tocacco plant Native American Tobaccoo flower, leaves, and buds

tocacco Tobacco is an annual or bi-annual growing 1-3 meters tall with large sticky leaves that contain nicotine. Native to the Americas, tobacco has a long history of use as a shamanic inebriant and stimulant. It is extremely popular and well-known for its addictive potential.

tocacco nicotina Nicotiana tabacum

tocacco Nicotiana rustica leaves. Nicotiana rustica leaves have a nicotine content as high as 9%, whereas Nicotiana tabacum (common tobacco) leaves contain about 1 to 3%

tocacco cigar A cigar is a tightly rolled bundle of dried and fermented tobacco which is ignited so that its smoke may be drawn into the mouth. Cigar tobacco is grown in significant quantities in Brazil, Cameroon, Cuba, Dominican Republic, Honduras, Indonesia, Mexico, Nicaragua, Sumatra, Philippines, and the Eastern United States.

tocacco Tobacco is an agricultural product processed from the fresh leaves of plants in the genus Nicotiana. It can be consumed, used as an organic pesticide, and in the form of nicotine tartrate it is used in some medicines. In consumption it may be in the form of cigarettes smoking, snuffing, chewing, dipping tobacco, or snus.

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Smoking racket

In 2006, the global nicotine replacement therapy (NRT) market was estimated at $1.7 billion. The pharmaceutical industry places tobacco smokemore messages about quitting in front of smokers than any other source: in the USA, smokers see 10.37 pharmaceutical cessation advertisements per month compared with 3.25 from health agency messages. The constant megaphoning of the idea that quitting requires drugs is causing a rather spurious tail to wag a large banished dog carrying an important message.

Twenty years after the launch of NRT, studies repeatedly show two thirds to three quarters of permanent ex-smokers stop unaided and about half find it easier than anticipated - a phenomenon that also occurs with problem drinking, gambling and narcotics use. But when was the last time you heard that good news? Instead, the increasing medicalisation of cessation emphasizes the opposite and that serious attempts at quitting should be pharmacologically mediated.

The good news on cessation is treated almost like a state secret. There are no campaigns highlighting that most ex-smokers quit unaided despite globally hundreds of millions having done so. Among my colleagues, unassisted cessation is rarely researched, instead framed in studies often funded by the pharmaceutical industry as a challenge to be eroded by persuading more to use drugs. Yet if a smoker asked “how do most smokers quit?”, failure to emphasise that most have always stopped unaided would be like explaining that most cyclists have professional tuition rather than being self-taught or that most domestic cooks attend cooking classes.

Quitting has become increasingly pathologised, risking distortion of public awareness of its natural history, to the obvious benefit of the drug industry. Research on cessation is dominated by ever-finely tuned accounts of how smokers can be encouraged to do anything but go it alone when trying to quit - exactly opposite of how a very large majority of ex-smokers succeeded.

A large body of evidence from clinical trials shows unequivocally that those who use NRT in trials have 50%-70% greater success than those using placebo. But clinical trial conditions overstate real world efficacy because of factors such as trialists getting free drugs, effects caused by the research attention paid to them and subjects’ desire to please the researchers with whom they interact. A 2005 review concluded “sales of NRT were associated with a modest decrease in cigarette consumption immediately following the introduction of the prescription nicotine patch in 1992. However, no statistically significant effect was observed after 1996, when the patch and gum became available OTC.” Moreover, one review found only 23% of NRT placebo-controlled trials assessed blindness integrity and 71% of these trials found that subjects could detect if they had been assigned to the active agent.

Another review of all NRT randomized controlled trials found 51% of industry-funded trials reported statistically significant cessation effects, against 22% of non-industry trials.

Many assume that we are now down to a “hard core” of smokers. Ex-smokers are assumed to be dominated by those who were not heavily addicted and so who were better able to quit unaided and that a greater proportion of today’s smokers need help. But recent data comparing smoking in 50 US states provides compelling evidence against this idea: the average cigarettes smoked daily and the percentage who smoke daily are all much lower in US states with low smoking prevalence, exactly the opposite of what would follow.

When citizens have common, self-limiting ailments, traits and behaviours like smoking regularly redefined as needing treatment, avoidable iatrogenic consequences and burgeoning health care expenditure can follow. But the steady erosion of human agency as populations lose confidence in changing unhealthy practices is of greater concern. There are serious negative consequences arising from smokers being increasingly imbued with messages that serious efforts at cessation require treatment.

When unassisted cessation and willpower are dismissed in pharmaceutical industry supported propaganda, smokers might understandably feel that it would be foolish of them to attempt to stop unaided. Because most assisted cessation attempts end in relapse, such “failure” risks being interpreted by smokers as “I tried and failed using a method that my doctor said had the best success rate. Trying to quit unaided - which I never hear recommended - would be therefore sheer folly.” Such reasoning is likely to disempower smokers, inhibiting quit attempts through anticipatory, self-defeating fatalism.

Pharmacotherapy is also irrelevant in today’s largest tobacco markets, which are nations with massive populations on low incomes, making the drugs prohibitively expensive. In Indonesia, three months NRT costs as much 7 year’s supply of cigarettes. It would be a disaster for tobacco control progress if such nations were to be influenced to proliferate labor-intensive and expensive approaches based on assisted cessation before they implemented comprehensive and sustained population-focused cessation policies and programs like tax rises, advertising bans and graphic pack warnings.

The persistence of unassisted cessation as the most common way that most smokers have always succeeded in quitting is an unequivocally positive message which should be openly embraced by health authorities as the front-line, primary “how” message in all clinical encounters and public communication about cessation. Along with motivational “why” messages designed to stimulate cessation attempts, smokers should be repeatedly told that cold turkey and reducing then quitting are the methods most commonly used by successful ex-smokers; that more smokers find it unexpectedly easy or moderately difficult than find it very difficult to quit; and that “failures” are a normal part of the natural history of cessation - rehearsals for eventual success.

Simon Chapman,
10 February 2010

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