2. Cessation

The aim: to support even greater numbers of smokers to quit.

Nearly 80,000 quit dates were set with the NHS in the most recent year of recording, with more than a third succeeding at four weeks. However, we narrowly missed our target for reducing adult prevalence to 22% by 2010.  People living in our most deprived areas are still far more likely to smoke, and less likely to succeed in quitting.  We must build on the excellent work achieved over the past decade and ensure that we create a supportive environment for smokers who want to quit.  We must increase the momentum by ensuring an adequate profile and resources for Scottish stop-smoking services.

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Short term measures

• Stop-smoking services are both effective and cost-effective, but more can be done to close the health inequalities gap.  We need to develop a wider variety of evidence-based approaches to smoking cessation with all service users. We must monitor the use of incentive schemes and consider additional approaches to measure successful outcomes alongside traditional 4 week quit rates.
• We know that some people find services hard to access.  We must learn from effective approaches to working with 'hard to reach' groups, and ensure that stop-smoking services are available, accessible and successful in engaging with people.
• We need to develop and implement quality standards for Scottish stop-smoking services, evaluating gaps in current training provision, and developing new training packages where appropriate.
• We need evidence-based social marketing campaigns which tie in to local work, to highlight the dangers of taking up smoking at any age and the benefits of quitting.
• Smoking is a major driver of health inequalities and cannot be tackled in isolation.  We need to ensure that all relevant Government health and social policies consider the impact of tobacco within communities.
• We must encourage the UK Government to replace the current information on tobacco products about tar and nicotine emissions with more effective, standardised communications about harm, and the benefits of stopping tobacco use.
• As part of a package of measures to support smokers to quit, price is an important tool.  We must increase tobacco duty to cover the cost of smoking by 5% each year, and produce a budget-by-budget review of impacts.
  
  

Medium term measures

• Many more professionals within health and community services could raise the issue of smoking with their clients.  We need to develop routine stop-smoking advice and referral procedures in all services that discuss health issues with service users.
• We need to ensure that all health professionals in Scotland are equipped during their initial training to give brief advice on tobacco use and refer service users to stop-smoking services where appropriate.
• Smoking cessation is a dynamic field and new methods are being tested every year.  We must continue to ensure that services are supported to integrate new evidence-based developments in treatments into their work.
  
  

Long term measures

• In the long term we need the price of tobacco products to reflect the costs of tobacco use to the Scottish economy.  This would mean significantly increasing the price of hand-rolling tobacco through the tax system, and considering prohibiting tax and duty-free tobacco products in the UK.

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SHORT TERM

• Stop-smoking services are both effective and cost-effective, but more can be done to close the health inequalities gap.  We need to develop a wider variety of evidence-based approaches to smoking cessation with all service users. We must monitor the use of incentive schemes and consider additional approaches to measure successful outcomes alongside traditional 4 week quit rates.

Rationale:

Success at quitting smoking is known to be related to a complex mix of factors. Living in deprived areas, urban areas and having higher dependence on nicotine reduces the odds of success at quitting, whereas being employed or older increased the chances. Service type, intervention type, NHS Board and pharmacotherapy type also have a large influence on outcomes.

Smoking cessation professionals in Scotland currently follow standardised procedures for measuring quit rates at 4 weeks, 3 months and 1 year, in accordance with the minimum dataset which was developed by PATH. This information is required in order to assess performance against national health improvement targets. There is currently no means of recording intermediate indicators of success. Even where a quit attempt is unsuccessful, there are likely to be other fundamental changes which occur, such as an increased understanding of the harm caused by smoking to self and others; or  a reduction in cigarette consumption accompanied by lower CO readings.

A lot of the research on the use of incentive schemes has been done in the US where they operate a different type of healthcare system. Sometimes schemes are effective, and they work for some people, but the evidence is mixed. It has been suggested that they are more effective for quitting smoking than for other health outcomes such as effective weight loss. It has also been suggested that early success may dissipate when rewards are no longer offered.

