Mayo report on addressing the worldwide tobacco epidemic through effective, evidence-based treatment
Report of an expert meeting, March 1999, Rochester (Minnesota) USA
III. Implementing Treatment
1. Make treatment a public health priority
Tobacco dependence is listed as a disorder in the current International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), (World Health Organization, 1992). This underscores the obligation to provide treatment as part of an overall public health strategy. Meeting this responsibility may involve collaboration among such constituencies as public health departments, health agencies, insurers, regulatory agencies, non-profit groups, scientific organizations, and treatment providers. Collaborative groups can unite to approach governments about the nature and health threat of tobacco use, and about treatment options.
An initial step to providing effective treatment is to make treatment a public health priority. Offering treatment requires planning and education. Needs vary from country to country, but many of the principles are broadly applicable. Treatment for most tobacco users need not be expensive or elaborate, but it should be consistent and effective. To government leaders, Dr Brundtland (1999) offers this challenge:
People in government have the power to act. Those actions, both personal and official, will decide if tobacco shall claim new millions of victims in your home countries. Those actions will help prevent the cost of treating hundreds of thousands of cancer and heart disease patients from breaking the back of your health systems in the coming decades. Those actions will see to it that children don't lose their parents prematurely through cancer and heart diseases caused by smoking. Those actions will help prevent teenagers from being fooled into an addiction which gives them only a 50% chance of surviving middle age.
2. Make treatment available
Treatment must not be the privilege only of those who can afford private help and expensive medications. Health care systems - in whatever form they exist in different countries - should establish a goal of offering accessible, practical, scientifically based and proven interventions to all tobacco users, regardless of economic level, age, sex, and level of tobacco dependence. These interventions can be implemented by health professionals and supported by local leaders in governments and the community. The concept of treatment should be broadened to include treating tobacco use in children and adolescents, reducing family exposure to tobacco, motivating tobacco users to quit, and providing treatment medications when appropriate (Hatsukami & Lando, 1998). These efforts will also strengthen prevention measures. The process of providing treatment can be facilitated by incorporating tobacco dependence treatment into primary care, drug dependence treatment (American Psychiatric Aaaociation, 1996), reproductive and maternal and child services (Windsor, Boyd & Orleans, 1998), programmes with outreach to underserved populations (Ahluwalia, 1997), and non-traditional venues such as religious institutions.
Cultural cohesion and traditions unique to a given locale can provide a framework for treatment and may in some cases reduce the need for formal treatment. Those with experience in culturally unique settings (e.g. Groth-Marnat, Leslie & Renneker, 1996) recommend the following: encouraging indigenous people to develop their own programmes; considering unique rituals that could increase tobacco users' power to change; enhancing change by working with healers or others of status in the community; considering health promotion in relation to cultural values; and not expecting or demanding early change. They also suggest gradually developing a committed relationship over time.
3. Assess tobacco use and offer treatment
Health care providers should assess and document tobacco use and should provide proven treatments as an essential part of total health care to individuals of all socioeconomic levels. Ongoing monitoring of tobacco use (World Health Organization, 1998) is a critical aspect of thorough and careful epidemiological research. The complex demographics of tobacco use are important to consider in assessing use and providing treatment. An example of this is the use of moist oral snuff in Sweden, where more women than men smoke, but as many men use snuff (nonfermented) as use cigarettes (e.g. Schildt et al., 1998). Some tobacco users also consume multiple forms of tobacco. Additionally, overall smoking prevalence rates can be misleading. Although overall rates may decrease, the rate may increase among a high-risk group, such as young women. Also, when comparing smoking rates across age groups over time, it is important to follow the cohort and not only compare persons in an age group at one time point with those in the same age group at a later time point. Another factor to consider in examining smoking and cessation rates is the extent of tobacco exposure. Research indicates that ceasing to smoke is somewhat easier for individuals who are less dependent on tobacco. Current ex-smokers may have been less dependent on tobacco than are continuing smokers, a possibility that underscores the necessity of surveying not only prevalence of use and extent of tobacco exposure but also level of tobacco dependence and motivation to quit (Fagerström et al., 1996; Ramström, 1997).
