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Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in * Dashboard * Publications * Account settings * Log out Search… Search NCBI Primary site navigation Search Logged in as: * Dashboard * Publications * Account settings Log in Search PMC Full-Text Archive Search in PMC * Advanced Search * Journal List * User Guide * * * * * * PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Lancet Reg Health West Pac . 2023 Jun 16;39:100826. doi: 10.1016/j.lanwpc.2023.100826 * Search in PMC * Search in PubMed * View in NLM Catalog * Add to search REAL-WORLD TOBACCO CESSATION PRACTICE IN CHINA: FINDINGS FROM THE PROSPECTIVE, NATIONWIDE MULTICENTER CHINA NATIONAL TOBACCO CESSATION COHORT STUDY (CNTCCS) Zhao Liu ZHAO LIU aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Find articles by Zhao Liu a,b,c,d,e,al, Rui Qin RUI QIN aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China fGraduate School of Peking Union Medical College, Beijing, China Find articles by Rui Qin a,b,c,d,e,f,al, Xue-Jun Hu XUE-JUN HU gDepartment of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China Find articles by Xue-Jun Hu g, Li-Jun Liu LI-JUN LIU hDepartment of Respiratory and Critical Care Medicine, Baiyin First People's Hospital of Gansu Province, Baiyin, Gansu Province, China Find articles by Li-Jun Liu h, Su-Qin Xu SU-QIN XU iDepartment of Pulmonary and Critical Care Medicine, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei Province, China Find articles by Su-Qin Xu i, Guo-Chao Shi GUO-CHAO SHI jDepartment of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Find articles by Guo-Chao Shi j, Hong Zhou HONG ZHOU kDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China Find articles by Hong Zhou k, Jing Bai JING BAI lDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Province, China Find articles by Jing Bai l, Chun-Mei Zhang CHUN-MEI ZHANG mDepartment of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China Find articles by Chun-Mei Zhang m, Yong Qi YONG QI nDepartment of Pulmonary and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China Find articles by Yong Qi n, Wei Zhou WEI ZHOU oDepartment of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China Find articles by Wei Zhou o, Shu-Hua Lan SHU-HUA LAN pDepartment of Pulmonary and Critical Care Medicine, Nanping People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Nanping, Fujian Province, China Find articles by Shu-Hua Lan p, Jin Tong JIN TONG qDepartment of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China Find articles by Jin Tong q, Tong-Sheng Su TONG-SHENG SU r3rd Department of Acupuncture and Moxibustion, Shaanxi Hospital of Traditional Chinese Medicine, Xi'an, Shaanxi Province, China Find articles by Tong-Sheng Su r, Qiang Wang QIANG WANG sDepartment of Respiratory and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China Find articles by Qiang Wang s, Xin-Yan Yang XIN-YAN YANG tDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China Find articles by Xin-Yan Yang t, De-Jun Sun DE-JUN SUN uDepartment of Respiratory and Critical Care Medicine, The People's Hospital of Inner Mongolia Autonomous Region, Hohhot, Inner Mongolia Autonomous Region, China Find articles by De-Jun Sun u, Li-Ming Zhu LI-MING ZHU vDepartment of Respiratory and Critical Care Medicine, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan Province, China Find articles by Li-Ming Zhu v, Xiao-Yang Chen XIAO-YANG CHEN wDepartment of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China Find articles by Xiao-Yang Chen w, Hong Chen HONG CHEN xDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China Find articles by Hong Chen x, Yu-Peng Xie YU-PENG XIE yDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China Find articles by Yu-Peng Xie y, Zhi-Hua Xiao ZHI-HUA XIAO zDepartment of Respiratory and Critical Care Medicine, The Third People's Hospital of Datong City, Datong, Shanxi Province, China Find articles by Zhi-Hua Xiao z, Yan-Bin Chen YAN-BIN CHEN aaDepartment of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China Find articles by Yan-Bin Chen aa, Bo Zhao BO ZHAO abDepartment of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China Find articles by Bo Zhao ab, Qiu-Ge Wu QIU-GE WU acDepartment of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China Find articles by Qiu-Ge Wu ac, Wen-Li Chen WEN-LI CHEN adDepartment of Respiratory and Critical Care Medicine, The Affiliated Hospital of Chengde Medical College, Chengde, Hebei Province, China Find articles by Wen-Li Chen ad, Dong-Yan Li DONG-YAN LI aeDepartment of Pulmonary and Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China Find articles by Dong-Yan Li ae, Hongbo Liu HONGBO LIU abDepartment of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China Find articles by Hongbo Liu ab, An-Qi Cheng AN-QI CHENG aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Find articles by An-Qi Cheng a,b,c,d,e, Zi-Yang Cui ZI-YANG CUI afDepartment of Geriatric Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China Find articles by Zi-Yang Cui af, Liang Zhao LIANG ZHAO aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Find articles by Liang Zhao a,b,c,d,e, Jin-Xuan Li JIN-XUAN LI aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China agCapital Medical University China-Japan Friendship School of Clinical Medicine, Beijing, China Find articles by Jin-Xuan Li a,b,c,d,e,ag, Xiao-Wen Wei XIAO-WEN WEI aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China agCapital Medical University China-Japan Friendship School of Clinical Medicine, Beijing, China Find articles by Xiao-Wen Wei a,b,c,d,e,ag, Xin-Mei Zhou XIN-MEI ZHOU aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Find articles by Xin-Mei Zhou a,b,c,d,e, Zheng Su ZHENG SU aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Find articles by Zheng Su a,b,c,d,e, Kian Fan Chung KIAN FAN CHUNG ahNational Heart and Lung Institute, Imperial College London and Royal Brompton and Harefield NHS Trust, London, UK Find articles by Kian Fan Chung ah, Zheng-Ming Chen ZHENG-MING CHEN aiNuffield Department of Population Health, University of Oxford, Oxford, UK Find articles by Zheng-Ming Chen ai, Dan Xiao DAN XIAO aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China fGraduate School of Peking Union Medical