Public Health and Smoking Cessation

Quitting the habit means fighting nicotine addiction. "It's not like drinking, where you have a huge social drinking population of nonaddicted people. People who smoke regularly tend to be addicted,"

By | March 24, 2003

Quitting the habit means fighting nicotine addiction. "It's not like drinking, where you have a huge social drinking population of nonaddicted people. People who smoke regularly tend to be addicted," says Timothy Baker, associate director, University of Wisconsin Center for Tobacco Research and Intervention.

With nearly half the US adult population lighting up in 2000, public-health researchers are hard-pressed to figure out what helps--and what doesn't--in the fight against nicotine addiction.

BIG BROTHER Laws and taxes. "The two things that have the biggest and most immediate effect on smoking are ... smoke-free workplaces and restaurants, and (cigarette) tax increases," says Stanton Glantz, director, Center for Tobacco Control Research and Education, University of California, San Francisco. For example, Glantz's recent paper1 showed that when workplaces become smoke-free, workers almost immediately smoke 29% fewer cigarettes per day. Glantz says getting such a dramatic effect through cigarette taxes could require increases of as much as $3 (US) per pack. (However, high taxes may increase crime. In October 2002, Canada Wire reported that Imperial Tobacco Canada blamed high cigarette taxes for a $2.6 million warehouse heist; the Libertarian Party also has long pointed to the link between high cigarette taxes and black-market crime.)

Although personal health warnings are not particularly effective, new in-your-face warning labels are grabbing smokers' attention; for example, Canadian cigarettes have labels showing rotting lungs and decaying teeth. "Those seem to work very well," says Glantz. In fact, a Canadian Cancer Society study showed that 44% of smokers said the gory warnings increased their motivation to quit. The extra-large labels cover nearly half the pack, a standard recommended by the recently finalized World Health Organization's Framework Convention on Tobacco Control. The treaty also supports restrictions on tobacco advertising, increasing taxes, government financing of tobacco control programs, and holding tobacco companies liable for costs related to tobacco use, according to the WHO Web site.

PHONES, PATCHES, AND SNUS Telephone-counseling "quit lines," which advise smokers on how to restructure their lives and deal with urges, are also helpful. "[Anti-smoking] drugs are always more effective if used in conjunction with counseling, and now people can get counseling without leaving their homes," says Baker.

Although these antismoking drugs can help smokers quit, they are not a runaway success. For example, the steady, continuous dose of nicotine from patches and gums does not compare to the nearly instantaneous impact of inhaled nicotine. Furthermore, when nicotine replacement therapy became available over the counter, its efficacy diminished. "These products are a multimonth program which have to be carefully guided," says Robert Naso, senior vice president of Nabi Biopharmaceuticals, a company that is developing a nicotine vaccine. "The efficacy is much lower than it ought to be, because people don't use them properly."

The new, so-called harm-reduction products are getting mixed reactions from public health officials. These can include "safer" cigarettes (see Can Science Make Cigarettes Safer?), novel nicotine products, and smokeless tobacco, such as low nitrosamine Snus from Sweden. "Snus is the most interesting harm-reduction story in the world," says Kenneth Warner, director, University of Michigan Tobacco Research Network. Perhaps because of its low cost compared to cigarettes, almost 30% of Swedish men use Snus. "The Swedish government has studied this stuff to death, and to date, there is no compelling evidence that it has any adverse health consequences. ... Whatever they eventually find out, it is dramatically less dangerous than smoking," says Warner.

But Warner is concerned about the products that appeal to kids. Cigalettes, for example, are a minty, compressed-tobacco candy that delivers a powerful nicotine jolt. He says kids may try the novel products for their strong kick and self-image appeal, but they could become addicted and graduate to smoking.

And even if they don't graduate to cigarettes, the youngsters still face the dangers of nicotine. Besides being an addictive substance, it increases blood pressure and heart rate. A 2001 study implicated nicotine in angiogenesis, a process tumors use to attract new blood vessels and that may contribute to vascular dysfunction in smokers.2

The funds from the US state tobacco settlement, won in 1998, were supposed to add their own strong kick to antismoking programs. But the majority of that funding, $8.7 billion alone in 2003, is not being spent on anything related to smoking. However, those states that are spending on cessation programs report some success. For example, Massachusetts, saw cigarette consumption drop 36% between 1992 and 2000, compared to just 16% for the rest of the country, excluding California.

Current deficit problems, however, could deter future antismoking successes. Facing budget woes, many states have cut spending on antismoking initiatives. Even Massachusetts cut its tobacco-spending program by 90% for 2003, according to the National Center for Tobacco-Free Kids. In fact, just four states--Maine, Maryland, Minnesota and Mississippi--are funding tobacco-prevention programs at the minimum levels recommended by the Centers for Disease Control and Prevention: 20% to 25% of a state's settlement proceeds.

Mignon Fogarty ( is a freelance writer in Santa Cruz, Calif.

1. C.M. Fichtenberg, S.A. Glantz, "Effect of smoke-free workplaces on smoking behaviour: systematic review," Brit Med J, 325:188, 2002.

2. C. Heeschen et al., "Nicotine stimulates angiogenesis and promotes tumor growth and atherosclerosis," Nature Med, 7:833-9, 2001.

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