Introduction
In 1999, WHO convened a meeting of experts from developed and developing countries at the Mayo Clinic Nicotine Dependence Centre in Rochester, Minnesota, USA. The objective of this meeting was to prepare a statement on the treatment of tobacco dependence based upon the best available scientific information at that time. The experts recommended that Governments and health professionals could reduce the likelihood of tobacco-related diseases by doing the following:
The following report summarizes the group's findings. The subheadings in sections II and III represent its main conclusions and recommendations.
I. Background
The worldwide epidemic of tobacco-related disease and death continues to worsen as tobacco use spreads. This unnecessary, human-created epidemic will kill about 500 million people who are alive today. The Director General of the World Health Organization, Dr Gro Harlem Brundtland (1999) has described her first awareness of tobaccos health impact: "The evidence told a shocking story. . . . What I saw was an emerging epidemic. Worldwide mortality from tobacco is likely to rise from about 4 million deaths a year in 1998 to about 10 million a year in 2030. Ten million deaths that is more than the total deaths from malaria, maternal and major childhood conditions, and tuberculosis combined". Not only were those statistics "shocking", but more than 70% of the deaths are predicted to be in the developing world. She added: "By 2020, smoking will cause about one in three of all adult deaths, up from one in six adult deaths in 1990".
The day that Dr Brundtland took office, on 21 July 1998, WHO launched its Tobacco Free Initiative, with the goals of galvanizing global support for scientifically sound tobacco control policies and strategies; building partnerships to heighten awareness and mobilize resources; and accelerating national, regional, and global strategies. A significant aspect of this overall approach is a "focus on individuals". In her words, "To change the trends, we need to get smokers to quit and nonsmokers not to pick up the addictive habit".
Effective treatment for tobacco addiction, also called tobacco dependence, is a significant component of an overall tobacco control strategy to reduce exposure to tobacco worldwide. Through effective treatment for tobacco dependence, millions of people could be saved from disease and premature death. Treatment and prevention can work hand in hand as complementary strategies that reduce tobacco-caused disease and maximize benefits to public health. Henningfield & Slade (1998) explain that reducing tobacco exposure at individual and population levels through treatment could result in dramatic decreases in mortality from smoking-related causes, even within just a few years (see Figure 1). By the year 2010, nearly 2 million fewer smokers would die each year worldwide if effective treatment were combined with tobacco control measures. By 2025, the annual number of lives saved would be 4 million. By 2050, more than half of the cumulative premature deaths from tobacco would be prevented, representing some 12 million lives (World Health Organization, 1999b).
Such treatment, however, is not widely available. Even in developed areas such as Europe and North America, treatment is not available for all tobacco users who need or want it. When it is available, many tobacco users are not motivated to take advantage of it. Although smoking has been studied more extensively than any other form of tobacco, public access to effective treatment remains low throughout much of the world. Additionally, treatment regimens for forms of tobacco other than cigarette smoking are largely unavailable in most countries. In the United States of America, historically only about 2.5% of smokers who attempt to quit smoking without assistance succeed in any given cessation effort (e.g. Garvey et al., 1992; Giovino, Shelton & Schooley, 1993). More than a third of current cessation attempts in the United States involve the use of medication (Hughes, in press), a sizeable increase that has coincided with the availability of new treatment medications. The likelihood of long-term abstinence among quitting smokers increases with the addition of behavioural treatment and nonprescription and prescription medication (see Fiore et al., 1996).
Scientists and clinicians have learned much about how to help tobacco users quit. Even so, many key questions remain, including:
II. Tobacco and treatment
At least one-third of the global adult population, or 1.1 billion people aged 15 years and older, smoked cigarettes in the early 1990s. About 300 million of these smokers were in developed countries, twice as many men as women using tobacco. In less developed countries, about 700 million men and 100 million women were smokers. An estimated 48% of men and 7% of women in developing countries smoked. In industrialized countries, 42% of men and 24% of women smoked, representing a marked increase among women (World Health Organization, 1997). Although tobacco use has decreased in many developed countries, it has increased in most developing countries. Data-gathering studies such as the WHO MONICA project (to MONItor trends and determinants of CArdiovascular disease) have tracked rising smoking rates among European women smokers and among Asian men, two populations of concern (Dobson et al., 1998). Reports from various countries are informative:
Tobacco dependence may be higher among remaining smokers in countries with low smoking prevalence, where smokers of lower levels of dependence have already stopped. Although prevalence rates may be low, those remaining users may have more difficulty quitting (Fagerström et al., 1996).
A long-term tobacco user has a 50% chance of dying prematurely from tobacco-caused disease (Thun et al., 1995). In 1990, tobacco accounted for nearly a quarter of all male deaths and 7% of all female deaths worldwide, including more than 40% of deaths among men in formerly socialist areas. Tobacco-related diseases shortened the lives of affected smokers by an average of 16 years (Peto et al., 1996). A decade ago, tobacco caused some 3 million deaths per year. At present, tobacco causes some 4 million premature deaths yearly, a million of these occurring in developing countries that can least afford the health care burden.
