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Cessation

Is it time to stop subsidising nicotine replacement therapies?

4 Feb, 15 | by Becky Freeman, Web Editor

By Simon Chapman, University of Sydney

Nicotine replacement therapy (NRT) became available in Australia in 1984 (gum) and 1993 (patches), first as prescription-only items. From 1988, they started becoming available as an over-the-counter item, with patches available without prescription from 1997. Today, some forms of NRT can even be bought in supermarkets.

If prescribed, NRT attracts a government subsidy. In the 17 months from July 2013 to Dec 2014, data provided by the Department of Health show 199,818 NRT scripts cost the government A$8,617,804.

But 31 years later, what should governments do if data show that NRT is little better, or even a good deal worse, at helping smokers quit than if they try to do it cold turkey?

Globally, the pharmaceutical industry understandably wants to convince quitters to use their products as much as possible. The smoking cessation field has long been dominated by research and promotional activity on how to deter smokers from ever attempting to quit without pharmacological or behavioural assistance, despite this being the way that most smokers have always quit.

Claims have abounded for years that NRT can significantly increase a smoker’s chance of quitting compared to placebo. These claims have overwhelmingly derived from clinical trials. But clinical trials differ markedly from real world use of NRT:

  • clinical trials exclude many people who might purchase NRT, such as those with any mental illness
  • there are major problems with blindness integrity (unsurprisingly, many smokers pickled in nicotine for years can guess if they have been allocated to the placebo arm of the trial)
  • trialists are contacted an average of 7.6 times by eager and supportive research staff trained to maximise retention of participants in the study
  • trialists are often paid for their participation
  • the drugs participants get are always free.

All this combines to produce an unreal situation and where trial participants do not represent all smokers and can be highly motivated to complete the trial to “please” the researchers.

So 31 years on, how does NRT perform away from clinical trials in the real world?

One of the world’s most rigorous and important data sets on smoking cessation comes from the Smoking in England study. A recent paper from that project casts a pall over any impact of NRT, other than generating more expensive urine in most of those who use it.

The paper reported on 1,560 English smokers who had made at least one recent and serious quit attempt. At six months, 23% were not smoking on the day they completed the questionnaire.

Several things stand out from this important study. First, smokers who used NRT obtained over the counter had by far the worst quit rate (15.4%) of any of the methods used. Even quitting unassisted (without using any medication or professional support), much denigrated by the makers of NRT and many smoking-cessation professionals, saw 24.2% taking this approach quit: a rate 57% higher than in those using NRT obtained over the counter.

The authors of the paper speculate that this low rate of success for NRT-users may be explained by “inappropriate usage and low adherence in the real world”.

Over the past three decades, NRT has been massively promoted via advertising and by pharmacists and doctors who have been heavily targeted by visiting sales reps. Doctors have been deluged with reprints of scientific articles on the virtues of NRT, and many have attended often lavishly catered educational meetings. Today, undying optimists still flying a flag for NRT still think there is hope that its users might one day start using NRT properly. Meanwhile, most who buy it keep smoking.

Second, the “most effective” method of quitting was also by far the least popular and acceptable. Using a prescribed medication (including NRT) and receiving specialised support for “at least six sessions” from one of England’s dedicated smoking cessation services saw 38.7% quit. But while the authors emphasised this throughout the paper, they were silent on how this best rate multiplied by the relatively small numbers availing themselves of these services would make much impression on the national goal of significantly boosting England’s quit rate at the population level. Any “most effective” way of quitting radically reduces in importance if few people are prepared to use it.

Only 4.8% of people attempting to quit were prepared to avail themselves of the “full monty” specialist cessation centres. These, even with the best success rate, contributed just 29 of the 359 who had quit using any method (8% of all quitters). This compared with 168 who had quit unassisted (a rate of 24.2%), yielding in this study nearly six times as many quitters as the specialist centres.

Third, having doctors write prescriptions for NRT or other prescribed cessation medications, and offering brief advice on quitting, produced a success rate only marginally higher than unassisted cessation (27.8% v 24.2%).

The fourth stand out message is what was not emphasised in the paper. If over-the-counter NRT (as it is mostly used), produces a far worse quit rate than smokers going cold turkey, where is the chorus of smoking cessation experts telegraphing this message to the community? How much worse would the data have to be before cessation experts declare its use-by date has arrived?

