- Email: [email protected]
MS 09.01 Global Tobacco Control
November 2017 upregulated genes were common between the TAZ and YAP activated cells, TAZ induced transcription of genes encoding cytokines and their receptors more than YAP. Among the upregulated cytokines, we observed that TAZ binds to the promoter region of the gene encoding IL1-beta along with TEAD transcription factors, which increased IL1beta transcription and subsequently cell proliferation of immortalized mesothelial cells. In contrast, IL1-beta knockdown or an IL1 receptor antagonist inhibited cell proliferation of MM cells, suggesting that ILbeta signaling suppression may have stronger inhibitory effects on MM cells with TAZ activation. The mevalonate pathway has recently been reported to play a pivotal role in regulating the downstream events of the Hippo pathway. We identified antitumor effects of statin on MM cells with Hippo signaling pathway inactivation. Statin attenuated proliferation and migration of MM cells harboring a NF2 mutation by accelerating YAP phosphorylation/inactivation. Interestingly, not all MM cells with NF2-Hippo pathway inactivation exhibited statin sensitivity. All the statin high-sensitive MM cell lines had increased p-YAP/ YAP ratios (inactivation) after statin exposure, whereas in statin lowsensitive cells, the p-YAP/YAP ratio was generally low or unchanged. Genetically, the statin high-sensitive MM cells harbored NF2 and/or LATS2 mutations without BAP1 mutation, whereas BAP1 mutations were frequently identified in statin low-sensitive cells. Indeed, the YMESO-25 cell line, carrying both NF2 and BAP1 mutations, regained moderate statin-sensitivity after transfection with a wild-type BAP1 plasmid, indicating that BAP1 mutations interfered with the anti-proliferative effects of statins on MM cells with Hippo pathway inactivation. However, the interactions between BAP1 and the Hippo pathway remain to be elucidated. In conclusion, YAP and TAZ activation via NF2Hippo pathway inactivation is essential for MM cells to acquire more malignant phenotypes, and therefore, detailed understanding of the biology of this pathway is required to develop new therapeutic modalities against MM based on dysregulation of this pathway. Keywords: Hippo pathway, mevalonate pathway, NF2
MS 08.07 Achieving Equitable Access to Novel Treatments for all Patients L. Darlison Department of Respiratory Medicine, University Hospitals of Leicester, Leicester/GB The UK has the highest incidence of Mesothelioma in the world with over 2700 cases diagnosed in 2014 (Cancer Research UK 2017). Data for 80% of these patients was submitted and analyzed as part of the UK’s National Lung Cancer Audit Mesothelioma Report (NLCAMR) 2016 (Royal College of Physicians [RCP] 2016). The report confirmed that an increasing number of patients are receiving chemotherapy in the UK particularly patients with a good performance status; 53% compared to 41% in the audit’s 2014 report. The current audit does not identify the proportion of patients who receive their treatment as part of a clinical trial however the report recommends “All patients should be offered access to relevant clinical trials even if this requires referral outside of their network” (RCP 2016). With an increasing number of mesothelioma clinical trials now available in the UK, and more in development, facilitating seamless movement of patients from one specialist clinical team to another is essential. Mesothelioma UK, a national charity dedicated to improving outcomes for those affected by Mesothelioma, is establishing a comprehensive package of services and resources specifically to support this. The charity’s vision, for ensuring equitable access to treatment and trials is outlined in the charity’s 2016-2021 Strategy, The Next Five Years (Mesothelioma UK 2016). This presentation provides insight into readily transferable measures Mesothelioma UK has developed to support equitable access to treatment and care across the UK. Reference: 1.Cancer Research UK 2017 (Last viewed August 4, 2017). Keywords: Equitable Treatment Access
Abstracts
S1689
MS 09.01 Global Tobacco Control E. Stone Thoracic Medicine and Kinghorn Cancer Centre, St Vincent’s Hospital Sydney, Darlinghurst/NSW/AU The history of global tobacco control starts at the beginning of the twentieth century with early data linking the smoking of tobacco with the risk of lung cancer, a previously rare disease. The buildup of scientific evidence for the link gained pace toward the middle of century when landmark publications brought more widespread recognition of the phenomenon.1,2 The pivotal US Surgeon General Report from 1964 gave a clear message that tobacco smoking was unequivocally associated with an increased risk of developing lung cancer.3 Over the following decades the paradigm of tobacco control recognizable today culminated in the development the first global public health treaty, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), which came into force in 2005 and currently lists 181 countries as Parties to the Convention.4 In 2008, the FCTC launched the MPOWER measures (Table 1), six steps proven to lead to reduction in tobacco use around the world5 and that provide the ability to benchmark the effects of tobacco control strategies between countries.6 In countries with robust implementation, these measures have achieved what may have once been unthinkable, the saving of millions of lives6 and the reduction in smoking rates