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1.  Association of smoking cessation and weight change with cardiovascular disease among people with and without diabetes 
Smoking cessation reduces the risks of cardiovascular disease (CVD), but weight gain that follows quitting smoking may weaken the CVD benefit of quitting.
To test the hypothesis that weight gain following smoking cessation does not attenuate the benefits of smoking cessation among people with and without diabetes.
Design, Setting, and Participants
Prospective community-based cohort study using data from the Framingham Offspring Study collected from 1984 to 2011. At each 4-year exam, self-reported smoking status was assessed and categorized as smoker, recent quitter (≤ 4 years), long-term quitter (> 4 years), and non-smoker. Pooled Cox proportional hazards models were used to estimate the association between quitting smoking and 6-year CVD events and to test whether 4-year change in weight following smoking cessation modified the association between smoking cessation and CVD events.
Main outcome measure
Incidence over 6 years of total CVD events, comprising coronary heart disease, cerebrovascular events, peripheral artery disease, and congestive heart failure.
After a mean follow-up of 25 years (SD, 9.6), 631 CVD events occurred among 3251 participants. Median 4-year weight gain was greater for recent quitters without diabetes (2.7 kg, Interquartile range [IQR] −0.5-6.4) and with diabetes (3.6 kg, IQR −1.4-8.2) than for long term quitters (0.9 kg, IQR −1.4-3.2 and 0.0 kg, IQR −3.2-3.2, respectively, p<0.001). Among people without diabetes, age and sex-adjusted incidence rate of CVD was 5.9/ 100 person-exams (95% confidence interval [CI] 4.9-7.1) in smokers, 3.2/ 100 person-exams (95% CI 2.1-4.5) in recent quitters, 3.1 /100 person-exams (95% CI 2.6-3.7) in long-term quitters, and 2.4 /100 person-exams (95% CI 2.0-3.0) in non-smokers. After adjustment for CVD risk factors, compared with smokers, recent quitters had a hazard ratio (HR) for CVD of 0.47 (95% CI, 0.23-0.94) and long-term quitters had an HR of 0.46 (95% CI, 0.34-0.63); these associations had only a minimal change after further adjustment for weight change. Among people with diabetes, there were similar point estimates that did not reach statistical significance.
Conclusions and Relevance
In this community based cohort, smoking cessation was associated with a lower risk of CVD events among participants without diabetes, and weight gain that occurred following smoking cessation did not modify this association. This supports a net cardiovascular benefit of smoking cessation despite subsequent weight gain.
PMCID: PMC3791107  PMID: 23483176
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.
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.
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
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
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
PMCID: PMC3000429  PMID: 21170313
3.  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:
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: member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website:
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:
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.
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.
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
4.  The cost-effectiveness of smoking cessation support delivered by mobile phone text messaging: Txt2stop 
The txt2stop trial has shown that mobile-phone-based smoking cessation support doubles biochemically validated quitting at 6 months. This study examines the cost-effectiveness of smoking cessation support delivered by mobile phone text messaging.
The lifetime incremental costs and benefits of adding text-based support to current practice are estimated from a UK NHS perspective using a Markov model. The cost-effectiveness was measured in terms of cost per quitter, cost per life year gained and cost per QALY gained. As in previous studies, smokers are assumed to face a higher risk of experiencing the following five diseases: lung cancer, stroke, myocardial infarction, chronic obstructive pulmonary disease, and coronary heart disease (i.e. the main fatal or disabling, but by no means the only, adverse effects of prolonged smoking). The treatment costs and health state values associated with these diseases were identified from the literature. The analysis was based on the age and gender distribution observed in the txt2stop trial. Effectiveness and cost parameters were varied in deterministic sensitivity analyses, and a probabilistic sensitivity analysis was also performed.
The cost of text-based support per 1,000 enrolled smokers is £16,120, which, given an estimated 58 additional quitters at 6 months, equates to £278 per quitter. However, when the future NHS costs saved (as a result of reduced smoking) are included, text-based support would be cost saving. It is estimated that 18 LYs are gained per 1,000 smokers (0.3 LYs per quitter) receiving text-based support, and 29 QALYs are gained (0.5 QALYs per quitter). The deterministic sensitivity analysis indicated that changes in individual model parameters did not alter the conclusion that this is a cost-effective intervention. Similarly, the probabilistic sensitivity analysis indicated a >90 % chance that the intervention will be cost saving.
This study shows that under a wide variety of conditions, personalised smoking cessation advice and support by mobile phone message is both beneficial for health and cost saving to a health system.
PMCID: PMC3751449  PMID: 22961230
Smoking cessation aid; Economic evaluation; Text message; I18
5.  Within a smoking-cessation program, what impact does genetic information on lung cancer need to have to demonstrate cost-effectiveness? 
Many smoking-cessation programs and pharmaceutical aids demonstrate substantial health gains for a relatively low allocation of resources. Genetic information represents a type of individualized or personal feedback regarding the risk of developing lung cancer, and hence the potential benefits from stopping smoking, may motivate the person to remain smoke-free. The purpose of this study was to explore what the impact of a genetic test needs to have within a typical smoking-cessation program aimed at heavy smokers in order to be cost-effective.
