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Smoking Cessation

Mary Ellen Wewers, PhD, MPH
Professor
College of Public Health
The Ohio State University, Columbus, OH
Columbus, Ohio

Introduction

In excess of $96 billion dollars are spent annually for direct healthcare costs attributable to tobacco, with another $97 billion in indirect expenditures, such as lost productivity (1). Tobacco is responsible for more than one in five deaths in the United States, or a total of 440,000 deaths annually (2). Approximately 3 million deaths per year worldwide were attributed to tobacco and, if current trends continue, 10 million deaths per year will be due to tobacco use in 2020 (3). Today, 43.4 million people, or 19.8% of the US adult population, smoke (4).  Among adult men the estimate is 22.3% and 17.4% among adult women.  Smoking prevalence is highest for those aged 18-24 (22.2%) and 25-44 (22.8%). In regard to socioeconomic status, smoking prevalence is highest for those living below the poverty line (28.8%), while 44.0% of those with a general education development (GED) diploma are categorized as current smokers.  Of note, there is convincing evidence that greater than 70% of all current smokers want to quit smoking (5), and in 2006, 44.2% adult smokers stopped smoking for at least 1 day during the past 12 months in a serious quit attempt (4).  However, based on US estimates, the annual quit rate is approximately 0.5% with 4.7% having quit for 3-12 months in the past year.  For adolescent smokers, 55.8% want to stop smoking and more than 54% tried to stop during the past year (6). Approximately 50% of smokers report being advised to quit by their healthcare provider (7).  An evidence-based clinical practice guideline, Treating Tobacco Use and Dependence: 2008 Update (1), published by the US Public Health Service, recommends that all patients who smoke should be offered efficacious therapy including pharmacotherapy and behavioral strategies to promote abstinence. The current US guideline is similar to recommendations from the UK and Australia.  The following is a review of several websites that contain elements of the US Public Health Service’s guideline.  The list is quite limited but serves as a resource for clinicians to manage this chronic condition of nicotine dependence.

Last Update: January 2010

Search

The search for websites addressing the topic of smoking cessation used a search engine (Google™) and yielded approximately 1,310,000 sites.  Limiting the term to “smoking cessation clinical practice guidelines” narrowed the sites to about 160,000.  Because of the overwhelming number of sites, those listed below represent only several established federal and nonprofit health organizations and foundations with a commitment to preventive healthcare. In addition to their emphasis on prevention, these websites were chosen because of their established record of providing smoking cessation treatment to the public, their dedication to providing educational resources to clinicians who specialize in tobacco-attributable diseases, and their involvement in promoting a research agenda aimed at tobacco use prevention and cessation.

Best Websites

Medline Plus

This is a website directed by the National Library of Medicine and includes information from the National Institutes of Health on over 700 diseases and conditions. A list of hospitals, physicians and a medical encyclopedia and dictionary are all part of the website. Links to information about clinical trials are also present.

  1. Authority: This website is sponsored by the National Library of Medicine and the National Institutes of Health. The site was last updated on 12/01/09. Rating: 5

  2. Currency: The site contains a variety of topics including recent news releases, the latest news from the NIH, an overview of cessation and treatment approaches including the most recent version of the US Public Health Services Tobacco Cessation Clinical Practice Guideline. Topics also include tobacco use during youth and pregnancy. There is a link that includes a date and description of all changes to the website. Rating: 5

  3. Accuracy: The site contains a variety of topics including recent news releases, the latest news from the NIH, an overview of cessation and treatment approaches including the most recent version of the US Public Health Services Tobacco Cessation Clinical Practice Guideline. Topics also include tobacco use during youth and pregnancy. There is a link that includes a date and description of all changes to the website. Rating: 5

  4. Navigation & Readability: The site search is fantastic. Results are organized by topic and subtopic on the left. Listed are the top five results per subtopic with links to all results, very much like a built-in, automatic refine results. The navigation is clear and consistent; top-level navigation is visible on all pages; persistent navigation is clear and helpful at the top of the page. There is exhaustive content indexed in subsections, with alphabetized links always available from subpages. The formatting is regular, clear and consistent. The text is clear and easy to read. Rating: 5

  5. Utility: The site map is clear, comprehensive, well organized and includes a site index, which is a real plus with a research-oriented site. All images have alt tags and there is a skip navigation link. All information is in HTML and is also available in Spanish. The site is browser independent. Rating: 5

Summary: This is an excellent site and was rated excellent across all criteria. The content is comprehensive and contains state-of-the-science recommendations. It provides a wealth of smoking cessation information for clinicians and smokers of all ages. This site is definitely recommended for bookmarking.*****

American Lung Association

This is a national, voluntary health organization dedicated to the prevention of lung disease and the promotion of lung health. Its website covers topics about programs related to asthma, tobacco control, environmental health, advocacy, multicultural programs and communication channels, including public service announcements, news releases and conferences.

