Risk Factors | Cancer Prevention Institute of Canada

Smoking cessation has been called the “gold standard” of prevention strategies in healthcare in that smoking cessation produces additional years of life at costs well below those estimated for many other accepted medical treatments.[1] One comprehensive review of preventive services rated tobacco cessation counselling for adults as second in priority based on effectiveness and cost-effectiveness, second only to childhood vaccinations.[2]

The US Task Force on Community Preventative Services (TFCPS) has produced an influential grid[4] for tobacco control policies that are community-based approaches rather than individual therapies; these can range from government legislation / taxation, to advertising controls or campaigns, to programs directly related to the healthcare system. The TFCPS identified several potential interventions related to cessation:[5]

Reorganized into the framework being used in this report, each of these interventions will be briefly assessed with a note of the TFCPS recommendation in each case, augmented by other reviews.[6] In addition, the various clinical services offered to individuals will be itemized and evaluated. Methods which are not recommended are not necessarily ineffective, only that they are not yet supported by compelling evidence. Note: policy approaches related to bans on tobacco use are noted in other subsections later in the report.

Community-based Interventions

Mass Media Advocacy / Counter-advertising

Mass media interventions are directed either at changing individual smoking behaviour or changing social norms about smoking.[7] In the very successful California tobacco control program of the 1990s, it was calculated that the media component accounted for 17.4% of the decline in cigarette consumption.[8]

The Cochrane review on this topic is only at the protocol stage, but its initial literature summary offered these conclusions:[9]

The TFCPS review concluded, based on 14 studies, that high-intensity counter-advertising is a strongly recommended intervention.[10] B.C. can continue to benefit from such campaigns, and should learn from the studies that have determined the best anti-smoking advertisements. The most effective media approaches reportedly are those which attacked the tobacco companies for deceitfulness and manipulation, which revealed the harmful effect of environmental tobacco smoke, and which underlined the addictive nature of nicotine; advertising that rehearsed the well-known health effects of smoking, on the other hand, are less useful.[11],[12]

Self-help Materials

Self-help or patient education materials usually come in print, but sometimes in audio, video or internet format. In spite of some inconsistency in the data, a 2004 Cochrane review of 52 trials[13] offered 3 conclusions:

Web-based Cessation Resources

A new type of self-help platform is interactive websites, for example, the QuitNet service operated in conjunction with the Boston University School of Public Health since 1996.[14] In addition to standard tobacco control and health information, the site has several features aimed at encouraging an individual web-user to set a quit date and medication plan, get questions answered, and gain “moral support” through partners and a general on-line conversation. At the point of registering, a modest amount of “tailored” motivation occurs, e.g., calculating, based on smoking intensity, the amount of money one would save annually if the quit were successful. As of May 2004, QuitNet has 335,000 registered users world-wide.

Formal evaluations of web-based resources encounter numerous methodological challenges, including low response rates, contamination of control groups due to unrestricted access to websites and so on. Initial results from evaluations appear to show an increase in smoking cessation at one month after access to the site but all studies are uncontrolled with a very low response rate.[15],[16],[17],[18]

A key advantage of web-based resources is that they can reach large segments of the population at minimal overall cost. Given that a large proportion of smokers quit on their own,[19] web-based resources may be a helpful adjunct in that process.

Telephone Help Lines

Telephone contact can either be part of a proactive counselling plan, i.e., planned follow-up by telephone, or a reactive one, i.e., responding to smokers calling in to cessation help lines or quit lines. A Cochrane review (of 27 trials in total) supports both types of telephone intervention when compared against interventions that do not involve personal contact, but notes that the greatest effectiveness usually involves multiple contacts with the client.[20] The evidence for reactive help-lines is limited. Trials where proactive telephone support was added to counselling or nicotine replacement therapy failed to detect any additional effect on cessation rates.

The 2000 report Treating Tobacco Use and Dependence, a clinical practice guideline sponsored by the US Public Health Service[21] found (based on a met-analysis of 58 studies) that proactive help lines did have a modest effect on abstinence rates, as indicated on the following table.