Two strategies were modelled for a hypothetical cohort of heavy smokers aged 50 years; individuals either received or did not receive a genetic test within the course of a usual smoking-cessation intervention comprising nicotine replacement therapy (NRT) and counselling. A Markov model was constructed using evidence from published randomized controlled trials and meta-analyses for estimates on 12-month quit rates and long-term relapse rates. Epidemiological data were used for estimates on lung cancer risk stratified by time since quitting and smoking patterns. Extensive sensitivity analyses were used to explore parameter uncertainty.
The discounted incremental cost per QALY was AU$34,687 (95% CI $12,483, $87,734) over 35 years. At a willingness-to-pay of AU$20,000 per QALY gained, the genetic testing strategy needs to produce a 12-month quit rate of at least 12.4% or a relapse rate 12% lower than NRT and counselling alone for it to be equally cost-effective. The likelihood that adding a genetic test to the usual smoking-cessation intervention is cost-effective was 20.6% however cost-effectiveness ratios were favourable in certain situations (e.g., applied to men only, a 60 year old cohort).
The findings were sensitive to small changes in critical variables such as the 12-month quit rates and relapse rates. As such, the cost-effectiveness of the genetic testing smoking cessation program is uncertain. Further clinical research on smoking-cessation quit and relapse rates following genetic testing is needed to inform its cost-effectiveness.
PMCID: PMC2949618  PMID: 20843376
6.  Does the duration of smoking cessation have an impact on hospital admission and health-related quality of life amongst COPD patients? 
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.
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).
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.
PMCID: PMC4027923  PMID: 24868154
HRQoL; hospital admission and hospital stay; chronic obstructive pulmonary disease (COPD)
7.  Population-Based Smoking Cessation Strategies 
Executive Summary
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.
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
Anxiolytic drugs
Opioid antagonists
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
8.  Slimming World in Stop Smoking Services (SWISSS): study protocol for a randomized controlled trial 
Trials  2013;14:182.
Quitting smokers gain weight. This deters some from trying to stop smoking and may explain the increased incidence of type 2 diabetes after cessation. Dieting when stopping smoking may be counterproductive. Hunger increases cravings for smoking and tackling two behaviours together may undermine quitting success. A meta-analysis of randomized controlled trials (RCTs) showed individualized dietary support may prevent weight gain, although there is insufficient evidence whether it undermines smoking cessation. Commercial weight management providers (CWMPs), such as Slimming World, provide individualized dietary support for National Health Service (NHS) patients; however, there is no evidence that they can prevent cessation-related weight gain.
Our objective is to determine whether attending Slimming World from quit date, through referral from NHS Stop Smoking Services, is more effective than usual care at preventing cessation-related weight gain.
This RCT will examine the effectiveness of usual cessation support plus referral to Slimming World compared to usual cessation support alone. Healthy weight, overweight and obese adult smokers attending Stop Smoking Services will be included. The primary outcome is weight change in quitters 12 weeks post-randomization. Multivariable linear regression analysis will compare weight change between trial arms and adjust for known predictors of cessation-related weight gain.
We will recruit 320 participants, with 160 participants in each arm. An alpha error rate of 5% and 90% power will detect a 2 kg (SD = 2.5) difference in weight gain at 12 weeks, assuming 20% remain abstinent by then.
This trial will establish whether referral to the 12-week Slimming World programme plus usual care is an effective intervention to prevent cessation-related weight gain. If so, we will seek to establish whether weight control comes at the expense of a successful quit attempt in a further non-inferiority trial.
Positive results from both these trials would provide a potential solution to cessation-related weight gain, which could be rolled out across England within Stop Smoking Services to better meet the needs of 0.75 million smokers stopping with NHS support every year.
Trial registration
Current Controlled Trials ISRCTN65705512
PMCID: PMC3698185  PMID: 23782870
Weight gain; Smoking cessation; Prevention; Obesity; Commercial weight management provider
9.  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.
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.
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
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
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
PMCID: PMC3491001  PMID: 23139643
10.  Estimating the probabilities of making a smoking quit attempt in Italy: stall in smoking cessation levels, 1986-2009 
BMC Public Health  2012;12:183.
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.
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.
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.
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.
PMCID: PMC3378462  PMID: 22410134
11.  Online Social and Professional Support for Smokers Trying to Quit: An Exploration of First Time Posts From 2562 Members 
Both intratreatment and extratreatment social support are associated with increased rates of smoking cessation. Internet-based social support groups have the capability of connecting widely dispersed groups of people trying to quit smoking, making social support available 24 hours a day, seven days a week, at minimal cost. However, to date there has been little research to guide development of this particular feature of Web-assisted tobacco interventions (WATIs).
Our objectives were to compare the characteristics of smokers who post in an online smoking cessation support group with smokers who do not post, conduct a qualitative analysis of discussion board content, and determine the time it takes for new users to receive feedback from existing members or moderators.
Data were collected from version 5.0, a WATI equipped with an online social support network moderated by trained program health educators that was operational from November 6, 2004, to May 15, 2007. Demographic and smoking characteristics for both users and nonusers of the online social support network were analyzed, and qualitative analyses were conducted to explore themes in message content. Posting patterns and their frequency were also analyzed.
