Population-based smoking cessation strategies: a summary of a select group of evidence-based reviews

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 interventionsTelephone counsellingPost-secondary smoking cessation programs (colleges/universities)Community-wide stop-smoking contests (i.e. Quit and Win)Community interventionsPhysician advice to quitNursing interventions for smoking cessationHospital-based interventions for smoking cessationPharmacotherapies for smoking cessation, specifically:Nicotine replacement therapiesAntidepressantsAnxiolytic drugsOpioid antagonistsClonidineNicotine receptor partial agonistsReviews 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:

What are the efficacy and cost-effectiveness of the selected population-based strategies for smoking cessation?

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.

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.

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).