Intended for healthcare professionals

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Feature Tobacco Control

Tar wars over smoking cessation

BMJ 2011; 343 doi: (Published 08 August 2011) Cite this as: BMJ 2011;343:d5008

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A fallacious argument

Simon Chapman argues against providing tobacco treatment services to
low and middle income country patients, and for focusing efforts (almost)
exclusively on population-based measures such as cigarette tax. His
argument rests on several fallacies.

For Chapman, 'One of the best kept secrets in tobacco control is that
the great majority of ex-smokers quit without any formal assistance,' so
population-based measures are more cost-effective. But when someone quits
cold turkey, not thanks to tobacco treatment, that quit cannot always be
accredited to population-based measures.(1)

Chapman also points out the presently-high cost of treatment such as
nicotine replacement therapy (NRT), concluding, 'At these prices, NRT
remains beyond the reach of anyone but wealthy elites in the world's
poorest nations'. But high drug costs are often artificial and remediable.
NRT was recently included on WHO's essential medications list, providing a
potential mechanism for the low-cost production and distribution of
generic NRT.(2) In November 2010, the Fourth Conference of the Parties to
the Framework Convention on Tobacco Control (FCTC) unanimously called for
the stepwise adoption of tobacco treatment programs in all countries,
including low-income countries, and for identifying ways to cut treatment
costs.(3) It is conceivable that NRT prices may fall dramatically. Earlier
this decade, the price of second-line tuberculosis treatments fell by 90%
after a concerted effort to improve supply chains.(4)

The populations that resort to clinical treatment are quite
particular; typically, those with the highest nicotine dependency,(5) who
cannot quit on their own. Accusing clinical cessation programs of
ineffectiveness is thus somewhat akin to accusing geriatricians of
granting their patients lower future life-expectancy than pediatricians
grant their patients. Elsewhere we expound related ethical worries,(6)
questioning the fairness of abandoning these increasingly-identified
populations. To illustrate, nicotine is known to metabolize more slowly
among African-Americans than among other American patients, leading to
lower rates of successful unaided cessation.(7) Would denying aided
cessation be fair toward African-Americans?

Chapman's working assumption is that if cessation programs are
expensive, they necessarily come at the expense of population-based
measures. The reality is that the budgets for clinical cessation often
come from existing general health services budgets, while the budgets for
legislation and campaigns often derive directly from funds appropriated
from general or tobacco taxes. It is rarely politically realistic to
transfer clinical care funds into funding legislative efforts. Since the
cost-effectiveness of clinical cessation exceeds that of most current
clinical therapeutics, nations should pursue clinical cessation alongside
population-level tobacco control policies.

Nir Eyal, DPhil

Department of Global Health and Social Medicine, Harvard Medical School,
and Program in Ethics and Health, Harvard University, Boston, MA, USA

Asaf Bitton, MD MPH

Departments of Medicine and Health Care Policy, Harvard Medical School,
Boston, MA, USA


1. West, R., McNeill, A., Britton, J., Bauld, L., Raw, M., Hajek, P.,
Arnott, D., Jarvis, M. and Stapleton, J. (2010). Should Smokers be Offered
Assistance with Stopping? Addiction, 105, 1867-1869.

2. Kishore, S. P., Bitton, A., Cravioto, A. and Yach, D. (2010).
Enabling Access to New WHO Essential Medicines: the Case for Nicotine
Replacement Therapies. Global Health, 6, 22.

3. WHO. (2010). FCTC/COP4(8) Guidelines for Implementation of Article
14 of the WHO Framework Convention on Tobacco Control (Demand Reduction
Measures Concerning Tobacco Dependence and Cessation). Geneva: World
Health Organization.

4. WHO Working Group on DOTS-Plus for MDR-TB. (2000). Procurement of
second-line antituberculosis drugs for DOTS-Plus pilot projects
(WHO/CDS/TB/2000.276), 5-6 July 1999.

5. Fagerstrom, K. and Furberg, H. (2008). A Comparison of the
Fagerstrom Test for Nicotine Dependence and Smoking Prevalence Across
Countries. Addiction, 103, 841-845.

6. Bitton A, Eyal N. Too Poor To Treat? The Complex Ethics of Cost-
Effective Tobacco Policy in the Developing World. Public Health Ethics.
2011. epub June 8, 2011, 1-12.

7. Perez-Stable, E. J., Herrera, B., Jacob, P. III and Benowitz, N.
L. (1998). Nicotine Metabolism and Intake in Black and White Smokers.
JAMA, 280, 152-156.

Competing interests: We declare that we have no connections to the pharmaceutical industry or other competing interests. Chapman dismisses any defense of providing medication to patients addicted to nicotine as commercially-driven. We exemplify a refutation of this rhetoric.

25 August 2011
Nir Eyal
Assistant Professor of Global Health and Social Medicine
Asaf Bitton
Harvard Medical School and Harvard University