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EDITORIAL
doi:10.1111/add.12575
Supporting economically disadvantaged tobacco users to help them stop: time to review priorities? Support for cessation is not accessible to most tobacco users, especially those living in low- and middle-income countries. Researching and implementing smoking cessation interventions in low- and middle-income countries could play a major role in reducing global health inequalities.
More than a billion people in the world use tobacco. Most of these people smoke cigarettes on a daily basis and 70% of them live in low- and middle-income countries [1]. However, availability and access to cessation support is limited mainly to smokers living in high-income countries—a good example of the ‘inverse care law’ [2]. Recognizing the strong addictive properties of tobacco, article 14 of the 2003 World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) obliges its signatory countries to provide cessation support to those who want to quit tobacco use [3]. It further argues that providing cessation support increases social acceptability and public support for other tobacco control measures. In 2010, guidelines on the implementation of article 14 were issued that outlined the infrastructure and system changes required to provide cessation support [4]. Despite this, only a handful of low- and middleincome countries have the basic infrastructure and systems in place to offer cessation support to tobacco users [5]. According to a recent survey, only a quarter of low-income countries have an official national tobacco cessation strategy; one-fifth have an official responsible for it; one-tenth have treatment guidelines; none have an identified budget for cessation; 5% have quit-lines (telephone helplines to support quitting); and few have any specialist behavioural support [5]. Since the inception of the WHO FCTC, there has been an understandable emphasis on driving tobacco demand down by making its consumption less attractive, less affordable and more socially unacceptable. Therefore, policies considered as ‘best buys’, including increasing taxes on tobacco, campaigns and warnings to raise awareness about the harms of tobacco use, legislations to create smoke-free public and work-places and comprehensive bans on tobacco advertising and promotion, have received higher priority [6]. However, neglecting support for cessation will cost lives, particularly among heavier smokers with higher levels of dependence, and it is likely that it will widen health inequalities within these © 2014 Society for the Study of Addiction
countries, as those who can stop tobacco use manage to do so leaving a preponderance of those who cannot do so without help to suffer the health consequences. An important issue when it comes to assessing the usefulness of cessation support in low- and middleincome countries is a lack of directly applicable evidence. Almost all trials are in high-income countries and focus on smoking. Smokeless tobacco is consumed by a quarter of a billion people living in South Asia, yet there is very little evidence on cessation support interventions in this population. Moreover, nicotine replacement therapy, a cornerstone of pharmacotherapy, has so far failed to show a significant treatment effect in low-income settings [7]. It may be that low-cost, wide-reaching interventions such as text messaging and low-cost medications such as cytisine could address the need [8,9]. A recent Cochrane review of studies evaluating use of mobile phones in tobacco cessation concluded that such approaches can be beneficial, and recommended their further evaluation in low-income settings [10]. While setting up specialist centres would be costly and require an infrastructure that does not currently exist, integrating tobacco cessation within existing public health programmes is feasible and could be highly costeffective. Patients with tuberculosis and HIV generally tend to be poorer and have a higher smoking prevalence than the general population. Training health professionals dealing with such patients in behavioural support treatment for tobacco cessation offers an effective and feasible solution [11,12]. Other broader approaches to cessation such as introducing teaching on cessation treatment in undergraduate medical curricula and community-based cessation approaches have also been tried in India and Indonesia [13]. The WHO FCTC guidelines on article 14 offer a helpful framework to make health infrastructure and systems changes to offer cessation support to tobacco users. Partner countries are also obliged to develop countryspecific treatment guidelines. However, no ‘core guidelines’ on treating tobacco dependence were provided in this regard [14]. In order to address the existing treatment gap in tobacco dependence, this editorial calls for two specific actions. The first is for WHO to help build expert consensus guidelines on the most feasible, costeffective, accessible and equitable cessation interventions for low- and middle-income settings. The second is for WHO FCTC signatory governments to prioritize and Addiction, 109, 1221–1222
1222
Editorial
donor agencies to support wider provision of these interventions. Equally important is the need for rigorous evaluations of interventions in low- and middle-income settings to establish support that is particularly well suited to those cultures and settings. It is unrealistic to expect the countries to fund such research, but high-income countries, the highest of whom owe their income level to exploitation of poorer nations, arguably have a moral obligation to make such a research a greater priority. Declaration of interests None. Keywords Cessation, dependence, guidelines, lowand middle-income countries, smoking, tobacco. KAMRAN SIDDIQI
Department of Health Sciences, University of York and Hull York Medical School, ARRC Building, Heslighton, York YO10 5DD, UK. E-mail: [email protected] References 1. Ng M., Freeman M. K., Fleming T. D., Robinson M., Dwyer-Lindgren L., Thomson B. et al. Smoking prevalence and cigarette consumption in 187 countries, 1980–2012. JAMA 2014; 311: 183–92. 2. Eriksen M., Mackay J., Ross H. The Tobacco Atlas, 4th edn. Atlanta, GA: World Lung Foundation; 2012. 3. World Health Organization. WHO Framework Convention on Tobacco Control. 2003. Available at: http://www.who.int/ fctc/text_download/en/ [accessed 25 April 2014] (Archived at http://www.webcitation.org/6P5tGa042 on 25 April 2014).
