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Should health care services provide treatment for addicted smokers?

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Last week’s issue of the leading medical journal, “The Lancet” included two comment articles on the issue of whether it makes sense to fund healthcare services to help smokers to quit.

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
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About the Author


MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.

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