If the focus is on methods that yield high numbers of quitters throughout a population, this paper shows – as have many others – that cold turkey produced nearly 90% as many quitters (168) than from all other methods combined (191). Yet cold turkey is denigrated in pharmaceutical industry messaging like Pfizer’s “Don’t go cold turkey”.

The neglect of serious study of the way most smokers actually quit may be keeping us from gaining important insights that could be useful in campaign messaging.

Important questions also need to be asked about whether continuing the substantial government investment in subsidised-NRT is sensible. In the six months July to December 2012 (latest available data), the Commonwealth spent A$8.7m in media placement of anti-smoking messages trying to stimulate smokers to make quit attempts. How many more attempts might have been made had that figure been able to draw on the money being allocated to subsidised NRT?

Two studies of various Australian policies and programs’ impact on declining smoking prevalence between 1995 and 2011 found no evidence of impact of NRT sales or advertising volume.

Editor’s note: please ensure your comments are courteous and on-topic.

The Conversation

This article was originally published on The Conversation.
Read the original article.

Is it better to be a thin smoker or a fat ex-smoker?

22 Sep, 14 | by Becky Freeman, Web Editor

Weight gain when quitting smoking is a common concern, particularly amongst women. The increased attention of excess weight impacting on health suggests that some smokers may feel they are not achieving any net health benefits from quitting smoking if they gain weight once they stop smoking.

In this podcast I talk to Prof Siahpush about his paper examining if it is indeed better to be a thin smoker or a fat ex-smoker.

Mohammad Siahpush, PhD is a Professor in the Department of Health Promotion, Social & Behavioral Health at the University of Nebraska Medical Center, College of Public Health. He describes his research as being “about trying to understand what makes people behave the way they do. In looking for answers, I examine characteristics of individuals as well characteristics of the environments where people live.”

Read the full paper: It is better to be a fat ex-smoker than a thin smoker: findings from the 1997–2004 National Health Interview Survey−National Death Index linkage study goo.gl/OfH037

https://soundcloud.com/bmjpodcasts/is-it-better-to-be-a-thin-smoker-or-a-fat-ex-smoker

Reports from the Asia Pacific Association for the Control of Tobacco #APACT2013 Conference

29 Aug, 13 | by Marita Hefler, News Editor

 

Editor’s note: The first edition of the ASEAN Tobacco Control Atlas was launched to coincide with the conference. Click here to read additional reporting by SEATCA and download the report. Dr Marewa Glover from the University of Auckland Centre for Tobacco Control Research writes here about how e or m health ideas are an area that need more attention, and here about the importance of helping smokers quit to achieve Endgame goals.

—————

E. Ulysses Dorotheo, MD, FPAO

Southeast Asia Tobacco Control Alliance (SEATCA)

Framework Convention Alliance (FCA)

The Asia Pacific Association for the Control of Tobacco (APACT) marked a milestone with its 10th APACT Conference in Chiba, Japan last 18-21 August 2013, with a record 785 delegates from 42 nations participating.

In his David Yen Memorial Lecture, Mr. Kyoichi Miyazaki traced the conference’s history back to the visionary advocates who contributed to APACT’s establishment in 1989 and its early years of growth (particularly David Yen, Ted Chen, Judith Mackay, Prakit Vathesatogkit, Gregory Connolly, Richard Daynard, Terry Pechacek, Takeshi Hirayama, David Sweanor, Nigel Gray, Martin Kawano, and Kwan-Mo Chung, among others) in response to pressure to open the Asian markets to United States (US) tobacco companies wishing to invade the region.

Dr. Judith Mackay immediately followed up with a forward-looking plenary lecture on the tobacco endgame in line with the conference theme “Ending the Tobacco Epidemic – Protecting and Keeping Healthy Lives”, and over the next few days, best practices for measures to reduce tobacco consumption, such as optimal tobacco taxation, cost-effective cessation, and smoke-free policy advocacy, were discussed in plenary sessions, symposia, and poster presentations. Particular recognition was given to Australia for legislating the world’s first plain packaging of tobacco products, to Thailand for standing up to Big Tobacco’s intimidation by litigation for requiring the world’s largest (85%) pictorial health warnings, and to New Zealand for trendsetting a 2025 endgame target.