  1. Authority: The website is sponsored by the American Lung Association. Rating: 5

  2. Currency: The link “Stop Smoking” provides information about a variety of smoking cessation support and resources. There are links to information about nationwide resources, medications, smoking and pregnancy, women and smoking, and smoking and your baby. The list is quite comprehensive. This page also allows the user to register for the ALA’s Freedom From Smoking Online program, which is an intensive type of treatment. The Quitter in You campaign is a newly-added feature on the website. A treatment link for professionals eventually takes the user to a COPD section, but the link was unable to be accessed. Using the site’s search function for “smoking cessation guidelines” did not provide any relevant hits for clinicians. The latest site update is not listed. Rating: 3

  3. Accuracy: The smoking cessation fact sheet for patients provides accurate information about resources. There is no apparent (or easily-accessed) information about cessation treatment for professionals. Rating: 3

  4. Navigation & Readability: This site has excellent navigation. Top-level navigation is visible on all pages; second- and third-level navigation is consistent and always visible. Breadcrumb navigation always shows exactly where the user is in the hierarchy. The site search is good, however, all results show up on one page, which makes finding what is needed more difficult. The site map is comprehensive but poorly organized—the entire site is listed in one long-threaded list in no particular order. Rating: 4

  5. Utility: Most information is also available in Spanish, but top navigation always links to English even if Spanish is selected. Some site navigation disappears completely if JavaScript is turned off, making it impossible to navigate for some users. Rating: 4

Summary: The site is valuable but it was somewhat difficult to find and access treatment recommendations. This feature may discourage clinicians from using this site as a resource. Although not readily apparent to the user, this site does serve as an excellent resource for clinicians to refer smoking patients. Free online smoking cessation counseling is available and could enhance pharmacotherapy. The navigation, readability and utility of the site is excellent for the consumer.****

American Heart Association

This is a national, voluntary health agency whose mission is to reduce disability and death from cardiovascular diseases and stroke. The website includes topics about cardiovascular clinical conditions among adults and children, life-saving techniques such as CPR and ECC, healthy lifestyles such as exercise, diet and nonsmoking, and a scientific section for health professionals and researchers.

  1. Authority: This website is sponsored by the American Heart Association. Rating: 5

  2. Currency: Smoking cessation resources for clinicians can be obtained from the main menu clicking “For Healthcare Professionals,” then “Improve Patient Care” and finally “Get with the Guidelines.” Here there is much information about cessation resources and examples of materials that can be shared with patients. The 2000 version of the USPHS Clinical Practice Guideline is still posted and has not been updated with the 2008 release. The site changes daily but the last update is not specified. Rating: 4

  3. Accuracy: The information is accurate for the most part. The section on nicotine replacement is extensive and appropriate, given concerns that patients with heart disease raise about safety of the products. Again, while accurate, the information does not reflect recommendations from the most recent release of the USPHS guideline (2008). Rating: 4

  4. Navigation & Readability: The site search returned many relevant results; its site map had an index, however, it only has first- and second-level links. Some links leave the site to other websites that look very similar, which is confusing. The navigation is consistent, but a little involved and confusing. Navigation is always available via pop-out menus, but collapses when entering second, third or fourth levels. There is regular formatting. However, no distinction is made between headings in main and subsections. Rating: 3

  5. Utility: The site is slow to load due to overload of JavaScript and many unnecessary images. Most images do not have ‘alt tags’, or a text description of the content of an image and there is no skip navigation link that allows for bypassing repeated materials. The PDF links are labeled but do not open in new windows. The site navigation disappears completely if JavaScript is turned off, making it impossible to navigate for some users. Rating: 3

Summary: This site received mixed reviews. Its clinical utility is outstanding. The currency and accuracy could be improved with the addition of the most recent guideline. The discussion of pharmacotherapy, especially nicotine replacement, remains excellent. Unfortunately, the navigation, readability and utility functions diminished its overall rating.****

National Institutes of Health, Centers for Disease Control, U.S. Department of Health and Human Services. First Gov

This is a website that includes a group of government agencies, specifically the National Cancer Institute, the Centers for Disease Control and Prevention, the National Institutes of Health, US Department of Health and Human Services and First Gov. Website topics include an online guide to quitting smoking, a link to an expert cessation counselor, information about the health consequences of tobacco use, recent tobacco-related research studies, health professionals information and a health risk appraisal tool for smokers.