NHS Tayside has implemented 'Give it Up for Baby' with great success in Dundee, where there are significant areas of poverty and a strong correlation between deprivation and smoking. This smoking cessation incentive scheme uses financial incentives in the form of grocery vouchers to encourage pregnant smokers to quit smoking. Women who are eligible for the program are identified by midwives, local pharmacists and health visitors. Initial data indicate that 'Give it up for Baby' has been more successful than previous approaches. By the end of the first year alone, 55 mothers had quit using the program in Dundee, and a total of 140 had quit across the Tayside region. Women who fully engage with the program receive an average payment of £210. Expenditure indicates a cost per quitter figure of about £1,700. The British Heart Foundation has estimated that treating disease directly caused by smoking produces medical bills of more than £5billion a year in the UK alone.

NICE has recommended financial incentives to encourage problem drug users to comply with treatment. It has stopped just short of recommending incentives for cessation during pregnancy, but recommends more UK research on this issue. A number of observational studies are now underway to evaluate financial incentives for smoking cessation. However, to date no UK trial exists, though one is currently planned in Glasgow, with recruitment to begin shortly. Incentives represent a most promising approach to improve the uptake of NHS stop smoking services. The outcomes of ongoing research and future studies should influence further policy developments in this area.

The optimal form of support to aid smoking cessation in those who are motivated and want help to quit involves the combination of multi-session, intensive behavioural support (delivered face-to-face in groups or individually, or by telephone), together with pharmacotherapy. That has been, and remains, the reason for placing a strong emphasis in Scotland on referral to NHS smoking cessation services.

In specific target groups and populations such as deprived groups, young people, pregnant women and psychiatric patients, tailored approaches and support should be offered.Offering a range of interventions is important to meet varying needs, and provide flexibility and choice, and to increase quit attempts and successful quitting. There is still limited evidence on the effectiveness of different strategies in different population groups. We therefore need to continue to develop more varied evidence-based approaches to smoking cessation with all service users in order to continue to reduce the number of people who smoke in Scotland.

Evidence base:

Cahill K, Perera R (2008b) Competitions and incentives for smoking cessation. Cochrane Database of Systematic Reviews. Issue 3. Art. No.: CD004307. DOI: 10.1002/14651858.CD004307.pub3

Lumley J, Oliver SS, Chamberlain C, Oakley L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2004, Issue 4.

Ussher MH, Taylor A, Faulkner G. Exercise interventions for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD002295. DOI: 10.1002/14651858.CD002295.pub3. .

Saul JE et al. (2007). Impact of a statewide Internet-based tobacco cessation intervention. Journal of Medical Internet Research 9 (3): e28.

National Institute for Health and Clinical Excellence. Should incentives be used to encourage healthy living? 2010.

Ranney, L. et al. (2006) Systematic review: Smoking cessation intervention strategies for adults and adults in special populations. Annals of Internal Medicine 145: 845-856.

A guide to smoking cessation in Scotland 2010. Planning and providing specialist smoking cessation services. NHS Health Scotland and ASH Scotland, 2010.

• We know that some people find services hard to access.  We must learn from effective approaches to working with 'hard to reach' groups, and ensure that stop-smoking services are available, accessible and successful in engaging with people.

Rationale:

Whilst Scottish cessation services appear to be successfully targeting some groups of smokers, both reach and cessation rates are lower than English estimates (though services have markedly increased throughput in more recent years). In 2007, reach in Scotland was 3.5% compared to 13-17% in England.  One month cessation rates in Scotland were 37.5% compared to 50% in England.

The challenge remains to sustain and build on current stop-smoking service provision in Scotland, and to develop more flexible, accessible and sustainable approaches to help smokers quit.  There is a need to further develop and refine cessation services for disadvantaged groups, young people and pregnant smokers and those who are not in employment or are manual workers. There is a clear direction from the Scottish Government to reduce levels of tobacco use which is reflected in key targets. More needs to be done to ensure services are accessible and achieve higher success rates.

Pharmacy-based interventions in Aberdeen have been shown to be associated with increased and more highly rated interactions, together with a trend toward higher smoking cessation rates. Recent research based in Glasgow has demonstrated that both traditional group support and pharmacy-based support are extremely cost effective. These findings indicate that community pharmacy schemes have the potential to make a significant contribution to national smoking cessation targets.   

In addition to pharmacies which offer standard, brief intervention support, a national community pharmacy scheme was launched in Scotland in 2008 in which 12 weeks of structured behavioural support (ordinarily 1:1) and NRT is offered in accordance with national service specifications. The aim is to provide extended access through the NHS to a smoking cessation support service, including the provision of advice and smoking cessation products, in order to help smokers successfully stop smoking. Pharmacists and their support staff are encouraged to seek out clients pro-actively, such as those with cardiac or respiratory disease, clients from disadvantaged neighbourhoods, pregnant women or young people.