*Format of Intervention*	*Estimated Odds* Ratio (95% C.I.)[22]	*Estimated Abstinence* *Rate (95% C.I.)*
No format	1.0	10.8%
Self-help	1.2 (1.02, 1.30)	12.3% (10.9, 13.6)
Proactive Telephone Counselling	1.2 (1.1, 1.4)	13.1% (11.4, 14.8)
Group Counselling	1.3 (1.1, 1.6)	13.9% (11.6, 16.1)
Individual Counselling	1.7 (1.4, 2.0)	16.8% (14.7, 19.1)

Based on this review, notice also that the use of self-help materials marginally increases abstinence rates.

Multi-component Approaches

The TFCPS, based on a literature review of the published evaluations (32 studies in total), strongly recommended a multi-component approach to cessation using, at a minimum, patient education materials and proactive telephone support (see Clinical Interventions and Management below). It was also noted that mass media efforts augmented effectiveness in many cases.

The Task Force result seems to contradict the conclusion of a Cochrane review of community interventions for smoking among adults.[23] Half of the 32 studies included in the Cochrane review featured a single intervention community and a control community, and only a handful used randomization to assign the communities. The pooled results were modest. For example, the estimated net decline in smoking prevalence ranged from -1.0% to 3.0% per year in studies where men and women were combined. The effect on cessation rates was usually not part of the studies.

There is a continuum between community-wide multi-component interventions and comprehensive strategies drawing on different intervention categories (see Comprehensive Strategies below), so that it is sometimes difficult to know how best to label a project.

Other Community-based Interventions

According to the TFCPS,[24] insufficient evidence currently exists for the following interventions:

Quit competitions, for example, have been tried and tested in Ontario, with a cessation success rate of only 0.17%.[25]

Workplace-based Interventions

The workplace represents a parallel to the school setting for youth, namely a place where large, stable population of adults spend a large amount of their time, therefore offering a potentially useful venue for encouraging smoking cessation. Although the nature of the workplace is rapidly changing in today’s society, the traditional advantages the workplace offers for public health efforts still pertain, including:[26]

There is considerable variation from country to country in the extent of workplace tobacco control programs. The involvement of companies in Europe has been relatively low in contrast with the US, where a remarkable 87% of firms had instituted some form of smoking ban according to a 1992 survey.[27]

The key Cochrane review in this area categorizes workplace interventions into those aimed at the workforce as a population and those directed towards individuals. Comprehensive programs that combine the two approaches were also considered, but the evidence is limited.[28]

Environmental and Social Support

Environmental support can include large and small posters and other forms of large group communication; such measures are hard to evaluate because they can be part of comprehensive programs with other, confounding interventions (especially social support). There is limited evidence that poster campaigns are effective.[29],[30]

Social support involves a buddy system or peer group, often added to other interventions. Limited research (only 2 studies) did not show a significant differential effect of social support approaches compared with control.[31]

Competitions and Incentives

A variety of rewards have been used in workplaces (salary bonuses, promotional items, luxury goods and holidays) within a variety of systems: [32] reward for attendance at a program or for actual success; competition between staff, peer group basis, or individual rewards; positive incentives versus (rarely) disincentives.

There is limited evidence (based on 6 studies) that participation rates in programs can be increased through competitions and incentives instigated by employers.[33] Community-based incentive programs may fare better than those in the workplace setting, but the research is incomplete.[34] Upcoming Cochrane reviews will be further examining this issue, as well as programs focused on providing incentives to healthcare professionals for the delivery of smoking cessation interventions.

Individual Cessation Campaigns

Not surprisingly, the individual initiatives found to be effective in other settings, including advice from a health professional, individual and group counselling and pharmacological treatment, provided similar results in the workplace. As noted in the National Cancer Prevention Policy of Australia, however, the main problem with individual interventions is that they require a formal commitment that relatively few smokers are prepared to invest the time or money.[35] Even though there is strong evidence that individual programs in the workplace increase cessation rates among the participating employees, and even though the employer is covering most of the costs, the absolute numbers of smokers who quit are low.[36]

Tobacco Bans

Obviously one of the ways to reduce environmental tobacco smoke (ETS) is to reduce smoking; but, conversely, efforts to limit smoking in the workplace or other public places sometimes motivate people to quit smoking or at least reduce consumption,[37],[38],[39],[40],[41] though some of the evidence is inconsistent.[42] This provides one of the strong arguments to integrate smoking behaviour changes with the topic of ETS (see below), as we have done in this section of the report.

