Understanding Smokers' Daily Routines Key to Better Quit Rates

Kristin Jenkins

March 28, 2018

There's an urgent need to better understand why people start smoking, the barriers to quitting, and how to motivate one billion smokers worldwide to reduce their health risks, according to the head of a controversial new antismoking agency.

The World Health Organization (WHO) estimates that 7.2 million people die each year as a direct result of the negative health consequences of smoking, including lung cancer and other cancers. Unless more is done to prevent smoking globally, the WHO predicts that one billion people will die of tobacco-related diseases this century.

Results from a global survey of smoking suggest that quit rates could be higher if smoking cessation programs focused on the different behavioral, emotional, and social factors that act as key drivers for smoking in different cultures, said Derek Yach, MD, founder and president of the Foundation for a Smoke-Free World.

As previously reported by Medscape Medical News, Yach came under harsh criticism last year when the Foundation was launched with a 12-year, $80-million funding commitment from Phillip Morris International (PMI). Yach is a well-known antismoking crusader and is the primary architect of the WHO Framework Convention on Tobacco Control.

New Survey

Now, the Foundation is highlighting results from its State of Smoking 2018 survey of more than 17,000 current and former smokers in 13 countries, which show that smoking behavior is deeply embedded in the daily rituals and routines for waking, eating, drinking, and socializing.

This finding and others explain why focusing on the physiologic aspects of addiction, such as nicotine craving, "has not proven very successful at bringing an end to smoking worldwide," Yach stated during a March 19 press briefing in New York City.

Smoking cessation programs and products need to be customized for different groups in different economic conditions, Yach suggested. "In this age of personalized medicine, it is only logical that we should stop treating the world's smokers as one homogeneous group and start developing and embracing a wide range of solutions."

With this in mind, the Foundation will be redoubling its efforts to support the development of more effective smoking cessation programs and products, including smokeless products.

"The healthcare system needs to better engage with smokers, and medical providers need more effective tools to help smokers quit," said Yach. "The pipeline of smoking cessation products that actually work is very weak, and there has been no new drug [to help smokers quit] in the past 20 years. We have a huge job ahead of us if we want to reduce smoking rates in the next generation."

"We hope to accelerate the innovation of more effective products and services for smoking cessation," Yach told Medscape Medical News. "Over the next few months, we will be engaging with smokers, healthcare professionals, academics, policy makers, innovators, and investors in a range of countries. Our objective from this engagement is to better understand the drivers and barriers to innovation in this area, to then determine where the Foundation can make the most positive contribution."

When asked to comment, David Hammond, PhD, the Canadian Institutes of Health Research Applied Chair in Public Health at the University of Waterloo, Ontario, Canada, agreed that to quit smoking, it's important to consider contributing behavioral, emotional, and social factors. However, he also said that he did not see anything new in the survey's findings.

Hammond, who has served as an advisor to the WHO Framework Convention on Tobacco Control, emphasized that nicotine remains the fundamental factor in promoting and sustaining addiction.

"The survey feels as much like a public relations activity than an important research contribution," Hammond told Medscape Medical News. "If this global survey is a measure of the Foundation's contribution, I would suggest they have a long way to go before making novel contributions to the field."

Hammond added that there are "legitimate concerns about the independence of the Foundation in the way that it was established, particularly given PMI's well-established track record of undermining tobacco control interventions. Indeed, if PMI were truly committed to reducing smoking, they could cease their marketing activities and stop legal challenges to basic public health laws, including cigarette marketing restrictions."

Offering guidance and support is still one of the most effective things a clinician can do to help patients quit, Hammond said. "Ask and encourage them to quit, discuss the range of options available for support, and follow up on their smoking status," he said.

Writing a prescription for a medication to help a patient quit is more effective than instructing the patient to buy the same medication over the counter, he pointed out. "This is likely due to the advice and support that comes with clinical interactions," he said.

Clinicians should expect to be asked about e-cigarettes — and be ready to discuss them. More research is needed to determine whether e-cigarettes should be integrated into clinical practice guidelines, Hammond commented. He noted that e-cigarettes have become one of the most popular ways to try to quit smoking in many Western countries.

Many leading health agencies, including the Centers for Disease Control and Prevention and the American Cancer Society, have reached a consensus that e-cigarettes are less harmful than combustible cigarettes, Hammond said. e-Cigarettes are thought to reduce health risks by helping people to stop smoking completely, he noted.

