Editorial
In today’s society, it’s difficult to understand why anyone would start smoking. Cigarettes have become increasingly expensive in developed countries as governments raise taxes, with the average cost of 20 cigarettes approaching £8 in the UK, and around $12 in New York City, which has the highest cigarette taxes in the USA. There are graphic warnings splashed across packets telling purchasers that smoking kills, and also providing a plethora of information explaining how smoking will reduce both a person’s lifespan and their quality of life. Why then do people continue to take up the habit, and crucially, how can the number of current smokers be reduced? The effect of nicotine as an addictive substance is well known, and the physical cravings felt by smokers makes quitting difficult. However, there are several other likely behavioural drivers that also perpetuate the cycle of smoking. Cigarettes are often linked in peoples’ minds to relaxation and reward, and can constitute a social crutch, giving confidence in difficult situations. It is essential to address both addictive and behavioural aspects, if any attempts to quit are to be successful. Highlighting the importance of this area, Nancy Rigotti summarises the latest research on smoking cessation in a Review in this month’s issue of The Lancet Respiratory Medicine. The proven benefits of pharmacotherapy, as well as counselling and behavioural support, are discussed alongside the need for further work to target smokers who are not ready to quit, and to improve long-term cessation rates. Such efforts are crucial to reduce the more than a billion smokers estimated worldwide. This paper will also be presented at the May 2013 ATS conference in Philadelphia as part of a joint symposium with The Lancet on global efforts for tobacco control. Rather than making the effort to tease out the individual drivers behind smoking, another strategy is to penalise smokers as a group through higher taxes on cigarettes, higher medical insurance rates, and, perhaps most controversially, employers choosing not to hire people who smoke. WHO have adopted the latter policy, and justifies its decision as being in keeping with an organisation that is at the forefront of the global campaign to curb the tobacco epidemic. However, although the argument of upholding a uniform policy against tobacco is valid, there could be other reasons for such strict employment criteria, such as avoiding www.thelancet.com/respiratory Vol 1 May 2013
increased healthcare costs and reduced productivity in employees who smoke—a meta-analysis by the University of Nottingham showed that current smokers had a 33% increase in risk of absenteeism compared with nonsmokers. Excluding a qualified candidate because they smoke could be the start of a slippery slope. Public health campaigns are now targeting other lifestyle choices such as diet, exercise, and alcohol consumption, which are also known to have an effect on one’s health and incurred healthcare costs. Will these people also end up subject to employment restrictions? A 2012 report by the Centers for Disease Control and Prevention on smoking in adults in the USA also showed that people below the poverty line, those with a lower level of education, and those with disabilities, were more likely to smoke. As such, measures to penalise smokers could disproportionately affect those most in need. Efforts may be better directed to discouraging young people from taking up smoking. As New York City celebrates the 10-year anniversary of its smoking ban in indoor public places and announces a drop in adult smoking rates from 22% in 2002 to 14% in 2010, less has been said about the fact that the rate of teenage smoking has plateaued at 8·5% since 2007. This worrying finding is mirrored in the UK, where a report from Cancer Research UK has shown that despite a general decline in teenage smoking from 2000 to 2011, the number of teenagers aged 11–15 years starting to smoke increased by 50 000 from over 156 000 in 2010 to over 207 000 in 2011. Tackling this age group, for whom the thought of dying early seems a very distant threat, needs a different approach. Campaigns for this audience would do well to publicise the more tangible effects of smoking on skin ageing or fertility. We urge that more cities adopt a no-smoking policy so that social smoking will become more difficult, which might lead children to choose never to smoke. A report in The Lancet on the global burden of disease estimated that 6·3 million deaths were attributable to tobacco smoking in 2010. As we are learning in other areas of medicine, a one-size strategy doesn’t fit all, and smoking cessation therapy should be tailored to the individual. The blame culture towards smokers is not constructive, and more supportive tobacco cessation strategies must remain at the forefront of public health policy and funding. ■ The Lancet Respiratory Medicine
Steve Vowles/Science Photo Library
Smoking—still trying to kick the habit
See Review page 241 See Series Lancet 2013; 381: 1570, 1581, and 1588 For more on smoking and absence from work see Addiction 2013; 108: 307 For the CDC report on smoking see http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6144 a2.htm?s_cid=mm6144a2_e For more on adult smoking rates in New York City see http://www. nyc.gov/html/doh/downloads/ pdf/epi/databrief12.pdf For more on teenage smoking rates in New York City see http:// www.nyc.gov/html/doh/html/ data/youth-risk-behavior.shtml For the Cancer Research UK report see http://www. cancerresearchuk.org/cancerinfo/cancerstats/types/lung/ smoking/lung-cancer-andsmoking-statistics#children For the Global Burden of Disease study see Articles Lancet 2012; 380: 2224–60