College, Beijing, China agCapital Medical University China-Japan Friendship School of Clinical Medicine, Beijing, China ajDepartment of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China Find articles by Dan Xiao a,b,c,d,e,f,ag,aj,∗, Chen Wang CHEN WANG bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China ajDepartment of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China Find articles by Chen Wang b,c,d,e,aj, for the China National Tobacco Cessation Cohort Study (CNTCCS) Study Group * Author information * Article notes * Copyright and License information aDepartment of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China bWHO Collaborating Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China cChina National Center for Respiratory Medicine, Beijing, China dChina National Clinical Research Center for Respiratory Diseases, Beijing, China eInstitute of Respiratory Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China fGraduate School of Peking Union Medical College, Beijing, China gDepartment of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China hDepartment of Respiratory and Critical Care Medicine, Baiyin First People's Hospital of Gansu Province, Baiyin, Gansu Province, China iDepartment of Pulmonary and Critical Care Medicine, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei Province, China jDepartment of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China kDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China lDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Province, China mDepartment of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China nDepartment of Pulmonary and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China oDepartment of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China pDepartment of Pulmonary and Critical Care Medicine, Nanping People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Nanping, Fujian Province, China qDepartment of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China r3rd Department of Acupuncture and Moxibustion, Shaanxi Hospital of Traditional Chinese Medicine, Xi'an, Shaanxi Province, China sDepartment of Respiratory and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China tDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China uDepartment of Respiratory and Critical Care Medicine, The People's Hospital of Inner Mongolia Autonomous Region, Hohhot, Inner Mongolia Autonomous Region, China vDepartment of Respiratory and Critical Care Medicine, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan Province, China wDepartment of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China xDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China yDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China zDepartment of Respiratory and Critical Care Medicine, The Third People's Hospital of Datong City, Datong, Shanxi Province, China aaDepartment of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China abDepartment of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China acDepartment of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China adDepartment of Respiratory and Critical Care Medicine, The Affiliated Hospital of Chengde Medical College, Chengde, Hebei Province, China aeDepartment of Pulmonary and Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China afDepartment of Geriatric Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China agCapital Medical University China-Japan Friendship School of Clinical Medicine, Beijing, China ahNational Heart and Lung Institute, Imperial College London and Royal Brompton and Harefield NHS Trust, London, UK aiNuffield Department of Population Health, University of Oxford, Oxford, UK ajDepartment of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China ∗ Corresponding author. Department of Tobacco Control and Prevention of Respiratory Disease, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China. danxiao@263.net al Contribute equally. Received 2023 Mar 27; Revised 2023 May 26; Accepted 2023 May 31; Collection date 2023 Oct. © 2023 The Authors This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). PMC Copyright notice PMCID: PMC10624982 PMID: 37927997 SUMMARY BACKGROUND Tobacco cessation is proven to be the most effective and cost-effective strategy for smokers to reduce their risk of smoking-related disease and premature death. Providing effective, efficient, safe, and patient-centred tobacco cessation treatment to reach those who need them is a significant challenge. To date, only a few nationwide studies in China have assessed the overall clinical care practice and treatment outcome of tobacco cessation. METHODS This a prospective, nationwide, multicenter, cohort study covering all Eastern China, Northwest China, Central China, North China, Southwest China, Northeast China, and South China. Participants who were current smokers aged 18–85 years attending clinic for smoking cessation were included. All the participants were treated with 3-month cessation treatment and followed up for 3 months. Data were collected prospectively using online system. The primary outcome was 7-day point abstinence rate at 24 weeks, validated biochemically by an expired carbon monoxide level of less than 10 ppm. The participants lost to follow-up or not providing validation were included as non-abstainers. FINDINGS A representative sample of 3557 participants were recruited and 2943 participants were included into this analysis. These participants had mean age of 53.05 years, and 94.8% were males, with 75.8% showing symptoms of tobacco dependence. A total of 965 (32.8%) participants were treated with Bupropion + behavioural counselling, followed by 935 (31.8%) with behavioural counselling, 778 (26.4%) with Varenicline + behavioural counselling, 135 (4.6%) with alternative treatments + behavioural counselling, and 130 (4.4%) with nicotine replacement therapy (NRT) + behavioural counselling. After 3-month treatment and 3-month follow-up, 21.74% of the participants quit smoking at 24 weeks. In the multivariable-adjusted analyses, quitting smoking was significantly associated with female, higher socioeconomic status, poor health condition, different treatment received, and less smoking intensity. The tobacco cessation treatment varied widely across different areas of China. In