-->PONE-D-26-19073-->-->Integrating smoking cessation into HIV care settings: A systematic review of the evidence on intervention effectiveness and cost-effectiveness-->-->PLOS One

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Reviewer #1: Partly

Reviewer #2: No

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Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The paper has several clear strengths. It frames the public health importance of smoking in people living with HIV convincingly, defines a focused review objective, uses a structured PRISMA-based methodology, and documents a broad database search performed in March 2026. The manuscript also appears ambitious in scope because it includes effectiveness, costs, and cost-effectiveness, and it adds newer studies from low- and middle-income settings that were underrepresented in prior reviews.

At the same time, the draft would benefit from substantial editorial revision before submission. The main issues concern, consistency of terminology, clarity of methods, tighter interpretation of findings, and stronger alignment between the stated objectives and the results actually obtained.

The stated aim is to provide up-to-date evidence on both effectiveness and cost-effectiveness of smoking cessation interventions for people living with HIV. However, the Results section explicitly states that no studies evaluating cost or cost-effectiveness were identified, which creates a mismatch between the title/aim and the actual evidence base retrieved

The review combines randomized trials, non-randomized studies, cohort studies, and apparently single-arm intervention studies. This broad inclusion can be justified, but the manuscript should explain more explicitly why such heterogeneous designs were combined, what question each design answers, and how this affects causal interpretation.

Several methods passages are difficult to follow because the syntax is dense. For example, the sections on pooling multiple intervention arms, factorial trials, SMART designs, and choice of random-effects estimator are methodologically relevant but need much clearer wording for an international journal audience.

The draft repeatedly emphasizes that it expands the literature and addresses major gaps, especially in low- and middle-income countries. That may be true, but the paper should avoid sounding stronger than the evidence allows because only four LMIC randomized trials were identified and no economic evaluations were found.

The Results section contains many details that read like extracted notes rather than a synthesized narrative. For instance, descriptions of individual interventions, control conditions, and study designs are often exhaustive, but the reader still has difficulty identifying the central comparative findings.

Reviewer #2: General comments:

This manuscript presents results for a systematic review (SR) on smoking cessation interventions in people living with HIV (PLWH).

My main criticism of this manuscript is that I don't entirely follow why a SR this broad is necessary just two years after a Cochrane review was published. I think the justification provided in lines 70-77 for why some sort of evidence synthesis is needed for low- and middle-income countries. That is very compelling and I found it interesting that multiple studies have been published since the Cochrane review was completed. But, I don't understand why the high-income countries (HICs) are included in this SR. The thesis statement for this manuscript appears to be in line 80 ("...address these evidence gaps..."), but no case has been made for what those evidence gaps are beyond the lack of LMIC studies.

Said differently, why are HICs included? Have the conclusions changed since the Cochrane review? If so, why do another "global" SR?

In addition, the results evidence synthesis appears to happen together for HICs and LMICs, so it's not entirely clear to me how this is helping the evidence gap for LMICs. Maybe your argument is that a greater proportion of the evidence is coming from LMICs. That's a fair point, but it would seem to me to that synthesizing the evidence from LMICs and then comparing that to the HIC-dominated Cochrane review would be more compelling since the results from LMIC would be reported on its own.

My recommendation is to limit this SR to only LMICs since that is the identified evidence gap. I apologize if I have missed something major with your manuscript, but that seems to me to be the major contribution to the literature. Feel free to correct me if I am wrong. I also think since you are doing an SR and that there is not that much information that exists, you might consider being more lenient with some of your inclusion/exclusion criteria. For instance, on lines 92-93, you mentioned that studies required a minimum 6-month follow-up. You may want to relax that somewhat if there are more studies that could be included.

Also, my understanding is that a SR doesn't pool results together and a meta-analysis does. Since you pooled results, shouldn't this be a meta-analysis?

Finally, this is a very long paper. I got lost in the methods and found myself questioning whether all of the methods are actually relevant. You are going to lose readers or they are just going to skip sizeable sections of this. I urge you to think very carefully about the methods and results sections because they are overwhelming. I strongly encourage you to shift some of this information to the supplement so that the manuscript is more manageable to the majority of readers. Those who want all the gory details can go to the supplement.

Specific comments:

1. (line 153) Please provide a methodological citation for the Paule-Mandel estimator.

2. (line 156) Please provide a methodological citation for the HKSJ model.

3. (line 170) "were" should be "was".

4. (lines 170-189) I think you can rely on the GRADE citations to do the heavy-lifting here and you can just state the domains.

5. (line 208) I don't know what "These" is referring to since the previous sentence only discussed four articles.

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Reviewer #1: No

Reviewer #2: No

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Integrating smoking cessation into HIV care settings: a systematic review and meta-analysis of effectiveness and the evidence gap in cost-effectiveness

PONE-D-26-19073R1

Dear Dr. Nguyen,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Giuseppe Vittorio De Socio, MD, PhD

Academic Editor

PLOS One

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