Smoking cessation

Quitting tobacco use has many benefits for both individuals and society.

For individuals, quitting at any point in life provides both immediate and long-term benefits to health. Within a day of quitting, a smoker’s carbon monoxide levels approximate those of a nonsmoker. Women who stop smoking before pregnancy have babies with the same birth weight as those of mothers who never smoked. In addition, quitting has clear economic benefits: for a 40-year-old smoker, the lifetime costs of smoking are estimated to be US$ 20 000–56 000 (smoking less than 1 pack of cigarettes a day or more than 2 packs, respectively).

The United Kingdom provides examples of the burdensome cost of smoking to society. Treating smoking-related illnesses in England is estimated to have cost the National Health Service (NHS) £2.7 billion per year in 2006–2007: more than £50 million each week. In 2009, smoking accounted for 5% of all hospital admissions of adults aged 35 and over in England (462 000). Illnesses among children from exposure to secondhand smoke cause an estimated 300 000 visits to general practitioners and about 9500 hospital admissions in the United Kingdom each year.

While the taxation of tobacco in the United Kingdom contributes around £10 billion annualy, the overall economic costs of tobacco use to society have been estimated to be £13.74 billion. These societal costs comprise not only treatment of smoking-related illness but also the loss in productivity from smoking breaks and increased absenteeism, the costs of cleaning up cigarette butts and fighting smoking-related house fires, and the loss of economic output from people who die from diseases related to smoking or exposure to secondhand smoke.

Smokers want to quit

Recent surveys – the Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) – reveal great opportunity for smoking cessation among both young people and adults. Key GYTS findings in over 30 countries in the WHO European Region show that about 7 out of 10 smokers aged 13–15 years expressed interest in quitting.

Among adults in the four European countries participating in GATS, more than half of current smokers were interested in quitting: 50.1% in Poland, 53.0% in Turkey, 60.3% in the Russian Federation and 67.9% in Ukraine.

Shared commitment to quitting

Smoking cessation requires commitment shared by individuals and national authorities. Along with an individual approach, a supportive environment is needed to encourage tobacco consumers in their attempts to quit. According to information collected for the “WHO global report on the tobacco epidemic, 2009”, about 87% of countries in the WHO European Region allow nicotine replacement therapies (NRTs) to be sold, but only about 40% offer toll-free quitlines.

The evidence shows that, in any setting, pharmaceutical treatment (NRT and/or bupropion) approximately doubles success rates. Nevertheless, only three countries fully cover and four partially cover the cost of NRTs through national/federal health insurance or the national health service. This clearly puts low-income smokers at a disadvantage.

Barriers to quitting

Inequities in vulnerability and exposure to tobacco use are most evident at two stages in life:

• adolescence, when those with lower socioeconomic status are most at risk of taking up tobacco; and
• young adulthood, when successful attempts to quit follow a steep socioeconomic gradient and are more difficult for those from disadvantaged backgrounds.

For example, 60% of the most affluent smokers in the United Kingdom have succeeded in quitting, compared to 15% of the poorest. This pattern is repeated across the WHO European Region: people in the lower social strata have a significantly higher risk of dying from smoking than those in the highest social strata: in the case of Poland, the risk is more than four times greater.

Higher levels of nicotine addiction are one of the factors that make disadvantaged groups more likely to fail to quit. Disadvantaged people are likely to start smoking at a younger age and have less access to cessation services. Unfortunately, as a very recent ACCESS (Access strategies for teen smoking cessation in Europe) study of 10 partner countries in the European Union shows, the development of smoking-cessation interventions for young people has been neglected.

Further, the Global Health Professions Student Survey (GHPSS – conducted in over 25 countries in the WHO European Region) revealed that the vast majority of third-year medical, dental, nursing and/or pharmacy students had not received any formal training on counselling or treating patients to quit using tobacco. This large gap in the training curriculum contributes to the new GATS findings: that many health workers do not ask smokers about their habit or encourage them to quit. According to the GATS results, half of adult smokers in Ukraine who visited a health professional in the last year were not even asked whether they smoked. Even more startling, only 31.8% of smokers in the Russian Federation (34.2% of men and 27.5% of women) who had been asked about smoking by a health professional were actually advised to quit.

Another barrier is that the only health-system-wide programmes that include smoking cessation are those for maternal health. Tobacco-control messages in such programmes often focus on the health of the fetus, not the mother. This approach fails to support long-term quitting and increases relapse after childbirth. Further, cessation services and self-help materials often do not address women’s reasons for smoking and concerns about stopping, such as weight gain.

Action: maximizing opportunity

The WHO Framework Convention on Tobacco Control (WHO FCTC) stresses the importance of providing cessation services to tobacco users. These can reduce health inequities if designed to target current tobacco users from disadvantaged groups in ways that maximize access, appropriateness and effectiveness.

WHO/Europe, with the Centers for Disease Control and Prevention (CDC), increases countries’ capacity to design, implement and evaluate comprehensive national action plans on tobacco, and to monitor implementation of the WHO FCTC’s key articles, such as Article 14 on cessation services and support, through the Global Tobacco Surveillance System (GTSS). GTSS comprises the GYTS, GHPSS and GATS mentioned above, along with the Global School Personnel Survey.

In addition, WHO/Europe promotes the exchange of knowledge across the Region, and disseminates best practices and models for cessation through country field studies and publications. A recent publication, called “Empower women”, gives countries practical guidance in developing gender-sensitive policies and programmes, and describes tobacco-cessation initiatives taken in the Region. Some of these address the joint issues of gender sensitivity and low-income women smokers.