Last updated November 2014
Policy section
Chair Tom Houston
Ohio Health Nicotine Dependence
Program at McConnell Heart Health
Center, USA
Peter Anderson
Independent Consultant on
Public Health, Spain
Mike Cummings
Department of Health Behavior,
Roswell Park Cancer Institute,
USAJoe Gitchell
Pinney Associates Inc,
Natasha Herrera
Centro Médico Docente la
Trinidad, Venezuela
Tai Hing Lam
School of Public Health and
Department of Community
University of Hong Kong,
Ann McNeill
Division of Epidemiology and
Health, University of
Nottingham, UK
David SweanorSmoking and Health Action
Foundation, Canada
Last updated November 2014
• To provide information on policies concerning the
treatment of tobacco dependence and to signpost
important policy documents.
Last updated November 2014
Evidence Base
• Based on evidence presented largely in the other
• Strength of evidence statements therefore not given.
Last updated November 2014
Smoking: all tobacco use, including the use of e-cigarettes
Smoking cessation: Includes all tobacco cessation,
whether it occurs as a result of broader tobacco control
measures or individual support of dependent smokers
through treatment or outside of treatment.
Tobacco dependence treatment: A more narrow activity,
compared to smoking cessation, and involves helping
and supporting tobacco users overcome their
dependence on nicotine.
Tobacco Dependence Treatment Specialist (ENSP,
2012): A professional who possesses the skills,
knowledge and training to provide effective, evidencebased interventions for tobacco dependence treatment.
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Key Findings
• Tobacco treatment essential for impact on public
health within next 30 to 50 years.
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Key Finding 1: Important Publications
• The World Health Organization Framework Convention
on Tobacco Control (FCTC): An international public
health treaty.
• Article 14 of the FCTC states that countries shall develop
evidence based treatment guidelines and take effective
measures to promote adequate treatment for tobacco
• A recent estimate revealed that 7.4 million premature deaths
could be prevented as a result of 41 countries implementing the
evidence-based tobacco control practices listed in the WHO
framework convention (Levy et al., 2013).
Levy DT, Ellis JA, Mays D, Huang AT. Smoking-related deaths averted due to three years of policy progress.
Bulletin of the World Health Organization. 2013;91(7):509-518
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Key Finding 2: Diagnostic Publications
• Two of the most widely used classifications of substance
• World Health Organization’s International Classification of
Diseases (ICD 10; WHO, 1992)
• American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM V; APA, 2013)
• Both define tobacco dependence/tobacco use disorder and
associated withdrawal as substance use disorders.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5 th edition.
Washington: American Psychiatric Association. 2013.
World Health Organization. The ICD-10 classification of mental and behavioural disorders. Geneva: World Health
Organization. 1992
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Key Finding 3
• Increasing tobacco cessation is essential for reducing
tobacco-related morbidity and mortality.
• Tobacco use is the leading cause of preventable death,
and is estimated to kill more than 5 million people each
year worldwide.
• Most of these deaths are in low- and middle-income countries.
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Unless Current Smokers Quit, Tobacco Deaths
will Rise Dramatically in the Next 50 years
Estimated cumulative tobacco deaths 1950-2050 with different intervention strategies
Tobacco deaths (millions)
If proportion of
young adults taking
up smoking halves
by 2020
If adult
consumption halves
by 2020
World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80.
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Key Finding 4
• Most attempts to stop smoking are unsuccessful even in
countries with long-standing and well-established
tobacco control movements.
• Reasons for the high relapse rate among smokers are
1. tobacco product design and marketing
2. tobacco outlets are ubiquitous, and ease of purchase
normalizes their use in society
3. many smokers are also highly over-optimistic about their
likelihood of successful quitting.
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Key Finding 5
• Mass media campaigning (e.g., advertising or news
coverage) can encourage tobacco users to seek help in
stopping smoking.
• Tobacco control campaigns should be sustained over time given
that quitting behavior was observed within the first month of
exposure to campaign advertisements, not in subsequent
months (Langley et al., 2012).
• Recent Cochrane Collaboration review found that
comprehensive tobacco control programs that include mass
media campaigns can be effective in changing smoking behavior
(Bala et al., 2013).
Bala MM, Strzeszynski L, Topor-Madry R, Cahill K. Mass media interventions for smoking cessation in adults. The
Cochrane database of systematic reviews. 2013;6:CD004704.
Langley TE, McNeill A, Lewis S, Szatkowski L, Quinn C. The impact of media campaigns on smoking cessation activity:
a structural vector autoregression analysis. Addiction (Abingdon, England). 2012;107(11):2043-2050.
Last updated November 2014
Key Finding 6
• Young people respond to smoking cessation
interventions that are designed for adults.
• Adult cessation campaigns are more effective with
teenagers than campaigns with a specific focus on
teenagers (Hill, 1999).
Hill D. Why we should tackle adult smoking first. Tob Control. 1999; 8: 333-335.
