacle preventing significant progress in this important area of health promotion.
PMCID: PMC2625988  PMID: 2738951
14.  A research agenda for assessing the potential contribution of genomic medicine to tobacco control 
Tobacco Control  2007;16(1):53-58.
This paper identifies research priorities in evaluating the ways in which “genomic medicine”—the use of genetic information to prevent and treat disease—may reduce tobacco‐related harm by: (1) assisting more smokers to quit; (2) preventing non‐smokers from beginning to smoke tobacco; and (3) reducing the harm caused by tobacco smoking. The method proposed to achieve the first aim is “pharmacogenetics”, the use of genetic information to optimise the selection of smoking‐cessation programmes by screening smokers for polymorphisms that predict responses to different methods of smoking cessation. This method competes with the development of more effective forms of smoking cessation that involve vaccinating smokers against the effects of nicotine and using new pharmaceuticals (such as cannabinoid antagonists and nicotine agonists). The second and third aims are more speculative. They include: screening the population for genetic susceptibility to nicotine dependence and intervening (eg, by vaccinating children and adolescents against the effects of nicotine) to prevent smoking uptake, and screening the population for genetic susceptibility to tobacco‐related diseases. A framework is described for future research on these policy options. This includes: epidemiological modelling and economic evaluation to specify the conditions under which these strategies are cost‐effective; and social psychological research into the effect of providing genetic information on smokers' preparedness to quit, and the general views of the public on tobacco smoking.
doi:10.1136/tc.2006.016303
PMCID: PMC2598463  PMID: 17297074
15.  Comparison of Tobacco Control Scenarios: Quantifying Estimates of Long-Term Health Impact Using the DYNAMO-HIA Modeling Tool 
PLoS ONE  2012;7(2):e32363.
Background
There are several types of tobacco control interventions/policies which can change future smoking exposure. The most basic intervention types are 1) smoking cessation interventions 2) preventing smoking initiation and 3) implementation of a nationwide policy affecting quitters and starters simultaneously. The possibility for dynamic quantification of such different interventions is key for comparing the timing and size of their effects.
Methods and Results
We developed a software tool, DYNAMO-HIA, which allows for a quantitative comparison of the health impact of different policy scenarios. We illustrate the outcomes of the tool for the three typical types of tobacco control interventions if these were applied in the Netherlands. The tool was used to model the effects of different types of smoking interventions on future smoking prevalence and on health outcomes, comparing these three scenarios with the business-as-usual scenario. The necessary data input was obtained from the DYNAMO-HIA database which was assembled as part of this project. All smoking interventions will be effective in the long run. The population-wide strategy will be most effective in both the short and long term. The smoking cessation scenario will be second-most effective in the short run, though in the long run the smoking initiation scenario will become almost as effective. Interventions aimed at preventing the initiation of smoking need a long time horizon to become manifest in terms of health effects. The outcomes strongly depend on the groups targeted by the intervention.
Conclusion
We calculated how much more effective the population-wide strategy is, in both the short and long term, compared to quit smoking interventions and measures aimed at preventing the initiation of smoking. By allowing a great variety of user-specified choices, the DYNAMO-HIA tool is a powerful instrument by which the consequences of different tobacco control policies and interventions can be assessed.
doi:10.1371/journal.pone.0032363
PMCID: PMC3285691  PMID: 22384230
16.  Simulation-Based Estimates of Effectiveness and Cost-Effectiveness of Smoking Cessation in Patients with Chronic Obstructive Pulmonary Disease 
PLoS ONE  2011;6(9):e24870.
Background
The medico-economic impact of smoking cessation considering a smoking patient with chronic obstructive pulmonary disease (COPD) is poorly documented.
Objective
Here, considering a COPD smoking patient, the specific burden of continuous smoking was estimated, as well as the effectiveness and the cost-effectiveness of smoking cessation.
Methods
A multi-state Markov model adopting society's perspective was developed. Simulated cohorts of English COPD patients who are active smokers (all severity stages combined or patients with the same initial severity stage) were compared to identical cohorts of patients who quit smoking at cohort initialization. Life expectancy, quality adjusted life-years (QALY), disease-related costs, and incremental cost-effectiveness ratio (ICER: £/QALY) were estimated, considering smoking cessation programs with various possible scenarios of success rates and costs. Sensitivity analyses included the variation of model key parameters.