The use of pharmacy schemes offers the potential for greater accessibility and flexibility of services, thereby reaching an increased number of smokers. We must continue to support their use and learn from this and other approaches designed to work more effectively with hard to reach groups in Scotland.

Targets for smoking cessation services in Scotland are set by the Scottish Government. The current target from 2011/12 - 13/14 is that smoking cessation services should achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40% most-deprived within-Board SIMD areas over the three years ending March 2014.

Evidence base:

Sinclair HK et al. (1998). Training pharmacists and pharmacy assistants in the stage-of-change model of smoking cessation: a randomised controlled trial in Scotland. Tobacco Control 7: 253-261.

Boyd KA and Briggs AH (2009). Cost-effectiveness of pharmacy and group behavioural support smoking cessation services in Glasgow. Addiction 104 (2): 317-325.

Bauld, L., Judge, K. & Platt, S. (2007) Assessing the Impact of Smoking Cessation Services on Reducing Health Inequalities in England: Observational Study. Tobacco Control, 16, 400-404.

Information Centre (2007) Statistics on Smoking: England, 2007.

Heeley, C. The Scottish Smoking Cessation Service: an assessment of its success at targeting different groups of smokers and helping them to quit in 2007: Summary Paper. 2008.

Lancaster, T., Stead, L., Silagy, C. & Sowdon, A. (2000) Regular Review: Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. British Medical Journal, 321, 355-358.

• We need to develop and implement quality standards for Scottish stop-smoking services, evaluating gaps in current training provision, and developing new training packages where appropriate.

Rationale:

The success of stop smoking services depends on highly trained and skilled advisers to provide advice to smokers who are motivated to quit. The development of quality standards focused on the user experience across all cessation settings will ensure the delivery of high quality and equitable services across the country. Diversification of service delivery remains essential in order to better meet the needs of all smokers who want to quit. Ensuring high quality delivery of service remains paramount to success in reducing the number of people who smoke in Scotland.

The development of quality standards should build upon and incorporate existing smoking cessation guidance for Scotland produced by NHS Health Scotland and ASH Scotland. It should also take into account the national training standards for stop-smoking work in Scotland developed by Partnership Action on Tobacco and Health (PATH) in 2009, PATH recommendations on data collection and evaluation of stop smoking services, and the smoking cessation minimum dataset and smoking cessation database. Developing quality standards should also assist in identifying any gaps in current training provision and facilitate the development of new training packages where appropriate. It should support the development of new models of service provision including within the voluntary sector.

The NHSScotland Quality Strategy is a development of the Better Health, Better Care Action Plan (2007) which builds on the significant healthcare achievements of the last few years. It has been informed by a wide range of discussions involving people working in NHSScotland, patients and carers and by a series of events in early 2010 involving independent primary care contractors. The ultimate aim of the Healthcare Quality Strategy is to deliver the highest quality healthcare services to people in Scotland. It will mean that the NHS will listen to people's views, gather information about their perceptions and personal experience of care, and use that information to further improve care. In relation to smoking cessation, this could mean, for example, looking more closely at barriers to accessing services, client feedback/complaints and commendations.

Evidence base:

NHS Health Scotland and ASH Scotland. A guide to smoking cessation in Scotland 2010. Edinburgh: Health Scotland. 2010.

Quality Standards for the Delivery of Smoking Cessation Services in Northern Ireland. June 2008.

PATH Scottish National Training Standards: Stop smoking support. December 2009.

• We need evidence-based social marketing campaigns which tie in to local work, to highlight the dangers of taking up smoking at any age and the benefits of quitting.

Rationale:

With a growing evidence base for its effectiveness in tackling tobacco use, social marketing is already being used extensively in England at local, regional and national levels. In Scotland we have the Health Improvement Social Marketing Strategy, although little tobacco control work has emerged from this since its development. We need to develop a long term social marketing strategy to tackle tobacco use in Scotland, which should utilise the specialist knowledge and internationally renowned experience of the Institute for Social Marketing, a collaboration between the University of Stirling and the Open University. The strategy should also consider new approaches, including exploiting new media to communicate with people about the harmful effects of taking up smoking and the benefits of creating a smoke-free future. It should take a long term approach and link up with local services to ensure greatest impact.

