Policy

1. treatobacco.net Policy

2. 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, USA Joe Gitchell Pinney Associates Inc, USA Natasha Herrera Centro Médico Docente la Trinidad, Venezuela Tai Hing Lam School of Public Health and Department of Community Medicine, University of Hong Kong, China Ann McNeillDivision of Epidemiology and Public Health, University of Nottingham, UK David Sweanor Smoking and Health Action Foundation, Canada

3. Purpose • To provide information on policies concerning the treatment of tobacco dependence and to signpost important policy documents.

4. Evidence Base • Based on evidence presented largely in the other databases. • Strength of evidence statements therefore not given.

5. Terminology 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, evidence-based interventions for tobacco dependence treatment.

6. Key Findings • Tobacco treatment essential for impact on public health within next 30 to 50 years.

7. 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 dependence. • 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

8. Key Finding 2: Diagnostic Publications • Two of the most widely used classifications of substance dependence: • 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

9. 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.

10. Unless Current Smokers Quit, Tobacco Deaths will Rise Dramatically in the Next 50 years — Baseline — If proportion of young adults taking up smoking halves by 2020 — If adult consumption halves by 2020 Estimated cumulative tobacco deaths 1950-2050 with different intervention strategies 520 500 500 400 340 300 Tobacco deaths (millions) 220 200 190 100 70 0 1950 2000 2025 2050 Year World Bank. Curbing the epidemic: Governments and the economics of tobacco control. World Bank Publications, 1999. p80.

11. 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 numerous: • tobacco product design and marketing • tobacco outlets are ubiquitous, and ease of purchase normalizes their use in society • many smokers are also highly over-optimistic about their likelihood of successful quitting.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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 curricula

17. 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 abstinence.

18. Key Finding 11 • Cessation attempts could be increased and smoking-related harm reduced by providing indication for NRT that includes concurrent use while reducing cigarette consumption.

19. 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 countries.

20. 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.

21. 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.

22. Key Finding 15 • To be most effective, tobacco control efforts should be truly comprehensive, and include a variety of interventions. • Packaging and labeling • Access to treatment • Taxation • Education • Smoke free policies

23. 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.

24. 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, 2013). • 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.

25. Recommendations • 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.

26. 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.

27. 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 quitting.

28. Areas for Future Research (cont.) • Research on the cost-effectiveness of tobacco dependence treatments, especially in lower-income countries. • 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.