Principal Findings
At the horizon of a smoking COPD patient's remaining lifetime, smoking cessation at cohort intitialization, relapses being allowed as observed in practice, would result in gains (mean) of 1.27 life-years and 0.68 QALY, and induce savings of −1824 £/patient in the disease-related costs. The corresponding ICER was −2686 £/QALY. Smoking cessation resulted in 0.72, 0.69, 0.64 and 0.42 QALY respectively gained per mild, moderate, severe, and very severe COPD patient, but was nevertheless cost-effective for mild to severe COPD patients in most scenarios, even when hypothesizing expensive smoking cessation intervention programmes associated with low success rates. Considering a ten-year time horizon, the burden of continuous smoking in English COPD patients was estimated to cost a total of 1657 M£ while 452516 QALY would be simultaneously lost.
Conclusions
The study results are a useful support for the setting of smoking cessation programmes specifically targeted to COPD patients.
doi:10.1371/journal.pone.0024870
PMCID: PMC3173494  PMID: 21949774
17.  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
18.  “I know it’s bad for me and yet I do it”: exploring the factors that perpetuate smoking in Aboriginal Health Workers - a qualitative study 
Background
Aboriginal Health Workers (AHWs) have a mandate to deliver smoking cessation support to Aboriginal people. However, a high proportion of AHWs are smokers and this undermines their delivery of smoking cessation programs. Smoking tobacco is the leading contributor to the burden of disease in Aboriginal Australians and must be prevented. Little is known about how to enable AHWs to quit smoking. An understanding of the factors that perpetuate smoking in AHWs is needed to inform the development of culturally relevant programs that enable AHWs to quit smoking. A reduction of smoking in AHWs is important to promote their health and also optimise the delivery of smoking cessation support to Aboriginal clients.
Methods
We conducted a fundamental qualitative description study that was nested within a larger mixed method participatory research project. The individual and contextual factors that directly or indirectly promote (i.e. perpetuate) smoking behaviours in AHWs were explored in 34 interviews and 3 focus groups. AHWs, other health service staff and tobacco control personnel shared their perspectives. Data analysis was performed using a qualitative content analysis approach with collective member checking by AHW representatives.
Results
AHWs were highly stressed, burdened by their responsibilities, felt powerless and undervalued, and used smoking to cope with and support a sense of social connectedness in their lives. Factors directly and indirectly associated with smoking were reported at six levels of behavioural influence: personal factors (e.g. stress, nicotine addiction), family (e.g. breakdown of family dynamics, grief and loss), interpersonal processes (e.g. socialisation and connection, domestic disputes), the health service (e.g. job insecurity and financial insecurity, demanding work), the community (e.g. racism, social disadvantage) and policy (e.g. short term and insecure funding).
Conclusions
An extensive array of factors perpetuated smoking in AHWs. The multitude of personal, social and environmental stressors faced by AHWs and the accepted use of communal smoking to facilitate socialisation and connection were primary drivers of smoking in AHWs in addition to nicotine dependence. Culturally sensitive multidimensional smoking cessation programs that address these factors and can be tailored to local needs are indicated.
doi:10.1186/1472-6963-12-102
PMCID: PMC3394210  PMID: 22533609
19.  Individual-level factors associated with intentions to quit smoking among adult smokers in six cities of China: findings from the ITC China Survey 
Tobacco Control  2010;19(Suppl_2):i6-i11.
Background
Over 350 million smokers live in China, and this represents nearly one-third of the smoking population of the world. Smoking cessation is critically needed to help reduce the harms and burden caused by smoking-related diseases. It is therefore important to identify the determinants of quitting and of quit intentions among smokers in China. Such knowledge would have potential to guide future tobacco control policies and programs that could increase quit rates in China.
Objective
To identify the correlates of intentions to quit smoking among a representative sample of adult smokers in six cities in China.
Methods
Data from wave 1 (2006) of the International Tobacco Control (ITC) Policy Evaluation Project China Survey, a face-to-face survey of adult Chinese smokers in six cities: Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan, was analysed. Households were sampled using a stratified multistage design. About 800 smokers were surveyed in each selected city (total n=4815).
Results
Past quit attempts, duration of past attempts, Heaviness of Smoking Index (HSI), outcome expectancy of quitting, worry about future health and overall opinion of smoking were found to be independently associated with intentions to quit smoking, but demographic characteristics were not.
Conclusions
The determinants of quit intentions among smokers in China are fairly similar to those found among smokers in Western countries, despite the fact that interest in quitting is considerably lower among Chinese smokers. Identifying the determinants of quit intentions provides possibilities for shaping effective policies and programs for increasing quitting among smokers in China.
doi:10.1136/tc.2010.037093
PMCID: PMC2976002  PMID: 20935198
Smoking cessation; surveillance and monitoring; China; addiction; cessation; surveillance and monitoring
20.  Pathways of Change Explaining the Effect of Smoke-Free Legislation on Smoking Cessation in the Netherlands. An Application of the International Tobacco Control Conceptual Model 
Nicotine & Tobacco Research  2012;14(12):1474-1482.
