Expanding smoking cessation world-wide.

Abstract

Commentary to: Evaluating clinical stop-smoking services globally: towards a minimum data set Smoking cessation is the only practicable way to avoid a substantial proportion of tobacco deaths world-wide during the next few decades. Expanding cessation requires higher taxes and non-price interventions, but also much better monitoring of smoking cessation at the clinical and population level. Based on current smoking patterns, with approximately half of young men and one in 10 young women world-wide becoming smokers in early adult life, and most not stopping, annual tobacco deaths will rise from approximately 5 million in 2010 to more than 10 million a few decades from now 1-3, as the young smokers of today reach middle and old age. If current smoking patterns persist, tobacco will kill approximately 1 billion people this century, most in low- or middle-income countries (LMICs). In contrast, there were approximately 100 million deaths from tobacco in the 20th century, most of which were in developed countries 1, 2. The United Nations has endorsed the call for all countries to achieve a 30% reduction in the age-standardized death rates from non-communicable disease between ages 30 and 70 years between 2010 and 2030 4. Widespread cessation of smoking is the most important way to help achieve this goal, as continuing to smoke throughout adult life increases mortality from several major non-communicable diseases (and from tuberculosis) 1-3, 5. Compared to the relatively slow increase in smoking-attributable mortality following the uptake of smoking, the effects of cessation emerge reasonably rapidly. Those who begin smoking in early adult life but stop before age 40 avoid more than 90% of the excess risk during their next few decades of life compared to those who continue to smoke. Even those who stop at age 50 avoid more than half the risk, although some risks persist 6-9. The prevalence of ex-smoking in middle age is a useful measure of the success of tobacco control. In the European Union and the United States, there are now at least as many former as current smokers between the ages of 45 and 64 3, 10. Between 1990 and 2005, France tripled its inflation-adjusted cigarette prices by raising excise taxes substantially, and in so doing halved cigarette consumption 1. Today, the ratio of former smokers to current smokers in France is greater than the European average 10. In contrast, in most LMICs (with the notable exception of Brazil) there are far fewer former than current smokers (Table 1) 3. Tobacco cessation in LMICs has not been well studied. An analysis of the Global Adult Tobacco Surveys 11 found that cessation was associated with common tobacco control tools, namely price and non-price interventions 12. Higher rates of exposure to work-site smoking bans, exposure to anti-smoking media messaging, warning labels and higher cigarette or bidi (in South Asia) prices were also associated with higher odds of recent quit attempts 11. Throughout the world, most former smokers manage to quit unaided, but physician support or telephone-based or internet-based counseling and support can increase the likelihood of success. In motivated individuals, pharmacological treatments can also increase quit rates 3, 12. Skinner and colleagues 13 propose a minimal data set that can be used to guide and monitor cessation programs in clinical populations at the national level. Their proposal applies mainly to populations accessing clinical-based guidance and cessation programs. As such, it is more relevant to cessation support in high- or middle-income countries, where clinical services are better organized than in lower-income countries. Their minimal data set is a useful contribution to considering how to standardize cessation monitoring. In addition to improve monitoring of cessation among clinical patients, complementary efforts to build population-level metrics for cessation are required. Better population-based monitoring would include more effective reporting of ex-smoking prevalence in middle age, including by levels of education or income 14. The reduction in diseases from cessation can also help to accelerate demand for cessation services. However, cessation remains relatively uncommon in most LMICs, and it is therefore difficult to estimate the benefits of reducing specific diseases in these settings. Hence, the current quantified benefits of cessation are quantified mainly in high-income countries 6-9. As cessation rates rise in LMICs, epidemiological studies will be required to quantify their benefits 5. Cessation is the only practicable way to avoid a substantial proportion of tobacco deaths before 2050, as a substantial reduction by 2025 in uptake by adolescents will have its main effect on mortality rates after 2050 1-3, 12. Thus, efforts to expand the monitoring of smoking cessation at the clinical and population levels should be considered global health priorities. None.