particular, the areas with higher usage of cessation medication were associated with better cessation treatment outcome. INTERPRETATION The CNTCCS is the first large-scale nationwide cohort study of smoking cessation in China. Rich data collected from this prospective cohort study provided the opportunity to evaluate the clinical practice of tobacco cessation treatment in China. FUNDING Chinese Academy of Medical Sciences (CAMS) Initiative for Innovative Medicine (CAMS 2021-I2M-1-010), Heilongjiang Provincial Science and Technology Key Program (2022ZXJ03C02), and National Key R&D Program of China (grant no. 2017YFC1309400). Keywords: Smoking, Smoking cessation, Cohort study, China National Tobacco Cessation Cohort Study (CNTCCS) -------------------------------------------------------------------------------- RESEARCH IN CONTEXT. EVIDENCE BEFORE THIS STUDY We searched PubMed and China National Knowledge Infrastructure database for articles published up to March 8, 2023 using the terms “tobacco cessation”, “cohort study”, “real world study”, and “China”. We screened papers by reviewing abstracts to identify full-text reports that were relevant to the study aims. As a result, we found there was no nationwide cohort study of tobacco cessation in China and world, and the current real-world study of tobacco cessation were mostly based on Caucasians populations. ADDED VALUE OF THIS STUDY To the best of our knowledge, China National Tobacco Cessation Cohort Study (CNTCCS) is the first and largest cohort study for tobacco cessation in China. Our data indicated that approximately 1 out of 5 smokers quit smoking after 6 months; successful quitting smoking was significantly associated with female, higher socioeconomic status, poor health condition, different treatment received, and less smoking intensity. The tobacco cessation treatment varied widely across different areas of China. In particular, the areas with higher usage of cessation medication were associated with higher cessation treatment outcome. IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE The data obtained could be used to better understand the “real world” situation of tobacco cessation practice in China. It will also serve as an evidence-based platform for conducting future research, which will ultimately improve the treatment and management provided to smokers. INTRODUCTION Tobacco use is a significant threat to human health and social development, causing an estimated 8 million annual deaths worldwide from a wide range of chronic non-communicable diseases.1 China, which accounts for more than 20% of the world population, consumes more than 40% of the world's total cigarettes, with more than one million annual deaths from tobacco.2 Moreover, approximately half of current smokers in China are nicotine dependent, translating to 183.5 million adults.3 Tobacco cessation is proven to be the most effective and cost-effective strategy for smokers to reduce their risk of smoking-related disease and premature death.4 Smokers who give up smoking before the age of 40 can reduce their risk of dying from smoking-related diseases by 90% compared to that of persistent smokers.5 In addition, tobacco cessation could also improve quality of life and increase lifespan.6 Currently, evidence-based tobacco cessation strategies include population-level interventions (brief advice, quit lines, mCessation), individual specialist approaches (behavioral support, cessation clinics) and pharmacologic interventions (nicotine replacement therapies and non-nicotine pharmacotherapies).7 Implementing these measures has been shown to result in a 2–15% increase in the proportion of tobacco users who quit tobacco use for 6 months or more, over no intervention.8 However, providing effective, efficient, safe, and patient-centred tobacco cessation treatment to reach those who need them is a significant challenge. To date, only a few nationwide studies9, 10, 11 have discussed the clinical care practice of tobacco cessation in China. To help fill the evidence gap, a nationwide multicenter cohort study, China National Tobacco Cessation Cohort Study (CNTCCS), was initiated in December 2017. As the first national cohort study of tobacco cessation in China, CNTCCS aimed to (1) evaluate the treatment outcome and longitudinal trends of tobacco cessation during 6-month follow-up period, (2) identify the predictors of successful tobacco cessation; (3) measure the regional-level variation in cessation treatment after adjusting for provider, practice, and patient characteristics; (4) promote the standardization of diagnosis and treatment of tobacco cessation; and (5) provide real-world evidence for policy-making of tobacco control in China. This study described the baseline characteristics of the participants recruited before June of 2021, and analyzed the treatment outcomes of the participants whose 6-month follow-up data were available. In addition, this study aimed to propose several key measures for improving tobacco cessation practice in China. By providing a detailed analysis of baseline characteristics and treatment outcomes, this study could help inform China public health policy in the future. METHODS STUDY DESIGN The China National Tobacco Cessation Cohort Study (CNTCCS) is an ongoing nationwide multicenter prospective cohort study of tobacco cessation with a 6-month follow-up period in a real-world setting. Currently a total of 27 centers (hospitals) dispersing all 7 areas of China (Eastern China. Northwest China, Central China, North China, Southwest China, Northeast China, and South China) participated in this study. A complete list of CNTCCS members and sites were presented in Appendix Table S1. The study protocol was presented in Appendix Material. The CNTCCS has complied with all relevant ethical regulations, and was approved by Institutional Review Boards at all study centers. Informed consent was obtained from all participants of the study. The CNTCCS was registered in the Chinese Clinical Trial Registry (No. ChiCTR1800016919, URL: http://www.chictr.org.cn). STUDY PARTICIPANTS The CNTCCS has recruited consecutive smokers who seek cessation treatment since December 2017. The smokers were included into CNTCCS if they met all the following criteria: (1) voluntarily participated in CNTCCS; (2) aged 18–85 years; (3) current