In addition to general smoking restriction by-laws, the current targets for specific smoking bans are the workplace, home and school; recently, automobiles carrying children have been added to the list. Tobacco bans are the most prevalent workplace intervention; they can take a number of forms, from complete prohibition of smoking on the premises to restrictions of smoking to designated areas (with or without ventilation). As the most studied type of public tobacco restriction, a number of benefits of a smoke-free workplace have been identified in the literature:[43],[44],[45]

There is consistent evidence that workplace tobacco bans can decrease consumption during shifts (and thus exposure to ETS), but, as noted above, conflicting results concerning decreased smoking prevalence.[46] In the Cochrane review of this area, 5 out of 13 studies reported no change in prevalence, and four studies reported small decreases.

Although limited, these and other data provide motivation to continue exploring, expanding and evaluating tobacco

bans and smoke-free environments. The recent Canadian National Population Health Survey report for 2002/03 confirmed the reduction in consumption expected with smoking bans in workplaces, and also noted that more smokers in smoke-free homes quit over the preceding 8 years compared to homes where other smokers lived (17% versus 12%).[47] Another optimistic result emerged from a US national survey, which estimated that requiring all workplaces in that country to be smoke-fee would reduce smoking prevalence by 10%.[48]

One of the key issues in this area of tobacco control is the possible negative economic consequences associated with smoking bans, especially in the hospitality industry. Scollo and colleagues[49] reviewed 97 studies that made statements about the economic consequences associated with tobacco bans in restaurants and bars. They found that all studies concluding that there were negative economic consequences (N=35) were supported by the tobacco industry and had serious methodological flaws. None (N=21) of the better designed studies completed by independent researchers found a negative impact on revenue or jobs.

School-based Interventions

Despite the importance of reducing adolescent tobacco use, relatively little research has been conducted in the area of teen smoking cessation, including school-based programs.[50] In the late 1990s, Health Canada conducted a literature review which looked at 6 studies tracking self-initiated cessation; having fewer friends who smoked and being a lighter smoker were predictors of quitting success, whereas family influences played less of a role. Only 11 studies were identified which examined adolescent smoking-cessation programs, mainly involving 3 to 6 educational sessions in a high school setting; short-term cessation success was reported, but few data were available regarding long-term follow-up.[51]

Perhaps understandably, more effort has been put in to the prevention of smoking initiation among youth; however the persistence of a teen smoking cohort and ongoing incidence have combined to change the perspective of researchers and policy-makers. At about the same time the Canadian review was being completed, US authorities began to develop more programs to help youth stop smoking.[52]

By 1999, Sussman and colleagues found 17 studies focusing on youth smoking cessation, almost none of them RCTs. On average 21% of teen smokers quit, though this number dropped to 13% at 6 month follow-up, close to naturally occurring quit rates.[53] Two years later the same lead author identified 66 adolescent cessation studies, though this incorporated a wide variety of interventions, including those that normally would be included under policy approaches. Just over half of the studies were controlled; the average quit rate over 8 months was 12% (compared to 7% in control groups).[54]

Clinical Interventions and Management

The 2000 report Treating Tobacco Use and Dependence, a clinical practice guideline sponsored by the US Public Health Service (updating its 1996 guideline), identified the following recommended counselling modalities:[55] brief physician advice; various kinds of counselling; and arranging support care outside of the clinic per se. Each of these categories will be elaborated below.

Brief Advice and Counselling

Brief tobacco dependence treatment is now the recommended minimum strategy in approaching all cases of smoking in primary care. Such a brief intervention is sometimes referred to as physician advice; it can comprise as little as three minutes of contact. A 2004 Cochrane review of 34 trials[56] suggested that simple advice has a small positive effect on cessation rates. Compared to offering no advice, brief advice produced an absolute increase in cessation rates of 2.5%.