In contrast, the conference also recognized the varying degrees of tobacco control implementation in individual countries and underscored the need for full and accelerated FCTC implementation across our region in order to slow the tobacco death clock. Indonesia, for example, remains the only Asian country not a party to the FCTC, and conference host, Japan, still has no national law to protect the public from secondhand smoke. In this regard, delegates and speakers also shared experiences relating to the increasing incidence and overtness of tobacco industry interference in public policy (e.g. through their so-called Corporate Social Responsibility (CSR) activities, litigation against effective tobacco regulation, and stakeholder engagement in international trade policies) and called on governments to immediately and fully implement FCTC Article 5.3 and its guidelines, to ban CSR activities by the industry, and to explicitly exclude tobacco products from international, regional, and bilateral trade and investment agreements, such as the Trans-Pacific Partnership agreement currently being negotiated, noting that, except for the US, all TPP negotiators are Parties to the FCTC.

The 10th APACT further recognized the importance of the youth as future leaders who must be meaningfully engaged to realize the tobacco endgame in the Asia Pacific region, because just as in 1989, continuing collaboration is needed to overcome Big Tobacco, which relentlessly targets young people of Asia for its profits.

The next APACT Conference will be in 2016 in Qingdao, China.

An enormous set of lungs demonstrate in graphic detail the effect of smoking

An enormous set of lungs demonstrate in graphic detail the effect of smoking

New WHO report: more tobacco advertising bans, smoke free spaces save millions of lives

11 Jul, 13 | by Marita Hefler, News Editor

 

The World Health Organisation Report on the Global Tobacco Epidemic 2013 was launched in Panama City on 10 July. Panama was selected as the venue for this high level, global event in recognition of the country’s leadership in tobacco control.

The report shows the number of people worldwide covered by at least one life-saving measure to limit tobacco use has more than doubled in the last five years. Three billion people are now covered by national anti-tobacco campaigns. Other highlights include:

  • The number of people covered by tobacco advertising, promotion and sponsorship (TAPS) bans, the focus of this year’s report, increased by almost 400 million people, the majority of whom reside in low and middle-income countries.
  • 24 countries with 694 million people have introduced complete TAPS bans. However, 67 countries currently do not ban any TAPS activities, or have a ban that excludes advertising in national broadcast and print media.
  •  Effective health warning labels on tobacco packaging continue to be established by more countries. In the past five years, a total of 20 countries with 657 million people put strong warning label requirements in place.
  • More than half a billion people in nine countries have gained access to appropriate cessation services in the past five years. However, there has been little progress since 2010, as only four additional countries with a combined population of 85 million were newly provided access to cost-covered services including a toll-free national quit line.
  • Creation of smoke-free public places and workplaces continues to be the most commonly established measure at the highest level of achievement. 32 countries have passed complete smoking bans covering all work places, public places and public transportation means between 2007 and 2012, protecting nearly 900 million additional people.
  • Nearly 3.8 billion people (54% of the world’s population) live in a country that has aired at least one national anti-tobacco mass media campaign on TV and/or radio for a duration of at least three weeks in the past two years.

The report is the fourth in a series by WHO on MPOWER measures – the six evidence-based tobacco control measures that are the most effective in reducing tobacco use. (Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn people about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, and Raise taxes on tobacco

Read more and download the report here.

Click here for additional reporting from the World Lung Foundation.

Cameroon: Cigarettes are eating your baby alive campaign

4 Jul, 13 | by Marita Hefler, News Editor

 

Today marks the launch of the first-ever national mass media campaign to warn people of Cameroon about the harms of tobacco. The campaign, called ‘Cigarettes Are Eating Your Baby Alive,’ was developed by the Ministry of Health and World Lung Foundation. It graphically depicts how tobacco harms not both smokers, as well as their children and loved ones exposed to tobacco smoke. It will air on TV, radio, outdoor venues and SMS for eight weeks. The campaign is designed to empower citizens with new knowledge and spur advocacy and government to protect citizens from tobacco.

The campaign concept was rated as effective by African audiences in rigorous testing of tobacco control messaging conducted by World Lung Foundation in 2012. It was originally developed by the New York City Department of Health and Mental Hygiene and has been used effectively in Bangladesh, India, Mexico, Russia, and Vietnam, among other countries.