Introduction:
This study aims to test the pathways of change from individual exposure to smoke-free legislation on smoking cessation, as hypothesized in the International Tobacco Control (ITC) Conceptual Model.
Methods:
A nationally representative sample of Dutch smokers aged 15 years and older was surveyed during 4 consecutive annual surveys. Of the 1,820 baseline smokers, 1,012 participated in the fourth survey. Structural Equation Modeling was employed to test a model of the effects of individual exposure to smoke-free legislation through policy-specific variables (support for smoke-free legislation and awareness of the harm of [secondhand] smoking) and psychosocial mediators (attitudes, subjective norm, self-efficacy, and intention to quit) on quit attempts and quit success.
Results:
The effect of individual exposure to smoke-free legislation on smoking cessation was mediated by 1 pathway via support for smoke-free legislation, attitudes about quitting, and intention to quit smoking. Exposure to smoke-free legislation also influenced awareness of the harm of (secondhand) smoking, which in turn influenced the subjective norm about quitting. However, only attitudes about quitting were significantly associated with intention to quit smoking, whereas subjective norm and self-efficacy for quitting were not. Intention to quit predicted quit attempts and quit success, and self-efficacy for quitting predicted quit success.
Conclusions:
Our findings support the ITC Conceptual Model, which hypothesized that policies influence smoking cessation through policy-specific variables and psychosocial mediators. Smoke-free legislation may increase smoking cessation, provided that it succeeds in influencing support for the legislation.
doi:10.1093/ntr/nts081
PMCID: PMC3509014  PMID: 22491892
21.  Changing behaviour 
Clinical Evidence  2006;2006:0203.
Key Points
Individual change in behaviour has the potential to decrease the burden of chronic disease due to smoking, diet and low physical activity.
Smoking quit rates can be increased by simple advice from a physician or trained counsellor, overall and in people at high risk of smoking related disease, with low intensity advice as effective as high intensity advice. Advice from a nurse, telephone counselling, individualised self help materials and taking exercise may also be beneficial. Training health professionals increases the frequency of offering antismoking interventions but may not increase their effectiveness. Nicotine replacement therapy, bupropion and nortriptyline may improve short term quit rates as part of smoking cessation strategies.Moclobemide, selective serotonin reuptake inhibitors, anxiolytics and acupuncture have not been shown to be beneficial.Smoking cessation programmes increase quit rates in pregnant women, but nicotine patches may not be beneficial compared with placebo.
Physical activity in sedentary people may be increased by counselling, with input from exercise specialists possibly being more effective than physicians, in women over 80 years and in younger adults.
Advice on eating a low cholesterol diet leads to a mean 0.2 to 0.3 mmol/L decrease in blood cholesterol concentration in the long term, but no consistent effect of this on morbidity or mortality has been shown. Intensive interventions to reduce sodium intake lead to small decreases in blood pressure, but may not reduce morbidity or mortality. Advice to lose weight leads to greater weight loss than no advice, and cognitive behavioural therapy may be more effective than dietary advice. Maintenance strategies involving personal or family contact, walking training or multifactorial approaches may be more effective at maintaining weight loss compared with no strategies, but have resource implications.We don't know whether lifestyle advice, with or without financial incentives, can prevent weight gain, or whether training health professionals leads to greater weight loss in people in their care.
PMCID: PMC2907629
22.  Development and Alpha Testing of QuitIT: An Interactive Video Game to Enhance Skills for Coping With Smoking Urges 
JMIR Research Protocols  2013;2(2):e35.
Background
Despite many efforts at developing relapse prevention interventions, most smokers relapse to tobacco use within a few months after quitting. Interactive games offer a novel strategy for helping people develop the skills required for successful tobacco cessation.
Objective
The objective of our study was to develop a video game that enables smokers to practice strategies for coping with smoking urges and maintaining smoking abstinence. Our team of game designers and clinical psychologists are creating a video game that integrates the principles of smoking behavior change and relapse prevention. We have reported the results of expert and end-user feedback on an alpha version of the game.
Methods
The alpha version of the game consisted of a smoking cue scenario often encountered by smokers. We recruited 5 experts in tobacco cessation research and 20 current and former smokers, who each played through the scenario. Mixed methods were used to gather feedback on the relevance of cessation content and usability of the game modality.
