A Population-Based Approach to Fighting the Health Threats of Tobacco
By: Ètashè Okpola
Nicotine, the addictive component of tobacco, was first extracted in 1828 by the German physicians Wilhelm Heinrich Posselt and Karl Ludwig Reimann. It is a strong water-soluble parasympathomimetic alkaloid produced in the nightshade family of plants (Mishra et al., 2015).
Other substances in tobacco smoke include polycyclic aromatic hydrocarbons, and tobacco-specific nitrosamines that cause DNA damage and, consequently, cancer. As a major component of tobacco, debates around both nicotine’s health hazards and potential health benefits have emerged from several schools of thought.
In 2014, a report by Harvard Health argued, albeit with an acknowledgement of its health risks, in favour of the potential benefits of nicotine. Compared to non-smokers, the report revealed that tobacco smokers present with lower rates of Parkinson’s disease, and patients with schizophrenia presented with improved cognitive performance with the use of the nicotine patch which, in combination with the antipsychotic drug haloperidol (Haldol), showed promising results for the treatment of Tourette’s disorder (HHP, 2014).
This study stands in slight contrast with another study on the harmful effects of nicotine by Mishra et al., which highlighted nicotine as a carcinogenic substance that poses a potential threat to cardiovascular, respiratory, renal, and reproductive systems and argues against the quality of proof on the beneficial effects of nicotine (Mishra et al., 2015). Despite these debates, it is worth noting that nicotine, although the major driver, is only one driver of tobacco use culture.
Drivers of Tobacco Use Culture
The dissolution of the Soviet Union on 25 December 1991 resulted in significant changes in the region’s cigarette industry. With the privatization of state‐owned tobacco monopolies and subsequent investment in the industry by transnational tobacco companies (TTCs), strategic advertising (which had been non‐existent in Soviet times) and distribution techniques, alongside a weakening in tobacco control legislation, rapidly increased cigarette consumption across the region (Perlman et al., 2007).
Per the most recent World Health Organization (WHO) data on the prevalence of current tobacco smoking among persons aged 15 years and older, Russia was estimated to be among the top five highest consumers of tobacco smoking in the world (WHO, 2015). By the collapse of the Soviet Union, the TTCs invested approximately 1.7 billion USD between 1992 and 2000 in Russia, which significantly increased their market shares and production capacities (Perlman et al., 2007). The increased rate of tobacco use was largely influenced by heavy advertising, which is another driver of tobacco use culture.
Another notable driver of tobacco use culture is the cognitive dissonance of smokers. As established, consistent consumption of nicotine results in addiction. And as a habit, addiction could be reversed via techniques that foster the development of newer habits. However, tobacco consumers are plagued with a continuous circle of indulgence, even in populations with good knowledge of its negative health consequences. The resulting question would be why smokers have difficulties with forming new habits and quitting. Cognitive dissonance is a theory in social psychology occurring when a person holds two beliefs that contradict one another. It refers to the mental conflict that occurs when a person’s behaviours and beliefs do not align. Nicotine is an addictive substance, and addiction is a form of pleasure. To maintain consistency of the pleasurable feeling from tobacco, habitual smokers — who are knowledgeable about its negative health impact — rationalize their behavior with biases such as: “We’ll all die eventually,” “I will quit in two weeks,” “My exercising will make up for this horrible habit,” or “It’s impossible to avoid doing anything just to stay alive” (Fotuhi et al, 2012).
Cognitive dissonance, when paired with the cultural legacy of people; the social norm of a given period; and social engineering through movies, advertising, and other known drivers of smoking (e.g. genetics, second-hand smoking, peer-groups) potentially maintains the global tobacco use culture.
The Fight Against Tobacco and Its Health Threats
In 2007, WHO launched MPOWER, a practical approach to improve implementation of the Framework Convention on Tobacco Control (FCTC) (WHO, 2019). The MPOWER measures include:
- Monitor tobacco use and prevention policies
- Protect people from tobacco use
- Offer help to quit tobacco use
- Warn about the dangers of tobacco
- Enforce bans on tobacco advertising, promotion, and sponsorship
- Raise taxes on tobacco.
Educational measures in the form of campaigns have been widely used to protect people from tobacco use and warn about the dangers of tobacco. Although the tobacco epidemic is a major public health threat with a death record of over eight million people annually, WHO reports that a large number of people remain unaware of the negative health consequences associated with tobacco use. This lack of awareness reflects the high prevalence of tobacco consumption in low- and middle-income countries (LMICs) where information might not be readily available. It is estimated that about 80% of the world’s 1.1 billion smokers are residents of LMICs, which also have the highest number of tobacco-related illnesses and deaths (WHO, 2019). Awareness campaigns either through mass or local media, by organisations, institutions, and individual groups, remains a powerful long-term method for improving awareness in LMICs.
