Tar wars over smoking cessationBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5008 (Published 08 August 2011) Cite this as: BMJ 2011;343:d5008
- Simon Chapman, professor of public health, University of Sydney
Tobacco control is the poster child for those now rallying behind international action to control non-communicable disease. In nations that have implemented comprehensive policies and programmes to reduce tobacco use, there have been often continuing and large scale falls in smoking prevalence over the past 20 to 40 years, in the number of cigarettes smoked per day, and—the ultimate test of effectiveness—in the incidence of index diseases like lung cancer.1
The World Health Organization’s Framework Convention on Tobacco Control, with 174 nations having now ratified its legally binding provisions, has inspired thinking about the applicability of the tobacco control model to chronic disease at large.2 This momentum should be profiled and boosted by the September United Nations High-level Meeting on Non-communicable Diseases.
Although preventing uptake among young people has long been a mantra for governments of all political stripes, far more lives will be saved over the next decades by promoting cessation in current smokers.3 There is now extensive consensus on what the so called best buys in tobacco control are when reducing consumption across whole populations is the goal.
All parties—including the perennially protesting tobacco industry (“Of all the concerns . . . taxation alarms us the most”4)—agree that tobacco tax increases are the ace in the pack. Promoting quit attempts in large numbers of smokers is the most important strategy for improving cessation rates throughout a population.5
Australia has seen daily smoking prevalence fall to 15.1%, with tax and well funded mass media awareness campaigns being mainly responsible.6 Youth smoking prevalence is also the lowest on record, because youths are influenced by adult targeted campaigns7 and the growing denormalisation of smoking.
One of the best kept secrets in tobacco control is that the great majority of ex-smokers quit without any formal assistance.8 Between two thirds and three quarters of long term ex-smokers stop without using nicotine replacement therapy or other drugs or attending any sort of smoking cessation service.9 10 Only 1-7% of smokers will even call a quitline.11
Before the advent of nicotine replacement therapy, some 37 million American smokers stopped smoking.12 Other than the early non-specific pack warnings, there were few to none of the policies that we see today driving this exodus. Millions quit because they were exposed to years of news reports of the growing bad news on smoking and health.13
There is a conventional wisdom that those who have quit smoking are those who were least addicted: they were low hanging fruit who could be stimulated by anti-smoking policies to quit by themselves. But those who still smoke, the argument proceeds, are mostly those who are impervious to population health measures like tobacco excise increases, the growing denormalisation of smoking, and the messages in mass reach advertising campaigns.14
Against this view is evidence from 50 US states for 2006-7 that indicates that the mean number of cigarettes smoked daily, the percentage of cigarette smokers who smoke within 30 minutes of waking, and the percentage who smoke daily are all significantly lower in US states with low smoking prevalence, compelling evidence against the “hardening” hypothesis that would predict just the opposite.15
There is a longstanding debate between those in tobacco control with clinical perspectives who are preoccupied with smoking cessation rates16 and those whose focus is on maximising cessation numbers throughout populations.17 This debate seems likely to intensify in low income nations where the global tobacco epidemic is now well established, where the bulk of global tobacco caused deaths are already occurring, but where tobacco control tends to be rudimentary.
Those wanting the best possible population-wide impact to flow from the current UN momentum on non-communicable disease control will need to be vigilant against the lobbying activities of the pharmaceutical industry smoking cessation juggernaut, with its mission to medicalise smoking cessation and discredit unassisted cessation as a recipe for failure.
The industry, with its formidable promotional and public relations budgets, and an army of research consultants whose findings tend to show better outcomes than researchers not funded by industry,18 has a clear commercial interest in eroding public and professional confidence in unassisted cessation.
This is despite the enduring superiority of unassisted cessation across decades in delivering far more ex-smokers than all other approaches to cessation combined.9 19 Smokers are now recommended to use NRT (nicotine replacement therapy) before they quit (“pre-quit”), while attempting to quit, in combination, and long after stopping to prevent relapse.
A large body of clinical trial evidence provides the bedrock for this advice. But there are major differences between clinical trials and real world use in smoking cessation.20 21 Unlike real world users, those taking part in trials get free pharmaceuticals; have frequent contact with trial researchers, creating Hawthorne effects; and are paid travel and expenses.