to historic post-WWII lows.6 There have been enormous benefits, with a reduction in cigarette consumption, altered rates of disease and a reduction in smoking uptake. But the inconsistencies in regulation and in MPOWER implementation around the world have led to problems with the shifting of tobacco industry efforts to the developing world7, the targeting of vulnerable groups for new market share7 and the entrenchment, in some countries, of the tobacco industry in the halls of government. New threats to global tobacco control are starting to appear from the impacts of globalization of trade,7 newer products whether “low-harm” or otherwise and from focused, covert attacks by the tobacco industry itself. This presentation aims to review the development and impact of current tobacco control policy, to examine emerging threats to tobacco control, to focus on evasive maneuvers of the globalizing tobacco industry and to discuss possible future tobacco control strategies that these developments will require. Over the last half century the tobacco industry in the developed world has become globalized. Four companies have come to dominate the global tobacco trade, Philip Morris International, British American Tobacco, Japan Tobacco International and Imperial Tobacco.8 This has given companies such as PMI the economic clout to oppose, delay and threaten tobacco control strategies such as plain packaging and smoking bans.9 The tobacco industry in Asia, a region of the world with very high smoking rates, is heading towards globalization. Companies such as Korean Tobacco and Ginseng (KT&G) and the China National Tobacco Corporation (CNTC) have developed foreign exports with government support8 and have strengthened their domestic operations with consolidation and restructuring.8 New global tobacco players have the potential to generate new competition, innovation and price reduction, all with detrimental impacts on public health8. The development of “low-harm” products such as electronic nicotine delivery systems (ENDS), including e-cigarettes, has opened new frontiers in regulatory control with concerns that such products may open new developed world markets for tobacco companies that otherwise continue to sell tobacco cigarettes in low and middle-income countries.7 Tobacco companies use international trade relations to oppose the implementation of tobacco control measures; in the fight against plain packaging in Australia, the tobacco industry invoked trade treaties and the possibility of unfair trade restrictions. The tobacco industry holds to a culture of political sabotage that includes infiltration of government by lobbyists and open recognition of the value of political skills in undermining public health initiatives in tobacco control. All of these developments call for a modernization of the tobacco
S1690 control paradigm. This may include financial pressures such as disinvestment in the tobacco industry by pension funds,10 staunch regulatory approaches to ENDS and perhaps the development of finely honed political skills to match or surpass those of the tobacco industry. Even creative approaches to the dissemination of data, such as maps showing countries moving towards plain packaging or graphical presentation of the country-by-country distribution of tobacco factories may help inform the community and subvert the newer “low-harm” messages of the large tobacco companies. Many successes over many years can be attributed to traditional tobacco control, the emphasis on the science and the FCTC and MPOWER measures. However, the tobacco industry has very strong drive for survival with multiple strategies for evasion of control. The scientific arguments are irrefutable but are not enough to overcome an industry prepared to either deny the science, to ignore it while developing market share where regulations are weak or to espouse overt evasion techniques in company documents. MPOWER is no longer enough as the opposition does not play by the rules. Effective long-term global tobacco control will need to draw upon many resources including scientific evidence, economic pressure, the ability to avoid distractions and delaying tactics, resolute evaluation and regulation of ENDS and, ultimately, political dexterity in dealing with an industry prepared to do just about anything to maintain profit. References: 1. Wynder EL, Graham EA. . Bull World Health Organ 2005;83(2):146e53. 2. Doll R, Hill AB. Bull World Health Organ 1999;77(1):84e93. 3. Health USSGAC on S and, General USPHSO of the S. Smoking and Health. http://profiles.nlm.nih.gov/NN/B/B/M/Q/ 4. United Nations Treaty Collection https://treaties.un.org/pages/ ViewDetails.aspx?src¼TREATY&mtdsg_no¼IX-4&chapter¼9&clang¼_ en 5. WHO j MPOWER [Internet]. WHO. [cited 2015 Jun 1];: http:// www.who.int/tobacco/mpower/en/ 6. Levy DT, Yuan Z, Luo Y, Mays D. Tob Control 2016;tobaccocontrol-2016-053381. 7. Gilmore AB, Fooks G, Drope J, Bialous SA, Jackson RR. Lancet Lond Engl 2015;385(9972):1029e43. 8. Lee K, Eckhardt J. Glob Public Health 2017;12(3):367e79. 9. Peeters S, Costa H, Stuckler D, McKee M, Gilmore AB. Tob Control 2016;25(1):108e17. 10. Tobacco Free Portfolios http://www.tobaccofreeportfolios.org/. Keywords: Tobacco Control, Tobacco industry, Globalization Table 1. MPOWER Measures MPOWER Measures Monitoring tobacco use and prevention policies Protecting people from tobacco smoke Offering help to quite tobacco use Warning about the dangers of tobacco Enforcing bans on tobacco advertising, promotion and sponsorship Raising tobacco taxes