The UK health secretary Andrew Lansley has recently changed plans to freeze spending on public health media campaigns, including smoking. The decision follows research by the Department of Health which demonstrated that spending on media campaigns in any given quarter are associated with smoking cessation activity in that quarter.

Evidence base:

Local Government Improvement and Development. Social marketing approach to tobacco control. A practical guide for local authorities. July 2010.

MacAskill S, Lindridge A, Stead M, Eadie D, Hayton P and Braham M (2008). Social marketing with challenging target groups: Smoking cessation in prisons in England and Wales. International Journal of Nonprofit and Voluntary Sector Marketing, 13(3): 251-261.

Hastings G and McClean N (2006). Social marketing, smoking cessation and inequalities [Editorial]. Addiction, 101: 303-304.

National Institute for Health and Clinical Excellence (NICE). Preventing the uptake of smoking by children and young people. July 2008.

Wakefield MA, Loken B and Hornik, RC (2010). Use of mass media campaigns to change health behaviour. Lancet 376(9748):1261-71.

• Smoking is a major driver of health inequalities and cannot be tackled in isolation.  We need to ensure that all relevant Government health and social policies consider the impact of tobacco within communities.

Rationale:

Tobacco dependence is often only one of several competing health and social care issues that individuals have to deal with. Ensuring that all relevant health and social policies consider the impact of tobacco within communities would substantially increase the potential for joined up working among different health and social care services, and better emphasise the overall wellbeing of the service user. Anti-poverty strategies and community health plans which do not aim to reduce tobacco use will not best serve our communities.

• We must encourage the UK Government to replace the current information on tobacco products about tar and nicotine emissions with more effective, standardised communications about harm, and the benefits of stopping tobacco use.

Rationale:

Cigarette packets are currently required to include figures for the amounts of tar, nicotine and carbon monoxide that are emitted from a cigarette when it is smoked. Yields as determined by machine smoking do not provide useful information as individual smokers take in varying amounts of tar, nicotine and carbon monoxide depending on their smoking pattern.

A recent consultation on the EC Tobacco Products Directive discussed the possibility of replacing the current compulsory text warnings with emissions content that was more meaningful to the smoker. Because of the very well-established evidence that current machine-measured TNCO values are misleading to the consumer, ASH Scotland supports the removal of TNCO emissions from the Directive, and suggests they are replaced with qualitative information on the hazardous effects of tobacco emissions, and are required to include information on quitting smoking.

Evidence base:

Gray N. and Boyle, P. (2006) Editorial: Publishing tobacco tar measurements on packets.  British Medical Journal 329: 813.

Gallopel-Morvan K, Moodie C, Hammond D, Eker F, Beguinot E, Martinet Y. Consumer understanding of cigarette emission labelling. Eur J Public Health. 2010 Jul 2.

Scientific Committee on Tobacco and Health (SCOTH). A survey of 184 UK brands (Jan -Dec 2002) for tar, nicotine and carbon monoxide yields in cigarette smoke.

Kozlowski, LT et al. Cigarette design. In: Risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine. NCI Tobacco Control Monograph 13.  ch 2 Nov 2001.

• As part of a package of measures to support smokers to quit, price is an important tool.  We must increase tobacco duty to cover the cost of smoking by 5% each year, and produce a budget-by-budget review of impacts.

Rationale:

Rates of duty on tobacco products are determined by UK and European law. In recent years the UK government has increased tax only by or below the level of inflation, thereby missing the opportunity to maximise the impact of a powerful public health intervention. In 2010, it was announced that tobacco duty would rise by 1% above inflation for the current year and made a commitment to raising tobacco duty by 2% above inflation from 2011 to 2014. In the most recent budget in March 2011, the Chancellor announced these increases will continue to be implemented.  In addition, hand-rolled tobacco will receive a further 10% increase in duty and the tobacco duty scheme will be restructured to disproportionately increase the cost of the cheapest cigarette brands.  

The WHO Framework Convention on Tobacco Control (Article 6) recognises that raising tobacco prices through tax increases and other means is an effective and important means of reducing tobacco consumption by various segments of the population, and in particular young persons and those on low incomes. Whilst price increases can have an almost immediate effect on smoking uptake, they may take some time to change current smokers' addictive behaviour and so to be effective price increases must be sustained over the long term. Increasing prices is a regressive measure which will have a greater proportionate impact on low-income smokers. To reduce the impact on poorer smokers stop smoking services should be even better targeted to meet the specific needs of low income groups.