© 2014 Society for the Study of Addiction
4. World Health Organization. Guidelines for implementation of Article 14 of the WHO Framework Convention on Tobacco Control. 2010. 5. Pine-Abata H., McNeill A., Murray R., Bitton A., Rigotti N., Raw M. A survey of tobacco dependence treatment services in 121 countries. Addiction 2013; 108: 1476–84. 6. Mackay J. M., Bettcher D. W., Minhas R., Schotte K. Successes and new emerging challenges in tobacco control: addressing the vector. Tob Control 2012; 21: 77–9. 7. Ward K. D., Asfar T., Al Ali R., Rastam S., Weg M. W., Eissenberg T. et al. Randomized trial of the effectiveness of combined behavioral/pharmacological smoking cessation treatment in Syrian primary care clinics. Addiction 2013; 108: 394–403. 8. Zhu S. H., Lee M., Zhuang Y. L., Gamst A., Wolfson T. Interventions to increase smoking cessation at the population level: how much progress has been made in the last two decades? Tob Control 2012; 21: 110–8. 9. West R., Zatonski W., Cedzynska M., Lewandowska D., Pazik J., Aveyard P. et al. Placebo-controlled trial of cytisine for smoking cessation. N Engl J Med 2011; 365: 1193– 200. 10. Whittaker R., McRobbie H., Bullen C., Borland R., Rodgers A., Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2012; 11: CD006611. 11. Lifson A. R., Lando H. A. Smoking and HIV: prevalence, health risks, and cessation strategies. Curr HIV/AIDS Rep 2012; 9: 223–30. 12. Siddiqi K., Khan A., Ahmad M., Dogar O., Kanaan M., Newell J. N. et al. Action to stop smoking in suspected tuberculosis (ASSIST) in Pakistan: a cluster randomized, controlled trial. Ann Intern Med 2013; 158: 667–75. 13. Nichter M., for the Project Quit Tobacco International G. Introducing tobacco cessation in developing countries: an overview of Project Quit Tobacco International. Tob Control 2006; 15: i12–7. 14. Wen C. P., Tsai M. K., Hsu C. C. Commentary on Pine-Abata et al. (2013): cessation guideline—to develop or not to develop? A question for each developing country. Addiction 2013; 108: 1485–6.
Addiction, 109, 1221–1222
EDITORIAL
doi:10.1111/add.12575
Supporting economically disadvantaged tobacco users to help them stop: time to review priorities? Support for cessation is not accessible to most tobacco users, especially those living in low- and middle-income countries. Researching and implementing smoking cessation interventions in low- and middle-income countries could play a major role in reducing global health inequalities.
More than a billion people in the world use tobacco. Most of these people smoke cigarettes on a daily basis and 70% of them live in low- and middle-income countries [1]. However, availability and access to cessation support is limited mainly to smokers living in high-income countries—a good example of the ‘inverse care law’ [2]. Recognizing the strong addictive properties of tobacco, article 14 of the 2003 World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) obliges its signatory countries to provide cessation support to those who want to quit tobacco use [3]. It further argues that providing cessation support increases social acceptability and public support for other tobacco control measures. In 2010, guidelines on the implementation of article 14 were issued that outlined the infrastructure and system changes required to provide cessation support [4]. Despite this, only a handful of low- and middleincome countries have the basic infrastructure and systems in place to offer cessation support to tobacco users [5]. According to a recent survey, only a quarter of low-income countries have an official national tobacco cessation strategy; one-fifth have an official responsible for it; one-tenth have treatment guidelines; none have an identified budget for cessation; 5% have quit-lines (telephone helplines to support quitting); and few have any specialist behavioural support [5]. Since the inception of the WHO FCTC, there has been an understandable emphasis on driving tobacco demand down by making its consumption less attractive, less affordable and more socially unacceptable. Therefore, policies considered as ‘best buys’, including increasing taxes on tobacco, campaigns and warnings to raise awareness about the harms of tobacco use, legislations to create smoke-free public and work-places and comprehensive bans on tobacco advertising and promotion, have received higher priority [6]. However, neglecting support for cessation will cost lives, particularly among heavier smokers with higher levels of dependence, and it is likely that it will widen health inequalities within these © 2014 Society for the Study of Addiction
