Improving the treatment of tobacco dependence

Efforts to treat tobacco dependence are meant to supplement rather than to replace attempts to stop the tobacco industry's predatory recruitment of new smokers. Over 1.2 billion people worldwide regularly smoke tobacco products,¹ not including the use of roll-your-owns or smokeless tobacco. Reductions in numbers of deaths caused by tobacco over the next 50 years will depend largely on the success of tobacco users in breaking or controlling their addiction. Only in the second half of this century will our progress, such as it is, towards reducing the uptake of smoking among young people manifestly affect mortality.²

Three articles in this issue show the importance of smoking cessation or discuss the growing repertoire of effective pharmacological and behavioural approaches for treating nicotine dependence.^2–4 Their publication coincides with the 11th world conference on tobacco or health, which will focus on treatment issues such as quality, availability, and affordability.

There are some simple messages that clinicians can and should communicate to all patients. Firstly, don't smoke. Secondly, if you do smoke, there are major health benefits to stopping as soon as possible, no matter what your age or how long you have been smoking. Thirdly, a wide array of effective cessation treatments is now available.

Underscoring the health benefits of smoking cessation is the report by Doll et al based on a comparison of two case-control studies conducted 40 years apart in the United Kingdom (p 323).² They confirm that the risk of lung cancer has increased massively in smokers over this period and extend previous evidence of the substantial reduction in risk seen in people who stop smoking.⁵ Even smokers who stop at 50 or 60 avoid much of their excess risk of developing lung cancer. The benefits of cessation become progressively greater with younger age of quitting.²

Also encouraging to both health providers and their patients is the wide array of effective smoking cessation treatments. Lancaster et al provide an up to date and comprehensive menu of treatments proved to be effective for smoking cessation (p 355).³ Their overview is based on a Cochrane review and complements other recent reviews of cessation treatment,^6–9 including the guideline released by the US surgeon general in June (www.surgeongeneral.gov/tobacco/).¹⁰

Interesting but less certain are the long term implications of the randomised clinical trial by Bollinger et al (p 329).⁴ Participants in the trial were adult smokers who had failed at least one previous attempt to stop smoking within the past 12 months. Smokers randomised to oral nicotine inhalers during the first four months of the trial reduced their cigarette consumption by over 50% per day during 24 months of follow up compared with smokers given a placebo inhalant. Several important questions are not answered by this trial, however. It remains unclear whether short and medium term reductions in the number of cigarettes smoked increase the likelihood of cessation. Either compensatory smoking—for example, more frequent puffing or deeper inhalation—or more prolonged smoking may offset the expected benefits of reducing the number of cigarettes smoked.¹⁰ More research is needed to sort out the benefits and risks of strategies of “harm reduction” applied to smoking.^11–14

The infrastructure that would motivate clinicians to deliver these simple yet powerful messages to patients who are dependent on tobacco is woefully inadequate. About half of current smokers surveyed in the United States report that they have never been counselled to quit smoking by their doctors or other health professionals, even though over 70% of smokers visit a healthcare setting each year.¹⁰ Patients who do successfully stop smoking say that counselling by their health provider provided important motivation.

Several measures could dramatically improve the availability and quality of medical treatment for tobacco dependence. Firstly, health systems and health insurance should cover counselling, pharmacological and behavioural interventions, and follow up for relapse. Secondly, physicians, health insurers, and policymakers must be educated that tobacco dependence is comparable to the addictive grip of opiates, amphetamines, and cocaine. Tobacco dependence is also a chronic relapsing condition: like other addictions and chronic diseases, it warrants repeated clinical intervention. An important challenge is to integrate the available, evidence based, and cost effective treatment of tobacco use and dependence into medical practice.

Papers pp 323, 329, Clinical review p 355