MS 09.03 Cost Effectiveness of Smoking Cessation H.G. Seo Center for Early Detection of Cancer, National Cancer Center, Seoul/KR WHO estimates that tobacco kills more than 7 million people each year. More than 6 million of these deaths are the result of direct tobacco use while around 890,000 deaths are the result of non-smokers being exposed to second-hand smoke. Around 60-70% of smokers want to quit smoking. However, the success rate for quitting smoking is quite low without a systematic approach. Counselling and medication can help increase the success rate. Only 24 countries provide national comprehensive cessation services with full or partial costcoverage to assist tobacco users to quit. This represents merely 15% of the world’s population. FCTC article 14 concerns the provision of support for reducing tobacco dependence and cessation, including counselling, psychological support, nicotine replacement, and education programs. Parties are required to develop and disseminate national guidelines on tobacco cessation and are encouraged to establish sustainable infrastructure for such services. Tobacco use treatment
Journal of Thoracic Oncology
Vol. 12 No. 11S2
are not only clinically effective, but are cost-effective as well. Tobacco use treatments, ranging from clinician advice to medication to specialist-delivered intensive programs, are cost-effective in relation to other medical interventions such as treatment of hypertension, hyperlipidemia and to other preventive interventions such as periodic mammography. Even though a single application of any effective treatment for tobacco dependence may produce sustained abstinence in only a minority of smokers, tobacco use treatment remains highly cost effective. For example, Fiore and colleagues estimate the cost per life-year saved of tobacco dependence treatment to be $3,539. These estimates compare favorably with other health interventions in the U.S. like statins (which costs $50,000 per life-year saved), and diabetes treatment ($34,000 per life-year saved). Most effective way for more clinicians to intervene is to provide them with information regarding multiple effective treatment options and to ensure that they have ample institutional support to use these options. Clinicians, administrators, insurers, and purchasers can cooperate to encourage a culture in which intervention for smokers is an essential part of standard care. Korea is one such successful example. Eighty percent increase of price for a pack of cigarette since 1st of Jan, 2015 provided the momentum for other kinds of tobacco control activities. Even though only a small portion of increased tobacco tax was distributed to tobacco control activity, the tobacco control budget in 2015 has jumped by 13 times compared to previous year. 1. 246 Smoking Cessation Clinic in Health centers : All the health centers in Korea have smoking cessation clinic and gives counselling and NRTs for free. 2. Quitline: Nationwide quitline service is located in National Cancer Center. It gives counselling over the phone with proactive service for free. 3. Hospital based smoking cessation service: If a smoker visits hospital and gets counselling and medication(NRTs, bupropion, and varenicline) the fees for counselling and medication is actually free. National Health Insurance Foundation supports this program. 4. Community Smoking Cessation Center: There are 18 community smoking cessation centers in Korea. They provide three different services. 1) Residential 5 days smoking cessation program: intensive program which gives counselling, medication, etc. for free. 2) Residential 2 days smoking cessation program : short-term education program for free 3) Visiting program : Some underprivileged smokers, such as female smokers or adolescents who does not go to school, disabled smokers, or college students tend to not use smoking cessation programs due to various reasons. So community smoking cessation centers visit those special underprivileged populations. This service gives counselling and NRTs for free. References: 1. Fiore MC, Jaén 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. Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA. 1997; 278: 1759-1766. 3. Guerriero C, Cairns J, Roberts I, Rodgers A, Whittaker R, Free C. The cost-effectiveness of smoking cessation support delivered by mobile phone text messaging: Txt2stop. Eur J Health Econ. 2013; 14: 789-797. 4. Krumholz HM, Weintraub WS, Bradford WD, Heidenreich PA, Mark DB, Paltiel AD. Task force #2–the cost of prevention: can we afford it? Can we afford not to do it? 33rd Bethesda Conference. J Am Coll Cardiol. 2002; 40(4): 603-615. 5. Stapleton JA, Lowin A, Russell MAH. Prescription of transdermal nicotine patches for smoking cessation in general practice: evaluation of cost-effectiveness. Lancet. 1999; 354: 210-215. 6. Tengs TO, Adams ME, Pliskin JS, Safran DG, Siegel JE, Weinstein MC, Graham JD. Five hundred life saving interventions and their cost effectiveness. Risk Analysis. 1995; 15: 369-390. 7. Linda Bauld, Ph.D., Kathleen A. Boyd, MSc., Andrew H. Briggs, D.Phil., John Chesterman, Ph.D., Janet Ferguson, MPH., Ken Judge, Ph.D., Rosemary Hiscock, Ph.D.; One-Year Outcomes and a Cost-Effectiveness Analysis for Smokers Accessing GroupBased and Pharmacy-Led Cessation Services, Nicotine & Tobacco Research, Volume 13, Issue 2, 1 February 2011, Pages 135e145, 8.