During the study period, 16,764 individuals registered; of these, 70% (11,723) reported being American. The mean age of registrants was 38.9 years and 65% (10,965) were female. The mean number of cigarettes smoked was 20.6 per day. The mean score for the 41% (6849) of users who completed the Fagerström Test for Nicotine Dependence was 5.6. Of all registered members, 15% (2562) made at least one post in the online social support network; 25% of first posts received a response from another member within 12 minutes, 50% within 29 minutes. The most frequent first posts were from recent quitters who were struggling with their quit attempts, and most responses were from members who had quit for a month or more. Differences in demographic and smoking characteristics between members who posted on the support group board at least once and those who did not post were statistically but not clinically significant.
Peer responses to new users were rapid, indicating that online social support networks may be particularly beneficial to smokers requiring more immediate assistance with their cessation attempt. This function may be especially advantageous for relapse prevention. Accessing this kind of rapid in-person support from a professional would take an inordinate amount of time and money. Further research regarding the effectiveness of WATIs with online social support networks is required to better understand the contribution of this feature to cessation, for both active users (posters) and passive users (“lurkers”) alike.
PMCID: PMC2956324  PMID: 20719739
Internet; social support; addiction; treatment; tobacco; WATI
12.  Simulation-Based Estimates of Effectiveness and Cost-Effectiveness of Smoking Cessation in Patients with Chronic Obstructive Pulmonary Disease 
PLoS ONE  2011;6(9):e24870.
The medico-economic impact of smoking cessation considering a smoking patient with chronic obstructive pulmonary disease (COPD) is poorly documented.
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.
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.
The study results are a useful support for the setting of smoking cessation programmes specifically targeted to COPD patients.
PMCID: PMC3173494  PMID: 21949774
13.  Healthcare Costs Around the Time of Smoking Cessation 
The Affordable Care Act mandates that new insurance plans cover smoking-cessation therapy without cost-sharing. Previous cost difference estimates, which show a spike around the time of cessation, suggest premiums might rise as a result of covering these services.
The goal of the study was to test (1) whether individuals in an RCT of pharmacotherapy and counseling for smoking cessation differed in their healthcare costs around the cessation period, and (2) whether the healthcare costs of those in the trial who successfully quit were different from a matched sample of smokers in the community.
Generalized linear regression models were used to analyze healthcare cost data on individuals enrolled in a comparative effectiveness trial of cessation therapies between October 2005 and May 2007. Cost differences for the period preceding and subsequent to the cessation attempt were assessed by trial participants' 12-month sustained quit status. Healthcare cost differences between sustained quitters and a sample of community-dwelling smokers, matched to these quitters on the basis of health services use around the time trial participant enrolled and by demographics, were also examined. Data were analyzed in 2011.
All three groups had a spike in cost associated with the index clinic visit. Regression results revealed little difference in healthcare costs by quit status for trial participants until the sixth quarter post-quit. By that quarter, continuous sustained quitters cost $541 (p<0.001) less than continuing smokers. Continuous sustained quitters cost less than their matched community-dwelling smokers in almost every quarter observed. The cost difference ranged from $270 (p=0.01) during the quarter of quit, to $490 (p<0.01) in the 6th quarter after quitting.
The inclusion of smoking-cessation therapy does not appear to raise short-term healthcare costs. By the sixth quarter post-quit, sustained quitters were less costly than trial participants who continued smoking.
Trial registration
This study is registered at NCT00296647.
PMCID: PMC3358703  PMID: 22608375
14.  A prospective investigation of the impact of smoking bans on tobacco cessation and relapse 
Tobacco Control  2001;10(3):267-272.
BACKGROUND AND OBJECTIVES—To examine the long term impact of workplace smoking bans on employee smoking cessation and relapse. Over three years we studied a total of 1033 current or former smokers (intervention group) employed in smoke-free hospitals and 816 current or former smokers (comparison group) employed in non-smoke-free workplaces. The design of this natural experiment is a prospective cohort study. We randomly selected both hospitals and employees from 12 strata based on hospital size and state tobacco regulations, and sampled employees in the same communities. Main outcome measures were post-ban quit ratio and relapse rate.
RESEARCH DESIGN—Between groups comparisons were conducted using the Cochran-Mantel-Haenszel statistic for general association, stratified Cox proportional hazards models, and the CMH analysis of variance statistic based on ranks. McNemar's test and the sign test were used to test for changes over time within each group.
RESULTS—Differences in the post-ban quit ratio were observed between intervention and comparison groups (p ⩽ 0.02). For employees whose bans were implemented at least seven years before survey, the post-ban quit ratio was estimated at 0.256, compared with 0.142 for employees in non-smoke-free workplaces (p = 0.02). After controlling for a variety of factors, time to quit smoking was shorter for the hospital employees (p < 0.001), with an overall relative risk of quitting of 2.3. Contrary to expectations, relapse rates were similar between the groups.
