Comments of Prevention and health promotion

Tobacco consumption 

Tobacco consumption kills five million people a year globally and that number is set to rise to eight to 10 million by 2030 (4). Half of all smokers die prematurely as a result of smoking and yet, if people stop smoking, they can return to having the same risk as nonsmokers within 10 to 15 years.

The world has largely recognised the extreme dangers that tobacco poses and, consequently, the WHO, for instance, has created the Framework Convention on Tobacco Control, which commits countries to regulating tobacco sales, reducing consumer demand for tobacco, improving the environment and health of tobacco workers, and encouraging research. A total of 168 countries out of a possible 192 have signed the convention, the United States and Indonesia being the largest countries not to follow suit.

We know a great deal about public health measures that are effective in reducing tobacco consumption. The WHO has put together the MPOWER package of six policies which are known to be effective (4).

They include the following:

- Monitor tobacco use and prevention policies.
- Protect people from tobacco smoke.
- Offer help to quit tobacco use.
- Warn about the dangers of tobacco.
- Enforce bans on tobacco advertising, promotion and sponsorship.
- Raise taxes on tobacco.

We need to support research in a number of areas: tobacco control, surveys of smoking levels, global cigarette consumption, the economic effects on individual countries (tobacco leads to losses not gains, as the costs of damage outweigh income from taxation), smoking costs to employers, economic costs of fires and litter, costs to smokers, tobacco company documents, litigation, the tobacco industry and the recruitment of scientists to the tobacco company cause.

Banning smoking in workplaces and public places, and increasing taxes on tobacco, are two of the most effective interventions (4).

Figure 1. Effectiveness of Various Forms of Nicotine Replacement Therapy in Helping People to Stop Smoking

Figure 1 shows data from a Cochrane Review on smoking cessation rates after various forms of nicotine replacement therapy (4, 5). The vast majority (between two thirds to three quarters) of ex-smokers stop smoking completely with no assistance (6, 7). This data comes from nations which have experienced two decades of major promotion of nicotine replacement therapy, using budgets that dwarf public campaign expenditure on smoking cessation.

Most smokers (by far) quit after being exposed to mass-reach policies, campaigns and the changing culture of smoking. They do not use drugs, go to counselling or even phone quitlines. This is an important and very positive message.

Nearly all the trials on nicotine replacement therapy have been conducted in wealthy countries. These nations differ substantially from low and middle-income countries in their culture of smoking control (smoking is far more accepted in most low and middle-income countries; there is scant tobacco control in most of them, including few motivational campaigns urging cessation). It is unwise to assume a similar interest, on the part of the population, in nicotine replacement therapy in the countries where most of today’s smokers live.

Countries that have implemented comprehensive bans on advertising (meaning bans on media and point-of-sale advertising) have seen much greater falls in tobacco consumption than countries that have not introduced such bans (4, 8). There are clearly issues around causation here, but the evidence on the effectiveness of comprehensive bans is strong. Reducing taxes on tobacco leads to higher consumption and raising them reduces consumption (4, 9). This sensitivity to price has been seen repeatedly in many countries at different times and is well established.

Much of the evidence on reducing the harm tobacco causes concentrates on cigarettes, but in many regions of the world, such as South Asia, other forms of smoked tobacco like bidis and smokeless, oral tobacco consumption are common, particularly among women and young people.

What we know much less about is the effect of these policies, including nicotine replacement therapy, in patients with complex chronic conditions. Indeed, of some 40 Cochrane reviews on smoking cessation none involve patients with established chronic disease. Often a whole range of trials exclude or control for polypathology.

It is also important to acknowledge that the control of tobacco use is made much more difficult by the presence of a powerful tobacco industry which is focused on promoting tobacco sales worldwide. These companies are increasingly concentrating their energies on low and middle-income countries, where the number of smokers and potential smokers is substantial and controls may be weak. These countries often depend on tobacco for economic development.