MS 08.07 Achieving Equitable Access to Novel Treatments for all Patients L. Darlison Department of Respiratory Medicine, University Hospitals of Leicester, Leicester/GB The UK has the highest incidence of Mesothelioma in the world with over 2700 cases diagnosed in 2014 (Cancer Research UK 2017). Data for 80% of these patients was submitted and analyzed as part of the UK’s National Lung Cancer Audit Mesothelioma Report (NLCAMR) 2016 (Royal College of Physicians [RCP] 2016). The report confirmed that an increasing number of patients are receiving chemotherapy in the UK particularly patients with a good performance status; 53% compared to 41% in the audit’s 2014 report. The current audit does not identify the proportion of patients who receive their treatment as part of a clinical trial however the report recommends “All patients should be offered access to relevant clinical trials even if this requires referral outside of their network” (RCP 2016). With an increasing number of mesothelioma clinical trials now available in the UK, and more in development, facilitating seamless movement of patients from one specialist clinical team to another is essential. Mesothelioma UK, a national charity dedicated to improving outcomes for those affected by Mesothelioma, is establishing a comprehensive package of services and resources specifically to support this. The charity’s vision, for ensuring equitable access to treatment and trials is outlined in the charity’s 2016-2021 Strategy, The Next Five Years (Mesothelioma UK 2016). This presentation provides insight into readily transferable measures Mesothelioma UK has developed to support equitable access to treatment and care across the UK. Reference: 1.Cancer Research UK 2017 (Last viewed August 4, 2017). Keywords: Equitable Treatment Access
Abstracts
S1689
MS 09.01 Global Tobacco Control E. Stone Thoracic Medicine and Kinghorn Cancer Centre, St Vincent’s Hospital Sydney, Darlinghurst/NSW/AU The history of global tobacco control starts at the beginning of the twentieth century with early data linking the smoking of tobacco with the risk of lung cancer, a previously rare disease. The buildup of scientific evidence for the link gained pace toward the middle of century when landmark publications brought more widespread recognition of the phenomenon.1,2 The pivotal US Surgeon General Report from 1964 gave a clear message that tobacco smoking was unequivocally associated with an increased risk of developing lung cancer.3 Over the following decades the paradigm of tobacco control recognizable today culminated in the development the first global public health treaty, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), which came into force in 2005 and currently lists 181 countries as Parties to the Convention.4 In 2008, the FCTC launched the MPOWER measures (Table 1), six steps proven to lead to reduction in tobacco use around the world5 and that provide the ability to benchmark the effects of tobacco control strategies between countries.6 In countries with robust implementation, these measures have achieved what may have once been unthinkable, the saving of millions of lives6 and the reduction in smoking rates to historic post-WWII lows.6 There have been enormous benefits, with a reduction in cigarette consumption, altered rates of disease and a reduction in smoking uptake. But the inconsistencies in regulation and in MPOWER implementation around the world have led to problems with the shifting of tobacco industry efforts to the developing world7, the targeting of vulnerable groups for new market share7 and the entrenchment, in some countries, of the tobacco industry in the halls of government. New threats to global tobacco control are starting to appear from the impacts of globalization of trade,7 newer products whether “low-harm” or otherwise and from focused, covert attacks by the tobacco industry itself. This presentation aims to review the development and impact of current tobacco control policy, to examine emerging threats to tobacco control, to focus on evasive maneuvers of the globalizing tobacco industry and to discuss possible future tobacco control strategies that these developments will require. Over the last half century the tobacco industry in the developed world has become globalized. Four companies have come to dominate the global tobacco trade, Philip Morris International, British American Tobacco, Japan Tobacco International and Imperial Tobacco.8 This has given companies such as PMI the economic clout to oppose, delay and threaten tobacco control strategies such as plain packaging and smoking bans.9 The tobacco industry in Asia, a region of the world with very high smoking rates, is heading