While brief advice is just marginally effective, there is evidence that more intensive advice or counselling is considerably more effective than minimal interventions. Intensified person-to-person contact (individual, group, or proactive telephone counselling) can include practical tools such as problem-solving, various supportive techniques, and follow-up after cessation (to prevent relapse). A Cochrane review of 15 trials (which specifically focused on cessation specialists rather than regular clinicians) found that counselling was 62% (odds ratio[57] of 1.62) more likely to achieve successful smoking cessation than minimal intervention.[58]

In the report Treating Tobacco Use and Dependence the authors summarized the results of 43 studies of various intensity levels of person-to-person contact. Their results suggest a clear relationship between increased intensity of cessation counselling and abstinence rates, as indicated on the following table.

*Level of Contact*	*Estimated Odds* Ratio (95% C.I.)[59]	*Estimated Abstinence* *Rate (95% C.I.)*
No Contact	1.0	10.9%
Minimal Counselling (<3 minutes)	1.3 (1.01, 1.60)	13.4% (10.9, 16.1)
Low Intensity Counselling (3-10 minutes)	1.6 (1.2, 2.0)	16.0% (12.8, 19.2)
Higher Intensity Counselling (>10 minutes)	2.3 (2.0, 2.7)	22.1% (19.4, 24.7)

This same report, based on a meta-analysis of 45 studies, also noted a strong relationship between the number of treatment sessions and abstinence rates, as indicated on the following table.

*Number of Sessions*	*Estimated Odds* *Ratio (95% C.I.)*	*Estimated Abstinence* *Rate (95% C.I.)*
0-1 Session	1.0	12.4%
2-3 Sessions	1.4 (1.1, 1.7)	16.3% (13.7, 19.0)
4-8 Sessions	1.9 (1.6, 2.2)	20.9% (18.1, 23.6)
>8 Sessions	2.3 (2.1, 3.0)	22.1% (21.0, 28.4)

Finally, counselling administered by both physician clinicians and non-physician clinicians (e.g. nurses, health educators, psychologists, etc.) effectively increases abstinence rates (based on a meta-analysis of 37 studies), as indicated on the following table.

*Type of Clinician*	*Estimated Odds* *Ratio (95% C.I.)*	*Estimated Abstinence* *Rate (95% C.I.)*
*No Clinician*	1.0	10.2%
*Self-help*	1.1 (0.9, 1.3)	10.9% (9.1, 12.7)
*Non-physician Clinician*	1.7 (1.3, 2.1)	15.8% (12.8, 18.8)
*Physician Clinician*	2.2 (1.5, 3.2)	19.9% (13.7, 26.2)

Group Therapy

Group therapy offers individual members the opportunity to learn skills and techniques to change behaviour and stop smoking, as well as to provide each other with psychosocial support. There are over 100 different group therapy programs described in the literature.[60] The groups can be led by professional facilitators, clinical psychologists, health educators, nurses or physicians. The rationale for including group therapy in the arsenal of cessation strategies is that it lies between intensive counselling and self-help approaches, and perhaps is less expensive than the former and more effective than the latter. A range of components are used in group therapy; there is evidence that aids for cognitive and behavioural skills and avoiding relapse are especially useful.

A 2004 Cochrane review of 52 randomized trials[61] offered these conclusions concerning group therapy:

Supportive Care

Suggesting and /or arranging support outside of treatment is commonly promoted as part of the treatment of smokers in primary care. The approaches include creating a smoke-free home, using help-lines and peer groups, partner enhancement, and assigning “buddies.” The positive effect (based on survey evidence) of a smoke-free home on youth smoking initiation was highlighted earlier in the report. In the preceding section, the limited evidence for passive help-lines was noted.

A review of “buddy systems” suggested that they may provide some benefit in clinical settings; research methodology in many cases was poor.[62] There is a lack of evidence regarding the efficacy of using “buddies” in community programs.