smoking; (4) willing to quit smoking; (5) expired air carbon monoxide no less than 10 ppm; (6) signed the informed consent form. The smokers were excluded if they had severe cardiovascular diseases (eg, acute myocardial infarction), cerebrovascular diseases (eg, stroke), neuropsychiatric disorders severe impairment of liver and kidney function (eg, renal failure), being pregnant or breastfeeding, and had severe psychiatric illness (eg, seizure and anorexia), or were allergic to cessation medications. All patients were informed of the nature and aims of the study and signed an informed consent form. BASELINE DATA COLLECTION A standard data collection protocol was developed by the steering committee. All study physicians had participated the China Training Courses for Stop-Smoking Specialists,12 and given a specific training by China–Japan Friendship Hospital during the kick-off meeting of CNTCS. For each participant, a baseline survey was conducted to collect information. The demographics information included gender, age, ethnicity, education, marital status, income, and residential location; health-related characteristics included self-reported health status, blood pressure, body weight, medical history (such as CVD, cancer, respiratory diseases, depression, Anxiety), and alcohol use; tobacco-related characteristics included diagnosis of tobacco dependence, number of cigarettes smoked per day, and duration of smoking; Fagerstrom Test for Nicotine Dependence (FTND),13 and expired carbon monoxide (CO) reading. The diagnostic criteria of tobacco dependence3 were based on international criteria (ICD-10, DSM-4) and tailored to Chinese population according to China Clinical Guideline for Tobacco Cessation (2015 version): tobacco dependence was diagnosed if they had 3 or more of the following 6 symptoms or signs: (1) craving, or a strong desire or urge to use tobacco; (2) a persistent desire or unsuccessful efforts to cut down or control tobacco use; (3) experiencing tobacco withdrawal symptoms (such as irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, insomnia) after abrupt cessation of tobacco use, or reduction in the amount of tobacco used; (4) tolerance, defined as the need for markedly increased amounts of tobacco to achieve the desired effect; (5) given up or reduced important social, occupational, or recreational activities because of tobacco use; and (6) continued tobacco use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco. All the CO level was measured by using Bedfont Micro Smokerlyzers (Bedfont Scientific, UK), which was calibrated per year. All the study centers used the same machine. TOBACCO CESSATION TREATMENT The tobacco cessation treatment was categorized as Varenicline + behavioural counselling, Bupropion + behavioural counselling, nicotine replacement therapy (NRT) + behavioural counselling, behavioural counselling and alternative treatments (treatments not recommended by China Clinical Guideline for Tobacco Cessation, including acupuncture and traditional Chinese herb decoction) + behavioural counselling. For the benefits of the participants, although CNTCCS was an observational study, we required all the study centers to provide tobacco cessation treatment based on China Clinical Guideline for Tobacco Cessation (2015 version).14 The keys of tobacco cessation treatment included: * • All the participants should be screened for tobacco dependence. * • All the participants are suggested to set a target quit date (TQD) within 2 weeks after medication. * • Simply encouraging participants to stop smoking is insufficient. All participants should be provided with evidence-based treatment to help them stop. * • All the participants are advised to receive 12 weeks of treatment. * • The clinician should follow both currently-available scientific evidence and patient's preference for a proper choice of one therapy over another, paying particular attention to those patients having contraindications to these drugs due to the presence of specific comorbidities. * • For the participants who are prescribed with medications, the medication use is explained at baseline assessment. Participants are encouraged to use their medications from the next day, and to stop smoking completely from their TQD onward. * • The standard practice was to prescribe a one-month supply. However, if participants specifically requested a three-month supply, the physicians had the discretion to accommodate this request. FOLLOW-UP DATA COLLECTION All the participants were required to make face-to-face visits at study site at 1, 2, 4, 6, 9, 12, and 24 weeks after initiation of treatment. Participants were also included in a WeChat discussion group where they receive reminders for follow-up visits. Each follow-up visit takes approximately 30–45 min. The follow-up questionnaire included self-reported information on smoking status, medication use, and CO readings. The follow-up questionnaires were identical for all follow-up periods. The interviewers entered the data collected into the case report form (CRF). At each site, all data from each CRF were manually checked for completeness and correctness by a research staff. Beijing Natureself Technology Development Co., Ltd, an independent organization, served as the on-line centre of aggregated de-identified data. An online system of Case Report Form (CRF) developed by the expert advisory panel were used for data collection (https://jieyan.einmatrix.com). OUTCOME ASSESSMENTS The primary outcome (successful smoking quitting) is 7-day point abstinence rate at 24 weeks, validated biochemically by an expired carbon monoxide level of less than 10 ppm.15 Secondary outcomes included validated 7-day point abstinence rate at 1 week, 2 weeks, 4 weeks, 6 weeks, 9 weeks and 12 weeks; the CO-validated abstinence rate in different subgroups; risk factors of successful quit rate at 24 weeks; treatment usage rate across different regions of China. For all abstinence outcomes, participants lost to follow-up or not providing validation will be included as non-abstainers. STATISTICAL ANALYSIS Based on our earlier study16 and previous large trials,17, 18, 19 we estimated the quit rate in this study was 30% in the Varenicline group and 20% in the behavioral counselling group. Then sample size of 300 per group was needed to provide 80% power, assuming a 