Elements that should be considered in assessing tobacco exposure in a country include other tobacco use in addition to cigarettes (e.g. smokeless tobacco and cigars), ratio of men and women tobacco users, subgroups based on socioeconomic status, urban or rural residence, age of onset of tobacco use, types of tobacco material, frequency of use, and amounts of use. With this information, health care planners in a country can assess the potential disease burden of tobacco, and can plan interventions accordingly. However, few countries have access to such data at present (Ramström, 1997).
Providing effective treatment for tobacco users with different levels and patterns of usage necessitates an adaptive application of evidence-based treatment principles. Health care providers should assume responsibility for learning about tobacco use and treatment, so that they can provide proven interventions for patients and clients with differing needs. Additionally, health care providers, educators, and community leaders should take advantage of teachable moments and opportunities for prevention and intervention.
4. Set an example for peers and patients by ceasing tobacco use
In some areas of the world, large percentages of physicians and other health professionals smoke, presumably because smoking is a sign of status in some cultures. Health workers function as exemplars and educators for their patients, and consequently should set an example by abstaining from tobacco. When this point is emphasized in professional organizations and through the education system that trains professionals, their tobacco use rates decline. An example of this occurred in the United States, where nearly 19% of physicians smoked a decade after the first US Surgeon General's advisory committee report in 1964 on the health costs of smoking. As tobacco use among health professionals became a focus of concern, that rate dropped to 3% by the early 1990s. In parallel, the smoking rate among registered nurses fell from 32% to 18% between the mid-1970s and the early 1990s. Among licensed practical nurses it fell from 37% to 27% (Nelson et al., 1994).
5. Fund effective treatment
Governments and health care organizations should ensure that evidence-based treatment is widely available and, where appropriate, is reimbursable to health care providers. Increasing the institutional and human capacity for providing this service involves training health care workers to deliver treatment and implementing a curriculum for students in the health professions. Only about a third of the world's medical schools currently provide instruction in tobacco dependence treatment, although 88% include the topic of tobacco in their curriculum. Respondents to a worldwide survey about tobacco education in medical schools indicated that programmes could be enhanced if selected staff received training in countries with well developed programmes, if international experts offered training, if materials were more available, if the public received more information about tobacco, and if legislation and governmental attitudes were more supportive (Richmond et al., 1998).
Another aspect of effective treatment is the development of resource centres to provide information on treatment certification, resources and materials, and updated information on effective treatments and guidelines (Hatsukami & Lando, 1998). Web-based sites can provide extensive information to the public and to professionals. Additionally, treatment standards are enhanced by encouraging the creation and maintenance of centres of excellence in treating tobacco dependence. An overarching result of this process is the reduction of barriers between tobacco users and treatment, so that effective treatment can be made available to all tobacco users regardless of age, sex, ethnicity, locale, and income level. However, even direct efforts to remove barriers require careful evaluation. For example, allowing medications to be sold without a physician's prescription removes one barrier but may create another if smokers are unable or unwilling to buy the medications unless the expense is subsidized.
6. Motivate tobacco users
Most tobacco users who would like to quit are not yet ready to do so (Etter, Perneger & Ronchi, 1997). Governments, health providers, and community groups share a responsibility for motivating tobacco users to stop and to remain abstinent. This can be accomplished through educating the public about the health risks of tobacco use; enacting smoke-free laws and policies; encouraging tobacco users to seek treatment; and making treatment available, affordable, and accessible. If health professionals and researchers focus as much on efforts to prompt attempts at tobacco cessation as on creating new approaches to treatment, many additional tobacco users will be motivated to quit. One motivational approach is for health professionals to explain at each visit the risks of tobacco, the rewards of cessation, and the relevance to the individual (Fiore et al., 1996). Many experimental studies have shown that physician advice does increase both immediate and more distant attempts to quit. Recent work using the Transtheoretical, or Stages of Change, model (Prochaska & DiClemente, 1992) indicates that this approach can prompt successful cessation and is acceptable to a majority of smokers. Another model is motivational interviewing (Miller & Rollnick, 1991), which has been effective in alcohol and drug dependence treatment.
