Policies for helping smokers who cannot quit: a prerequisite for maximum prevention of tobacco induced diseases

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Oral presentation by Lars Ramström at the 7th Annual Conference of ISPTID, Kyoto, Japan, 26-28 September, 2008

Oral presentation by Lars Ramström at the 7th Annual Conference of ISPTID, Kyoto, Japan, 26-28 September, 2008

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  • Prevention of tobacco induced diseases is a very multifaceted issue. I am here going to focus on an aspect that, in recent years, has gained increasing attention, namely the need to help smokers who cannot quit so that they can find other means to minimise their risk for tobacco induced diseases. In order to put these matters in context, we need an overview of goals and objectives in the field of tobacco control.
  • The overall goal for tobacco control can be formulated as: ” Maximum prevention of tobacco induced diseases”. This goal includes intermediate objectives concerning measures to help specific target groups such as: Never tobacco users, and Current tobacco users.
  • The objective of measures to help never tobacco users should be: PREVENTING ONSET OF TOBACCO USE. The strength of such measures is: In individuals for whom these measures have been successful, tobacco induced diseases will not occur. But there are weaknesses: - Measures to prevent onset of tobacco use have limited success rate. - Even when they are successful, there is virtually no reduction of disease in the nearest 30-40 years, because, in that period, virtually all cases of tobacco induced diseases will occur among those who already smoke. This is further illustrated by data published in a report from the World Bank .
  • The curves in this graph show the estimated cumulative tobacco deaths 1950 to 2050 by different intervention policies, The black curve represents a ”no intervention” scenario. The red curve represents a scenario where onset of smoking in young people has been cut to half from the year 2000 to 2020 - a quite optimistic scenario. But the result in terms of reduction of deaths is very modest. However, in a still longer time perspective, prevention of onset will yield substantial health gains. So, primary prevention policies are important - but not enough. The World Bank has also estimated the outcome of a scenario where adult smoking is cut to half from the year 2000 to 2020.
  • As illustrated by the blue curve, quitting smoking makes a substantial difference, and the health gain appears quite soon. Therefore……..
  • The #1 objective of measures to help current tobacco users should be: QUITTING ALL TOBACCO/NICOTINE USE The strength of such measures is that they can make disease risks decrease substantially, eventually approaching never-user levels. But there are weaknesses: - Treatments in clinical settings reach a limited fraction of smokers and have limited success rate. - Quit attempts made outside clinical settings (the majority of all quit attempts) get no or inadequate support. In summary; Cessation policies are important - but not enough. Some reasons behind the weaknesses of cessation policies can be illustrated by ”real life” data regarding quit attempts.
  • Some smokers do not make any quit attempt at all. In Sweden this group is quite small, less than 10% of all ever daily smokers, but in many other countries the percentage is substantially higher. Even more important is the outcome of actual quit attempts. Among those who have made one or more quit attempts, there are large proportions who do still smoke. These proportions differ substantially according to level of nicotine dependence.
  • The proportion of those who do still smoke is increasing with increasing level of nicotine dependence. For those with very high level of dependence it may be virtually impossible to quit nicotine use. Consequently there is a need to help these people minimise their health risks by other means. P reviously, this need has been largely neglected in governmental policies, but a few months ago it was recognised by the British Department of Health.
  • In the background document for a ”Consultation on the future of tobacco control”, the Brtish Department of Health identifies four main areas. One is: ”Helping those who cannot quit”: considering…… (text on slide) ……..… quit altogether.” Just two weeks ago The Royal College of Physicians of London responded to the consultation by publishing a report summarizing updated scientific evidence in the field.
  • Already in the subtitle the report highlights the harm reduction component of the suggested ”Radical strategies” for ”Ending tobacco smoking in Britain”.
  • Here are some excerpts from the section discussing the overall principles concerned. What is harm .... (text on the slide) ………... by nicotine addiction. The issue on smoke-free nicotine is discussed more in detail in a following section.
  • What is …. (text on the slide) ………...alternative to smoking. The latter remark implies a discussion on alternatives to medicinal nicotine.
  • Nicotine can … (text on the slide) ……less hazardous than smoking. The last remark, that smokeless tobacco products are substantially less hazardous than smoking, deserves particular attention, since there is a common misunderstanding that the difference were just a small one. This point can be further clarified by examples of quantitative data.
  • In this chart each bar represents the relative risk of death for males with different tobacco use The green sector of each bar represents never smokers’ death risk, taken as a reference. The red sector in the bars for snus users and cigarette smokers represents the excess risk, above that of never smokers. For users of snus, the Swedish kind of smokeless tobacco that was mentioned by the Royal College of Physicians, the death risk is much closer to that of never smokers than to that of cigarette smokers. The pieces of evidence that have now been presented, imply a need for an additional objective for measures to help current tobacco users.
  • This objective should be: Switching to a nicotine product that is markedly less harmful. The strength of this strategy is, that it offers a realistic alternative even for highly nicotine dependent people, and also, that disease risks can decrease almost as much as when quitting. And there are weaknesses: - Continued exposure to nicotine - Maintenance of nicotine dependence - Limited availability of appropriate products Now, as a final summary:
  • Primary… (text on slide) ………………enough.
  • In order to…. (text on slide) ………..smokeless tobacco.

