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Role of Taxation as a Smoking Cessation Intervention?
Submit responseMarch 20, 2007
The Editor Annals of Internal Medicine 190 N. Independence Mall West Philadelphia, PA 19106-1572
TO THE EDITOR: Your review of smoking cessation intervention strategies1 failed to mention the impact of state or federal taxation on smoking consumption.
Many jurisdictions are considering legislation to raise taxes on each pack of tobacco consumed.2 Although taxes on tobacco consumption are regressive (they are taxes on the poorest, least educated citizens)3, and they are “sin taxes” (they do not outlaw the use of tobacco, they merely make it more expensive)4 studies have shown that they at least temporarily decrease tobacco use5 – especially by young smokers, who are discouraged from smoking because their discretionary income is limited.
It would be interesting to hear the NIH panel’s thoughts on tobacco excise taxation, in particular their estimates of how many millions of American lives might be saved by tax policy, compared to the use of other tobacco cessation interventions such as nicotine substitutes, antidepressant drugs, counseling, or psychotherapy.
Donald Venes, M.D.
P.O. Box 6489 Brookings, OR 97415
503-804-3739
venes@mac.com
1 Ranney L, Melvin C, Lux L, McClain E, and Lohr KN. Systematic Review: Smoking Cessation Intervention Strategies for Adults and Adults in Special Populations. Ann Intern Med. 2006; 145:845-856.
2 Kosseff J. Smith Plan for Kids Raises Cigarette Tax. Oregonian, February 28, 2007
3 Remler DK. Poor Smokers, Poor Quitters, and Tobacco Tax Regressivity. AM J Public Health 2004 Feb;94(2):225-9
4 McKinley A. Public Health: Tobacco Taxes and Internet Sales—2005. End of Year Issue Brief. Issue Brief Health Policy Track Serv. 2005 Dec 31; 1-7
5 Ding A. Curbing Adolescent Smoking: A Review of the Effectiveness of Various Policies. Yale J Biol Med 2005 Jan;78(1):37-44.
Conflict of Interest:
None declared
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Smoking cessation in cancer survivors
Submit responseRanney et al (1) did not include a very important group of patients in their review of smoking cessation intervention strategies in special populations. Cancer survivors are unique in that they experience one of the most devastating consequences of smoking and yet a significant number of them continue to smoke. In fact the smoking rates in cancer survivors are only slightly lower than the general population. In a cohort of childhood cancer survivors, Emmons and colleagues (2) have demonstrated that quit rate was more at 8 and 12 month follow-ups in the group who received a peer counseling program. Even then, the quit rate of 15% in this group at 12 months is concerning, and attests to the less than optimal therapeutic interventions available to treat nicotine addiction in this particular population at the present time.
1. Ranney L, Melvin C, Lux L, McClain E, Lohr KN. Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med 2006;145(11):845-56.
2. Emmons KM, Puleo E, Park E et al. Peer-delivered smoking counseling for childhood cancer survivors increases rate of cessation: the partnership for health study. J Clin Oncol. 2005;23(27):6516-23.
Conflict of Interest:
None declared
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Who should be targeted by smoking cessation intervention?
Submit responseIn the recent review on smoking cessation intervention(1) the authors have comprehensively reviewed the efficacy of tested strategies, and concluded that using effective smoking treatments is strongly encouraged for all populations. One of the important aspects of smoking-related health issue is that it is intimately association with socioeconomic status of the population. Particularly, smoking is much more prevalent (2), more intense (3), earlier to be initiated(4), and more difficult to quit(5) in lower than in higher socioeconomic class, resulting in significantly more serious smoking- attributable morbidity and mortality of the class(6). These facts indicate that it is this class of smokers who potentially benefit the most by quitting smoking, and therefore should be targeted by smoking cessation intervention. However, it is not known if the most �geffective�h currently available smoking cessation intervention, such as combined pharmacotherapy in combination with counseling, works in this class, and, more importantly, if such interventions are accessible by those smokers. The authors mentioned in the review about the intervention specialized to several situations, such as psychiatric and substance abuse conditions, however, socioeconomic status of smokers was not addressed, suggesting that most of the studies do not focus on the issue at this moment. Not only efficacy but also accessibility and feasibility should be weighed in pursuing smoking cessation intervention to maximize health gain by the intervention. (Word count:220)
1. Ranney L, Melvin C, Lux L, McClain E, Lohr KN. Systematic Review: Smoking Cessation Intervention Strategies for Adults and Adults in Special Populations. Ann Intern Med 2006;145(11):845-856.