CONCLUSION—Employees in workplaces with smoking bans have higher rates of smoking cessation than employees where smoking is permitted, but relapse is similar between these two groups of employees. The results of this investigation have international applicability for policy makers, clinicians, employers, and employees. Countries should review smoking policies in workplaces in light of their own smoking patterns and efforts to deal with environmental tobacco smoke.

Keywords: smoking cessation; smoking relapse; tobacco addiction; tobacco dependence; smoking bans; employee health; workplace health; workplace smoking
PMCID: PMC1747578  PMID: 11544392
15.  Contribution of H. pylori and Smoking Trends to US Incidence of Intestinal-Type Noncardia Gastric Adenocarcinoma: A Microsimulation Model 
PLoS Medicine  2013;10(5):e1001451.
Jennifer Yeh and colleagues examine the contribution of IHelicobacter pyloriI and smoking trends to the incidence of past and future intestinal-type noncardia gastric adenocarcinoma.
Please see later in the article for the Editors' Summary
Although gastric cancer has declined dramatically in the US, the disease remains the second leading cause of cancer mortality worldwide. A better understanding of reasons for the decline can provide important insights into effective preventive strategies. We sought to estimate the contribution of risk factor trends on past and future intestinal-type noncardia gastric adenocarcinoma (NCGA) incidence.
Methods and Findings
We developed a population-based microsimulation model of intestinal-type NCGA and calibrated it to US epidemiologic data on precancerous lesions and cancer. The model explicitly incorporated the impact of Helicobacter pylori and smoking on disease natural history, for which birth cohort-specific trends were derived from the National Health and Nutrition Examination Survey (NHANES) and National Health Interview Survey (NHIS). Between 1978 and 2008, the model estimated that intestinal-type NCGA incidence declined 60% from 11.0 to 4.4 per 100,000 men, <3% discrepancy from national statistics. H. pylori and smoking trends combined accounted for 47% (range = 30%–58%) of the observed decline. With no tobacco control, incidence would have declined only 56%, suggesting that lower smoking initiation and higher cessation rates observed after the 1960s accelerated the relative decline in cancer incidence by 7% (range = 0%–21%). With continued risk factor trends, incidence is projected to decline an additional 47% between 2008 and 2040, the majority of which will be attributable to H. pylori and smoking (81%; range = 61%–100%). Limitations include assuming all other risk factors influenced gastric carcinogenesis as one factor and restricting the analysis to men.
Trends in modifiable risk factors explain a significant proportion of the decline of intestinal-type NCGA incidence in the US, and are projected to continue. Although past tobacco control efforts have hastened the decline, full benefits will take decades to be realized, and further discouragement of smoking and reduction of H. pylori should be priorities for gastric cancer control efforts.
Please see later in the article for the Editors' Summary
Editors' Summary
Cancer of the stomach (gastric cancer) is responsible for a tenth of all cancer deaths world-wide, with an estimated 700,000 people dying from this malignancy every year, making it the second most common cause of global cancer-related deaths after lung cancer. Unfortunately, the projected global burden of this disease estimate that deaths from gastric cancer will double by 2030. Gastric cancer has a poor prognosis with only a quarter of people with this type of cancer surviving more than five years. In order to reduce deaths, it is therefore of utmost importance to identify and reduce the modifiable risk factors associated with gastric cancer. Smoking and chronic gastric infection with the bacteria Helicobacter pylori (H. pylori), are known to be two common modifiable risk factors for gastric cancer, particularly for a type of gastric cancer called intestinal-type noncardia gastric adenocarcinoma (NCGA), which occurs at the distal end of the stomach and accounts for more than half of all cases of gastric cancer in US men.
Why Was This Study Done?
H. pylori initiates a precancerous process, and so infection with this bacteria can increase intestinal-type NCGA risk by as much as 6-fold while smoking doubles cancer risk by advancing increasing progression of existing lesions. Changes in these two risk factors over the past century (especially following the US Surgeon General's Report on Smoking and Health in 1964) have led to a dramatic decline in the rates of gastric cancer in US men. Understanding the combined effects of underlying risk factor trends on health outcomes for intestinal-type NCGA at the population level can help to predict future cancer trends and burden in the US. So in this study, the researchers used a mathematical model to estimate the contribution of H. pylori and smoking trends on the decline in intestinal-type NCGA incidence in US men.
What Did the Researchers Do and Find?
The researchers used birth cohorts derived from data in two national databases, the National Health and Nutrition Examination Survey (NHANES) and National Health Interview Survey (NHIS) to develop a population-based model of intestinal-type NCGA. To ensure model predictions were consistent with epidemiologic data, the researchers calibrated the model to data on cancer and precancerous lesions and using the model, projected population outcomes between 1978 and 2040 for a base-case scenario (in which all risk factor trends were allowed to vary over time). The researchers then evaluated alternative risk factors scenarios to provide insights on the potential benefit of past and future efforts to control gastric cancer.
