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April 1999

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Tobacco Dependence

The worldwide epidemic of tobacco-related disease and death continues to worsen as tobacco use spreads. Millions of lives could be saved with effective treatment for tobacco dependence. However, such treatment is currently unavailable for many tobacco users throughout the world. For this reason, the World Health Organization, in preparation for World No-Tobacco Day 1999 (May 31), offers the following information and recommendations to governments, organizations, health-care professionals, and tobacco users and non-users worldwide.

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Tobacco use is widespread. At least one-third of the global adult population, or 1.1 billion people, use tobacco. Although overall tobacco use is decreasing in many developed countries, it is increasing in most developing countries. An estimated 48% of men and 7% of women in developing countries smoke; in industrialized countries, 42% of men and 24% of women smoke, representing a marked increase among women. Tobacco use is a paediatric epidemic, as well. Most tobacco use starts during childhood and adolescence.

Tobacco kills. A long-term tobacco user has a 50% chance of dying prematurely from tobacco-caused disease. Each year, tobacco causes some 4 million premature deaths, with 1 million of these occurring in countries that can least afford the health-care burden. This epidemic is predicted to kill 250 million children and adolescents who are alive today, a third of whom live in developing countries. By the year 2030, tobacco likely will be the world’s leading cause of death and disability, killing more than 10 million people annually and claiming more lives than HIV, tuberculosis, maternal mortality, motor vehicle accidents, suicide, and homicide combined.

Tobacco products are highly addictive. Because tobacco products are carefully designed to undermine efforts to quit using them, quitting is not simply a matter of choice for the majority of tobacco users. Instead, it involves a struggle to overcome an addiction. Tobacco use typically is woven into everyday life, and can be physiologically, psychologically, and socially reinforcing. Many factors combine with tobacco’s addictive capacity to make quitting difficult, including media depictions and cultural and societal acceptance of tobacco use.

Quitting tobacco at any point in life provides both immediate benefits and substantial long-term benefits to health. No amount of tobacco use is safe. Abstinence from tobacco products and freedom from exposure to second-hand smoke are necessary for maximizing health and minimizing risk. Effective treatment for tobacco dependence can significantly improve overall public health within only a few years.

The currently available, proven treatment methods work. Hundreds of controlled scientific studies have demonstrated that treatment can help tobacco users achieve permanent abstinence. Effective treatment can involve a variety of methods, such as a combination of behavioural treatment and pharmacotherapy (nicotine replacement and non-nicotine medications). Population-based methods such as telephone helplines and national and international tobacco-free days also can help deliver treatment.

Implementing Treatment

1. Make Treatment a Priority. Governments should rank treatment as an important public-health priority.

2. Make Treatment Available. Health-care systems should offer practical interventions to all tobacco users, regardless of economic level, age, and sex. This effort includes preventing and treating tobacco use in children and adolescents, reducing family exposure to tobacco, and providing treatment medications when appropriate. This process is facilitated by incorporating tobacco dependence treatment into drug abuse treatment, reproductive and maternal-child services, and other programs.

3. Assess Tobacco Use and Offer Treatment. Health-care providers should assess and document tobacco use and should provide treatment as an essential part of quality health care. Health-care providers should assume responsibility for learning about tobacco use and treatment, and for providing proven interventions. Providers, educators, and community leaders should take advantage of teachable moments and opportunities for prevention and intervention.

4. Health-care professionals should set an example for their peers and patients by quitting tobacco use. Governments and education systems can help this process by funding treatment and education programs for health professionals in training.

5. Fund Effective Treatment. Governments and health care organizations should fund treatment based on methods that have been demonstrated to be effective, and should make treatment widely available. Increasing the institutional and human capacity for providing this service involves training health-care workers to deliver treatment, implementing curriculum for students in the health professions, developing resource centres, encouraging the creation and maintenance of centres of excellence in treating tobacco dependence, and reducing the barriers between tobacco users and treatment.

6. Motivate Tobacco Users. Governments, health providers, and community groups share a responsibility for motivating tobacco users to quit and remain abstinent. They should educate the public about the health risks of tobacco use, encourage tobacco users to seek treatment, and help make treatment available, affordable, and accessible.

7. Monitor and Regulate Tobacco. Governments should monitor and report on tobacco use, and should tax and regulate the sale and marketing of tobacco products. These efforts reduce initiation of tobacco use and help fund effective treatments. Responsible regulation of tobacco products reduces tobacco use and limits risk. Regulatory authorities should prohibit marketing strategies that give false reassurances about minimized health risks and divert attention from quitting. Additionally, all possible steps should be taken to reduce the harmfulness of tobacco products. Governments should collaborate to provide meaningful and accurate ratings of nicotine and other chemicals in tobacco products, and to reduce the toxicity and addictiveness of those products. Treatment medications should be at least as accessible as tobacco products.

8. Develop New Treatments. Investing in the science and technology of treatment improves the efficacy of treatment for those in diverse populations and under-served groups. Effective treatments should be developed for groups for whom treatment has not been available, such as children and adolescents.

Universal application of all of these measures is the most effective approach to tobacco treatment. The current escalation in tobacco use and in tobacco-related death and disease can only be reversed by investment in comprehensive tobacco control, which includes treatment for tobacco dependence. Governments, health-care and education systems, community and religious groups, as well as news and entertainment media should collaborate in promoting tobacco treatment.

World No-Tobacco Day on May 31, 1999, provides the opportunity for governments, health-professional bodies, and the media to join with WHO in committing themselves to take local, national, and global action that could bend the trend of the tobacco epidemic.

(This statement, which is based upon the best available scientific information, was written by a group of experts from developed and developing countries hosted by the Mayo Clinic Nicotine Dependence Center and prepared for WHO to disseminate worldwide prior to 1999 World No-Tobacco Day. A full report will be available later in 1999; see http://www.who.int.)