Motivation to quit must be stronger than incentives for continuing to use tobacco. For many smokers, the incentive to smoke is driven by media depictions and by cultural and societal acceptance of tobacco use. By the time they are only a few years old, many children throughout the world can identify tobacco advertising icons (e.g. Emri et al., 1998; Fischer et al., 1991). Public education campaigns and counter-advertising face a substantial obstacle in overcoming the power of years of effective advertising and marketing of tobacco products. The Marlboro Man was named brand image of the century in 1999 by Advertising age magazine, whose editors expressed their ambivalence at selecting a symbol that had established Marlboro as the best-selling cigarette in the world. They acknowledged, "More than any other issue, the ethics of tobacco advertising - morally and legally - have divided the advertising industry". (Advertising age, 1999). They noted that the Marlboro Man's image has so much "clout" that no matter how minimal the imagery becomes, "reduced on occasion to little more than a saddle and a splash of red", the image is still evocative of "a mythical Marlboro country, of a mythical American cowboy and of the No. 1 brand of cigarettes that gave that cowboy real lung cancer".
No counter-advertising image has approached the success of the Marlboro Man, or even of his closest competitors in the contest for icon of the century - Ronald McDonald, The Green Giant, Betty Crocker, and the Energizer Bunny. Success in counter-advertising not only requires powerful images and an extensive advertising budget, but also depends on several factors that are difficult to achieve in many political climates: adequate, long-term funding; a campaign free from political interference; a broad-based focus not targeted exclusively at children; and a campaign that complements other tobacco control activities, such as support for indoor smoking restrictions (Cummings & Clarke, 1998).
Population-based methods such as telephone helplines and national and international tobacco-free days also can help motivate tobacco users toward treatment. A "Quit and Win" contest has resulted in success rates that far exceed typical cessation rates among tobacco users who stop without assistance (Tillgren et al., 1995). To be eligible to win prizes, participants - users of smokeless or smoked tobacco - had to remain abstinent for four weeks. Winners had to submit guarantees of no-tobacco status signed by two independent witnesses, and a smaller sample also had to pass a biological test (saliva measurement of cotinine, a metabolite of nicotine) for verification. A recruitment strategy combining mass media and local organizations attracted larger numbers of participants.
National and international tobacco-free days also can be effective ways to prompt tobacco users to quit, as well as to provide a forum for dissemination of health information. The 1999 World No-Tobacco Day was an opportunity for the Australian Federal Government to air commercials encouraging tobacco users to quit. The federal health minister publicized consumer reactions to an awareness campaign called "Every cigarette is doing you damage." Also in Australia, the New South Wales Cancer Council prepared for World No-Tobacco Day by launching an initiative to discount the cost of nicotine replacement gum by about 75%. A representative of the Cancer Council explained that low-income tobacco users had found the regular price of nicotine replacement gum to be "a bit of a barrier to taking up a course". (Australian Broadcasting Corporation, 1999a, 1999b.) On the other side of the Earth, seven Lebanese nongovernmental organizations marked World No-Tobacco Day with a "Put it out before it puts you out" campaign. They erected tents where they distributed leaflets and showed videos reflecting the dangers of smoking (Zaatari, 1999). The evidence of success of these events can be difficult to gather and assess.
However, one indication of the impact of no-tobacco days can be inferred from a study of occupational safety, in which data from 10 years of annual United Kingdom no-smoking days indicates a rise in abstinence from nicotine on those days (Waters, Jarvis & Sutton, 1998). Although these types of approaches might have small individual effects, their combined impact can be sizeable (Burns, in press).