Using these methods, the researchers estimated that the incidence of intestinal-type NCGA (standardized by age) fell from 11.0 to 4.4 per 100,000 men between 1978 and 2008, a drop of 60%. When the researchers incorporated only H. pylori prevalence and smoking trends into the model (both of which fell dramatically over the time period) they found that intestinal-type NCGA incidence fell by only 28% (from 12.7 to 9.2 per 100,000 men), suggesting that H. pylori and smoking trends are responsible for 47% of the observed decline. The researchers found that H. pylori trends alone were responsible for 43% of the decrease in cancer but smoking trends were responsible for only a 3% drop. The researchers also found evidence that after the 1960s, observed trends in lower smoking initiation and higher cessation accelerated the decline in intestinal-type NCGA incidence by 7%. Finally, the researchers found that intestinal-type NCGA incidence is projected to decline an additional 47% between 2008 and 2040 (4.4 to 2.3 per 100,000 men) with H. pylori and smoking trends accounting for more than 80% of the observed fall.
What Do These Findings Mean?
These findings suggest that, combined with a fall in smoking rates, almost half of the observed fall in rates of intestinal-type NCGA cancer in US men between 1978 and 2008 was attributable to the decline in infection rates of H. pylori. Rates for this cancer are projected to continue to fall by 2040, with trends for both H. pylori infection and smoking accounting for more than 80% of the observed fall, highlighting the importance of the relationship between risk factors changes over time and achieving long-term reduction in cancer rates. This study is limited by the assumptions made in the model and in that it only examined one type of gastric cancer and excluded women. Nevertheless, this modeling study highlights that continued efforts to reduce rates of smoking and H. pylori infection will help to reduce rates of gastric cancer.
Additional Information
Please access these Web sites via the online version of this summary at
The National Cancer Institute gives detailed information about gastric cancer
The Gastric Cancer Foundation has information on gastric cancer for patients and professionals
Cancer Research UK explains types of gastric cancer
PMCID: PMC3660292  PMID: 23700390
16.  Cost effectiveness of computer tailored and non-tailored smoking cessation letters in general practice: randomised controlled trial 
BMJ : British Medical Journal  2001;322(7299):1396.
To develop and evaluate, in a primary care setting, a computerised system for generating tailored letters about smoking cessation.
Randomised controlled trial.
Six general practices in Aberdeen, Scotland.
2553 smokers aged 17 to 65.
All participants received a questionnaire asking about their smoking. Participants subsequently received either a computer tailored or a non-tailored, standard letter on smoking cessation, or no letter.
Main outcome measures
Prevalence of validated abstinence at six months; change in intention to stop smoking in the next six months.
The validated cessation rate at six months was 3.5% (30/857) (95% confidence interval 2.3% to 4.7%) for the tailored letter group, 4.4% (37/846) (3.0% to 5.8%) for the non-tailored letter group, and 2.6% (22/850) (1.5% to 3.7%) for the control (no letter) group. After adjustment for significant covariates, the cessation rate was 66% greater (−4% to 186%; P=0.07) in the non-tailored letter group than that in the no letter group. Among participants who smoked <20 cigarettes per day, the cessation rate in the non-tailored letter group was 87% greater (0% to 246%; P=0.05) than that in the no letter group. Among heavy smokers who did not quit, a 76% higher rate of positive shift in “stage of change” (intention to quit within a particular period of time) was seen compared with those who received no letter (11% to 180%; P=0.02). The increase in cost for each additional quitter in the non-tailored letter group compared with the no letter group was £89.
In a large general practice, a brief non-tailored letter effectively increased cessation rates among smokers. A tailored letter was not effective in increasing cessation rates but promoted shift in movement towards cessation (“stage of change”) in heavy smokers. As a pragmatic tool to encourage cessation of smoking, a mass mailing of non-tailored letters from general practices is more cost effective than computer tailored letters or no letters.
What is already known on this topicBrief opportunistic advice on stopping smoking that is given face to face by health professionals increases rates of cessation by 2-3%Intensive, expert-led interventions increase cessation rates by up to 20% or more but are expensive and reach only a small proportion of smokersWritten advice tailored to an individual's “stage of change” (intention to stop in a particular period of time) has been claimed to be as effective as intensive interventions, but previous studies of tailored written advice did not biochemically validate cessationWhat this paper addsA simple standard letter sent to patients of general practices that gave brief advice on stopping smoking increased the biochemically validated rate of cessation by 2%A letter tailored to the individual's “stage of change” was not more effective than the non-tailored standard letterAlthough the increase in cessation resulting from the non-tailored standard letter was small, this intervention was highly cost effective
PMCID: PMC32255  PMID: 11397745
17.  Smoking Cessation and Body Weight: Evidence from the Behavioral Risk Factor Surveillance Survey 
Health Services Research  2012;47(4):1580-1602.
To investigate the role of smoking cessation in body weight.
Data Sources
2004–2005 and 2009–2010 Behavioral Risk Factor Surveillance Surveys (BRFSS) (N = 349,000), Centers for Disease Control and Prevention; Tax Burden on Tobacco (Orzechowski and Walker 2010).
Study Design
The Gaussian treatment effect model is estimated for three age categories by gender. Treatment effects of quitting smoking on body mass index (BMI) by quit length are calculated.