This mass media campaign was carried out with the technical and financial support of the Africa Tobacco Control Consortium (ATCC), Africa Tobacco Control Alliance (ATCA) and the Framework Convention Alliance. Additional funding was provided by the Bill and Melinda Gates Foundation and Bloomberg Philanthropies.

To view the public service announcement (French and English), click here.

Cameroon - cigarettes are eating you and your baby

Romania World No Tobacco Day: ‘Ex-smokers are unstoppable’

29 Jun, 13 | by Marita Hefler, News Editor

 

Photos and report credit: European Commission (http://www.exsmokers.eu/)

World No Tobacco Day in Romania highlighted the European Commission’s Ex-smokers are unstoppable’ campaign. A media roundtable was held, where two doctors discussed the benefits of smoking cessation. Two ex-smokers also shared their personal stories of quitting smoking. The event was attended by numerous media representatives, and obtained massive print, online, radio and TV coverage in Romania.

The event drew on the findings of a study conducted through the ‘ex-smokers are unstoppable’ campaign. Professor Doctor Florin Mihaltan, President of the Romanian Lung Society and one of the doctors who spoke at the roundtable, said: “The European Commission’s Ex-Smokers are Unstoppable campaign, through which this study was conducted, shifts the main focus from the dangers of smoking to the benefits of smoking cessation. These numbers illustrate the realities of life as a smoker, as well as an increase in people’s desire to quit.”

Romania pic 1

 

 

 

 

Professor Dr Florin Mihaltan (centre) with ex-smokers Cristina Matei (l) and Iulia Pop (r)

The majority of smokers who took part in the survey say that they smoke between 70 and 140 cigarettes per week (10-20 cigarettes per day), a figure which applies to 32.4% of Romanian smokers. Over half of Romanian smokers (56.3%) say that they want to quit their habit within a year. 80% of Romanians believe that willpower is the key to quitting while 43% identify motivation as the most important factor.

About 28% of Romanian smokers find it difficult to resist the urge to smoke when they are enjoying tea or coffee. 27% have a hard time socialising with other smokers when trying to quit, while 22% are most tempted by the “morning cigarette”. When asked how they would feel if they never smoked again, 42% of Romanians said that they would feel proud. Another 42% believe they would feel healthier and more in control of their health.  Over half of the 1,000 people questioned in Romania believe that smoking gets in the way of certain activities and 20% of respondents believe that smoking affects sporting performance. Half of smokers even avoid flying because of their habit.

Doctor Ioana Munteanu, President of the Tobacco Section of the Romanian Lung Society, who also spoke at the roundtable, said “Where the process of quitting smoking is concerned, it is very important for us to be aware of both the internal and the external factors which facilitate it. It is very interesting to see that a very large proportion of the respondents believe that the secret of quitting resides within themselves. Motivation plays a very important role, and identifying its sources represents the key to success when going through a nicotine withdrawal episode.”

Romania pic 2

 

 

 

 

Dr Ioana Munteanu (l) and ex-smoker Iulia Pop.

 

The European Commission’s “Ex-Smokers are Unstoppable” campaign inspires smokers to kick the habit by celebrating the achievements of ex-smokers from all over Europe. It offers people free help to stop smoking through iCoach, a free online stop-smoking tool based on extensive scientific research and clinical experience of psychologists and communication experts. Since the launch of the programme in June 2011, a total of 380,819 Europeans have registered to iCoach 22,325 of whom are Romanians. Romania ranks 4th among EU countries for total iCoach registrations. The self-reported quit rate for people signing up to iCoach is 40%. This is the proportion of people who classed themselves as a non-smoker after 3 months on the programme.

“If it’s not cancer, I’ll give up smoking”

16 Apr, 13 | by Marita Hefler, News Editor

"I promise you, I will do everything I can to make sure you did not die in vain. I will tell the world your story, and the story of other people killed by tobacco. I will challenge the tobacco industry, the tobacco lobbyists, and the politicians who listen to them."

Replacement smokers are the lifeblood of the tobacco industry. What’s it like to treat the victims of this insidious industry? In this powerful TEDx talk, pulmonologists Pauline Dekker and Wanda de Kanter show the heartbreaking, but all too typical, journey of a lung cancer patient, explode the idea of freedom of choice, and highlight the tactics of selling death.