Transcript

  • 1. Policies for helping smokers who cannot quit: a prerequisite for maximum prevention of tobacco induced diseases Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden 7th Annual Conference of ISPTID, Kyoto, Japan, 26-28 September, 2008
  • 2. Overall goal for tobacco control: Maximum prevention of tobacco induced diseases
    • This goal includes intermediate objectives concerning measures to help specific target groups such as :  Never tobacco users  Current tobacco users
  • 3. Objective of measures to help never-tobacco-users: Preventing onset of tobacco use
    • Strength:  In individuals for whom these measures have been successful, tobacco induced diseases will not occur
    • Weaknesses:
    •  Measures to prevent onset of tobacco use have limited success rate  Even when successful: Virtually no reduction of disease in nearest 30–40 years
  • 4.  
  • 5.  
  • 6. #1 objective of measures to help current tobacco users: Quitting all tobacco/nicotine use
    • Strength:  Disease risks decreasing substantially, eventually approaching never-user levels
    • Weaknesses:  Treatments in clinical settings reach a limited fraction of smokers and have limited success rate  Quit attempts made outside clinical settings (the majority of all) get no or inadequate support
  • 7. Occurrence of quit attempts in Sweden (% of all ever daily smokers) Men Women  Not made any quit attempt 9% 8%
    •  Made one or more quit attempts - but do still smoke 36% 47% - and have quit completely 55% 45% Source: ITS/FSI surveys of the Swedish population
  • 8. ” Do still smoke” after latest quit attempt by level of nicotine dependence
    • Men Women
    •  Low nicotine dependence 34% 36%
    •  Medium nicotine dependence 40% 56%
    •  High nicotine dependence 56% 66%
    • Source: ITS/FSI surveys of the Swedish population
  • 9. Main area #4 Helping those who cannot quit: considering the potential of a harm reduction approach in tobacco control to help people whose addiction to nicotine makes it extremely difficult to quit altogether.
  • 10.  
  • 11.  People smoke because they are addicted to nicotine, but nicotine itself is not especially hazardous; it is the other constituents of tobacco smoke that cause most of the harm.  Use of smoke-free nicotine would benefit smokers directly by reducing the personal harm caused by nicotine addiction What is harm reduction, and how would it work for smoking? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.
  • 12.  The safest form of nicotine is medicinal or ‘pure’ nicotine, such as that contained in nicotine replacement therapy (NRT) products including skin patches and chewing gum.  However, although helpful, few smokers find NRT to be a satisfying alternative to smoking What is the safest way to provide nicotine without smoke? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.
  • 13.  Nicotine can also be obtained without smoke from a range of tobacco products, usually referred to as ‘smokeless’ tobacco.  In Sweden, the availability and use by men of an oral tobacco product called snus, one of the less hazardous smokeless tobacco products, is widely recognised to have contributed to the low prevalence of smoking in Swedish men and consequent low rates of lung cancer.  All smokeless tobacco products are therefore more hazardous than medicinal nicotine, and in some cases especially so, but all are also substantially less hazardous than smoking. What are the alternatives to medicinal nicotine? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.
  • 14.  
  • 15. #2 objective of measures to help current tobacco users Switching to a nicotine product that is markedly less harmful
    • Strengths:
    •  Realistic alternative even for highly nicotine dependent people  Disease risks potentially decreasing almost as much as when quitting
    • Weaknesses:  Continued exposure to nicotine  Maintenence of nicotine dependence  Limited availability of appropriate products
  • 16. Summary and conclusions (1)
    • Primary prevention policies are important
    • - but not enough
    • Smoking cessation policies are important
    • - but not enough
  • 17. Summary and conclusions (2)
    • In order to prevent largest possible number of potentially preventable cases of tobacco induced diseases there is a need for policies helping those smokers who cannot quit to find less harmful alternatives, such as medicinal nicotine or low risk types of smokeless tobacco.