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Key Finding 7
• A range of effective & cost-effective treatments exist
which should be integrated into health care systems.
These include:
a system to identify tobacco users;
routine advice to stop by health care professionals;
intensive support given individually or in groups;
pharmacological approaches.
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Key Finding 8
• Treatment is more likely to be offered and used if
integrated into healthcare systems that have procedures
in place to identify smokers or tobacco users.
• As noted in the 2014 Surgeon General’s Report and set
forth by the 2007 IOM report, treatment strategies and
policies need to be coordinated across all levels of health
care and public health systems in order to dramatically
increase the number of smokers who quit each year.
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Key Finding 9
• Post-certification training increases the likelihood of
intervening with smokers, but not yet been shown to
influence outcome.
• However, reviews of medical education both in the UK and the
United States indicate continuing gaps in on tobacco cessation in
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Key Finding 10
• Increasing the availability of pharmacological treatments
increases their usage and possibly cessation rates.
• In some countries (mainly low and middle income
countries) NRT and bupropion are not available or are
expensive compared with cigarettes.
• A further consideration is access to not only
pharmacotherapies, but also e-cigarettes and how such
access might relate to quit attempts and tobacco
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Key Finding 11
• Cessation attempts could be increased and smokingrelated harm reduced by providing indication for NRT
that includes concurrent use while reducing cigarette
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Key Finding 12
• Smoking cessation interventions are very cost-effective
in producing population health gain, compared with other
preventive and medical interventions in high-income
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Key Finding 13
• Cost of pharmacological treatments appears to influence
usage, with lower cost increasing usage.
• Despite the cost-effectiveness associated with smoking
cessation interventions, an expert consensus report on
NRT policy noted that cost is a significant barrier to NRT
use (Kozlowski et al. 2007).
• This report suggested supplying NRT in packages that contain
fewer dose units as one way to overcome this obstacle and
create easier access to NRT.
Kozlowski L et al. Advice on using over-the-counter nicotine replacement therapy-patch, gum, or lozenge-to quit
smoking. Addict Behav. 2007; 32(10): 2140-2150.
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Key Finding 14
• Harm reduction approaches can reduce the harm caused
by tobacco use for those who cannot or will not stop.
• The term “harm reduction” overs a variety of approaches aimed
at reducing the harm from tobacco use.
• The rationale for these harm reduction approaches is that
dependence on nicotine underpins most tobacco use but it is
other constituents of tobacco smoke that cause most of the
harm, not nicotine.
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Key Finding 15
• To be most effective, tobacco control efforts should be
truly comprehensive, and include a variety of
Packaging and labeling
Access to treatment
Smoke free policies
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Key Finding 16
• Statistical modeling techniques are important for guiding
tobacco control strategies.
• The 2014 Surgeon General’s Report highlighted the
importance of systems-level modeling in tobacco control
policy by noting that it is “a needed tool for continually
revising tobacco control strategies, reflecting the
dynamic nature of the tobacco epidemic and its drivers”
(page 849).
U.S. Department of Health and Human Services. The Health Consequences of Smoking — 50 Years of Progress: A
Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking
and Health, 2014.
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Key Finding 17
• Endgame strategies share following underlying
assumptions (1) that the status quo burden from smoking
is unacceptable and (2) that reducing smoking
substantially will require something new, bold and
fundamentally different from the tried-and-true (Warner,
• Some proposed endgame strategies include:
• reducing the nicotine in cigarettes to non-addicting levels
• replacing combustion cigarettes with alternative products
Warner KE. An endgame for tobacco? Tobacco control, 2013; 22(suppl 1): i3-i5
Last updated November 2014
• Treatment is essential component of an integrated
tobacco strategy.
• A full range of effective treatments should be offered and
made accessible to all tobacco users.
• Treatment should be integrated into & funded within
healthcare systems.
• Education & training in cessation of tobacco use should
be in the curricula of health professionals.
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Recommendations (cont.)
• A range of indicated uses for treatments should be
offered that is consistent with the evidence on efficacy,
scientific understanding of the nature of tobacco use and
relapse, and consumer choice.
• Regulatory barriers should be reformed (for example
access to treatment products is much more restricted
than is access to tobacco products).
• Campaigns should increase public awareness of the
benefits of quitting & the options available.
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Areas for future research
• The relationship between tobacco control policies,
availability of treatment programs, and tobacco users'
desires to quit.
• The population impact of strategies to encourage use of
pharmacological treatments for purposes other than
cessation (e.g. temporary relief of withdrawal symptoms
and for harm reduction), and the impact of such uses on
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Areas for Future Research (cont.)
• Research on the cost-effectiveness of tobacco
dependence treatments, especially in lower-income
• Cessation approaches to adolescent and pregnant
tobacco users.
• Cessation in special population groups, including
mentally ill and patients with other addictions.
• Continue exploration of policy related to harm reduction.
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Policy -