 

SENEGAL: FIRST EVER NATIONAL TOBACCO CONTROL MASS MEDIA CAMPAIGN

2 Apr, 13 | by Marita Hefler, News Editor

Senegal has launched its first national mass media campaign about the harms of tobacco. Developed by the Ministry of Health and Social Action and World Lung Foundation, the campaign graphically depicts the tar that collects inside an average smoker’s lungs. It is hoped that the campaign will empower citizens with new knowledge, and also spur advocacy and government policies to protect citizens from tobacco.

Called ‘Sponge,’ the campaign will air on TV, radio, outdoor venues and SMS for eight weeks.  It was tested rigorously in Senegal, and is based on campaigns previously aired in Australia, China, India, Mauritius, Russia, the United States, and several other countries. Currently, three percent of all male deaths in Senegal can be attributed to tobacco use; a number set to skyrocket as the tobacco industry increases its efforts to addict more people to its products.

Across Africa, tobacco industry activity is booming. Women in Africa, who have a relatively low smoking prevalence compared to other regions of the world and are therefore seen as a growth market, are aggressively targeted by the industry. Initiation among young people is also a concern; according to The Tobacco Atlas, almost 20% of youth in Senegal report having an item with a tobacco logo on it, with even higher percentages in Chad (30%), Niger (30%) and Mauritania (28%). This data suggest young people are being subjected to aggressive marketing to addict a new generation of users.

The campaign television ad (in French) can be viewed from the World Lung Foundation website.

Nicotine replacement therapy isn’t all it’s cracked up to be

19 Feb, 13 | by Marita Hefler, News Editor

This article was originally published at The Conversation. The original URL is here.

Ross MacKenzie, Macquarie University

A study published in the latest edition of the journal Tobacco Control confirms what we’ve long suspected about nicotine replacement therapy (NRT): smokers don’t need to resort to these pharmaceuticals to quit.

Researchers at the Harvard School of Public Health and the University of Massachusetts analysed relapse rates among 787 Massachusetts smokers who had recently quit, in three waves of interviews between 2002 and 2006. Participants were asked how they quit smoking, if they used NRT and in which form – gum, patch or inhaler. They were also asked to describe the longest period of continuous use of the product and if they received any form of cessation counselling.

Accounting for variation by gender, race, age, education and level of nicotine dependence, the researchers found that people who relapsed into smoking did so at equivalent rates, whether or not they had used NRT to assist in their quit attempt.

The findings add to the growing literature that questions the effectiveness of NRT to help people quit smoking.

What does the evidence say?

Clinical trials have reported that NRT increases the success rate of quitting by 50% to 70% compared to those receiving placebo. But these impressive results have not been replicated in real-world settings. Population-level studies have found no beneficial effect of the use of nicotine replacement therapy.

Selection criteria covering trial participants and the terms of their participation are among the key reasons for the marked difference in findings.

Research shows that unassisted cessation, or cold turkey, remains the most successful method of quitting. Yet questions about the efficacy of NRT often provoke intense debate within the tobacco control community, with clear implications for countries with high smoking rates which are yet to implement comprehensive tobacco-control regulations.

Perceptions of the effectiveness of NRT are also relevant to Australia and other countries that have enacted advanced legislation. Australia’s adult smoking rate is at a historic low of 15.1%, but tobacco consumption remains a leading public health concern. Some 3.3 million adults continue to smoke daily or weekly, and 15,000 Australians die annually from smoking-related diseases. The total social cost to the national economy is estimated to be $31.4 billion.

More than 15,000 Australians die annually from a smoking-related diseases. Image from shutterstock.com

 

Tobacco control policy

Despite the growing evidence of the limitations of NRT in “real-world” situations, pharmaceutical patches, inhalers and gums continue to play a key role in smoking cessation policy.

The Quit Victoria website states that smokers “who have the best chance of quitting are those who get some coaching and use quitting medications”; while NSW Health says proper use of NRT products can be “the key to successfully quitting for good.”

The Commonwealth Department of Health and Ageing’s National Tobacco Campaign states that smokers can double the chances of quitting successfully by using cessation medication, but questions the veracity of ex-smokers’ claims to have quit without medication:

Though many people will say that they have quit cold turkey, often they have used medication or advice and support to help them through.