countries, as those who can stop tobacco use manage to do so leaving a preponderance of those who cannot do so without help to suffer the health consequences. An important issue when it comes to assessing the usefulness of cessation support in low- and middleincome countries is a lack of directly applicable evidence. Almost all trials are in high-income countries and focus on smoking. Smokeless tobacco is consumed by a quarter of a billion people living in South Asia, yet there is very little evidence on cessation support interventions in this population. Moreover, nicotine replacement therapy, a cornerstone of pharmacotherapy, has so far failed to show a significant treatment effect in low-income settings [7]. It may be that low-cost, wide-reaching interventions such as text messaging and low-cost medications such as cytisine could address the need [8,9]. A recent Cochrane review of studies evaluating use of mobile phones in tobacco cessation concluded that such approaches can be beneficial, and recommended their further evaluation in low-income settings [10]. While setting up specialist centres would be costly and require an infrastructure that does not currently exist, integrating tobacco cessation within existing public health programmes is feasible and could be highly costeffective. Patients with tuberculosis and HIV generally tend to be poorer and have a higher smoking prevalence than the general population. Training health professionals dealing with such patients in behavioural support treatment for tobacco cessation offers an effective and feasible solution [11,12]. Other broader approaches to cessation such as introducing teaching on cessation treatment in undergraduate medical curricula and community-based cessation approaches have also been tried in India and Indonesia [13]. The WHO FCTC guidelines on article 14 offer a helpful framework to make health infrastructure and systems changes to offer cessation support to tobacco users. Partner countries are also obliged to develop countryspecific treatment guidelines. However, no ‘core guidelines’ on treating tobacco dependence were provided in this regard [14]. In order to address the existing treatment gap in tobacco dependence, this editorial calls for two specific actions. The first is for WHO to help build expert consensus guidelines on the most feasible, costeffective, accessible and equitable cessation interventions for low- and middle-income settings. The second is for WHO FCTC signatory governments to prioritize and Addiction, 109, 1221–1222
1222
Editorial
donor agencies to support wider provision of these interventions. Equally important is the need for rigorous evaluations of interventions in low- and middle-income settings to establish support that is particularly well suited to those cultures and settings. It is unrealistic to expect the countries to fund such research, but high-income countries, the highest of whom owe their income level to exploitation of poorer nations, arguably have a moral obligation to make such a research a greater priority. Declaration of interests None. Keywords Cessation, dependence, guidelines, lowand middle-income countries, smoking, tobacco. KAMRAN SIDDIQI
Department of Health Sciences, University of York and Hull York Medical School, ARRC Building, Heslighton, York YO10 5DD, UK. E-mail: [email protected] References 1. Ng M., Freeman M. K., Fleming T. D., Robinson M., Dwyer-Lindgren L., Thomson B. et al. Smoking prevalence and cigarette consumption in 187 countries, 1980–2012. JAMA 2014; 311: 183–92. 2. Eriksen M., Mackay J., Ross H. The Tobacco Atlas, 4th edn. Atlanta, GA: World Lung Foundation; 2012. 3. World Health Organization. WHO Framework Convention on Tobacco Control. 2003. Available at: http://www.who.int/ fctc/text_download/en/ [accessed 25 April 2014] (Archived at http://www.webcitation.org/6P5tGa042 on 25 April 2014).
© 2014 Society for the Study of Addiction
4. World Health Organization. Guidelines for implementation of Article 14 of the WHO Framework Convention on Tobacco Control. 2010. 5. Pine-Abata H., McNeill A., Murray R., Bitton A., Rigotti N., Raw M. A survey of tobacco dependence treatment services in 121 countries. Addiction 2013; 108: 1476–84. 6. Mackay J. M., Bettcher D. W., Minhas R., Schotte K. Successes and new emerging challenges in tobacco control: addressing the vector. Tob Control 2012; 21: 77–9. 7. Ward K. D., Asfar T., Al Ali R., Rastam S., Weg M. W., Eissenberg T. et al. Randomized trial of the effectiveness of combined behavioral/pharmacological smoking cessation treatment in Syrian primary care clinics. Addiction 2013; 108: 394–403. 8. Zhu S. H., Lee M., Zhuang Y. L., Gamst A., Wolfson T. Interventions to increase smoking cessation at the population level: how much progress has been made in the last two decades? Tob Control 2012; 21: 110–8. 9. West R., Zatonski W., Cedzynska M., Lewandowska D., Pazik J., Aveyard P. et al. Placebo-controlled trial of cytisine for smoking cessation. N Engl J Med 2011; 365: 1193– 200. 10. Whittaker R., McRobbie H., Bullen C., Borland R., Rodgers A., Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2012; 11: CD006611. 11. Lifson A. R., Lando H. A. Smoking and HIV: prevalence, health risks, and cessation strategies. Curr HIV/AIDS Rep 2012; 9: 223–30. 12. Siddiqi K., Khan A., Ahmad M., Dogar O., Kanaan M., Newell J. N. et al. Action to stop smoking in suspected tuberculosis (ASSIST) in Pakistan: a cluster randomized, controlled trial. Ann Intern Med 2013; 158: 667–75. 13. Nichter M., for the Project Quit Tobacco International G. Introducing tobacco cessation in developing countries: an overview of Project Quit Tobacco International. Tob Control 2006; 15: i12–7. 14. Wen C. P., Tsai M. K., Hsu C. C. Commentary on Pine-Abata et al. (2013): cessation guideline—to develop or not to develop? A question for each developing country. Addiction 2013; 108: 1485–6.
Addiction, 109, 1221–1222