The current taxation system, which allows tobacco companies to deduct marketing costs as legitimate business expenses, runs counter to public health policy to curb the marketing of tobacco. The Government should also explore ways in which this deduction can be removed for the tobacco industry.

Draft EU Directive 2009
A new EU tax Directive has been proposed that, for the first time at EU level, links tax to public health protection objectives. Starting in 2014, the minimum tax would be raised to no lower than 60% of sales price. Because existing UK excise rates are above the proposed EU minimum threshold, the Government would be free to raise its rates, but not required to. ASH Scotland urges the UK Government to go further to keep tobacco tax rises above inflation, to assist in achieving its public health objectives. 

Tax and Smuggling
Tobacco companies oppose tax increases, arguing that price differentials between neighbouring countries are an incentive for smuggling, and that to combat smuggling, taxes must be reduced. The tobacco industry's arguments are undermined by case studies from across Europe, including Sweden, France and Spain, where increasing tobacco taxes has not led to increased smuggling. On the contrary, in Spain authorities have made significant progress in reducing the market share of smuggled cigarettes.

Evidence base:

Jha P, Chaloupka FJ. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington DC: World Bank, 1999

Townsend JL, Roderick P, Cooper J. Cigarette Smoking by socioeconomic group, sex, and age: effects of price income, and health publicity, BMJ 1994;309:923-7.

Directive amending Directives 92/79/EEC, 92/80/EEC and 95/59/EC on the structure and rates of excise duty applied on manufactured tobacco.

Villalbi J. Prices, Taxes and smuggling of tobacco in Spain: Evolution and relevance to health. Report of a seminar in Spain. Globalink, Legislation. 7/4/2000

Joosens, L. Taxes, prices and smuggling: Conference summary from Spain. Globalink 7/4/2000.

Warner K., The economics of tobacco, myths and realities. Tobacco Control 2000 9: 78-89

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MEDIUM TERM

• Many more professionals within health and community services could raise the issue of smoking with their clients.  We need to develop routine stop-smoking advice and referral procedures in all services that discuss health issues with service users.

• We need to ensure that all health professionals in Scotland are equipped during their initial training to give brief advice on tobacco use and refer service users to stop-smoking services where appropriate.

Rationale:

Many smokers are unaware of local stop-smoking services, or have a poor understanding of the range of services offered. 69% of smokers they would like to stop smoking completely.  However only 34% of smokers say they have received an offer of support to quit.

People who use the NHS for other reasons (maternity services, dentists and secondary care for example) should have easy access to specialist stop-smoking services during their care.

Engaging key healthcare professionals such as nurses, doctors, midwives and dentists in smoking cessation work has the potential to increase the reach of cessation services, resulting in a greater number of smokers who quit successfully over time.

It would also mean that smokers could receive support at any point they feel they might lapse - not just from NHS stop-smoking advisors. Training is an essential cornerstone of engaging these partners to ensure the necessary framework exists and make the service a success.

Evidence base:

Fairhurst A (2010) Developing a joined up approach to smoking cessation. Nursing Times; 106: 37, 12-13.

Campbell E et al. (2009) Increasing smoking cessation care provision in hospitals: A meta-analysis of intervention effect. Nicotine and Tobacco Research 11 (6) 650-662.

Rice VH and Stead LF (2008) Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews. Jan 23 (1): CD001188

Chestnutt IG (2010) Tobacco usage: the role of the dental team in smoking cessation. Dental Update 37 (1): 59-60, 62.

• Smoking cessation is a dynamic field and new methods are being tested every year.  We must continue to ensure that services are supported to integrate new evidence-based developments in treatments into their work.

Rationale:

Helping smokers stop is extremely cost-effective. The cost per life year saved of a comprehensive treatment service is about £1000 or less, representing excellent value for money. A continued Government commitment to supporting services remains critical, in order for them to integrate new evidence based developments in treatments into their work. An optimal service should play a leading and supporting role for all local health professionals, facilitating training opportunities, sharing good practice, contributing and communicating the evidence base, and assisting in the monitoring and evaluation of cessation interventions. Funding for research, sharing of innovative practice, and guidance for services is a necessary ongoing commitment.