towards globalization. Companies such as Korean Tobacco and Ginseng (KT&G) and the China National Tobacco Corporation (CNTC) have developed foreign exports with government support8 and have strengthened their domestic operations with consolidation and restructuring.8 New global tobacco players have the potential to generate new competition, innovation and price reduction, all with detrimental impacts on public health8. The development of “low-harm” products such as electronic nicotine delivery systems (ENDS), including e-cigarettes, has opened new frontiers in regulatory control with concerns that such products may open new developed world markets for tobacco companies that otherwise continue to sell tobacco cigarettes in low and middle-income countries.7 Tobacco companies use international trade relations to oppose the implementation of tobacco control measures; in the fight against plain packaging in Australia, the tobacco industry invoked trade treaties and the possibility of unfair trade restrictions. The tobacco industry holds to a culture of political sabotage that includes infiltration of government by lobbyists and open recognition of the value of political skills in undermining public health initiatives in tobacco control. All of these developments call for a modernization of the tobacco
S1690 control paradigm. This may include financial pressures such as disinvestment in the tobacco industry by pension funds,10 staunch regulatory approaches to ENDS and perhaps the development of finely honed political skills to match or surpass those of the tobacco industry. Even creative approaches to the dissemination of data, such as maps showing countries moving towards plain packaging or graphical presentation of the country-by-country distribution of tobacco factories may help inform the community and subvert the newer “low-harm” messages of the large tobacco companies. Many successes over many years can be attributed to traditional tobacco control, the emphasis on the science and the FCTC and MPOWER measures. However, the tobacco industry has very strong drive for survival with multiple strategies for evasion of control. The scientific arguments are irrefutable but are not enough to overcome an industry prepared to either deny the science, to ignore it while developing market share where regulations are weak or to espouse overt evasion techniques in company documents. MPOWER is no longer enough as the opposition does not play by the rules. Effective long-term global tobacco control will need to draw upon many resources including scientific evidence, economic pressure, the ability to avoid distractions and delaying tactics, resolute evaluation and regulation of ENDS and, ultimately, political dexterity in dealing with an industry prepared to do just about anything to maintain profit. References: 1. Wynder EL, Graham EA. . Bull World Health Organ 2005;83(2):146e53. 2. Doll R, Hill AB. Bull World Health Organ 1999;77(1):84e93. 3. Health USSGAC on S and, General USPHSO of the S. Smoking and Health. http://profiles.nlm.nih.gov/NN/B/B/M/Q/ 4. United Nations Treaty Collection https://treaties.un.org/pages/ ViewDetails.aspx?src¼TREATY&mtdsg_no¼IX-4&chapter¼9&clang¼_ en 5. WHO j MPOWER [Internet]. WHO. [cited 2015 Jun 1];: http:// www.who.int/tobacco/mpower/en/ 6. Levy DT, Yuan Z, Luo Y, Mays D. Tob Control 2016;tobaccocontrol-2016-053381. 7. Gilmore AB, Fooks G, Drope J, Bialous SA, Jackson RR. Lancet Lond Engl 2015;385(9972):1029e43. 8. Lee K, Eckhardt J. Glob Public Health 2017;12(3):367e79. 9. Peeters S, Costa H, Stuckler D, McKee M, Gilmore AB. Tob Control 2016;25(1):108e17. 10. Tobacco Free Portfolios http://www.tobaccofreeportfolios.org/. Keywords: Tobacco Control, Tobacco industry, Globalization Table 1. MPOWER Measures MPOWER Measures Monitoring tobacco use and prevention policies Protecting people from tobacco smoke Offering help to quite tobacco use Warning about the dangers of tobacco Enforcing bans on tobacco advertising, promotion and sponsorship Raising tobacco taxes
MS 09.03 Cost Effectiveness of Smoking Cessation H.G. Seo Center for Early Detection of Cancer, National Cancer Center, Seoul/KR WHO estimates that tobacco kills more than 7 million people each year. More than 6 million of these deaths are the result of direct tobacco use while around 890,000 deaths are the result of non-smokers being exposed to second-hand smoke. Around 60-70% of smokers want to quit smoking. However, the success rate for quitting smoking is quite low without a systematic approach. Counselling and medication can help increase the success rate. Only 24 countries provide national comprehensive cessation services with full or partial costcoverage to assist tobacco users to quit. This represents merely 15% of the world’s population. FCTC article 14 concerns the provision of support for reducing tobacco dependence and cessation, including counselling, psychological support, nicotine replacement, and education programs. Parties are required to develop and disseminate national guidelines on tobacco cessation and are encouraged to establish sustainable infrastructure for such services. Tobacco use treatment
