Offer help to quit tobacco use
Treatment of tobacco dependence helps smokers quit and supports other tobacco control initiatives
It is difficult for the world’s more than 1 billion tobacco users to quit. However, most smokers want to quit when informed of the health risks (127). Although most who quit eventually do so without intervention, assistance greatly increases quit rates (128). In November 2008, the Conference of the Parties asked a working group to develop guidelines to help Parties implement Article 14 of the WHO FCTC on cessation assistance and report to the Conference in 2010 (129).
Tobacco dependence treatment is primarily the responsibility of each country’s health-care system (1). Despite their lower population-wide impact, individual cessation interventions have a significant impact on individual health and are extremely cost-effective compared with many other health system activities (130).
People who quit smoking, regardless of their age, smoking history or health status, experience immediate and profound health benefits and can reduce most of the associated risks within a few years of quitting (131, 132).
Tobacco dependence treatment can include various methods, but programmes should include: cessation advice incorporated into primary health-care services; easily accessible and free telephone quit lines; and access to free or low-cost cessation medicines.
Integrated delivery of brief cessation counselling to tobacco users requires a well-functioning primary health-care system. Action to strengthen primary health care can draw on the WHOdeveloped health systems strengthening strategies to improve six health system building blocks (leadership/governance, health workforce, information support, medical products and technology, financing, and service delivery) (133).
Brief cessation counselling is relatively inexpensive when integrated into existing primary health-care services, is usually well received by patients, and is most effective when it includes clear, strong and personalized advice to quit (128). There are many existing opportunities or entry points to incorporate brief cessation counselling into primary health-care services. Integration of brief cessation counselling into management and prevention of cardiovascular disease as well as tuberculosis care is already in process (134, 135). Doctors and other health-care workers should also serve as role models by not smoking themselves. Advice and counselling can also be provided in the form of telephone quit lines, which should be free of charge and accessible to the public at convenient times (136).
Pharmacological treatment of nicotine addiction should ideally be used in conjunction with advice and counselling, although it is also effective when provided separately (128). Cessation medications can double the likelihood that someone will successfully quit, and this probability increases even further if the medication is administered in conjunction with counselling. Nicotine replacement therapy (NRT) has recently been added to the 16th WHO Model List of Essential Medicines because of the high-quality evidence of its effectiveness, acceptable safety and costeffectiveness (137). At least some forms of NRT should be broadly available at very affordable prices to the tobacco user wanting to quit.
Smoking cessation services are most effective when they are part of a coordinated tobacco control programme.
Wealthy countries with substantial financial resources should be expected to offer comprehensive quit smoking services at no or minimal cost, although low- and medium-income countries can effectively implement at least some cessation services. Most countries can use lower-cost counselling options effectively, even when financial support for medications is beyond budgetary limits. Uruguay, an example of a middle-income country that has a strong commitment to effective tobacco control, has implemented some components of a comprehensive cessation programme.
Although Uruguay covers the cost of some types of NRT and other medications, it does not cover other types due to cost constraints. While Uruguay has developed national treatment guidelines and provides extensive counselling services, there is currently no national quit line or formal mechanism for provision of physician counselling in primary care, although these services are planned for the near future when funding is made available.
Governments can use tobacco tax revenues to fund quit lines and subsidize clinical cessation services, and providing cessation support may also reduce opposition to other tobacco control policies.
Only 17 countries provide access to comprehensive help to quit smoking
■■ Three countries (Israel, Romania and United Arab Emirates) joined the group of countries offering comprehensive help to quit smoking in 2008, bringing the total number with a national quit line and coverage for costs of both NRT and some cessation services to 17, covering 8.2% of the world’s population (compared with 7.7% in 2007).
■■ High-income countries have made the greatest progress in offering help for people who want to quit tobacco use, with 27% operating a national quit line and at least partially covering the cost of the cost of both NRT and some cessation services. High-income countries are most able to afford to cover these costs.
■■ About a third of middle-income countries and less than 15% of low-income countries provide coverage for NRT and/ or cessation services. Only four middleincome countries and no low-income countries provide a national toll-free quit line and coverage for both NRT and cessation services.
■■ In the vast majority of low- and middleincome countries, the cost of cessation assistance is not covered by government, and 8% of middle-income and 29% of low-income countries provide no assistance to smokers at all.
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