For smokers unwilling or unable to quit the UK Government Cabinet Office’s behavioural insight team wants to explore and encourage the use of novel nicotine products to help people move away from traditional cigarettes.

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In the long term we need the price of tobacco products to reflect the costs of tobacco use to the Scottish economy.  This would mean significantly increasing the price of hand-rolling tobacco through the tax system, and considering prohibiting tax and duty-free tobacco products in the UK.

Rationale:

In the UK, 17% of smokers are thought to exclusively use roll-your own (RYO) cigarettes. Usage rates in Scotland are currently unknown. RYO smokers are twice as likely to believe RYO cigarettes pose less risk compared with factory-made (FM) cigarettes. They often mistakenly assume that RYO cigarettes contain less additives, and that, because they use less tobacco in smoking RYOs, they are somehow safer.

Yet studies of smoking machine emissions show much higher levels in RYO smoke, suggesting that hand-rolled cigarettes are as dangerous to health as manufactured cigarettes. There is no current Scottish data on the proportion of smokers that use a filter when making RYO cigarettes. Without the use of a filter, tar and nicotine levels are not regulated, which means that more tar, nicotine and carbon monoxide are inhaled.

EU regulations for tar and nicotine levels in cigarettes do not apply to rolling tobacco. Unless taxes, and thus prices, are brought into line, there is a real incentive for smokers to switch to hand-rolling cigarettes rather than cut down or quit.

In countries such as Finland where the price rise for hand rolling tobacco is greater than the price rise for manufactured cigarettes, the fall in manufactured cigarette consumption is accompanied by a fall in RYO use. Cigarette smokers are deterred from switching to hand-rolled cigarettes instead of stopping smoking. This increases the health benefits of raising taxes on manufactured cigarettes, discourages the use of potentially even more harmful forms of tobacco and may even lead to a greater reduction in health inequalities, given that RYO use is more common in men in less favourable socio-economic circumstances. The most recent budget has increased the duty on hand-rolled tobacco by 10%, however hand-rolled tobacco remains significantly more affordable than manufactured cigarettes.

Article 6 of the WHO FCTC, which is related to price and tax measures to reduce the demand for tobacco, requests the Parties to adopt measures prohibiting or restricting, as appropriate, sales to and/or importations by international travellers of tax- and duty-free tobacco products. There is some evidence that the availability of duty-free sales of tobacco products has facilitated illicit trade in tobacco products in many countries.

Prohibiting tax and duty free products in the UK, and significantly increasing the price of hand-rolling tobacco through the tax system would increase the public health impact of higher tobacco-product taxes by raising all tobacco product prices and by reducing opportunities for tax avoidance and tax evasion. Excise tax departments would need to collaborate with customs departments to minimise noncompliance and enable effective monitoring of trade. Such efforts would likely be most effective if undertaken in cooperation with regional and international tax and customs authorities.

It is likely that a proposal for a ban on world-wide duty-free sales of tobacco will be discussed at one of the 2011/12 meetings of the Framework Convention intergovernmental Negotiating Body. In the meantime, the extent of use of duty free in Scotland and in the UK as a whole requires clarification. Estimates of missed government tax revenue that could be used for improving the funding of tobacco control are also required.

Evidence base:

Shahab L West R and McNeill A (2009). A comparison of exposure to carcinogens among roll-your-own and factory made cigarette smokers. Addiction Biology 14 (3): 15-20.

Young D, Borland R, D Hammond K, Cummings KM, Devlin E, Yong H-H, O'Connor RJ, for the ITC Collaboration: Prevalence and attributes of RYO smokers in the International Tobacco Control (ITC) Four Country Survey. Tob Control 2006 , 15:iii76-iii82

Haukness A: Tar and nicotine yield in hand-rolled and manufactured cigarettes in Norway. National Council on Tobacco and Health, Oslo; 1994.  

Fowles J. Mainstream smoke emissions from 'RYO' loose-leaf tobacco sold in New Zealand. Report to the New Zealand Ministry of Health. 2008.

Laugesen M et al. (2009).Hand-rolled cigarette smoking patterns compared with factory-made cigarette smoking in New Zealand men. BMC Public Health 9 (194)  

Mindell, J.S. and Whynes, D.K. (2000) Cigarette consumption in the Netherlands 1970-1995: does tax policy encourage the use of hand-rolling tobacco? European Journal of Public Health 10 (3):  214-219.