06 novembre 2009
TOBACCO-CONTROL PROGRAMS
The use of evidence-based best practices for tobacco control has been widely promoted
and has succeeded in reducing tobacco use in the United States. Reducing tobacco use poses
special challenges because tobacco products are legal and easy to acquire, highly addictive, and
heavily promoted by the tobacco industry. About 50% of current everyday smokers attempt to
quit each year, but only 4–7% of those are successful. Creation of a tobacco-free culture thus
could be enhanced by development of an environment that encourages abstinence, denormalizes
tobacco use, and makes a variety of prevention and cessation services available.
Successful comprehensive tobacco-control programs with demonstrable, albeit
incomplete, effectiveness have been developed and implemented by numerous organizations,
including the National Cancer Institute and the Centers for Disease Control and Prevention; state
governments, including those of California and Massachusetts; and commercial organizations.
The programs use a combination of educational, clinical, social, and regulatory strategies to
denormalize tobacco use. Comprehensive tobacco-control programs vary in target audience, size,
funding sources, and administrative oversight and governance, but they share several key
components that contribute to their success: the development and implementation of a strategic
plan, dynamic leadership, effective and enforceable policies, communication interventions,
adequate resources, appropriate therapeutic interventions (including those for special
populations), surveillance and evaluation of effectiveness, and management capacity to bring
about change in response to the evaluation. If implemented in constructive harmony, those key
components can provide DoD and VA with the capacity to develop and operate their own
tobacco-control programs.
Communication interventions can increase tobacco users’ awareness of the benefits and
means of tobacco cessation, educate potential users about the hazards posed by tobacco, and
change social norms and attitudes toward tobacco. Public-education campaigns can inform
consumers about cessation medications or other interventions, such as quitlines. Conversely, the
advertising of tobacco products, particularly aimed at young adults, can increase demand for
tobacco products.
Smoking restrictions are most effective when they apply to a variety of public and private
settings, when they ban tobacco use completely rather than partially, and when they are strictly
enforced. Many governments, businesses, education institutions, and health-care facilities have
adopted and enforce tobacco-free policies.
The tobacco retail environment encompasses the accessibility of tobacco products and the
promotion of tobacco products, both at the point of sale and through advertising. Increased
tobacco prices, restricted access to products, and decreased out-of-pocket costs for treatment all
reduce consumption. Increasing tobacco prices is one of the most effective mechanisms both to
prevent tobacco use and to fund tobacco-control efforts. However, as tobacco taxes and tobaccofree
regulations have increased, tobacco manufacturers have responded with the development
and promotion of new tobacco products, particularly varieties of smokeless tobacco. The
advertising of those products increases their consumption.
Studies show that the rate and duration of tobacco abstinence are increased when
cessation interventions are used, but only about 21% of smokers who attempted to quit for at
least 1 day in the preceding year used a cessation medication. Behavioral interventions shown to
have some consistent effectiveness include brief advice and assistance from a health-care
provider during routine health-care visits, multisession telephone counseling, and face-to-face
group and individual treatment. Those interventions are most effective when combined with
pharmacologic treatments approved by the Food and Drug Administration (FDA). Combined
interventions can result in long-term abstinence rates of more than 30%. Effectiveness has a
dose-response relationship: multisession intensive interventions achieve significantly higher
abstinence rates than brief interventions. FDA-approved tobacco-cessation medications are
primarily nicotine-replacement therapies (such as nicotine gum or patch), bupropion, and
varenicline. The Public Health Service (PHS) clinical-practice guideline Treating Tobacco Use
and Dependence: 2008 Update provides an evidence base for tobacco-cessation treatments.