There is more evidence for the role of enhancing partner support, the distinction being that partners are usually known more intimately by the smoker. In the relevant Cochrane review,[63] the RCTs which examined providing a parallel program to enhance the role of partners failed to detect an increase in cessation rates among the smokers being supported; this may be attributed to the fact that the actual level of partner support did not increase in most cases. Of the 40 studies considered for this Cochrane review, only 8 were accepted. One Alberta study that was not

included did show improvements in cessation rates, but these effects only persisted in men at 1-year follow-up.[64] More study is needed of the effectiveness of using partners to improve cessation rates; the most promise has been shown with live-in, married or equivalent-to-married partners.[65]

Health Events

One of the key issues associated with smoking cessation in individuals is the timing of the intervention. Former smokers frequently note that health concerns were a primary motivator in their cessation attempts. A systematic review of interventions for smoking cessation in hospitalized patients in 2001[66] concluded that “high intensity behavioural interventions that include at least 1 month follow up contact are effective in promoting smoking cessation in hospitalised patients”. More recent studies[67],[68],[69] continue to support the notion that hospitalization offers a ‘window of opportunity’. Other studies have found that smoking cessation advice provided in the context of cancer screening[70], to cancer survivors[71] or to individuals with impaired lung function[72] significantly increased quit rates, although these findings are at times ambiguous[73]. Given the evidence, McBride and Ostroff[74] call on health care providers to utilize this ‘teachable moment’ to promote smoking cessation.

Smoking and Post-Surgical Complications

Cigarette smoking has also been associated with an increased rate of post-surgical wound infections and pulmonary and cardiovascular complications. A Cochrane review by Moller et al. in 2001 found observational studies but no RCTs supporting this conclusion.[75] In 2002, Moller and co-authors[76] published the results of an RCT investigating the effect of pre-operative smoking cessation on the frequency of post-operative complications in patients undergoing hip and knee replacement surgery. Patients assigned to the experimental arm met weekly with a nurse who designed individualized smoking cessation programs, including the use of nicotine replacement therapy. In this group, a remarkable 36 of 52 patients were able to quit smoking and the remainder reduced their consumption by at least 50%. Only 4 of the control group patients stopped smoking. As a result, patients in the experimental group had a significantly reduced post-surgical complication rate (18% vs. 52%).

Results similar to those by Moller et al. have more recently been observed by a Vancouver-based group of researchers.[77] This study noted, however, that while cessation rates were higher for the experimental group at 6 months, these differences no longer existed at 12 months post surgery.

Given the evidence, some health care providers have questioned whether smokers should be given a lower priority on surgical waiting lists if they do not agree to ‘fast’ from smoking for at least six weeks prior to surgery.[78],[79]

Summary of Non-pharmacological Interventions

Assessing / comparing the evidence of effectiveness for one-to-one counselling, group therapy and self-help materials are complex tasks. An estimate might order the interventions as follows (in order of declining effectiveness), but the data for firm delineations in each case are not presently available:

Although standardized self-help material sits low on the list, one motivation to still provide such aids is that most successful quitters achieve success on their own.[80] What this means is that, though more intensive clinical counselling interventions reportedly can produce higher quit rates among the intervention sample, such programs currently only reach 5% of the Canadian population.[81] Public health approaches, though less effective, can reach a much wider group. The natural conclusion which follows is that “methods to support otherwise unaided quit attempts therefore have the potential to help a far greater proportion of the smoking population.”[82] As such, standardized self-help materials represent “an important bridge between the clinical and public health approaches to smoking cessation.”[83]

Nicotine Replacement Therapy

Nicotine replacement therapy (NRT) works by exchanging the high concentrations o

f nicotine from cigarette smoking for lower doses delivered more slowly. The intervention helps reduce the cravings and withdrawal symptoms often associated with quitting. NRT also does not deliver the tar, chemicals and other harmful elements of tobacco smoke. Introduced in gum form in 1984, nicotine replacement therapy currently is the dominant strategy for individuals quitting smoking.[84] Other non-nicotine pharmaceuticals are also employed as aids to cessation (see below).

