STOP SMOKING PROBLEM USING ELKTRONIK MEDIUM

Introduction
Smoking is harmful to health. On average, lifelong smokers lose 10 years of life, and
about half of all lifelong smokers have their lives shortened by smoking. Stopping
smoking reverses or prevents many of these harms. However, cessation services in
Malaysia achieve variable success rates with smokers who want to quit. Approaches
to behaviour change can be supplemented with electronic aids, and this may
significantly increase quit rates and prevent a proportion of cases that relapse. About
two hundred and seventy-one original published materials related to tobacco use
were found in a search through a database dedicated to indexing all original data
relevant to Medicine and Health in Malaysia from 2000 - 2020. A total of 147 papers
were selected and reviewed on the basis of their relevance and implications for
future research. Findings were summarised, categorised and presented according to
epidemiology, behaviour, clinical features and management of smoking. Most
studies are cross-sectional with small sample sizes. Studies on smoking initiation
and prevalence showed mixed findings with many small-scale studies within the sub-
groups. The majority of the studies were related to factors that contribute to initiation
in adolescents. Nonetheless, there are limited studies on intervention strategies to
curb smoking among this group. There is a lack of clinical studies to analyse tobacco
use and major health problems in Malaysia. In addition, studies on the best
treatment modalities on the use of pharmacotherapy and behavioural counselling
have also remained unexplored. Reasons why smokers do not seek clinic help to
quit smoking need further exploration. A finding on the extent of effort carried out by
healthcare providers in assisting smokers to make quit attempts is not known.
Studies on economic and government initiatives on policies and tobacco use focus
mainly on the effects of cigarette bans, increased cigarettes taxes and the influence
of the tobacco industry. Recommendations are given for the government to increase
efforts in implementing smoke-free legislation, early and tailored interventions.
Clinical studies in this area are lacking, as are opportunities to research on ways to
reduce smoking initiation age and the most effective quit smoking strategies.
Objective
The primary research question we sought to answer was: What is the effectiveness
and cost-effectiveness of internet, pc and other electronic aids to help people stop
smoking? We addressed the following three questions: (1) What is the effectiveness
of internet sites, computer programs, mobile telephone text messages and other
electronic aids for smoking cessation and/or reducing relapse? (2) What is the cost-
effectiveness of incorporating internet sites, computer programs, mobile telephone
text messages and other electronic aids into current Malaysia smoking cessation
programmes? and (3) What are the current gaps in research into the effectiveness of
internet sites, computer programs, mobile telephone text messages and other
electronic aids to help people stop smoking?

Data sources
In 2020, approximately 22.8% (4,991,458) of Malaysian population aged 15 years
and above were smokers, 43.0 % (4.85 million) of men and 1.4% (143,566) of
women smoked manufactured cigarettes, hand-rolled and smokeless cigarettes. Out
of the current smokers, 20.5% (95% CI 19.2-21.0) were daily smokers; 38.8% (95 %
CI 36.4-39.4) of men and 1.1% of women (95 % CI 0.8-1.46). About one tenth of the
Malaysian population aged 15 years and above used smokeless cigarette (20.8% of
men and 0.8% of women). Majority of the current smokes in Malaysia smoked
manufactured cigarettes whilst hand-rolled cigarettes were popular among older
aged smokers (aged 65+) (3.5 %, 95 CI) 2.75-4.44 and smokers from rural areas
(4.6 %, 95 CI 3.96-5.42). Approximately 60% of current smokers smoked 15 sticks of
cigarettes and above. Exposure to Environmental Tobacco Smoke Overall, 37.1%
(8.09 million) of Malaysian adults aged 15 years and above were exposed to second-
hand smoke (SHS) at home; significantly higher among men (41,9%, 95 CI 40.04-
43.25), and without formal education (43.0 %, 95 CI 39.65-48.15). Among non-
smokers, the prevalence of exposure to SHS was 25.9% (4.36 million); higher
among females (31.3%, 95% CI 29.82-32.78), whilst older respondents (aged 65+,
19.6%, 95 CI 16.97-22.43) and Tertiary education (15.7%, 95 CI 13.92-17.59)
showed the lowest exposure an estimated of 37.3% of respondents working indoor
were exposed to ETS during the last one month. The exposure was two times higher
among men (48.1 % vs 24.1%) as compared to women. For non-smoker, the
estimate was 30.4%. Lowest among older age group (65+) (23.1%,95 CI 15.33-
35.67) and respondents with tertiary education attainment (25.3%, 95 CI 22.78-
22.94).

