Clinical Review ABC of smoking cessation

Policy priorities for tobacco control

BMJ 2004; 328 doi: http://dx.doi.org/10.1136/bmj.328.7446.1007 (Published 22 April 2004) Cite this as: BMJ 2004;328:1007
  1. Konrad Jamrozik
  1. professor of primary care epidemiology, Imperial College, London, and visiting professor in public health, School of Population Health, University of Western Australia, Perth

    Introduction

    Although many countries have implemented strategies for reducing tobacco use at individual and population level, no country to date has adopted a truly comprehensive control programme. In addition, the tobacco industry and the strategies it uses to counteract policies on tobacco control and thereby maintain and develop its commercial markets have both continued to evolve. All communities therefore face at least some “unfinished business” in relation to tobacco control, and those working in smoking cessation need to be familiar with the necessary policy responses.

    The healthcare industry

    Individuals and institutions in the healthcare industry have an important exemplar role. In many countries the prevalence of smoking among doctors differs little from that in the wider community. This considerably undermines individual practitioners' credibility in advising patients not to smoke and denies the profession as a whole the influence it might wield on public and political opinion and policy on tobacco.

    Figure1

    Prevalence of smoking among doctors around the world, according to data collected from 493 medical schools in 93 countries (36% response rate) in 1995. Data from Mackay et al(The tobacco atlas. Geneva: World Health Organization, 2002)

    Institutions that train health professionals need to make more time available in both undergraduate and postgraduate curriculums for teaching about smoking and especially about effective cessation interventions. Coverage of these topics is currently, for the most part, inadequate. As assessment shapes learning, these topics also need to feature prominently and regularly in major examinations.

    All healthcare facilities, including schools of medicine, nursing, and dentistry, should adopt and enforce comprehensive smoke-free policies across their entire campuses and not just in buildings. Where smoking rooms are provided for inpatients, these should have separate, externally ventilated air conditioning systems so that tobacco smoke is not recirculated into the rest of the building.

    Policies on smoke-free places

    The smoking of tobacco should eventually become an activity undertaken only by consenting adults in private. Although such a goal seems unattainable now, many current smoke-free policies were at one time viewed in the same way.

    In several countries, virtually all workplaces and public buildings (and other enclosed public places) are now smoke-free zones, with equivalent policies spreading steadily into venues such as outdoor sports arenas, as well as into private homes. An important omission has been schools, where smoke-free policies should cover not only buildings but also playgrounds. They should also extend to all school related events, including parents' meetings, excursions, and field trips. Several countries are seriously considering legislation to ban smoking in private cars carrying infants or children.

    Figure2

    Examples of stickers available in Australia to show visitors that private homes and cars are smoke-free environments

    Overall, it is now possible to conceive of communities where incremental changes will result in all public places becoming smoke free—and free also of all of the litter generated by smokers.

    One of the most simple and cost effective of all medical interventions is for doctors to tell every smoker they encounter in their work that giving up the habit is one of the most important things they can do for their health. Ascertaining smoking status and intervening as appropriate must become a routine component of all health care

    Advertising and sponsorship

    The tobacco industry has proved adept in identifying and exploiting loopholes in legislation designed to restrict how it advertises its products. Recent examples include the industry's expansion of in-store advertising—as advertising outdoors and in the mass media becomes illegal. Ultimately, tobacco products should become “under the counter” items that are not displayed and must be requested by name. Such an arrangement is entirely appropriate to the harm they do and their proper “adults only” status.

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    Given their danger—half of cigarette smokers who continue to smoke are killed prematurely by the habit—legislation on promotion of tobacco needs to cover all kinds of products and define promotional activities widely. Governments have been slow, for example, to deal with “same name” advertising (that is, advertising of other products carrying the cigarette's brand name, such as Marlboro clothing) and “product placement” (whereby celebrities or producers of entertainment are paid to use and display particular tobacco products prominently).

    The internet is already becoming a vehicle for unsolicited direct advertising of tobacco to children as well as to adults, making it even worse than sponsorship of international sport. Solving each of these problems requires a coordinated international response.

    Letter from US actor Sylvester Stallone agreeing in 1983 to smoke Brown Williamson products in five feature films in exchange for $500 000. From the Legacy Tobacco Documents Library at University of California, San Francisco http://legacy.library.ucsf.edu

    Young people and smoking?

    Rather than targeting children and teenagers, the best method of helping them not to start smoking is highly likely to be a policy of systematically driving down the prevalence of smoking among adults. Already evidence shows that young people in communities with active and prominent general programmes of tobacco control are beginning to realise that saying “no thanks, I've given up” is more “adult” than accepting the offer of a cigarette.