The major 2000 report Treating Tobacco Use and Dependence noted that several NRTs reliably increase long-term smoking abstinence rates. Each of the current delivery systems can be considered appropriate as a first-line treatment, including: [85]

Whereas all of these approaches were recommended for standard clinical practice, independent consumer practice has been more controversial. Over-the-counter NRT is efficacious and produces modest quit rates similar to that seen in prescription practice,[86] though its usefulness on its own has been questioned in a recent widely-discussed article.[87] A substantial Cochrane review of over 100 studies (comparing NRT to placebo or non-NRT control) disagrees with the latter point, concluding:

All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase the odds of quitting approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. [88]

Other Pharmacological Therapies

Nicotine may have an antidepressant effect on some smokers, which may be one reason why they find it difficult to quit, and why using antidepressants such as bupropion and notriptyline can be effective. Using such drugs not only act as a substitute for the nicotine effect, but also as pre-emptive strike against the depression that can sometimes accompany smoking cessation.

The current practice guidelines in the US recommend the following approach to clinicians working with smokers:[89]

A Cochrane review[90] of antidepressants for smoking cessation looked at atypical antidepressants bupropion (20 trials) and notriptyline (5 trials). The conclusion was that both agents increased the odds of cessation. In one trial, bupropion plus a nicotine patch was more effective than either therapy singly, but the result was not replicated in a second study.

Various classic antidepressants (e.g. serotonin selective uptake inhibitors) did not show an effect on cessation rates, nor did anxiolytics (which are also meant to impact serotonin and other brain chemicals).[91]

Other drugs have been tested as aids to smoking cessation. Some have proven ineffective, including the nicotine antagonist lobeline.[92] This compares with the modest benefits of nicotine antagonist mecamylamine, which is used in combination with NRT.[93] The rationale for the use of nicotine antagonists is that they block the rewarding effect of nicotine and thus may reduce the urge to smoke.

Opioid (narcotic) antagonists are also of interest as potential agents to attenuate the rewards of cigarette smoking. A limited investigation of the opioid naltrexone has not demonstrated a definite positive effect.[94]

A final drug, considered a second-treatment, is clonidine, which was originally used to lower blood pressure. Clonidine is an agent which affects the central nervous system and may reduce withdrawal symptoms. In a small number of trials, clonidine did prove effective in increasing smoking cessation, equating absolute increase in the likelihood of quitting of about 9%.[95]

Provider Reminder & Education

The assumption is well-established that physicians, and especially those operating in a primary care setting, are powerful allies in any comprehensive cessation strategy.[96] Over 70% of smokers visit their doctor at least once every year[97], however, “only half of current smokers report having ever been asked about their smoking status or advised to quit by their physician.”[98]

It seems likely, then, that systems which prompted physicians to be more proactive with smokers would be useful, either passive reminders built in to patient charts, for example, or continuing education about the value of physician advice around cessation attempts. In fact, the TFCPS does strongly recommend (based on 31 studies) a multi-component program including both provider reminders and education. [99] Such an approach increases provider delivery of advice to quit as well as patient cessation rates.[100] This approach can be further enhanced with the inclusion of self-help cessation materials.

More weakly recommended were provider reminder systems used on their own. There was insufficient evidence of the effectiveness of basic advice to providers that they “should counsel to quit,” or of provider feedback concerning their delivery of cessation advice.

Regulatory and Economic Interventions

Increased Unit Price for Tobacco Products

It has been argued that because nicotine is addictive, the purchase of tobacco products is more “price inelastic” than other non-addictive products i.e. consumers are resistant to stopping their purchase even if the price increases.

Despite this argument, Townsend and colleagues[101] calculated that for every 10% increase in cigarette price there would be a 5-6% decline in consumption in Britain; the decline would result from a combination of absolute quitting and reduced amounts of smoking per continuing smoker. The estimates for other high-income jurisdictions have been similar, though the World Bank pegged the expected decline in demand at a more conservative 4%.[102] Nonetheless, given that a tax increase incurs minimal administrative costs, and usually offers a net increase of revenue to governments even with reduced sales, the “cost-effectiveness of tax increases compares favourably with many health interventions.”[103] The TFCPS evaluation is consistent with this position; it draws on 17 studies to conclude that raising the unit price of tobacco products through taxation is a strongly recommended intervention.