20% loss to follow-up. As such, the total sample size was a minimum of 1500. The intent-to-treat (ITT) approach was applied in this analysis, and the participants who lost contact were recognized to be smokers. The measurement data are presented as means (SD). The t-test was used for comparisons which met Gaussian distribution and homogeneity of variance, whereas the nonparametric test was used for comparisons which did not meet homogeneity of variance. The categorical variables were presented with numbers (percentages), and chi-square test was used for numeral data comparisons. We utilized logistic regression analysis to measure the relationship between potential influencing factors and successful smoking quitting (primary outcome), represented with OR value at the 95% confidence interval. SPSS 19.0 statistical software (SPSS, Inc.) was used for statistical analysis. P < 0.05 was regarded as statistical significance. The authors had no access to information that could identify individual participants during or after data collection. PATIENT AND PUBLIC INVOLVEMENT Participants of the CNTCCS were not involved in setting the research question or the outcome measures, nor were they involved in developing plans for recruitment, design, or implementation of the study. No participants were asked for advice on interpreting or writing up of results. We intended to engage participants and the public to disseminate the results of our study. ROLE OF THE FUNDING SOURCE The funders of the study had no role in study design, data collection, data analysis, and data interpretation, or writing of the report. All authors had full access to all the data in the study and accepted the responsibility to submit it for publication. RESULTS Between December 2017 and January 2022, a total of 3918 adults were screened for eligibility, and 3557 participants who met the study criteria were recruited. Of these, 614 participants who provided unreliable data were excluded, and 2943 participants were included in this analysis. The geographical distribution of the participants is shown in Fig. 1. The flow chart of participants is shown in Appendix Fig. S1. FIG. 1. Open in a new tab Geographical distribution of the participants (N = 2943). The baseline characteristics of participants are summarized in Table 1. Overall, 94.8% of the participants were male; the average age (SD) was 53.05 (13.72) years; 90.5% were married, 40.1% had education level of college and higher, and 68.5% had monthly income less than 5999 RMB. Regarding the residual location, 25.7% lived in North China while only 1.8% lived in Southwest China. Totally, 80.6% of participants self-reported average or good health status; the average systolic pressure was 126.20 (22.91) mmHg, while the average diastolic pressure was 77.97 (10.51) mmHg; the average body weight was 72.06 (20.75) Kg; 58.9% of the participants reported alcohol use; 30.6% had respiratory diseases, 10.0% had CVD, and 4.4% cancers. As for the smoking behavior, 75.8% of the participants were diagnosed with nicotine dependence; the average number of cigarettes smoked per day (SD) was 19.10 (9.04), the average smoking duration (SD) was 28.66 (13.42) years; the average FTND (SD) was 4.80 (2.45) points. TABLE 1. Baseline characteristics of study participants. Characteristics With nicotine dependence N = 2231 Without nicotine dependence N = 712 Total N = 2943 Gender, n% Men 2127 (95.3) 663 (93.1) 2790 (94.8) Women 104 (4.7) 49 (6.9) 153 (5.2) Age (year) Less than 40 528 (23.7) 130 (18.3) 658 (22.4) 41–50 469 (21.0) 111 (15.6) 580 (19.7) 51–60 597 (26.8) 165 (23.2) 762 (25.9) 61 and above 637 (28.6) 306 (43.0) 943 (32.0) Mean (SD) 52.07 (13.38) 56.13 (14.33) 53.05 (13.72) Ethnicity, n% Han 2095 (93.9) 665 (93.4) 2760 (93.8) Others 136 (6.1) 47 (6.6) 183 (6.2) Marriage, n% Single 164 (7.4) 47 (6.6) 211 (7.2) Married 2025 (90.8) 638 (89.6) 2663 (90.5) Separated/divorced/widowed 42 (1.9) 27 (3.8) 69 (2.3) Education, n% Primary school or less 211 (9.5) 93 (13.1) 304 (10.3) Middle and high school 1079 (48.4) 381 (53.5) 1460 (49.6) College and higher 941 (42.2) 238 (33.4) 1179 (40.1) Monthly income (RMB) <1000 101 (4.5) 39 (5.5) 140 (4.8) 1000–2999 431 (19.3) 158 (22.2) 589 (20.0) 3000–5999 959 (43.0) 327 (45.9) 1286 (43.7) 6000–9999 475 (21.3) 119 (16.7) 594 (20.2) >10,000 265 (11.9) 69 (9.7) 334 (11.3) Residual location, n% Eastern China 322 (14.4) 30 (4.2) 352 (12.0%) Northwest China 388 (17.4) 63 (8.8) 451 (15.3%) Northeast China 515 (23.1) 223 (31.3) 738 (25.1%) South China 149 (6.7) 34 (4.8) 183 (6.2%) North China 563 (25.2) 194 (27.2) 757 (25.7%) Central China 260 (11.7) 149 (20.9) 409 (13.9%) Southwest China 34 (1.5) 19 (2.7) 53 (1.8%) Self-reported health status, n% Poor 455 (20.4) 119 (16.7) 574 (19.5) Average 731 (32.8) 232 (32.6) 963 (32.7) Good 1045 (46.8) 361 (50.7) 1406 (47.8) Blood pressure, mean (SD) Systolic pressure 125.63 (13.40) 128.00 (40.05) 126.20 (22.91) Diastolic pressure 77.70 (10.51) 78.81 (10.47) 77.97 (10.51) Alcohol use, n% Yes 1333 (59.7) 400 (56.2) 1733 (58.9) No 898 (40.3) 312 (43.8) 1210 (41.1) Body weight, mean (SD) 72.11 (22.90) 71.87 (11.74) 72.06 (20.75) Diseases at baseline, n% Respiratory diseases 698 (31.3) 203 (28.5) 901 (30.6) CVD 224 (10.9) 50 (7.0) 274 (9.3) Cancer 106 (4.8) 23 (3.2) 129 (4.4) Other chronic diseases 467 (20.9) 146 (20.5) 613 (20.8) Depression 65 (2.9) 23 (3.2) 88 (3.0) Anxiety 68 (3.0) 25 (3.5) 93 (3.2) Cigarettes smoked per day 1–9 122 (5.5) 95 (13.3) 217 (7.7) 10–19 666 (29.9) 368 (51.7) 1034 (35.1) 20–29 1185 (53.1) 226 (31.7) 1411 (47.9) 30 and above 258 (11.6) 23 (3.2) 281 (9.5) Mean (SD) 20.06 (9.16) 16.09 (7.92) 19.10 (9.04) Smoking duration (year) 1–9 159 (7.1) 53 (7.4) 211 (7.2) 10–19 462 (20.7) 116 (16.3) 578 (19.6) 20–29 541 (24.2) 155 (21.8) 696 (23.6) 30 and above 1069 (47.8) 388 (54.5) 1457 (49.5) Mean (SD) 27.98 (12.98) 30.77 (14.49) 28.66 (13.42) FTND 0–3 513 (23.0) 404 (56.7) 917 (31.2) 4–6 991 (44.4) 263 (36.9) 1254 (42.6) 7 and above 727 (32.6) 45 (6.3) 772 (26.2) Mean (SD) 5.34 (2.31) 3.13 (2.13) 4.80 (2.45) Treatment provided Bupropion + behavioural counselling 736 (33.0) 229 (32.2) 965 (32.8) Behavioural counselling 721 (32.3) 214 (30.1) 935 (31.8) Varenicline + behavioural counselling 576 (25.8) 202 (28.4) 778 (26.4) Alternative treatments + behavioural counselling 98 (4.4) 37 (5.2) 