  1. Authority: This website is jointly sponsored by the National Cancer Institute, Centers for Disease Control and Prevention, National Institutes of Health, US Department of Health and Human Services, and USA.gov. The site date changes daily but the last update is not specified. Rating: 5

  2. Currency: This comprehensive website features the latest formats under investigation for delivery of smoking cessation, i.e., instant messaging and proactive telephone counseling. In addition, other conventional, evidenced-based techniques for smoking cessation are presented. Rating: 5

  3. Accuracy: The site includes accurate and valid information for both health professionals and consumers. There is a link to a one-page listing of resources for health professionals. Rating: 5

  4. Navigation & Readability: Navigation is generally clear, consistent but incomplete: top-level navigation is always visible, persistent navigation is helpful but always at the very bottom of the page; second-level navigation, however, consists only of back-to links. This needs to be improved. There is no site search and the site map is incomplete, containing multiple links to identical pages. Rating: 2

  5. Utility: Most images have alt tags. However, there is no skip navigation link. The PDF links are not labeled and do not open in new windows. The site is browser independent and does not require any special plugins. Rating: 3

Summary: This website is intended primarily for the smoker. It provides accurate and current content and was one of the few sites to include live help for smoking cessation, as well as emphasis on proactive telephone counseling. The site needs some attention to navigation.***

U.S. Department of Health and Human Services

This website is directed by the US Surgeon General's Office. The website includes information about public health priorities, public health reports from the surgeon general, newsroom topics such as press releases and speeches and specific information about the Office of the Surgeon General.

  1. Authority: This website is sponsored by the US Department of Health and Human Services. The site’s last update is not specified. Rating: 5

  2. Currency: The content is based on the US Public Health Service’s Treating Tobacco Use and Dependence Clinical Practice Guideline: 2008 Update. Rating: 5

  3. Accuracy: The information is evidenced based and represents the findings from the expert panel’s meta-analysis. There is accurate information available for the consumer. Consumer information is also based on the materials released with the 2008 Clinical Practice Guideline. Materials are available in Spanish. Rating: 5

  4. Navigation & Readability: The website is contained fully within hhs.gov, but not accessible from anywhere within it. The top navigation has homepage and site map links that take the user to hhs.gov., which is very confusing. There is limited navigation; the only way to get anywhere is via a link from the homepage, and then clicking on a home link placed beneath the hhs.gov home link (which takes the user to a different site). The tobacco resources are not linked from anywhere on the homepage nor is the word “tobacco” mentioned. The only way to find resources on tobacco is via a site search. Rating: 2

  5. Utility: The text is clear and easy to read. PDF links are labeled as such, denote file sizes and open in new windows. The site is browser independent, and does not require any special plugins. Images have alt tags and there is a skip navigation link. Regular formatting is present, but sparse. Rating: 4

Summary: The currency and accuracy criteria are excellent. This site has useful information and is of interest to the clinician and smoker. Its overall rating is influenced by the navigation, readability and utility scores.***

Other Important Sites

Disclaimer

The author has no personal or financial interest in any of the websites discussed above. The author has no personal or financial interest in any of the websites discussed above. The reviewer has no personal or financial interests in the websites described above. The author served as a project member of a tobacco-related website, www.tobaccofreenurses.org, that was funded by the Robert Wood Johnson Foundation. This site was not included in this review.

References

  1. Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, May 2008.
  2. Centers for Disease Control and Prevention. Health United States, 2003, with Chartbook on Trends in the Health of Americans. CDC. National Center for Health Statistics 2003. Available from: http://www.cdc.gov/nchs/data/hus/tables/2003/03hus031.pdf.
  3. World Health Organization. Tobacco or Health: First Global Status Report. Geneva: WHO Tobacco or Health Programme, 1997.
  4. Centers for Disease Control. Cigarette smoking among adults – United States 2007. MMWR. 2008;57:1221-1226.
  5. Centers for Disease Control. Cigarette smoking among adults – United States 2000. MMWR. 2002;51:642-645.
  6. Centers for Disease Control. Youth risk behavioral surveillance system. Youth online: Comprehensive results, 2005. Available from: http://www.cdc.gov/healthyouth/tobacco/index.htm
  7. Lopez-Quintero C, Crum RM, Neumark YD. Racial/ethnic disparities in report of physician-provided smoking cessation advice: Analysis of the 2000 National Health Interview Survey. Am J of Publ Health 2006;96:2235-2239.