"The evidence suggests that e-cigarettes can help with quitting smoking, although we don't know if they are more or less effective than other forms of nicotine replacement therapy. Also, smokers should completely stop smoking, rather than smoking and vaping, to ensure they reduce their health risks," Hammond said.

Survey Details

For the survey, interviews were conducted with 17,421 smokers, exsmokers, and nonsmokers in Brazil, France, Greece, India, Israel, Japan, Lebanon, Malawi, New Zealand, Russia, South Africa, the United Kingdom, and the United States. Focus groups were also carried out in France, Greece, India, New Zealand, South Africa, the United Kingdom, and the United States.

Findings show that 80% of smokers live in the developing world and that many are confused about the relative harms of smoking, what smoking cessation programs and products work best, and what are the less harmful alternatives to smoking, such as e-cigarettes.

In India, for example, 40% of those surveyed thought e-cigarettes were more harmful than smoking regular cigarettes. By comparison, in New Zealand and Japan, 71% and 70% of respondents, respectively, said smoking e-cigarettes and using vaping devices were less harmful than smoking regular cigarettes.

"Nonsmokers often warn smoking relatives not to switch, yet we know that there is a reduction in risk," pointed out Yach. "How do we correct these misconceptions?"

Smokers were also more likely than nonsmokers to have a partner or spouse who smokes and to have close friends who smoke. Smokers knew the risks to health of smoking and considered themselves less healthy than nonsmokers, yet did not visit physicians as often as nonsmokers.

The survey also shows that smokers don't understand the risks of nicotine and believe it is more harmful to health than alcohol, sugar, or caffeine. These factors can affect smokers' motivation to quit or to try alternative products that are associated with less risk, Yach pointed out.

The vast majority of smokers in most countries surveyed tried to quit without assistance, choosing to go "cold turkey." This may have something to do with the fact that more than 50% of people in almost every country surveyed thought that nicotine causes cancer, said Yach. Studies have shown that 93% of smokers who quit smoking cigarettes by using nicotine replacements relapse within 6 months of quitting, he noted.

"They believe that nicotine causes cancer, bronchitis, heart disease, tuberculosis, and emphysema or chronic obstructive pulmonary disease. These beliefs are contrary to evidencethat suggests that nicotine does not cause these diseases," Yach said.

Although the nicotine in cigarettes drives dependence and addiction, "there is general consensus" that most of the carcinogenic effects from smoking cigarettes come from burning tobacco, Yach said.

"What has changed over the last 20 years is our understanding of nicotine, and separating nicotine, which causes addiction, from combustion and tar, which kills. Smokers smoke because of the nicotine, but they die because of the smoke and the tar. It's the combustion that does most of the killing, not the nicotine," he said.

Smokers who sought help to quit smoking often turned to nicotine-replacement therapy and prescription medicines first, the survey reveals. However, nicotine replacement therapies such as the patches and gum often have low success rates because they do not deliver nicotine in a way that mimics smoking, said Yach.

In France, Greece, Japan, Lebanon, New Zealand, Russia, the United Kingdom, and the United States, smokers are using e-cigarettes and other nicotine replacement devices to cut down or quit smoking cigarettes, the survey shows. "The e-cigarettes are actually mimicking this far better, and that's why we're seeing higher uptake on these," Yach noted.

In Japan in particular, there's been a big drop in the use of combustible tobacco during the past 18 months, because many smokers have switched to e-cigarettes. "The people want a cleaner, fresher smoking experience, and using an e-cigarette allows them to socialize with friends," Yach said.

More research is needed to assess whether there is a role for e-cigarettes and vaping devices to help smokers transition from cigarettes to cessation, Yach said. He noted that 80% to 90% of the research on smoking cessation is carried out in the United States and the United Kingdom. "We need to build up these centers of excellence in the countries where different solutions are needed," he suggested.

"I hope this survey will jolt many of the world's one billion smokers into action to stop smoking, spark a meaningful discussion on the deeply complex reasons so many people continue to smoke, and make clear the urgent need to develop more effective communications and interventions to help smokers quit or substantially reduce their risks," Yach said.

Dr Hammond has disclosed no relevant financial relationships.

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