Support for NRT has been translated into government policy, following a submission to the Pharmaceutical Benefits Advisory by Cancer Council Australia, Heart Foundation, Australian Council on Smoking, and Health and Quit Victoria. Nicotine patches have been subsidised on the Pharmaceutical Benefits Scheme as a prescription smoking-cessation aid since 2011, at a cost of $9 million in the first year of subsidisation.

Another promoter of NRT is, of course, the pharmaceutical industry. The 2011 global sales of NRT were worth an estimated US$2.4 billion. In Australia, patches, gum, and other forms of NRT have been available over the counter for years, and the market continues to expand. Sales increased by 7% in 2011 to $174 million, and market analysts predict continuing strong sales, due in part to the growing range of NRT products available in supermarkets.

Time for evidence-based policy

Pharmaceutical cessation products continue to attract support disproportionate to their usefulness. This distracts attention from the reality that the most common method used by most ex-smokers remains unassisted cessation.

Perhaps most importantly, it threatens funding for evidence-based population level interventions – such as tax increases and media campaigns – that have been primarily responsible for the precipitous drop in smoking rates in Australia in recent decades.

 

Stub It Out: a New Media Resource to Support an Innovative Cessation initiative

14 Sep, 12 | by Marita Hefler, News Editor

Nathan Cowie, Centre for Tobacco Control Research, University of Auckland.

12 September 2012

Stub It Out is a free game developed for Apple’s iPad by a small multidisciplinary team at the University of Auckland in New Zealand.  The game was released on the App Store last month.  The game is designed to be a resource complementing the WERO package – an attractive, culturally salient group stop smoking competition designed for Maori and Pacific Island smokers – priority groups for smoking cessation in New Zealand.

We wanted to create a resource that was innovative, attractive and engaging, not just another boring leaflet or booklet that people will look at once before discarding.  The gameplay is simple and fun, yet challenging.  Tobacco products sail across the screen and the player ‘taps’ them to stub them out.  The cigarette butts fall to the ground where they smoulder and emit smoke (making gameplay harder) until they are swept away with a ‘swipe’ gesture.  Cessation products also feature in the game and act as power-ups, temporarily slowing down the gameplay to make it easier to stub out the cigarettes and sweep away the butts.

We expect that this game could help smokers in a number of ways – as a distraction, a stress release, keeping hands busy, and by increasing awareness of cessation treatments.  Ideally the game would be used as an adjunct to behavioural support and or pharmacotherapy.

Dr Marewa Glover, Director of the Centre for Tobacco Control Research, came across this article by Canadian researchers, who had placed virtual cigarettes in a 3D virtual reality environment for participants to reach out and ‘crush’. Participants in the control condition entered the same virtual reality environment for the same duration, but instead of crushing virtual cigarettes they were to ‘grasp’ virtual balls. Though the mechanism is unknown, their results suggest that crushing virtual cigarettes in a virtual reality environment reduces nicotine dependence and encouraged retention of smokers in their psychosocial treatment programme.

Dr Glover, being a recent convert to the iPad, saw the potential of such an approach and set about designing the game Stub It Out to be part of the new media component (other components being website and an iOS app) of the WERO group stop smoking competition, which is being tested as an intervention to enable mass quitting as part of a programme of research to inform the rapid reduction of smoking prevalence in New Zealand.

Developing the game was a collaborative process. Dr Glover had been playing different games on the iPad and observing her 7 year old daughter playing games too. Debra Warren, a software developer from the National Institute of Health Innovation joined our team along with myself, Laura Wilson (graphic design), and Timi Hawea, a student from the Music and Audio Institute of New Zealand who created the background score and sound effects. As the development of the game progressed we tested it with our neighbours in the office and made adjustments accordingly. Eventually, on 22 August 2012 the game was released on the App Store and we started promoting it on Facebook, Twitter and any opportunity that presented itself.

Response to the game has been very positive so far and we intend to develop a version for the iPhone, and then for the Android operating system, so that we can maximise the potential audiences. We also plan to be able to customise the game so that it is salient to smokers in other parts of the world – Stub It Out India (if adapted) would feature localised backdrops and tobacco products that are available locally such as gutka and bidi, in addition to cigarettes and cigars.

A small sub study is currently in the design stages to evaluate if playing Stub It Out compared to a control iPad game has an effect of tobacco cravings.

Get Stub It Out on your iPad now:

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