New quitters only just replace the proportion of
those who relapse or die. The tobacco industry has long known how few smokers
quit, which is why it seldom opposes smoking cessation programming. According
to tobacco industry monitoring data, from 1971 to 1991, people who managed to
stay quit for one year as a percentage of ever-smokers was almost always in the
very narrow range of 1–2% per year. The lowest value was 0.4% in 1983 and the
highest was 2.2% in 1976 (Imperial Tobacco Ltd., 1991). More recent, but
similar low rates of quitting in Ontario were reported by the Ontario Tobacco
Research Unit (OTRU; 2016). During the period 2007–2014, annualized quit rates
were reported to be in the range of 1.3–2.2%.
Still, people do
successfully quit, eventually. It may take them many tries, but many are
successful. By 2014, there were about twice as many former smokers as current
smokers in Canada, as illustrated above. (Physicians for a Smoke_Free Canada, 2016).
How do people quit? Most
successful quitters do so on their own. In Ontario in 2014, only 1.7% of smokers
succeeded in quitting for a full year, and most of these quit on their
own. About two-thirds of those
successful quitters did not use any of the ten cessation services evaluated by
OTRU (OTRU; 2016). Currently, about
two-thirds to three-quarters of Americans who quit do so on their own (Chapman & Mackenzie, 2010). Looking back in
time, the figures are even higher. In 1986, it was estimated that over 90% of
Americans who had quit smoking up to that point in time had done so on their
own (American Cancer Society, 1986). In earlier years, less assistance
for smoking cessation was available.
Most people quit on their own.
But what of the others, those who do seek
assistance for smoking cessation? How successful are they? Nicotine replacement
therapy (NRT) is a popular form of providing smoking cessation assistance and a
Cochrane review of over 130 studies found that NRT achieved a success rate that
was 50–70% greater than that achieved with placebo (Stead et al.,2012). However,
there are sound reasons to believe that this apparent success is not maintained
when the therapy moves from the research environment to the real world. John
Pierce and his colleagues reported that after three or more months of
follow-up, Americans who quit smoking on their own had slightly higher success
rates than those who used NRT or some other form of assistance. Among heavy
smokers, the NRT three-month success rates was 9%, compared with 15% among
those who quit unassisted (Pierce et al., 2012).
Cessation programs have neither broad reach nor
outstanding success rates. The Ontario government provides support to 10
different smoking cessation programs. These programs all use well-established
forms of assistance of proven worth. They range from minimal interventions like
helplines to intensive system-wide interventions in health care settings. Their
reach and effectiveness were carefully evaluated. Collectively they reached
139,000 people—about 7% of all Ontario smokers. Of these, it was estimated that
about 12,000 actually quit smoking, which amounts to only about 0.6% of all
smokers in Ontario (OTRU, 2016). Ten government-supported forms of smoking
cessation assistance yielded a barely perceptible increase in the number of
people in Ontario who successfully quit smoking.
Many have been hopeful that electronic
cigarettes (e-cigarettes) would help people quit smoking. However, the evidence is not
encouraging. Those who use e-cigarettes
every day, particularly the newer tank systems, do show modest rates of success
at quitting cigarette smoking. However,
in the United States daily e-cigarette users account for only 19% of the users
of these products. (Berry et al., 2018). When the overall picture is
considered, taking into account all users of e-cigarettes, the evidence shows
that e-cigarettes depress smoking cessation behaviour. Moreover, they serve as
a gateway drug. Young users of
e-cigarettes are more likely to take up regular smoking. (Glantz and Bareham,2018).
The picture is bleak. Smoking cessation rates
are low. Few people use assistance, and assistance is not very helpful. E-cigarettes, a hoped-for solution to tobacco
addiction are proving to be anything but.
The weight of evidence shows that, a population level, they depress
quitting and serve as a gateway drug to regular cigarette smoking.
Yet no comprehensive tobacco control programs
will be credible unless it includes smoking cessation programming. Even if smoking
cessation is one of the least effective tobacco control measures, it is a
necessary part of a comprehensive tobacco control policy. Indeed Article 14 of the Framework Convention
on Tobacco Control obliges Parties to provide smoking cessation programs.
The Canadian federal, territorial and provincial governments all fund smoking cessation programs. While funding for these programs should continue, we should not expect them to be more successful in the future than they have been in the past. Progress towards the Canadian government's stated goal of achieving less than 5% tobacco use prevalence by 2035 will not be made by greatly increasing smoking cessation programming, but rather by strengthening other areas of comprehensive tobacco policies and programs. In future entries on this blog, we will explore some of these other ways that real progress could be made in tobacco control.
The Canadian federal, territorial and provincial governments all fund smoking cessation programs. While funding for these programs should continue, we should not expect them to be more successful in the future than they have been in the past. Progress towards the Canadian government's stated goal of achieving less than 5% tobacco use prevalence by 2035 will not be made by greatly increasing smoking cessation programming, but rather by strengthening other areas of comprehensive tobacco policies and programs. In future entries on this blog, we will explore some of these other ways that real progress could be made in tobacco control.
References
American Cancer Society. (1986).
Cancer facts and figures. Atlanta, GA. https://www.industrydocumentslibrary.ucsf.edu/tobacco/docs/#id=yxyk0154
Berry, K.M., Reynolds, L.M., Collins, J.M., et al. (2018). E-cigarette initiation and associated changes
in smoking cessation and reduction: the Population Assessment of Tobacco and
Health Study, 2013-2015. Tobacco Control.
http://dx.doi.org/110.1136/tobaccocontrol-2017-054108.
Chapman, S. & Mackenzie, R.
(2010). The global research neglect of unassisted smoking cessation: Causes and
consequences. PLoS Medicine, 7(2): http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000216.
Glantz, S.A. and Bareham, D.W. E-cigarettes: Use, effects on smoking, risks
and policy implications. (2018). Annual Review of Public Health. 39(28).
1-28.21. https://doi.org/10.1146/annurev-publhealth-040617-013757.
Imperial Tobacco Canada Ltd. (1991). The Canadian Tobacco Market at a Glance–December 1991. Montreal,
QC: Retrieved from Industry Documents Library website.
www.industrydocumentslibrary.ucsf.edu/tobacco/docs/lphb0223
Ontario Tobacco Research Unit. (2016). Smoke-Free Ontario Strategy Monitoring Report. Toronto.https://otru.org/2016-smoke-free-ontario-strategy-monitoring-report/
Pierce, J.P., Cummins, S.E., White,
M.M., Humphrey, A. & Messer, K. (2012). Quitlines and nicotine replacement
for smoking cessation: Do we need to change policy? Annual
Review of Public Health, 33, 341–356. https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031811-124624
Physicians for a Smoke-Free Canada (2016). Tobacco Use 2000-2014: Insights from the Canadian Community Health Survey. http://www.smoke-free.ca/CCHS/InsightsfromtheCCHS-2016.pdf
Stead, L.F., Perera, R., Bullen, C.,
Mant, D., Hartmann-Boyce, J., Cahill, K. & Lancaster, T. (2012). Can
nicotine replacement therapy (NRT) help people quit smoking? Cochrane Database of Systematic Reviews. Plain Language Summaries. http://www.cochrane.org/CD000146/TOBACCO_can-nicotine-replacement-therapy-nrt-help-people-quit-smoking