Involuntary exposure to tobacco smoke also poses a significant health risk that may not be evident from tobacco-use statistics alone (e.g. National Health and Medical Research Council, 1997). A recent meta-analysis of epidemiological studies from Japan, the United States, Scotland, England, China, New Zealand, Australia, Italy, and Argentina (He et al., 1999) identified an increased risk for coronary heart disease among those exposed to tobacco smoke. This confirmed findings from a previous meta-analysis (Law, Morris & Wald, 1997) that showed an increased risk of ischaemic heart disease among those exposed through passive smoking. The recent International Consultation on Environmental Tobacco Smoke (ETS) and Child Health (World Health Organization, 1999a) concluded that ETS is "a real and substantial threat to child health, causing death and suffering throughout the world". WHO estimates that that some 700 million children half the worlds children are exposed to tobacco smoke.
Tobacco use among children and adolescents is also an epidemic. Most tobacco use starts during childhood and adolescence (Mackay & Crofton, 1996), and worldwide statistics indicate an upward trend in tobacco initiation and use among children. Tobacco is available to children in many countries, even countries with legal prohibitions against tobacco sales to those younger than the age of accountability (e.g. DiFranza et al., 1994; Radecki & Zdunich, 1993). The numerous demographic and psychosocial factors implicated in tobacco use initiation and continued use among children and adolescents deserve continuing, thorough examination (Tyas & Pedersen, 1998).
Tobacco products are carefully designed to undermine efforts to stop using them (e.g. Hurt & Robertson, 1998). Consequently, cessation is not simply a matter of choice for the majority of tobacco users. Instead, it involves a struggle to overcome an addiction (Royal Society of Canada, 1989; US Department of Health and Human Services, 1988). As Stitzer and deWit (1998) explain, the "abuse liability" of nicotine from tobacco products is high.
This means that tobacco users are likely to regularly self-administer nicotine via tobacco, in spite of adverse consequences. Cigarettes are "the most highly abusable nicotine delivery product", Stitzer and deWit note. Benowitz (1998) points out that the nicotine in tobacco achieves many purposes. Nicotine is reinforcing, provides sensory stimulus that enhances satisfaction, affects performance, controls mood and body weight, and may be self-administered to relieve symptoms of some psychiatric disorders, such as depression.
Nicotine inhaled through smoking passes quickly through the arterial blood stream and into the brain, resulting in intense effects in the central nervous system that are behaviourally reinforcing because of their time proximity in relation to inhalation. Nicotine levels drop between cigarettes, allowing the brains nicotinic receptors to resensitize. Additionally, the rapid delivery of nicotine to the brain allows the smoker to regulate the dose of nicotine from a cigarette to achieve specific psychoactive effects.
In addition to these properties and effects, tobacco use also becomes woven into everyday life in physiologically, psychologically, and socially reinforcing ways. Numerous reports from many branches of science detail the interactions between genetics, demographics, personality, psychopathology, and other factors that contribute to the likelihood of a persons becoming and remaining a tobacco user. Particularly compelling is evidence indicating that smokers use the nicotine from smoked tobacco as a form of affect modulation or regulationa fact that becomes evident to many former tobacco users who experience depression during abstinence (American Psychiatric Association, 1996).
Understandably, withdrawal effects, the worst of which last about a month, are a major motivation for continuing to use tobacco. These well-examined effects of abstinence (Hughes & Hatsukami, 1986) pose an obstacle difficult for many smokers to overcome. Dependent smokers typically experience some constellation of the following symptoms during the early days and weeks of tobacco abstinence: cravings and urges to smoke, difficulty concentrating, nervousness, restlessness, irritability, anxiety, cognitive impairment, increased appetite and (eventually) weight gain. The development and refinement of medications have provided a safe way for smokers to stop using tobacco without experiencing the full range and extent of withdrawal symptoms (Hughes et al., 1999)
Quitting tobacco use at any point in life provides both immediate and long-term benefits to health. Within a day of ceasing, a smokers carbon monoxide levels approximate those of a nonsmoker. The acute cardiovascular effects of nicotine and tobacco begin to normalize, and heart rate decreases. At all ages, eliminating exposure to tobacco is a form of primary prevention of disease. Even those who have smoked for years and who are experiencing the health consequences of tobacco use can benefit from cessation. The risk of recurrent heart attack diminishes among newly abstinent patients with heart disease.
Quitting smoking reduces risks and increases exercise tolerance in those who already have peripheral artery occlusive disease. The clinical course of patients with gastric and duodenal ulcers improves when they stop using tobacco. Smokers with cancer can reduce their risk of additional cancers if they quit. Quitting smoking also reduces the risk of respiratory infections such as chronic obstructive lung disease. Women who stop smoking before pregnancy give birth to babies with the same birth weight as babies born to mothers who never smoked (see US Department of Health and Human Services, 1990.)
Conversely, no amount of tobacco use is safe. The use of any tobacco product, even one bearing claims of reduced risk, involves some hazard to health (US US Department of Health and Human Services, 1988; American Council on Science and Health, 1997). Risk varies from product to product: cigarettes carry a higher hazard for cardiovascular disease than smokeless tobacco, while fermented smokeless tobacco is implicated in oral cancers. Those who attempt to minimize their tobacco use to reduce health risk are often surprised to find that they are unable to smoke only a few cigarettes a day or use only a small amount of snuff. Because few tobacco users are able to avoid becoming addicted to nicotine, abstinence from tobacco products and freedom from exposure to second hand smoke are necessary for maximizing health and minimizing risk (see Whelan, 1997).