Table 1 Smoking Status by Gender

Smoking Status Overall Male Female

Percentage (95% CI)
Current tobacco smoker 22.8(21.86,23.81) 43.0(41.38,44.6) 1.4(1.05,1.75)
Daily smoker 20.5(19.63,21.46) 38.8(37.25,40.35) 1.1(0.82,1.44)
Occasional smoker 2.3(2.02,2.6) 4.2(3.69,4.76) 0.3(0.16,0.46)
Occasional smoker,
1.0(0.82,1.19) 1.8(1.49,2.2) 0.1(0.06,0.21)
formerly daily
Occasional smoker,
1.3(1.1,1.55) 2.4(2,2.83) 0.2(0.08,0.33)
never daily
Current non-smoker 77.2(76.19,78.14) 57(55.4,58.62) 98.6(98.25,98.95)
Former smoker 2.4(2.11,2.71) 4.3(3.74,4.85) 0.4(0.27,0.6)
Former daily smoker 1.7(1.48,1.96) 3.2(2.74,3.65) 0.2(0.08,0.28)
Former occasional
smoker 0.7(0.55,0.86) 1.1(0.86,1.4) 0.3(0.15,0.43)
Never smoker 74.8(73.75,75.8) 52.8(51.06,54.45) 98.2(97.82,98.58)

Review methods
Randomised controlled trials (RCTs) and quasi-RCTs evaluating smoking cessation
programmes that utilise computer, internet, mobile telephone or other electronic aids
in adult smokers were included in the effectiveness review. Relevant studies of other
design were included in the cost-effectiveness review and supplementary review.
Pair-wise meta-analyses using both random- and fixed-effects models were carried
out. Bayesian mixed-treatment comparisons (MTCs) were also performed. A de novo
decision-analytical model was constructed for estimating the cost-effectiveness of
interventions. Expected value of perfect information (EVPI) was calculated. Narrative
synthesis of key themes and issues that may influence the acceptability and usability
of electronic aids was provided in the supplementary review.
Results
This effectiveness review included 60 RCTs/quasi-RCTs reported in 77 publications.
Pooled estimate for prolonged abstinence relative risk (RR) = 1.32, 95% confidence
interval (CI) 1.21 to 1.45] and point prevalence abstinence (RR) = 1.14, 95% CI 1.07
to 1.22) suggested that computer and other electronic aids increase the likelihood of
cessation compared with no intervention or generic self-help materials. There was no
significant difference in effect sizes between aid to cessation studies (which provide
support to smokers who are ready to quit) and cessation induction studies (which
attempt to encourage a cessation attempt in smokers who are not yet ready to quit).
Results from MTC also showed small but significant intervention effect (time to
relapse, mean hazard ratio 0.87, 95% credible interval 0.83 to 0.92). Cost-threshold
analyses indicated some form of electronic intervention is likely to be cost-effective
when added to non-electronic behavioural support, but there is substantial
uncertainty with regard to what the most effective (thus most cost-effective) type of
electronic intervention is, which warrants further research. EVPI calculations
suggested the upper limit for the benefit of this research is around MYR 2000- MYR
3000 per person.

Limitations
The review focuses on smoking cessation programmes in the adult population, but
does not cover smoking cessation in adolescents. Most available evidence relates to
interventions with a single tailored component, while evidence for different modes of
delivery (e.g., e-mail, text messaging) is limited. Therefore, the findings of lack of
sufficient evidence for proving or refuting effectiveness should not be regarded as
evidence of ineffectiveness. We have examined only a small number of factors that
could potentially influence the effectiveness of the interventions. A comprehensive
evaluation of potential effect modifiers at study level in a systematic review of
complex interventions remains challenging. Information presented in published
papers is often insufficient to allow accurate coding of each intervention or
comparator. A limitation of the cost-effectiveness analysis, shared with several
previous cost-effectiveness analyses of smoking cessation interventions, is that
intervention benefit is restricted to the first quit attempt. Exploring the impact of
interventions on subsequent attempts requires more detailed information on patient
event histories than is available from current evidence.

Conclusions:
Our effectiveness review concluded that computer and other electronic aids increase
the likelihood of cessation compared with no intervention or generic self-help
materials, but the effect is small. The effectiveness does not appear to vary with
respect to mode of delivery and concurrent non-electronic co-interventions. Our cost-
effectiveness review suggests that making some form of electronic support available
to smokers actively seeking to quit is highly likely to be cost-effective. This is true
whether the electronic intervention is delivered alongside brief advice or more
intensive counselling. The key source of uncertainty is that around the comparative
effectiveness of different types of electronic interventions. Our review suggests that
further research is needed on the relative benefits of different forms of delivery for
electronic aids, the content of delivery, and the acceptability of these technologies for
smoking cessation with subpopulations of smokers, particularly disadvantaged
groups. More evidence is also required on the relationship between involving users
in the design of interventions and the impact this has on effectiveness, and finally on
how electronic aids developed and tested in research settings are applied in routine
practice and in the community.