Results
End-users rated the interface from 3.0 to 4.6/5 in terms of ease of use and from 2.9 to 4.1/5 in terms of helpfulness of cessation content. Qualitative themes showed several user suggestions for improving the user interface, pacing, and diversity of the game characters. In addition, the users confirmed a high degree of game immersion, identification with the characters and situations, and appreciation for the multiple opportunities to practice coping strategies.
Conclusions
This study highlights the procedures for translating behavioral principles into a game dynamic and shows that our prototype has a strong potential for engaging smokers. A video game modality exemplifies problem-based learning strategies for tobacco cessation and is an innovative step in behavioral management of tobacco use.
doi:10.2196/resprot.2416
PMCID: PMC3786125  PMID: 24025236
smoking cessation; health promotion game; tobacco, quitting self efficacy; behavioral medicine; virtual reality
23.  A pilot study combining individual-based smoking cessation counseling, pharmacotherapy, and dental hygiene intervention 
BMC Public Health  2010;10:348.
Background
Dentists are in a unique position to advise smokers to quit by providing effective counseling on the various aspects of tobacco-induced diseases. The present study assessed the feasibility and acceptability of integrating dentists in a medical smoking cessation intervention.
Methods
Smokers willing to quit underwent an 8-week smoking cessation intervention combining individual-based counseling and nicotine replacement therapy and/or bupropion, provided by a general internist. In addition, a dentist performed a dental exam, followed by an oral hygiene treatment and gave information about chronic effects of smoking on oral health. Outcomes were acceptability, global satisfaction of the dentist's intervention, and smoking abstinence at 6-month.
Results
39 adult smokers were included, and 27 (69%) completed the study. Global acceptability of the dental intervention was very high (94% yes, 6% mostly yes). Annoyances at the dental exam were described as acceptable by participants (61% yes, 23% mostly yes, 6%, mostly no, 10% no). Participants provided very positive qualitative comments about the dentist counseling, the oral exam, and the resulting motivational effect, emphasizing the feeling of oral cleanliness and health that encouraged smoking abstinence. At the end of the intervention (week 8), 17 (44%) participants reported smoking abstinence. After 6 months, 6 (15%, 95% CI 3.5 to 27.2) reported a confirmed continuous smoking abstinence.
Discussion
We explored a new multi-disciplinary approach to smoking cessation, which included medical and dental interventions. Despite the small sample size and non-controlled study design, the observed rate was similar to that found in standard medical care. In terms of acceptability and feasibility, our results support further investigations in this field.
Trial Registration number
ISRCTN67470159
doi:10.1186/1471-2458-10-348
PMCID: PMC2894778  PMID: 20565724
24.  Smoking: can we really make a difference? 
Heart  2003;89(Suppl 2):ii25-ii27.
The enormous health benefits of stopping smoking are now well established. Doctors have a vital role in motivating smokers and initiating quit attempts. The mainstay of National Health Service smoking cessation strategy should be the routine provision of brief opportunistic intervention in primary care, backed up by referral to a specialist smoking cessation service. There is an urgent need to increase substantially the numbers of smokers referred by general practitioners, other members of the primary care team, and those working in acute hospital trusts, to specialist smoking cessation services and for better channels of communication between the various agencies. Use of pharmacotherapy (nicotine replacement therapy or bupropion) in combination with behavioural support achieves higher cessation rates than either component alone and is the most effective way of helping smokers to stop. Smokers who quit often relapse and hence will need repeated help.
doi:10.1136/heart.89.suppl_2.ii25
PMCID: PMC1876294  PMID: 12695432
25.  New Methods for Tobacco Dependence Treatment Research 
Despite advances in tobacco dependence treatment in the past two decades, progress has been inconsistent and slow. This paper reviews pervasive methodological issues that may contribute to the lack of timely progress in tobacco treatment science including: the lack of a dynamic model or framework of the cessation process, inefficient study designs, and the use of distal outcome measures that poorly index treatment effects. The authors then present a phase-based cessation framework that partitions the cessation process into four discrete phases based on current theories of cessation and empirical data. These phases include: 1) Motivation, 2) Precessation, 3) Cessation, and 4) Maintenance. Within this framework it is possible to identify phase-specific challenges that a smoker would encounter while quitting smoking, intervention components that would address these phase-specific challenges, mechanisms via which such interventions would exert their effects and optimal outcome measures linked to these phase-specific interventions. Investigation of phase-based interventions can be accelerated by using efficient study designs that would permit more timely development of an optimal smoking cessation treatment package.
doi:10.1007/s12160-010-9252-y
PMCID: PMC3073306  PMID: 21128037

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