2. Bobak M, Jha P, Nguyen S. Poverty and smoking. In: Jha P, Chaloupka F, editors. Tobacco control in developing countries. Oxford: Oxford Unversity Press; 2000. p. 41-61.
3. Jarvis MJ, Wardle J, Waller J, Owen L. Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study. Bmj 2003;326(7398):1061.
4. Escobedo LG, Anda RF, Smith PF, Remington PL, Mast EE. Sociodemographic characteristics of cigarette smoking initiation in the United States. Implications for smoking prevention policy. Jama 1990;264(12):1550 -5.
5. Hymowitz N, Cummings KM, Hyland A, Lynn WR, Pechacek TF, Hartwell TD. Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tob Control 1997;6 Suppl 2:S57-62.
6. Jha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, Lopez AD. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet 2006;368(9533):367-70.
Conflict of Interest:
None declared
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Cessation pharmacology RCT findings not science based
Submit responseThe authors' strong pharmacology recommendation ignores a growing body of real-world performance evidence in which pharmacology never once prevails over those quitting without it. Instead they cite RCT evidence that we have known since Mooney, M., et al 2004 was generally not blind as claimed. Clinical efficacy? Absolutely. Real-world "effectiveness"? No.
I submit that pharmacology will never prevail in any "actual use" evaluation so long as nicotine remains a psychoactive chemical generating a potent dopamine/adrenaline high, and so long as 48 hours without it produces a powerful withdrawal syndrome that once experienced is difficult to forget.
The smoking "reduction" blinding assessment of Dar et al April, 2005 found that 3.3 times as many placebo group members correctly guessed placebo (54.5%) as guess nicotine (16.4%). Tonnesen's 1993 nicotine inhaler "quitting" study produced strikingly similar placebo findings with 3.8 times as many in the placebo group correctly guessing placebo (58%) as guessed nicotine (15%). Among inhaler users 3.5 times as many correctly guessed inhaler (46%) as guessed placebo (13%), while 42% on active and 27% on placebo claimed not to know treatment assignment.
The common thread between NRT, bupropion (Zyban) and varenicline (Chantix) is that to varying degrees they enhance dopamine flow by direct nicotinic receptor stimulation, inhibiting uptake or both. The end result is that the underlying current of early withdrawal anxieties and the urge to smoke are diminished to varying degrees.
RCT odds ratio victories are a product of: (1) a self-seeking study population responding to dangled "medication" in hopes of withdrawal syndrome reduction; (2) early and extremely high placebo group relapse rates fueled by frustrated expectations upon recognition of full-blown withdrawal; (3) partially fulfilled expectations within the active group upon encountering a somewhat diminished withdrawal syndrome; and (4) ongoing counseling, support and a myriad of study protocols having known efficacy that inured primarily to the benefit of the surviving active group.
This AIM study also finds no evidence of efficacy in self-help materials. It's a finding that's impossible to dispute but absence of evidence is not necessarily evidence of absence. Conventional quitting advice - trigger avoidance, crutch adoption, major lifestyle changes, lengthy planning and minimizing slip/ relapse significance - is utterly horrible. If ineffective, what harm is there in examining alternatives? "Never Take Another Puff" is a free 149 page PDF quitting book by Joel Spitzer that stands conventional wisdom on its head.
Conflict of Interest:
Editor of WhyQuit.com, a site devoted to abrupt nicotine cessation.