Effective treatment for tobacco dependence can significantly improve overall public health within only a few years. No other intervention or prevention mechanism has the potential to reduce tobacco-related disease and death as quickly as treatment for tobacco dependence (see Fig. 1; Henningfield & Slade, 1998). A combination of treatment and other tobacco control strategies, notably prevention, can reduce rates of death and disease dramatically. Over the next 30 years, the extent of tobacco-caused death and disease will be determined largely by the numbers of existing smokers who are able to become abstinence or greatly reduce their exposure to tobacco.
Tobacco users who attempt to quit on their own tend to remain abstinent only a few days at most. Medications and behavioural therapies are both effective, and each approach can be effective when used alone. The use of pharmacotherapy can double short-term success rates compared to placebos (Fiore et al., 1996). Controlled trials indicate that medications can work independently of behavioural or psychosocial therapy, or of other interventions (Hughes et al., 1999). Meta-analyses of hundreds of controlled scientific studies have created a road map for providing successful tobacco dependence treatment, even though the range of what constitutes treatment is wide. Treatment could involve attending a stop-smoking group at a local health clinic, or the use of over-the-counter medication. It could also involve a physician, dentist, psychologist, nurse, or pharmacist enquiring about tobacco use status and offering to help the user quit. Effective treatment can involve a variety of methods, such as a combination of behavioural treatment and pharmacotherapy (e.g. nicotine replacement, non-nicotine medication such as bupropion, or both). Treatments that are the most effective deal with the reality that tobacco dependence is a chronic disorder and the fact that dependent users are prone to relapse. A single treatment intervention may have only a minor impact, but extended efforts, information, and contact can result in long-term benefits.
An increasing number of governments have undertaken the task of outlining guidelines for effective treatment. Two leading efforts in this regard were guidelines issued in 1996 by the US Agency for Health Care Policy and Research (AHCPR), Smoking cessation (Fiore et al., 1996), and Englands "Smoking cessation guidelines for health professionals" published in the journal Thorax (Raw, McNeill, & West, 1998). This document was published in parallel with guidance on the cost-effectiveness of treatment. Additionally, the American Psychiatric Association (1996) published guidelines for treatment of tobacco dependence in psychiatric patients and tobacco users otherwise unable to quit. All three of these sets of guidelines are "evidence-based", in that their recommendations are based on statistical findings of treatment efficacy, and on published evidence and expert opinion.
The recommendations promoted in the various guidelines are similar. The treatments endorsed generally include brief advice, behavioural therapy, nicotine replacement, and bupropion. Primary care providers and their associates are asked to assess smoking status of patients at every opportunity, to advise tobacco users to stop, to assist them in doing so, to offer follow-up, and to refer the patient to a specialist service if necessary. Caregiver teams should recommend pharmacotherapy for all smokers who want to stop, and should provide accurate information and advice about medications. These expectations extend to all other health professionals as well. Psychologists (Wetter et al., 1998) and pharmacists (e.g., Sinclair et al., 1998; Tomasello, 1997) in particular have been given guidance in implementing recommendations such as those provided by the AHCPR. By the time the Thorax guidelines were published, the document had been endorsed by numerous governmental and professional groups, including nurses, physicians, midwives, and pharmacists.
Treatment for tobacco dependence has proved to be a cost-effective means of helping to control the overall tobacco use epidemic, as explained in the companion document to Englands treatment guidelines (Parrott et al., 1998). The authors outline potential health gains and costs of implementing interventions across the countrys population. In an examination of life-years saved as a result of treatment, tobacco dependence treatment compares favourably with most health care procedures, and is far less expensive than the median societal cost of many life-preserving medical interventions.
III. Implementing Treatment
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.
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.
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.
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).
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.
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).
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:
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.
IV. Conclusion
International gains in tobacco treatment start as a national commitment that reaches into the lives of individual tobacco users. This effort might involve coalitions and cooperation among health professionals, educators, journalists and entertainers, governments, researchers, and policy-makers. For the individual tobacco user, tobacco-free health might start with a question from a caregiver, such as a midwife or a dentist, leading to a life-lengthening commitment to tobacco abstinence. In the process of achieving and maintaining that abstinence, the tobacco user may need to draw on many resources, such as groups of other persons quitting tobacco, medications, and publications that provide information and encouragement.
Tobacco users must not be left to attempt to cease on their own without assistance and treatment, no matter how few resources a country or community may have. The first steps toward providing treatment might be relatively simple ones, such as instructing nurses in helping patients who smoke, including information about tobacco in course-work for dental hygienists, challenging physicians to stop using tobacco, encouraging counsellors to bring together tobacco users for group discussions, or recommending that pharmacists assist those using treatment medications. With the momentum of leagues of professionals and a committed worldwide public health community, tobacco dependence treatment can save many millions of lives.