Principal Findings
Quitting is found to be endogenous. Differentiated effects of quitting smoking on BMI are found among quitters by gender, between age groups, and by length of time since quitting smoking, and positive association between smoking cessation and body weight confirmed. Declining smoking rates have only a modest effect in the overweight population. The effects of quitting on BMI are considerably lower among younger men and women.
The price that must be paid, in terms of weight gain, to enjoy the health benefits of smoking cessation is trivial even for the obese population.
PMCID: PMC3401400  PMID: 22356600
BMI; BRFSS; smoking cessation; treatment effect model
18.  Effective smoking cessation interventions for COPD patients: a review of the evidence 
JRSM Short Reports  2011;2(10):78.
To review the effectiveness of smoking cessation interventions offered to chronic obstructive pulmonary disease (COPD) patients, and identify barriers to quitting experienced by them, so that a more effective service can be developed for this group.
A rapid systematic literature review comprising computerized searches of electronic databases, hand searches and snowballing were used to identify both published and grey literature.
A review of studies undertaken in north-western Europe (defined as: United Kingdom, Ireland, France, Germany, Benelux and Nordic countries).
COPD patients participating in studies looking at the effectiveness of smoking cessation interventions in this patient group, or exploring the barriers to quitting experienced by these patients.
Quantitative and qualitative papers were selected according to pre-specified inclusion and exclusion criteria, critically appraised, and quantitative papers scored against the NICE Levels of Evidence standardized hierarchy.
Main outcome measure
Percentages of successful quitters and length of quit, assessed by self-report or biochemical analysis. Among qualitative studies, identified barriers to smoking cessation had to be explored.
Three qualitative and 13 quantitative papers were finally selected. Effective interventions and barriers to smoking cessation were identified. Pharmacological support with Buproprion combined with counselling was significantly more efficacious in achieving prolonged abstinence than a placebo by 18.9% (95% CI 3.6–26.4%). Annual spirometry with a brief smoking cessation intervention, followed by a personal letter from a doctor, had a significantly higher ≥1 year abstinence rate at three years among COPD patient smokers, compared to smokers with normal lung function (P < 0.001; z = 3.93). Identified barriers to cessation included: patient misinformation, levels of motivation, health beliefs, and poor communication with health professionals.
Despite the public health significance of COPD, there is a lack of high-quality evidence showing which smoking cessation support methods work for these patients. This review describes three effective interventions, as well as predictors of quitting success that service providers could use to improve quit rates in this group. Areas that would benefit from urgent further research are also identified.
PMCID: PMC3205559  PMID: 22046497
19.  Characterizing Internet Searchers of Smoking Cessation Information 
The Internet is a viable channel to deliver evidence-based smoking cessation treatment that has the potential to make a large population impact on reducing smoking prevalence. There is high demand for smoking cessation information and support on the Internet. Approximately 7% (10.2 million) of adult American Internet users have searched for information on quitting smoking. Little is known about these individuals, their smoking status, what type of cessation services they are seeking on the Internet, or how frequently these searches for cessation information are conducted.
The primary goal of this study was to characterize individuals who search for smoking cessation information on the Internet to determine appropriate triage and treatment strategies. The secondary goal was to estimate the incidence of searches for cessation information using publicly available search engine data.
We recruited individuals who clicked on a link to a leading smoking cessation website (QuitNet) from within the results of a search engine query. Individuals were “intercepted” before seeing the QuitNet home page and were invited to participate in the study. Those accepting the invitation were routed to an online survey about demographics, smoking characteristics, preferences for specific cessation services, and Internet search patterns. To determine the generalizability of our sample, national datasets on search engine usage patterns, market share, and keyword rankings were examined. These datasets were then used to estimate the number of queries for smoking cessation information each year.
During the 10-day study period, 2265 individuals were recruited and 29% (N = 655) responded. Of these, 59% were female and overall tended to be younger than the previously characterized general Internet population. Most (76%) respondents were current smokers; 17% had quit within the last 7 days, and 7% had quit more than 7 days ago. Slightly more than half of active smokers (53%) indicated that they were planning to quit in the next 30 days. Smokers were more likely to seek information on how to quit and on medications; former smokers were more interested in how to cope with withdrawal. All participants rated withdrawal information and individually tailored information as being more useful, while displaying little interest in telephone counseling, expert support, or peer support. Publicly available data from large search engines suggest that 4 million Americans search for resources on smoking cessation each year.
This study adds to the limited data available on individuals who search for smoking cessation information on the Internet, supports the prior estimates of the size of the population, and indicates that these individuals are in appropriate stages for both active cessation interventions and aggressive relapse prevention efforts. Continued development and evaluation of online interventions is warranted, and organizations seeking to promote cessation should carefully evaluate the Internet as a possible modality for treatment and as a gateway to other traditional programs.
PMCID: PMC2018828  PMID: 17032633
Smoking; cessation; Internet; search engine; query
20.  Design of a comparative effectiveness evaluation of a culturally tailored versus standard community-based smoking cessation treatment program for LGBT smokers 
BMC psychology  2014;2(1):12.