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In today’s society, it’s difficult to understand why anyone would start smoking. Cigarettes have become increasingly expensive in developed countries as governments raise taxes, with the average cost of 20 cigarettes approaching £8 in the UK, and around $12 in New York City, which has the highest cigarette taxes in the USA. There are graphic warnings splashed across packets telling purchasers that smoking kills, and also providing a plethora of information explaining how smoking will reduce both a person’s lifespan and their quality of life. Why then do people continue to take up the habit, and crucially, how can the number of current smokers be reduced? The effect of nicotine as an addictive substance is well known, and the physical cravings felt by smokers makes quitting difficult. However, there are several other likely behavioural drivers that also perpetuate the cycle of smoking. Cigarettes are often linked in peoples’ minds to relaxation and reward, and can constitute a social crutch, giving confidence in difficult situations. It is essential to address both addictive and behavioural aspects, if any attempts to quit are to be successful. Highlighting the importance of this area, Nancy Rigotti summarises the latest research on smoking cessation in a Review in this month’s issue of The Lancet Respiratory Medicine. The proven benefits of pharmacotherapy, as well as counselling and behavioural support, are discussed alongside the need for further work to target smokers who are not ready to quit, and to improve long-term cessation rates. Such efforts are crucial to reduce the more than a billion smokers estimated worldwide. This paper will also be presented at the May 2013 ATS conference in Philadelphia as part of a joint symposium with The Lancet on global efforts for tobacco control. Rather than making the effort to tease out the individual drivers behind smoking, another strategy is to penalise smokers as a group through higher taxes on cigarettes, higher medical insurance rates, and, perhaps most controversially, employers choosing not to hire people who smoke. WHO have adopted the latter policy, and justifies its decision as being in keeping with an organisation that is at the forefront of the global campaign to curb the tobacco epidemic. However, although the argument of upholding a uniform policy against tobacco is valid, there could be other reasons for such strict employment criteria, such as avoiding www.thelancet.com/respiratory Vol 1 May 2013
increased healthcare costs and reduced productivity in employees who smoke—a meta-analysis by the University of Nottingham showed that current smokers had a 33% increase in risk of absenteeism compared with nonsmokers. Excluding a qualified candidate because they smoke could be the start of a slippery slope. Public health campaigns are now targeting other lifestyle choices such as diet, exercise, and alcohol consumption, which are also known to have an effect on one’s health and incurred healthcare costs. Will these people also end up subject to employment restrictions? A 2012 report by the Centers for Disease Control and Prevention on smoking in adults in the USA also showed that people below the poverty line, those with a lower level of education, and those with disabilities, were more likely to smoke. As such, measures to penalise smokers could disproportionately affect those most in need. Efforts may be better directed to discouraging young people from taking up smoking. As New York City celebrates the 10-year anniversary of its smoking ban in indoor public places and announces a drop in adult smoking rates from 22% in 2002 to 14% in 2010, less has been said about the fact that the rate of teenage smoking has plateaued at 8·5% since 2007. This worrying finding is mirrored in the UK, where a report from Cancer Research UK has shown that despite a general decline in teenage smoking from 2000 to 2011, the number of teenagers aged 11–15 years starting to smoke increased by 50 000 from over 156 000 in 2010 to over 207 000 in 2011. Tackling this age group, for whom the thought of dying early seems a very distant threat, needs a different approach. Campaigns for this audience would do well to publicise the more tangible effects of smoking on skin ageing or fertility. We urge that more cities adopt a no-smoking policy so that social smoking will become more difficult, which might lead children to choose never to smoke. A report in The Lancet on the global burden of disease estimated that 6·3 million deaths were attributable to tobacco smoking in 2010. As we are learning in other areas of medicine, a one-size strategy doesn’t fit all, and smoking cessation therapy should be tailored to the individual. The blame culture towards smokers is not constructive, and more supportive tobacco cessation strategies must remain at the forefront of public health policy and funding. ■ The Lancet Respiratory Medicine
Steve Vowles/Science Photo Library
Smoking—still trying to kick the habit
See Review page 241 See Series Lancet 2013; 381: 1570, 1581, and 1588 For more on smoking and absence from work see Addiction 2013; 108: 307 For the CDC report on smoking see http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6144 a2.htm?s_cid=mm6144a2_e For more on adult smoking rates in New York City see http://www. nyc.gov/html/doh/downloads/ pdf/epi/databrief12.pdf For more on teenage smoking rates in New York City see http:// www.nyc.gov/html/doh/html/ data/youth-risk-behavior.shtml For the Cancer Research UK report see http://www. cancerresearchuk.org/cancerinfo/cancerstats/types/lung/ smoking/lung-cancer-andsmoking-statistics#children For the Global Burden of Disease study see Articles Lancet 2012; 380: 2224–60
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