18 Aug 2008
Tobacco is hazardous not only because it contains 4000 chemicals, of which more than 50 cause cancer and many others can adversely affect the function of virtually every organ or cell in the human body (1), but also because it contains a highly addictive substance: nicotine.
Nicotine is a powerful psychoactive agent that plays a key role in tobacco dependence. Tobacco dependence perpetuates exposure to all the hazardous substances in tobacco. And tobacco dependence is a complex biologic, behavioural and social process that can defeat a tobacco user’s best intentions to quit (2).
The WHO International Classification of Diseases (ICD10) classifies tobacco dependence and withdrawal symptoms as substance use disorders. Tobacco dependence is a chronic disease that often requires repeated interventions and multiple attempts to quit. But effective treatments exist that can increase long-term abstinence (3).
Failure to address tobacco dependence can defeat the best laid plans to end the epidemic of death and disease due to tobacco. Even if tobacco control strategies were completely effective in preventing people from becoming tobacco users, the world would still have to face the burden of 1.5 billion current tobacco users for the next half century. The World Bank estimates that more than 180 million lives could be saved in just the first half of this century by implementing on a global scale what we now know about treating tobacco dependence (4). This, coupled with the WHO estimate that within 20 years tobacco dependence could become the world’s single largest cause of premature death or years lived with disability (5), creates a strong case for a concerted global effort to address the tobacco dependence treatment issue.
Survey after survey has shown that tobacco users want to quit. In many countries, more than 40% of tobacco users try to quit every year; but, unaided by a treatment program, only 4 to 7% are successful (6). Widespread implementation of other tobacco control policies – such as increased prices and taxes, prevention of smoking in public places, more explicit health warnings on cigarette packages, advertising and promotion bans, and health promotion and public information campaigns – is expected to motivate an even greater number of tobacco users to quit. Recognition of tobacco dependence as a disease and provision of treatment are therefore key elements for inclusion in a comprehensive tobacco control program.
Treatment of tobacco dependence encompasses a continuum of measures that can be used alone, but that are most effective when used together. These include:
- Community wide programs: Community wide programs such as WHO’s World No Tobacco Day, the American Cancer Society’s Great American Smoke-Out, WHO Europe’s Quit & Win or QuitNet are of limited effectiveness in getting any one tobacco user to quit but can still have a significant impact because of their wide reach (7). Quitlines, on the other hand, have been shown to be very effective when combined with individual counselling (8).
- Brief individual counselling: Brief individual counselling by physicians, dentists, pharmacists and nurses is a simple, effective means to get tobacco users to consider quitting, and to assist those who are motivated to quit (9). The five major components of a brief intervention (often called the 5 A’s) are: ask about tobacco use, advise to quit, assess willingness to make quit attempt, assist in quit attempt, and arrange follow-up (10). Assisting in the quit attempt may include providing self-help materials, referral to a clinic or Quitline and recommending or prescribing a nicotine replacement product or other medication.
- Specialized behaviour modification or cognitive counselling: Specialized behaviour modification or cognitive counselling, whether in an individual or a group setting, increases the rate of success in quitting. Counselling should include practical problem solving and skills training to help the tobacco user analyse his or her tobacco use behaviour, identify triggers associated with smoking and develop ways to cope with the triggers. It should also assure a supportive environment during treatment (11).
- Medications such as nicotine replacement products or others that block the desire for nicotine: Medications have proven to be effective in reducing the desire for cigarettes and the severity of withdrawal symptoms. Nicotine Replacement Therapy products (NRTs) reduce the desire for tobacco by substituting nicotine from tobacco with nicotine administered in gum, inhalers, sprays, lozenges or skin patches. Bupropion is an anti-depressant that has been shown empirically to reduce the desire for cigarettes. Varenicline appears to reduce the desire for tobacco through action at the receptor site for nicotine in the brain. Bupropion and Varenicline can have adverse effects and are therefore only available by prescription, as are some of the NRT medications in certain countries. NRTs and Bupropion have been shown to double (12, 13) and Varenicline to triple the success of attempts to quit smoking when compared to a placebo (14). The combination of counselling and medication is a more effective treatment for tobacco dependence than either medication or counselling alone (15).
Providing tobacco dependence treatments (both medication and counselling) as a paid or covered benefit by health insurance plans has been shown to increase the proportion of smokers who use cessation treatment, attempt to quit, and successfully quit. Therefore, treatments shown to be effective should be included as covered services in public and private health benefit plans (16). Although treatment of tobacco dependence has been referred as the ‘gold standard’ of healthcare cost-effectiveness (17), only nine out of 173 Member States of the WHO offer the full range of treatment and at least partial financial subsidies. They cover only 5% of the world’s population, leaving 95% without effective treatment of tobacco dependence (18). In order to secure immediate reductions in tobacco related disease and disability and ensure the best possible outcome of other effective tobacco control measures, a concerted global effort is required to extend treatment for tobacco dependence to all tobacco users who wish to quit.
(1) US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of progress. A Report of the Surgeon General. Rockville , Maryland : US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989. DHHS Publication No (CDC) 89-8411, p 79.
(2) US Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General. Rockville , Maryland : US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health, 1988, p 79.
(3) Fiore, MC, Jaén, CR, Baker, TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville , MD : US Department of Health and Human Services. Public Health Service. May 2008, p 6.
(6) Fiore, MC, Jaén, CR, Baker, TB, et al. Treating Tobacco Use and Dependence: 2008 Update, Clinical Practice Guideline. Rockville , MD : US Department of Health and Human Services. Public Health Service. May 2008, p 15.
(7) Secker-Walker RH, Gnich W, Platt S, Lancaster T. Community interventions for reducing smoking among adults. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD001745. DOI: 10.1002/14651858.CD001745.
(9) Fiore, MC, Jaén, CR, Baker, TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville , MD : US Department of Health and Human Services. Public Health Service. May 2008, p 37.
(12) Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000146. DOI: 10.1002/14651858.CD000146.pub3.
(14) Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No: CD006103. DOI: 10.1002/14651858.CD006103.pub2.
(15) Fiore, MC, Jaén, CR, Baker, TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville , MD : US Department of Health and Human Services. Public Health Service. May 2008, p 40.