Smoking prevalence rates among the lesbian, gay, bisexual, and transgender (LGBT) population are significantly higher than the general population. However, there is limited research on smoking cessation treatments in this group, particularly on culturally targeted interventions. Moreover, there are few interventions that address culturally specific psychosocial variables (e.g., minority stress) that may influence outcomes. This paper describes the protocol for a comparative effectiveness trial testing an evidence-based smoking cessation program, Courage to Quit, against a culturally tailored version for LGBT smokers, and examines the role of culturally specific psychosocial variables on cessation outcomes.
To examine the effectiveness of a culturally targeted versus standard smoking cessation intervention, the study utilizes a 2-arm block, randomized, control trial (RCT) design. Adult LGBT participants (n = 400) are randomized to one of the two programs each consisting of a six-session group program delivered in a community center and an eight week supply of the transdermal nicotine patch. Four individualized telephone counseling sessions occur at weeks 2, 5, 7, and 9, at times of greatest risk for relapse. Study outcome measures are collected at baseline, and 1, 3, 6, and 12 months post quit date. Primary outcomes are expired air carbon monoxide verified 7-day point-prevalence quit rates at each measurement period. Secondary outcomes assess changes in cravings, withdrawal symptoms, smoking cessation self-efficacy, and treatment adherence. Additionally, study staff examines the role of culturally specific psychosocial variables on cessation outcomes using path analysis.
Determining the efficacy of culturally specific versus standard evidence based approaches to smoking cessation is a critical issue facing the field today. This study provides a model for the development and implementation of a culturally tailored smoking cessation intervention for LGBT participants and addresses a gap in the field by examining the role of culturally psychosocial variables associated with cessation outcomes.
Trial registration
U.S. National Institutes of Health Clinical Trials NCT01633567 Registered 30 May 2012.
PMCID: PMC4269994  PMID: 25566383
Smoking cessation; LGBT; Culturally tailored
21.  Characteristics of Smoking Cessation in Former Smokers in a Rural Area of Japan 
Japan has a relatively high prevalence of smoking in men. Despite the importance of behavioral patterns on successful smoking cessation, only limited information is available in Japan. The present study collected data from former smokers in a rural community in Japan in order to identify health status at the time of cessation, predominant motivating factors, and the role of smoking cessation aids in individuals who successfully stopped smoking.
This cross-sectional study collected data using a self-reported questionnaire from 149 randomly-selected former smokers (119 men and 30 women, aged 20-79 years) who were residents of Nanao, Ishikawa Prefecture, Japan.
Of the male participants, 14.3% quit due to serious personal health problems, including cardiovascular disease, cancer, or respiratory tract disease, while 20.8% of former smokers experienced mild personal health problems or were pregnant at the time of cessation. An approximately equal number stopped smoking due to fear of illness in the absence of immediate health concerns. Compared to personal health motivations, a smaller number of male smokers quit due to anti-smoking social pressure or expense. We also observed a marked increase in former smokers who quit for these reasons in recent years. Smoking lost its appeal in 19.3% of male and 10.0% of female smokers. Approximately, 95% of quitters did not utilize health professional counseling or pharmacological therapy.
Personal health concerns in former smokers in Nanao, Japan were the predominant motivation for quitting smoking, with the vast majority of former smokers achieving successful smoking cessation by themselves.
PMCID: PMC3415185  PMID: 22891146
Counseling; Japan; motivation; pharmacological therapy; smoking cessation
22.  Design and study protocol of the maternal smoking cessation during pregnancy study, (M-SCOPE) 
BMC Public Health  2011;11:903.
Maternal smoking is the most significant cause of preventable complications during pregnancy, with smoking cessation during pregnancy shown to increase birth weight and reduce preterm birth among pregnant women who quit smoking. Taking into account the fact that the number of women who smoke in Greece has increased steadily throughout the previous decade and that the prevalence of smoking among Greek females is one of the highest in the world, smoking cessation should be a top priority among Greek health care professionals.
The Maternal Smoking Cessation during Pregnancy Study (M-SCOPE), is a Randomized Control Trial (RCT) that aims to test whether offering Greek pregnant smokers a high intensity intervention increases smoking cessation during the third trimester of pregnancy, when compared to a low intensity intervention. Prospective participants will be pregnant smokers of more than 5 cigarettes per week, recruited up to the second trimester of pregnancy. Urine samples for biomarker analysis of cotinine will be collected at three time points: at baseline, at around the 32nd week of gestation and at six months post partum. The control group/low intensity intervention will include: brief advice for 5 minutes and a short leaflet, while the experimental group/intensive intervention will include: 30 minutes of individualized cognitive-behavioural intervention provided by a trained health professional and a self-help manual especially tailored for smoking cessation during pregnancy, while counselling will be based on the ''5 As.'' After childbirth, the infants' birth weight, gestational age and any other health related complications during pregnancy will be recorded. A six months post-partum a follow up will be performed in order to re-assess the quitters smoking status.
If offering pregnant smokers a high intensity intervention for smoking cessation increases the rate of smoking cessation in comparison to a usual care low intensity intervention in Greek pregnant smokers, such a scheme if beneficial could be implemented successfully within clinical practice in Greece.