135 (4.6) NRT + behavioural counselling 100 (4.5) 30 (4.2) 130 (4.4) Open in a new tab Note: Data are shown as number (%) or mean (SD). FTND: Fagerstr€om Test for Tobacco dependence. Of all the participants analyzed, 965 (32.8%) participants were treated with Bupropion + behavioural counselling, followed by 935 (31.8%) with behavioural counselling, 778 (26.4%) with Varenicline + behavioural counselling, 135 (4.6%) with alternative treatments + behavioural counselling, and 130 (4.4%) with nicotine replacement therapy (NRT) + behavioural counselling. After 3-month treatment and 3-month follow-up, 866 (29.4%) participants lost contact, and 21.74% of the participants quit smoking at 24 weeks. Specifically, the CO-validated 24-week abstinence rate was 32.1% in the Varenicline group + behavioural counselling, 20.6% in the bupropion group + behavioural counselling, 17.3% in the behavioural counselling group, 16.2% in the NRT group + behavioural counselling, and 5.9% in the alternative treatments group + behavioural counselling (Fig. 2, Appendix Fig. S3 and Appendix Table S2). FIG. 2. Open in a new tab Comparison of abstinence rate between different treatments at different time points. Note: Bars represent proportion or mean and error bars 95% CI. NRT = Nicotine replacement therapy. Moreover, the CO-validated abstinence rate at 24 weeks was 35.3% in women and 21.0% in men (P < 0.05), highest (32.1%) in those aged less than 40 years and lowest (16.14%) in those aged 51–60 years (P < 0.05), highest (24.8%) in those with education level of college and higher and lowest (17.8%) in those with education level of primary school or less (P < 0.05), and 33.99% in those without nicotine dependence and 17.84% in those with nicotine dependence (P < 0.05) (Appendix Table S2 and Appendix Fig. S2). The treatment adherence was shown in Appendix Table S3. Overall, 2601 participants (88.38%) set target quit date (TQD), and 2915 (99.05%) received at least 1 dose of treatment. However, only 1336 (45.40%) received more than 80% of allocated medication and 1004 (34.11%) still using allocated treatment at 3-month follow-up. None used non-allocated treatment at any time point. In the multivariable-adjusted analyses (Table 2), according to the model 2, the CO-validated abstinence rate at 24 weeks was significantly associated with women, younger age, being Han ethnicity, higher education level and monthly income, alcohol use, greater systolic and diastolic pressure, having cancer and respiratory diseases at baseline, different place of residence, different treatment received (for alternative treatments + behavioural counselling, OR: 0.228, 95% CI: 0.108–0.483; for NRT + behavioural counselling, OR: 1.082, 95% CI: 0.786–1.357; for Bupropion + behavioural counselling, OR: 1.213, 95% CI: 0.955–1.541; for Varenicline + behavioural counselling, OR: 2.179, 95% CI: 1.721–2.761), without nicotine dependence, lower cigarettes smoked per day, shorter smoking duration, and lower FTND. TABLE 2. Adjusted ORs for successful quitting at week 24. Characteristics Number of cases Model 1 -------------------------------------------------------------------------------- Model 2 -------------------------------------------------------------------------------- OR (95% CI) P OR (95% CI) P Gender Men 2790 Ref Ref Women 153 2.112 (1.491–2.993) 0.000 1.985 (1.358–2.900) 0.045 Age 61 and above 658 Ref Ref 51–60 580 0.792 (0.616–1.019) 0.070 0.916 (0.700–1.197) 0.520 41–50 762 1.085 (0.838–1.405) 0.535 1.466 (1.096–1.961) 0.010 Less than 40 943 1.955 (1.553–2.462) 0.000 2.675 (1.990–3.594) 0.000 Ethnicity Others 183 Ref Ref Han 2760 2.173 (1.362–3.467) 0.001 2.117 (1.305–3.434) 0.002 Marriage Married 2663 Ref Ref Single 211 0.782 (0.564–1.084) 0.139 0.881 (0.626–1.240) 0.467 Separated/divorced/widowed 69 0.717 (0.359–1.431) 0.345 0.663 (0.324–1.358) 0.261 Education Primary school or less 304 Ref Ref Middle and high school 1460 1.139 (0.822–1.580) 0.434 1.453 (1.017–2.076) 0.040 College and higher 1179 1.214 (0.856–1.721) 0.276 1.878 (1.262–2.793) 0.002 Monthly income (RMB) <1000 140 Ref Ref 1000–2999 589 0.923 (0.655–1.300) 0.647 0.905 (0.633–1.293) 0.583 3000–5999 1286 1.239 (0.908–1.691) 0.176 1.284 (0.923–1.785) 0.138 6000–9999 594 1.787 (1.098–2.908) 0.020 2.504 (1.720–3.646) 0.000 >10,000 334 2.004 (1.422–2.822) 0.000 2.195 (1.286–3.746) 0.004 Self-reported health status Good 1406 Ref Ref Average 963 1.308 (1.017–1.681) 0.036 1.018 (0.614–1.687) 0.946 Poor 574 1.345 (1.033–1.752) 0.028 1.179 (0.731–1.901) 0.500 Systolic pressure at baseline 2943 1.013 (1.006–1.020) 0.000 1.008 (1.001–1.015) 0.035 Diastolic pressure at baseline 2943 1.018 (1.010–1.027) 0.000 1.018 (1.009–1.027) 0.000 Alcohol use at baseline No 1210 Ref Ref Yes 1733 1.632 (1.365–1.952) 0.000 1.663 (1.390–1.989) 0.000 Body weight 2943 1.002 (0.998–1.005) 0.440 1.001 (0.997–1.005) 0.568 CVD at baseline No 274 Ref Ref Yes 2669 1.133 (0.840–1.529) 0.413 1.008 (0.573–1.772) 0.979 Cancer at baseline No 129 Ref Ref Yes 2814 2.646 (1.475–4.748) 0.001 3.109 (1.273–7.591) 0.013 Respiratory diseases at baseline No 901 Ref Ref Yes 2669 1.133 (0.933–1.377) 0.209 1.783 (1.222–2.601) 0.003 Depression at baseline No 88 Ref Ref Yes 2855 0.795 (0.356–1.775) 0.576 0.737 (0.193–2.818) 0.653 Anxiety at baseline No 93 Ref Ref Yes 2850 0.929 (0.550–1.570) 0.785 1.157 (0.318–4.216) 0.825 Residual location South China 183 Ref Ref Northeast China 738 1.021 (0.632–1.650) 0.933 0.821 (0.497–1.357) 0.442 Southwest China 53 1.048 (0.449–2.447) 0.914 0.730 (0.299–1.779) 0.489 North China 757 1.836 (1.153–2.923) 0.011 1.855 (1.129–3.046) 0.015 Central China 409 1.973 (1.210–3.217) 0.006 1.523 (0.906–2.561) 0.112 Northwest China 451 2.393 (1.481–3.868) 0.000 2.136 (1.278–3.568) 0.004 Eastern China 352 2.711 (1.662–4.422) 0.000 3.078 (1.828–5.182) 0.000 Treatment received Behavioural counselling 935 Ref Alternative treatments + behavioural counselling 135 0.251 (0.120–0.526) 0.000 0.228 (0.108–0.483) 0.000 NRT + behavioural counselling 130 1.159 (0.820–1.420) 0.124 1.082 (0.786–1.357) 0.426 Bupropion + behavioural counselling 965 1.237 (0.980–1.560) 0.073 1.213 (0.955–1.541) 0.114 Varenicline + behavioural counselling 778 2.255 (1.793–2.836) 0.000 2.179 (1.721–2.761) 0.000 Nicotine dependence With nicotine dependence 2231 Ref Ref Without nicotine dependence 712 2.542 (2.090–3.091) 