Nicotine addiction is a chronic illness, and reducing the massive burden of death and disease associated with it will require matching individual treatments to patients, along with the necessary public health messages, concludes a Seminar in this week's edition of The Lancet. Future treatments in development include an antinicotine vaccine. And an accompanying Comment looks at the importance of a broad range of anti-tobacco strategies, and focuses on the importance of the implementation of The Framework for Tobacco Control.
In the Seminar, by Dr Dorothy Hatsukami, Tobacco Use Research Center, University of Minnesota, MN, USA and colleagues look at the startling death rates associated with smoking. There are around 1.2 billion smokers worldwide, more than half of whom will die from diseases caused by smoking. Roughly 5 million smokers die per year at present, though this could be 10 million per year by 2025 if present trends continue. Smoking prevalence varies greatly, from less than 5% to more than 55% in different countries. It also is generally much higher in men than women, so prevalence in both sexes needs to examined separately. 92% of the world's male population lives in countries where smoking prevalence in men is above 25%; by contrast, only about 10% of the world's female population lives in countries where female smoking prevalence is above 24%. In the UK and USA, male smoking prevalence is 25-35% and for women it is 14-24% in the USA, but above 24% - the highest category – in the UK. Examples of countries where smoking prevalence is above 55% in men include Russia and Kenya, while examples where it is above 24% for women include Brazil, Germany and Spain as well as the UK.
In the USA, although over 70% of smokers want to quit every year and 45% try to, less than 5% in the general population are successful. Treatment for nicotine addiction is a vital component that can enhance treatment success. Following recent US guidelines, the Seminar examines the role of counselling, eg, problem solving, coping and motivational skills. A wide range of nicotine-replacement therapies (NRTs), eg patches and gum, and non-nicotine products, along with the efficacy, side-effects and precautions for each, are discussed at length. The authors say: "Pharmacotherpaies for nicotine dependence can enhance quit rates by about two-three fold." Furthermore, The Seminar examined the improved rates of success in using combination nicotine patch and ad lib nicotine replacement products such as nicotine gum.
The authors also look at the limited benefits of cigarette reduction, which is also achieved more easily with the help of NRTs. But the authors say: "Smokers engage in substantial compensatory smoking – deeper inhalation per cigarette – so that a reduction of cigarette consumption of 50% or more results only in a 30% decrease in biomarkers for toxicant exposure." They conclude that the main benefit of cigarette reduction is that it may act as a stepping stone to stopping smoking completely.
New treatments in development are studied including a nicotine vaccine, which stimulates the immune system to develop antinictotine antibodies. Trials are at the preliminary stages for this. And large randomised trials have assessed the effect of the drug rimonabant on smoking cessation rates. Finally, pharmacogenetics – where treatment is matched to a patient based on their genetic profile – is also being examined as a possibility.
The authors conclude: "Nicotine or tobacco addiction should be treated as a chronic disorder. Treatment can need persistent efforts to try to assist tobacco users in their attempts at quitting. Relapse should be seen as a probable event …Treatment can improve these outcomes….The most crucial component of care is the actual delivery of such treatments."
In the accompanying Comment, Dr Kenneth Warner. School of Public Health, Ann Arbor, MI, USA, and Dr Judith Longstaff Mackay, Bloomberg Initiative to Reduce Tobacco Use, Hong Kong, China, discuss the importance of implementing The Framework Convention on Tobacco Control (FCTC), currently ratified by 154 countries. They conclude that the medical community needs to make treatment of tobacco dependence a high priority in everyday practice, and also to lobby governments - which are often conflicted by their own financial dependence on tobacco – to implement FCTC. They conclude: "Here is something simple, achievable, and unequivocally good that would relieve the suffering of literally millions of human beings."
For Dr Dorothy Hatsukami, Tobacco Use Research Center, University of Minnesota, MN, USA please contact Mary Lawson T) + 1 612-624-6165 E) hatsu001@umn.edu
Dr Kenneth Warner. School of Public Health, Ann Arbor, MI, USA contact by e-mail only E) kwarner@umich.edu
http://www.eurekalert.org/jrnls/lance/pdfs/Seminar p2027-2038 + Com 1976-78 June 14.pdf
Journal
The Lancet