Reimbursement and Incentives

The TFCPS review[104] found that reducing patient out-of-pocket costs for smoking cessation products was recommended by the evidence, though only weakly. Aspects of a healthcare systems approach noted in another major report, Treating Tobacco Use and Dependence[105] (US Public Health Service), include consistent and comprehensive documentation of tobacco users and any clinical intervention, and ensuring that insurance plans cover counselling (as well as pharmacological treatments) and that clinicians are reimbursed for counselling time. No specific evidence was provided concerning systematic documentation (which occupies a very brief section of the report), whereas the financial recommendations had moderate-to-weak support in the literature. In a report from 2000, the US Surgeon General[106] agreed with the basic tenor of the recommendations, concluding (based on two citations) that reimbursement policies, financial incentives and institutional support are all critical for effective clinical interventions in tobacco addiction.

Comprehensive Strategies

The Cochrane review noted earlier under Community Programs actually included results for what were properly comprehensive strategies. The intervention was defined in general as a coordinated, multidimensional program involving different segments of the community in a defined geopolitical area (e.g., municipality, region, province). [107] The weak results noted for those programs were confirmed in the US Surgeon General review of 2000. Several famous community trials of comprehensive strategies were conducted in the US in the early 1980s, following and concurrent with projects in other jurisdictions. The summary of the Surgeon General concerning these various trials remarked on “the lack of a consistently positive effect” and the fact that the impact on smoking prevalence was “modest.”[108] The two most rigorous trials showed limited evidence that prevalence was affected. The COMMIT study in the US showed no difference between intervention and control communities, whereas the Australian CART study offered some success for quit rates in men.[109],[110]

The Surgeon General’s assessment of more recent state-wide comprehensive strategies is more positive. Quoting from major reviews of the state campaigns, the conclusion is that smoking prevalence rates have declined, certainly among adults and perhaps among youth, as a result of sustained counter-advertising and other social marketing interventions.[111]

Social Denormalization

The potential usefulness of mass media advocacy or counter-advertising in influencing public attitudes towards tobacco was noted earlier. Sometimes the focus is on the dangers of smoking and the health and economic benefits of quitting. In many jurisdictions there has also been a goal to permanently change the public perception towards the legitimacy of tobacco industry practices. The latter approach, known as denormalization[112] (which includes counteracting the tobacco industry’s message that smoking is normal and desirable), has been successfully pursued in Canada, Australia, the UK, and several US states. The continued application of such an approach is part of the National Strategy for Tobacco Control in Canada. In that framework, meant to inform provincial plans, denormalization is defined as:

activities undertaken specifically to reposition tobacco products and the tobacco industry consistent with the addictive and hazardous nature of tobacco products, the health, social and economic burden resulting from the use of tobacco, and practices undertaken by the industry to promote its products and create social goodwill towards the industry.[113]

The full realization of results from new social norms surrounding tobacco and tobacco manufacturers remain to be experienced and explored.

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[2] Coffield AB, Maciosek MV, McGinnis JM et al. Priorities among recommended clinical preventive services. American Journal of Preventive Medicine. 2001; 21(1):1-9. Providing adolescents with antitobacco messages or advice to quit was also rated highly, though the evidence was less certain.

[3] Hopkins DP, Briss PA, Ricard CJ et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke American Journal of Preventive Medicine 2001; 20(2S): 16-66.

[4] For example, it informed a key section of Australia’s National Cancer Prevention Policy, 2004-06.

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[12] deMeyrick, J. Forget the “blood and gore”: an alternative message strategy to help adolescents avoid cigarette smoking Health Education 2001; 101(3): 99-107.

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[18] Cobb N, Graham A, Bock BC et al. Initial evaluation of a ‘Real World’ internet smoking cessation system Nicotine and Tobacco Research 2004 (in press).

[19] Fiore MC. The new vital sign. Assessing and documenting smoking status Journal of the American Medical Society 1991; 266(22): 3183-84.

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[21] U.S. Department of Health and Human Services. Treating Tobacco Use and Dependence: Clinical Practice Guideline June 2000.

[22] C.I. = Confidence Interval, the 95% confidence interval range given means that the ‘true’ number will fall within the given range 95 out of a 100 times.

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[24] Hopkins DP, Briss PA, Ricard CJ et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke American Journal of Preventive Medicine 2001; 20(2S): 16-66.

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CANCER PREVENTION INSTITUTE OF CANADA

Interventions to Increase Cessation Rates