0.000 2.683 (2.183–3.297) 0.000 Cigarettes smoked per day 30 and above 281 Ref Ref 20–29 1411 1.024 (0.967–1.084) 0.412 1.135 (1.082–1.191) 0.000 10–19 1034 1.116 (1.047–1.191) 0.001 1.214 (1.122–1.315) 0.000 1–9 217 1.313 (1.184–1.457) 0.000 1.349 (1.269–1.433) 0.000 Smoking duration 30 and above 1457 Ref Ref 20–29 696 2.105 (1.535–2.887) 0.000 1.557 (1.124–2.156) 0.008 10–19 578 3.162 (2.114–4.731) 0.000 1.868 (1.347–2.591) 0.000 1–9 212 9.116 (5.669–14.660) 0.000 2.970 (1.906–4.629) 0.000 FTND 7 and above 772 Ref Ref 4–6 1254 6.191 (4.102–9.343) 0.000 1.870 (1.016–3.442) 0.044 0–3 917 9.640 (6.043–12.571) 0.000 3.556 (1.915–6.604) 0.000 Open in a new tab Note: Model 1 was adjusted for gender and age; model 2 was adjusted for gender, age, ethnicity, marriage, education, monthly income, self-reported health status, location, treatment received, and nicotine dependence. FTND: Fagerstr€om Test for Tobacco dependence. Lastly, a regional disparity in tobacco cessation practice was observed. As shown in Fig. 3A, for Varenicline, the highest usage rate was observed in North China (41.9%); for Bupropion, the highest usage rate was observed in Northwest China (41.6%); for NRT, the highest usage rate was observed in Eastern China (15.0%), and for behavioural counselling, the highest usage rate was observed in South China (45.2%). As shown in Fig. 3B, the proportion of participants who had tobacco dependence ranged from highest in Eastern China (91.48%) and lowest in Northeast China (63.57%). As shown in Fig. 3C, the rate of lost contact was highest in Southwest China (47.10%) and lowest in Northwest China (22.17%). As shown in Fig. 3D, the abstinence rate at 24 weeks was highest in Eastern China (31.0%), followed by 26.8% in Northwest China, 24.2% in Central China, 22.6% in North China, 17.0% in Southwest China, 14.5% in Northeast China, and 13.1% in South China. Combined with the rate of medication use, it was suggested that the areas with higher usage of cessation medication were associated with higher cessation treatment outcome (Appendix Table S2). FIG. 3. Open in a new tab Comparison of different areas of China. Note: (A) Comparison of different cessation medication uses at different areas of China. (B) Comparison of participants who had tobacco dependence at different areas of China. (C) Comparison of participants who lost contact at different areas of China. (D) Comparison of cessation medication usage and treatment outcome at different areas of China. DISCUSSION To the best of our knowledge, CNTCCS is the first and largest cohort study for tobacco cessation in China. In the present study, we introduced the design and protocol of CNTCCS, and described the characteristics, clinical care practice and outcomes of the participants for whom 6-month follow-up data were available. The data obtained could be used to better understand the “real world” situation of tobacco cessation practice in China. It will also serve as an evidence-based platform for conducting future research, which will ultimately improve the treatment and management provided to smokers. First, one of the key purposes of CNTCCS was to evaluate the treatment outcome of tobacco cessation during 6-month follow-up period. In CNTCCS, we found that approximately 1 out of 5 smokers quit smoking after 6 months, which was similar to the 23.0% in a real-world study of 1560 participants in US,20 23.7% in a real-world study of 2802 participants in US,21 and 28.8% in a real-world study of 235 participants in Thailand.22 Specifically, Varenicline showed the best efficacy, which was consistent with many previous studies and recommendations of several clinical guidelines7,14; Bupropion is also welcomed as it is relatively cheap and may prevent weight gain after smoking cessation.23 The relatively low preference for NRT among Chinese patients may be attributed to the limited availability of NRT in most Chinese hospitals24; in addition, while e-commerce is popular in China and offers the potential for patients to buy NRT at a lower cost online, there is still a prevailing skepticism among Chinese patients when it comes to the quality and authenticity of medications available through online platforms. This mistrust in online medication purchases contributes to their hesitation in choosing NRT as a smoking cessation aid. It should be noted that acupuncture and herbal remedies were provided in CNTCCS. Although current evidence suggests that acupuncture and herbal remedies may increase the chance of stopping smoking,25,26 there is no consistent, bias-free evidence, and as some study centers are located in the hospitals of traditional Chinese medicine, they are more interested to use these methods to quit smoking. Nevertheless, we call for strong action to improve the adherence to the guideline of tobacco cessation. Second, we identified several predictors of successful tobacco cessation. Among them, tobacco dependence should be highly valued. Tobacco dependence is the key barrier to successful smoking cessation.27 In CNTCCS, nearly 75% of the participants showed symptoms of tobacco dependence, which was higher than 49.7% in a nationwide surrey in China which used the same criteria for screening tobacco dependence.3 This difference is not surprising and could be explained by “hardcore smokers” theory: smokers who are willing to seek treatment often had greater smoking intensity, particularly tobacco dependence.28 However, nearly 30% of the dependent smokers were treated only by behavioural counselling. This is worrying because, as recommended by several clinical guideline, dependent smokers should be treated by intensive cessation treatment, particularly the first-line medications, rather than simply being encouraged to stop smoking.7,14 Third, a key finding of our study is that the tobacco cessation treatment varied widely across different areas of China. Possible reasons included variations of economic level across different regions, the lack of familiarity with tobacco cessation guidelines, physician's own smoking status, etc. Importantly, our study showed that the areas with higher usage of cessation medication were associated with higher cessation treatment outcome, which highlighted the importance of the availability and affordability of the cessation medications. A previous study found that tobacco