Journal of Thoracic Oncology
Vol. 12 No. 11S2
are not only clinically effective, but are cost-effective as well. Tobacco use treatments, ranging from clinician advice to medication to specialist-delivered intensive programs, are cost-effective in relation to other medical interventions such as treatment of hypertension, hyperlipidemia and to other preventive interventions such as periodic mammography. Even though a single application of any effective treatment for tobacco dependence may produce sustained abstinence in only a minority of smokers, tobacco use treatment remains highly cost effective. For example, Fiore and colleagues estimate the cost per life-year saved of tobacco dependence treatment to be $3,539. These estimates compare favorably with other health interventions in the U.S. like statins (which costs $50,000 per life-year saved), and diabetes treatment ($34,000 per life-year saved). Most effective way for more clinicians to intervene is to provide them with information regarding multiple effective treatment options and to ensure that they have ample institutional support to use these options. Clinicians, administrators, insurers, and purchasers can cooperate to encourage a culture in which intervention for smokers is an essential part of standard care. Korea is one such successful example. Eighty percent increase of price for a pack of cigarette since 1st of Jan, 2015 provided the momentum for other kinds of tobacco control activities. Even though only a small portion of increased tobacco tax was distributed to tobacco control activity, the tobacco control budget in 2015 has jumped by 13 times compared to previous year. 1. 246 Smoking Cessation Clinic in Health centers : All the health centers in Korea have smoking cessation clinic and gives counselling and NRTs for free. 2. Quitline: Nationwide quitline service is located in National Cancer Center. It gives counselling over the phone with proactive service for free. 3. Hospital based smoking cessation service: If a smoker visits hospital and gets counselling and medication(NRTs, bupropion, and varenicline) the fees for counselling and medication is actually free. National Health Insurance Foundation supports this program. 4. Community Smoking Cessation Center: There are 18 community smoking cessation centers in Korea. They provide three different services. 1) Residential 5 days smoking cessation program: intensive program which gives counselling, medication, etc. for free. 2) Residential 2 days smoking cessation program : short-term education program for free 3) Visiting program : Some underprivileged smokers, such as female smokers or adolescents who does not go to school, disabled smokers, or college students tend to not use smoking cessation programs due to various reasons. So community smoking cessation centers visit those special underprivileged populations. This service gives counselling and NRTs for free. References: 1. Fiore MC, Jaén 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. Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA. 1997; 278: 1759-1766. 3. Guerriero C, Cairns J, Roberts I, Rodgers A, Whittaker R, Free C. The cost-effectiveness of smoking cessation support delivered by mobile phone text messaging: Txt2stop. Eur J Health Econ. 2013; 14: 789-797. 4. Krumholz HM, Weintraub WS, Bradford WD, Heidenreich PA, Mark DB, Paltiel AD. Task force #2–the cost of prevention: can we afford it? Can we afford not to do it? 33rd Bethesda Conference. J Am Coll Cardiol. 2002; 40(4): 603-615. 5. Stapleton JA, Lowin A, Russell MAH. Prescription of transdermal nicotine patches for smoking cessation in general practice: evaluation of cost-effectiveness. Lancet. 1999; 354: 210-215. 6. Tengs TO, Adams ME, Pliskin JS, Safran DG, Siegel JE, Weinstein MC, Graham JD. Five hundred life saving interventions and their cost effectiveness. Risk Analysis. 1995; 15: 369-390. 7. Linda Bauld, Ph.D., Kathleen A. Boyd, MSc., Andrew H. Briggs, D.Phil., John Chesterman, Ph.D., Janet Ferguson, MPH., Ken Judge, Ph.D., Rosemary Hiscock, Ph.D.; One-Year Outcomes and a Cost-Effectiveness Analysis for Smokers Accessing GroupBased and Pharmacy-Led Cessation Services, Nicotine & Tobacco Research, Volume 13, Issue 2, 1 February 2011, Pages 135e145, 8.