Trial participants are unrepresentative of the general population22 and cessation trials exclude those with mental health problems,23 who are heavily over-represented among smokers. NRT trials have poor blindness integrity, with over half of studies in one review showing trial participants were significantly more likely than chance to accurately guess that they had been allocated to the placebo arm, meaning that their faith in the treatment they were receiving was likely to be poor.
This may translate into poorer quitting outcomes, thus exaggerating differences between active and placebo NRT outcomes.24 Finally, far more trial participants complete the recommended drug course than in real world settings.21 25 All this combines to produce trial quit rates that are higher than those in real world settings. A recent Glasgow study found just 2.8% of smokers using medication who received up to 12 weeks of individual counselling with pharmacists had quit at one year.26
However, debates about real world effectiveness of cessation pharmacotherapy are somewhat ethereal to the circumstances of the vast majority of smokers in low income nations. In late 2009 in a Phnom Penh, Cambodia, pharmacy a pack of 105 pieces of 2 mg NRT gum was selling at $58.10 (£35.44; €40.62). Product information for 2 mg Nicorette gum advises a maximum of 24 pieces per day (www.nicorette.com/quit-smoking-products/nicorette-gum.aspx).
Even if that were halved, a 30 day supply would cost a Cambodian smoker $199.20, when average monthly income is $170.27 The cost of NRT and varenicline in low income nations in the Middle East and North Africa shows a similar picture.28 At these prices, NRT remains beyond the reach of anyone but wealthy élites in the world’s poorest nations.
Such costs mean that NRT is irrelevant to any serious talk about strategy that could make a national impact in low income nations. But the massive populations of low and middle income countries like China, India, Indonesia, Mexico, Bangladesh, and Nigeria collectively contain millions of affluent smokers who represent a goldmine to the pharmaceutical industry.
It can be expected that the industry will maximise every opportunity to surf the new UN inspired wave of interest and seek to continue to dominate public dialogue on cessation with pharmaceutical solutions. The WHO Framework Convention on Tobacco Control endorses assisted cessation but its provision is poor throughout much of the world.29
In the West, despite at least two decades of industry promotions, despite armies of drug retailers, and despite increasing success in the lobbying of governments to subsidise cessation pharmacotherapy, most ex-smokers continue to quit unaided. Every major tobacco control conference in the past 30 years has given major emphasis to ways of encouraging doctors and primary healthcare workers to routinely counsel and assist smokers to quit.
Yet recently, only 6.4% of 29 492 smokers in a UK health region were prescribed cessation medication in a two year study period.30 Reviewing the potential population impacts of various smoking cessation approaches, a 2000 US National Institutes of Health monograph concluded of physician interventions, “it is not clear that additional resources would add to the number of individuals encountering these interventions . . . the promise of these interventions as established in clinical trials is not fulfilled in their real-world applications.”31
Against this background, there ought to be a serious pause before governments in low and middle income countries embrace frontline, labour intensive, or pharmaceutical based cessation strategies, which will soak up large resources, have low consumer acceptability, particularly to the poor, and therefore make little contribution to population-wide cessation.
If smoking is to reduce in the world’s poorest nations, strategies commensurate with the size of the challenge need to be adopted. Easily implemented strategies that reach every smoker, like tax, graphic pack warnings, smokefree public places, and mass reach public awareness campaigns, need to be front and centre here, with assisted cessation placed in perspective.
Great encouragement can be taken from the current support by Bloomberg Philanthropy to assist in the development of mass reach awareness campaigns now running in India, China, Vietnam, Russia, Mexico, and Bangladesh, and major investment is occurring in capacity building to ensure that such campaigns are sustained (www.worldlungfoundation.org/).
Thailand32 and Uruguay are arguably world leaders in comprehensive tobacco control and their and other nations’ successes deserve to be megaphoned at the UN summit.
Cite this as: BMJ 2011;342:d5008
Competing interests: Simon Chapman is a director of Action on Smoking and Health, Australia and editor emeritus of Tobacco Control.
Provenance and peer review: commissioned; not externally peer reviewed.