cessation medications are unavailable and have limited availability in India; even when available, medications are unaffordable for most patients.29 This is very similar to China. Moreover, previous study has estimated that medical coverage of any nicotine replacement therapy products increases the usage by 20%.30 As such, our finding suggested that geographical targeting is required for more successful tobacco prevention and control in China, and we strongly recommend inclusion of tobacco cessation medication into national and provincial health insurance in China. Our study has important implications. The CNTCCS required all the study centers to provide the participants with evidence-based treatment, which might overrate the quality of tobacco cessation practice, and even violate the observational nature of cohort study, but this action indeed greatly improved the overall treatment quality of tobacco cessation. In the meantime, it generally would be optimal to analyze a clinical and genetic biobank to learn about disease natural history and characteristics, and compare the efficacy among different treatments. However, in China there is no biobank that has longitudinal data on tobacco cessation. With the clinical longitudinal data (particularly the treatment method and efficacy) and blood sample of approximately 3000 participants, CNTCCS provides a good start to establishing a “China Tobacco Cessation Biobank”, thus giving a robust support for future study of tobacco cessation in China and even the world. Our study has several strengths, including representative large sample of approximately 3000 participants, longitudinal clinical data collected from nationwide practices enrolled in CNTCCS, well-validated questionnaires, and stringent quality control process. However, we acknowledge several limitations. First, the selection of participating sites, although covering all areas of China, was by convenience in nature. Second, the included study sites may represent the hospitals with more resources and expertise than county-level or even more grassroots-level hospitals. As the CNTCCS continuously proceeds, more study sites will be included to overcome these limitations. Third, the site participation in CNTCCS is voluntary; this possible selection bias means that the actual practice situation is very likely to be even lower in the non-CNTCC Shospitals. Fourth, although included in the ITT analysis, nearly 30% of the participants lost contact. This might be due to the pandemic of COVID-19. Future studies may consider using mobile health methods to collect data during follow-up windows. Fifth, as this was a real-world study, it was difficult to explore the sole efficacy of medication therapy. Sixth, although we have considered many factors, other potentially important factors such as BMI, whether smokers were referred to the cessation services by healthcare professionals, how much the participants paid for treatments, the types of NRT used and whether single or combined NRT was used, were not assessed. Seventh, several important demographic and clinical information might be subject to recall bias from patients. CONCLUSION To the best of our knowledge, the CNTCCS is the first and largest nationwide cohort study of tobacco cessation in China and elsewhere. Rich data collected from this prospective cohort study provided the opportunity to evaluate the quality of care for tobacco cessation practice in China. CONTRIBUTORS All authors were involved in the planning of the study, literature review, data collection, interpretation of the findings, and manuscript preparation. Chen Wang and Dan Xiao conceived and designed the study. Dan Xiao supervised the study. Zhao Liu, Rui Qin, Xue-Jun Hu, Li-Jun Liu, Su-Qin Xu, Guo-Chao Shi, Hong Zhou, Jing Bai, Chun-Mei Zhang, Yong Qi, Wei Zhou, Shu-Hua Lan, Jin Tong, Tong-Sheng Su, Qiang Wang, Xin-Yan Yang, De-Jun Sun, Li-Ming Zhu, Xiao-Yang Chen, Hong Chen, Yu-Peng Xie, Zhi-Hua Xiao, Yan-Bin Chen, Bo Zhao, Qiu-Ge Wu, Wen-Li Chen, Dong-Yan LI, Hongbo Liu, An-Qi Cheng, Zi-Yang Cui, Liang Zhao, Jin-Xuan Li, Xiao-Wen Wei, Xin-Mei Zhou, and Zheng Su Contributed to the acquisition of data. Dan Xiao, Zhao Liu, Kian Fan Chung, and Zheng-Ming Chen drafted the report. Zhao L did the statistical analysis. All authors revised the report and approved the final version before submission. Dan Xiao is the guarantor and attest that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. DATA SHARING STATEMENT Data will be available upon reasonable request to the corresponding author immediately following publication to anyone wishing to access the data. DECLARATION OF INTERESTS All authors have completed the ICMJE uniform disclosure form, and all the authors declared no conflicts of interest; no financial relationships with any organisations that might have an interest in the submitted work; no other relationships or activities that could appear to have influenced the submitted work. ACKNOWLEDGMENTS The authors would like to thank the participants of China National Tobacco Cessation Cohort Study (CNTCCS). The authors appreciate every supporter who contributed to the CNTCCS. FOOTNOTES Appendix A Supplementary data related to this article can be found at https://doi.org/10.1016/j.lanwpc.2023.100826. APPENDIX A. SUPPLEMENTARY DATA Appendix Tables S1–S3 mmc1.docx (26.3KB, docx) Appendix Figs. S1–S3 mmc2.pptx (638KB, pptx) REFERENCES * 1.World Health Organization . World Health Organization; Geneva: 2019. WHO report on the global tobacco epidemic, 2019. [Google Scholar] * 2.Chen Z., Peto R., Zhou M., et al. 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SUPPLEMENTARY MATERIALS Appendix Tables S1–S3 mmc1.docx (26.3KB, docx) Appendix Figs. S1–S3 mmc2.pptx (638KB, pptx) -------------------------------------------------------------------------------- Articles from The Lancet Regional Health: Western Pacific are provided here courtesy of Elsevier ACTIONS * View on publisher site * PDF (856.5 KB) * Cite * Collections * Permalink PERMALINK Copy RESOURCES SIMILAR ARTICLES CITED BY OTHER ARTICLES LINKS TO NCBI DATABASES ON THIS PAGE * Summary * Introduction * Methods * Results * Discussion * Contributors * Data sharing statement * Declaration of interests * Acknowledgments * Footnotes * Appendix A. 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