From 2008 to 2013, Cyprus implemented excise tax increases on cigarettes and relatively cheaper roll-your-own tobacco. This tax increased the cost of cigarettes and increased the quit rate of addicted smokers (The Tobacco Atlas, n.d.). Pricing is a major driver of smoking, and tax increases are considered the most cost-effective way to reduce the global tobacco consumption rate. The WHO stipulates that raising tobacco prices by 10% decreases tobacco consumption by about 4% in high-income countries and by about 5% in LMICs (WHO, 2019). In addition to raising excise taxes on tobacco, implementing policy changes on advertising, age limits, retailer restrictions, and sponsorships is an important approach to mitigating the tobacco use crisis (Prochaska & Benowitz, 2019).
Pharmacists and Population-based Targeting for Fighting the Health Threats of Tobacco
Pharmacotherapy has played a huge role in enabling smoking cessation and health improvement among tobacco users. Nicotine replacement therapy (NRT)–in the form of gum, patches, lozenges, nasal spray and inhaler–has been an effective therapeutic approach for managing the neuropharmacological effects of nicotine. Other pharmacotherapy approaches include varenicline, cytisine, and bupropion (Prochaska & Benowitz, 2019).
The theory of cognitive dissonance shows that a majority of smokers with knowledge about the dangers of tobacco have an interest in quitting. In addition to pharmacotherapy, behavioural therapy measures–such as brief cessation advice, intensive counselling via in-person sessions, telephone support and quit-lines, text messaging, web-based services, or social media support–have also been implemented to improve quit rates among tobacco users (Prochaska & Benowitz, 2019).
However, the effectiveness of these therapeutic approaches heavily relies on the specific socioeconomic conditions of an economy. Disparities in the income ratio of a country, as seen in the gaps between a healthy and socioeconomically advantaged population versus an impoverished and socioeconomically disadvantaged population, demands increased funding on comprehensive regional/state tobacco control programs. The health state of low-income residents with especially high prevalence of tobacco use could benefit from a more equitable construct of a country’s socioeconomic state.
Also, in combination with individual-level interventions, population-based targeting requires action beyond control measures to address the root causes of tobacco use within a population. This calls for collaborations between public health stakeholders and other sectors responsible for health education, community design, social services, and agriculture.
As drug custodians and health educators, it is pertinent for young pharmacists to have a clear understanding of local population needs before the employment of the MPOWER measures in the fight against tobacco use. Increased awareness of the negative health impact of tobacco smoking is an important first-step approach for curbing the threat to low-income economies.
While excise taxes and policy changes will significantly improve the outcomes of the global campaign against tobacco, pharmacotherapy and behavioural therapy are also key approaches for fighting the tobacco use crisis. Population-based targeting is a needs-based approach that encourages specificity and could improve reach as well as save resources. It demands action beyond digital awareness campaigns and calls for a collaborative approach among healthcare professionals within specific regions in the fight against the health threats of tobacco.
References
Harvard Medical School (HMS). (2014). Nicotine: It may have a good side. Retrieved from: https://www.health.harvard.edu/newsletter_article/Nicotine_It_may_have_a_good_side
Fotuhi, O., Fong, G.T., Zanna, M.P., Borland, R., Yong, H.H., & Cummings, K.M. (2012, January 3). Patterns of cognitive dissonance-reducing beliefs among smokers: a longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009366/
Mishra, A., Chaturvedi, P., Datta, S., Sinukumar, S., Joshi, P., & Garg, A. (2015). Harmful effects of nicotine, 36(1), 24–31. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363846/
Perlman, F., Bobak, M., Gilmore, A., & McKee, M. (2007). Trends in the prevalence of smoking in Russia during the transition to a market economy. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598552/
Prochaska, J.J., & Benowitz, N.L. (2019, October 16). Current advances in research in treatment and recovery: Nicotine addiction. Retrieved from: https://advances.sciencemag.org/content/5/10/eaay9763
The Tobacco Atlas. (n.d.). Taxes. Retrieved from: https://tobaccoatlas.org/topic/taxes/
World Health Organization (WHO). (2015). Prevalence of tobacco smoking: Age-standardized prevalence of current tobacco smoking among persons aged 15 years and older. Retrieved from: http://gamapserver.who.int/gho/interactive_charts/tobacco/use/atlas.html
WHO. Factsheet. (2019, July 26). Tobacco. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/tobacco