7. Monitor and regulate tobacco
Some efforts that encourage and facilitate abstinence are within the domain of governments to accomplish or underwrite. These include monitoring and reporting on tobacco use, to provide accurate tracking of epidemiological data about the extent of tobacco exposure among a country's residents. Governments also bear the responsibility to tax tobacco products as a means of controlling accessibility (Meier & Licari, 1997; Warner et al., 1995). To stem widespread tobacco dependence, governments also must regulate the sale and marketing of tobacco products (Sweanor, 1997). When combined, these efforts help reduce initiation of tobacco use and fund effective treatments. Thus, the responsible regulation of tobacco products can reduce tobacco use and limit risk.
Necessary components of public education include accurate testing of tobacco products, awareness of product design, and responsible labelling. Many tobacco users throughout the world have no access to information about the tobacco they consume. Tobacco users typically are unaware of nicotine and tar levels (Kozlowski et al., 1998b). As a group, they do not know that so-called "light" and "ultra-light" cigarettes can give them the same tar and nicotine as regular cigarettes (Kozlowski et al., 1998a), or that smokers compensate for lower tar and nicotine in cigarettes (e.g. Kozlowski, Pillitteri & Sweeney, 1994). A committee advising the United Kingdom's Department of Health recently called on that country's Government to "require that the tobacco industry behave like other consumer product companies" (Henningfield & Slade, 1998; United Kingdom Department of Health and Social Security, 1998). The Scientific Committee on Tobacco or Health recommended that the United Kingdom Government require standards in assessing the health effects of products, acceptance that tobacco is a major cause of premature death, and standards of disclosure of the nature and magnitude of hazards to consumers. In this spirit, governments could collaboratively assess tobacco products in a way that would provide meaningful and accurate ratings of nicotine and other chemicals in tobacco products.
Governments also can regulate the toxicity and addictiveness of tobacco products to reduce the harm of tobacco use. Slade and Henningfield (1998) summarize steps that government regulatory agencies should explore:
8. Develop new treatments
Investing in the science and technology of treatment improves its efficacy. The recent development of medications for treating tobacco dependence is a success story for applied science. This research field has considered the new goals of tobacco use reduction and relief from withdrawal symptoms, employed new methods such as sensory replacement, and begun to tailor treatment to fit tobacco users' profiles and needs. Novel methods of pharmacotherapy offer tobacco users many choices. In addition, recent findings about the efficacy of new medications add further hope for higher rates of successful cessation.
Research should focus not on pharmacotherapy alone, but also on developing high-volume, lost-cost treatments for tobacco users and health systems with few economic resources. The development of new treatments involves much more than carrying out continuing series of clinical trials. Each new finding about the effects of nicotine and tobacco enhances the possibility of effective treatment. Examples include scientific findings about the effects of maternal tobacco use on the unborn child, possible genetic bases of nicotine addiction, sex-specific effects of nicotine on metabolism, and population trends in tobacco use. Even though information may not seem directly related to the design and implementation of a treatment programme, each piece of scientifically valid information adds to the pool of knowledge on which treatment is based. Virtually no areas of legitimate research should be considered too unrelated or trivial to have an impact on treatment.
Although present treatments can be efficacious, current scientific knowledge cannot perfectly predict how best to motivate and help a tobacco user to quit. Worldwide research efforts have yet to reveal many keys to successful prevention and treatment among diverse peoples and cultures. Nearly every treatment-related article in professional journals includes numerous recommendations for further exploration. Most major monographs or policy statements about the global tobacco epidemic include a "wish list" of areas that remain unexplored. The document Smoking kills: a white paper on tobacco (1998) lists seven major areas needing further research:
These areas for consideration are merely a beginning. Exploring each of them, as well as other worthwhile areas not listed, will open multiple avenues that can enlarge the effectiveness and appeal of tobacco dependence treatment.