Should health care services provide treatment for addicted smokers?
Wednesday, March 04, 2009
Jonathan Foulds, MA, MAppSci, PhD
Professor Simon Chapman (University of Sydney) argued that cessation services devour resources that could be better used for anti-tobacco mass-media campaigns and that these services give people the impression that smokers are unlikely to succeed alone. He has argued before that smoking cessation clinics should be abandoned.
Professor John Britton (University of Nottingham) defended the role of smoking cessation services. He acknowledged that population-level interventions (e.g. laws banning smoking in public places) have a greater potential to impact population smoking prevalence, but argued that impacting population smoking prevalence is not their primary purpose (any more than chemotherapy for cancer aims to decrease the population prevalence of cancer). He pointed out that we need treatment for the most addicted smokers, that the evidence from England shows that very high numbers of smokers are willing to use services when available (680,000 in England last year), and that cessation services are one of the most cost-effective healthcare interventions available.
I think part of the problem here is the perception that within the tobacco control tools at our disposal “population impact” strategies and “individual treatment” strategies represent an either/or choice. Quite simply, they are not. There are plenty of places where activities to increase the price of tobacco, ban smoking in public places, etc occur simultaneously with activities to provide more smokers with treatment to help them quit smoking (e.g. the United Kingdom, or some U.S. states). The relevant population-impact policy here is to persuade healthcare systems to routinely provide brief and specialist tobacco treatment options.
It is usually the case that population level interventions have a larger population impact than individual clinical interventions. Whether that involves eradicating the breeding-grounds of malaria-carrying mosquitos near population centers, or building a water purification plant it does not follow that it’s a waste of time to use anti-malarial medicines or treat people who catch infections.
Comparing effective population-based public health interventions with effective clinical interventions is like comparing apples and broccoli. They are both good for you, and having both is better than just one or neither. If the argument is about the use of scarce resources then tobacco treatment services should be evaluated against other clinical services (e.g. the treatment of alcohol problems, hypertension, diabetes or breast cancer), rather population-based policy interventions. If Chapman believes tobacco treatment services should be abandoned on the grounds of cost-effectiveness (on measures such as cost per quality adjusted life year gained), then he should simultaneously be arguing that a vast number of clinical services should be abandoned first, as tobacco treatment has amongst the biggest bang for the clinical treatment buck.
I have the utmost respect for both John Britton and Simon Chapman as tobacco control experts. But in this debate I have to agree with Professor Britton. If one wants to reduce the harms to health caused by smoking, it makes more sense to argue for more population-based interventions AND more clinical interventions, so that those addicted smokers who are persuaded to try to quit can have a better chance of doing so successfully.
Some recent statistics from the English smoking cessation services can be found at:
http://www.ic.nhs.uk/webfiles/publications/Stop%20smoking%20ANNUAL%20bulletins/SSS0708/SSS%202007-08%20final%20format%20v2.pdf
For the rationale for comprehensive tobacco control:
http://www.healthline.com/blogs/smoking_cessation/2008/05/why-comprehensive-tobacco-control.html
For a description of what a specialist tobacco treatment clinic does:
http://www.healthline.com/blogs/smoking_cessation/2008/02/what-does-tobacco-treatment-clinic-do.html
Labels: cessation, cigarette smoking, John Britton, jonathan foulds, nicotine dependence treatment, public health, services, simon chapman
3 Comments:
At Sun Mar 08, 03:17:00 AM 2009,
Simon said…
Jon -- you have articulated one of the most common reactions to my Lancet piece -- the idea that there ought to be no contest between the perspectives of mine and that represented by John Britton: there is room for both.
The problem with this argument is essentially why I wrote the article. The balance is now very much in the direction of the tail (of assisted cessation) wagging the dog (of encouraging people to "just do it"). The public discourse on cessation is dominated by those offering help and, as I said, turbo-charged by massive big pharma advertising making the same point. Many in cessation are frank in saying that they believe NRT and other pharmacotherapy should be front line, and that cold turkey is "the enemy". I have heard a pharma exec use those exact words.
I have often been in low income nations and met with people involved in tobacco control. Invariably, most are running small cessation interventions of no consequence to population-wide impact at all. It seemsd tragic that the little energy that exists is so easily funneled into that sort of work in such situations.
My article has generated lots of discussion -- and that's great.
Simon Chapman
At Sun Apr 05, 05:15:00 PM 2009,
Jonathan Foulds, MA, MAppSci, PhD said…
Simon, I have some sympathy with your point of view when applied to countries that have only very basic tobacco control activities (e.g. unrestricted advertising, low tobacco costs/taxes, minimal smoke-free air legislation, minimal media campaigns), and perhaps only rudimentary funding for basic medical services.
In those countries the discussion about where scarce resources should be spent first is more complex.
However, in countries like the United States and the UK I simply don't see "treatment" as being the leading component of tobacco control, in fact quite the opposite. Many U.S. states provide little or no direct treatment for smokers, with the default option being the ability to call the national telephone quitline. Patients with insurance can typically get their hypertension, diabetes or asthma medicines covered, but not their tobacco treatment (whether that be counseling or medicines).
I see any quit attempt as a positive thing, regardless of wether it is unassisted or not and cold turkey is not "the enemy". There are so many smokers out there that it makes sense to encourage them to try to quit using broadly available forms of assistance in the first instance (eg telephone counseling, internet support, OTC NRT). But a proportion of smokers will find it very hard to quit even with that assistance but could benefit from specialist tobacco treatment services. Such treatment is more cost effective than most other healthcare interventions and so in arguing against them are you simultaneously arguing against funding these other medical (eg mammography, hypertension medicines, cholestorol meds etc). If you are not arguing against paying for these other interventions, why are you, a tobacco control advocate singling out an intervention that helps with your own main area of interest....reducing smoking?
At Sat Jul 04, 05:08:00 AM 2009,
PPerker said…
Truly, we need treatment for the most addicted smokers. Lets make the world green!
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