Trial Registration Identifier NCT01210118
PMCID: PMC3260439  PMID: 22145828
23.  The reduction of tuberculosis risks by smoking cessation 
BMC Infectious Diseases  2010;10:156.
Smoking is known to aggravate tuberculosis (TB), but such information has been ignored in clinical practice, as it was not thought to be relevant. The aim of this study is to assess the benefits of smoking cessation on TB mortality reduction.
The study attempts to quantify smokers' risks on subsequent TB mortality and the change in such risks after smokers quit smoking. In this prospective cohort study, the TB mortality risks of smokers, never smokers and former smokers were compared, by using the Cox proportional model to estimate the hazard ratio (HR) of TB.
The cohort, consisting of 486,341 adults, participated in standard medical screening programs since 1994, including 5,036 with self-reported TB history. Of 15,268 deaths identified as of 2007, 77 were coded as TB.
Smokers with self-reported TB history (1.2%) had very high TB mortality (HR = 44.02). Among those without self-reported TB history, smoking increased TB mortality by nine-fold (HR = 8.56), but when they quit smoking, the risk was reduced by more than half (65%), to a level not different from those who had never smoked. The overwhelming majority of TB deaths (83%) occurred among those without self-reported TB history. Given the high smoking prevalence and the high HR, smoking accounted for more than one-third (37.7%) of TB mortality in Taiwan. Smokers reported less TB history but died more from TB than those who had never smoked.
Smokers had very high TB mortality, as much as nine times those who had never smoked, but once they quit, the risk reduced substantially and was similar to those who never smoked. Smoking cessation has benefits to the smokers far beyond reducing TB risk, but successful tobacco control could favorably impact the TB mortality rate and reduce this public health burden, which has long haunted the Taiwanese population. Smoking cessation could reduce nearly one-third of tuberculosis deaths.
PMCID: PMC2891758  PMID: 20529257
24.  Estimating the Effect of Smoking Cessation on Weight Gain: An Instrumental Variable Approach 
Health Services Research  2006;41(6):2255-2266.
To propose and test a method that produces an unbiased estimate of the average effect of smoking cessation on weight gain. Previous estimates may be biased due to unobservable differences in attributes of quitters and continuing smokers. An accurate estimate of weight gain due to cessation is important for policymakers, health managers, clinicians, consumers, and developers of smoking cessation aids.
Study Setting
Our analysis consisted of an instrumental variables (IVs) approach in which treatment assignment in randomized smoking cessation trials served as a random source of variation in probability of quitting.
Data Collection
We searched the medical literature for previously conducted smoking cessation trials that contained data suitable for our reanalysis.
Principal Findings
We identified one trial for our reanalysis, the Lung Health Study, a randomized smoking cessation trial with 5,887 smokers aged 35–60 from 1986 to 1994 in several sites across the United States. In our IV reanalysis, we estimated a 9.7 kg weight gain over 5 years due to cessation, as compared with the conventional estimate of 5.3 kg.
The true effect of smoking cessation on weight gain may be larger than previously estimated. This result indicates the importance of fully understanding the possible weight effects of cessation and underscores the need to accompany cessation programs with weight management interventions. The result, however, does not overturn the conclusion that the net health benefits of quitting are positive and very large. The application of the IV technique we propose is likely to be useful in a variety of contexts in which one is interested in the effect of one health condition on another.
PMCID: PMC1955320  PMID: 17116119
Smoking cessation; weight gain; instrumental variables
25.  Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study 
Tobacco Control  2007;16(6):400-404.
NHS stop smoking services are expected to play a key part in achieving the infant mortality and life expectancy health inequality targets in England by reducing smoking prevalence in deprived areas. This paper assesses the extent to which services have made a contribution to reducing inequalities in smoking between 2003–4 and 2005–6.
Synthetic estimates of baseline smoking prevalence data were compared with national monitoring data about the numbers of smokers in receipt of services and the proportion who self report quitting at four weeks. The social distribution of service recipients and quitters was compared with estimates of smoking prevalence to assess impact on inequalities. Comparisons were made between officially designated disadvantaged areas (the Spearhead Group) and others.
Short‐term cessation rates were lower in disadvantaged areas (52.6%) than elsewhere (57.9%) (p<0.001), but the proportion of smokers being treated was higher (16.7% compared with 13.4%) (p<0.001). The net effect was that a higher proportion of smokers in the most disadvantaged areas reported success (8.8%) than in more advantaged areas (7.8%) (p<0.001). Using the evidence‐based assumption that three‐quarters of short‐term quitters will relapse within one year, the absolute and relative rate gaps in smoking prevalence between Spearhead areas and others are estimated to fall by small but statistically significant amounts from 5.2 and 1.215 (CIs: 1.216 to 1.213) to 5.0 and 1.212 (CIs: 1.213 to 1.210) between 2003–4 and 2005–6.
NHS stop smoking services have probably made a modest contribution to reducing inequalities in smoking prevalence. To achieve government targets, however, requires both the development of more innovative cessation interventions for the most addicted smokers and action to ensure that other aspects of tobacco control policy make a larger contribution to inequality goals.
PMCID: PMC2807194  PMID: 18048617
health inequalities; smoking cessation; health services

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