    “Quit” campaigns directed specifically at teenagers have not received much attention to date, despite the fact that in many populations two thirds of those who ever try smoking abandon the habit before their mid-20s.

    Nicotine and tobacco regulation

    A comprehensive approach to tobacco control must also include systematic attention to the tobacco products themselves and to their presentation to the public. Tobacco companies, including those run as government monopolies, have to be flushed out from behind their “commercial and sensitive” smokescreen and be required to declare fully what they add to their products during manufacture, just as the makers of virtually all other products intended for human consumption are obliged to do.

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    Many governments have already abandoned voluntary agreements with tobacco companies on health warnings to be displayed on their products because the manufacturers regularly resist using those warnings that independent field testing show to be most arresting.

    Governments are under pressure to move on from mandating warnings of proved effectiveness by requiring plain “generic” packaging that is far less eye catching. Such regulation needs to be complemented by “probity” clauses that make it an offence to make misleading or untrue public pronouncements about tobacco products, their effects, and the activities of the tobacco industry in general.

    “Quit” campaigns need to be targeted at teenage smokers, notjust older smokers

    Strong arguments exist for consolidating into a single statutory instrument all legislation covering tobacco and nicotine and for imposing price and marketing restrictions on products in direct and consistent relation to their potential risk

    The tobacco industry

    The tobacco industry operates as a global entity while simultaneously maintaining notable sensitivity and responsiveness to local regulatory and other conditions. Its standard tactics are to debate almost endlessly the scientific evidence on the harm caused by its products, to cultivate (and regularly pay) spokespeople in other industries and in academia, and to purchase influence by making substantial donations to any political party that will accept them. Many of these strategies are designed to foster uncertainty in the minds of the public and governments, and all serve ultimately to delay effective action on tobacco control.

    The industry has responded to the growing number of stronger initiatives by Western governments, however, by shifting its primary focus to developing countries. Several factors in these countries conspire to cause needless repetition in this century of the sad experience of tobacco use in the Western world in the last: a lack of information; the long lead time between an increase in the prevalence of smoking and the consequent increase in the incidence of death and disease; and the appeal to farmers of a cash crop and to governments of considerable taxation revenues. Unless effective action is taken globally, more than a billion people will be killed by tobacco this century.



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    The tobacco industry is now targeting its products increasingly at developing countries

    The Framework Convention on Tobacco Control

    Such calculations prompted the World Health Organization to convene, in 1999, the first of a series of meetings to draw up an international treaty on tobacco control—that is, an effective global response to a problem already of global scale.

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    The Framework Convention on Tobacco Control comprises a core statement complemented by several separate instruments that individual governments may or may not adopt. Progress on drafting the document was slowed by considerable resistance from governments of countries that are home to major tobacco companies or that run state tobacco monopolies. The core document was adopted unanimously, however, by the 192 member countries of the World Health Assembly on 21 May 2003, just six days short of the 53rd anniversary of the publication of the first case-control study on smoking and lung cancer. Health professionals everywhere must now press their own governments to ensure that the convention is ratified and enacted in their own countries with minimum delay.

    Despite the strategies and tactics of the tobacco industry, smoking is firmly on the wane in most of the developed world, with the scope and momentum of governmental initiatives growing steadily

    Further reading

    • Richmond R, ed. Educating medical students about tobacco: planning and implementation. Paris: International Union Against Tobacco and Lung Disease, 1996.

    • Jha P, Chaloupka FJ. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC: World Bank, 1999.

    • Glantz SA, Slade L, Bero LA, Hanauer P, Barnes DE. The cigarette papers. Berkeley: University of California Press, 1996.

    Konrad Jamrozik is professor of primary care epidemiology, Imperial College, London, and visiting professor in public health, School of Population Health, University of Western Australia, Perth

    The campaign stickers are from ACOSH (Australia Council on Smoking and Health, www.acosh.org/); the letter from Sylvester Stallone is from the Legacy Tobacco Documents Library at the University of California at San Francisco (http://legacy.library.ucsf.edu/); and the photograph above is published with permission from Chris Stowers/Panos.

    The ABC of smoking cessation is edited by John Britton, professor of epidemiology at the University of Nottingham in the division of epidemiology and public health at City Hospital, Nottingham. The series will be published as a book in the late spring.

    Footnotes

    • Competing interests KJ received costs for travel and accommodation from SmithKlineBeecham to attend a meeting of the Australian Smoking Cessation Consortium that was convened by the drug company. See first article in this series (24 January 2004) for the series editor's competing interests