January 14, 2011 
Ireland was first to the post with its smoking ban, but more radical measures are needed to get more people to quit.
Despite the ban on smoking indoors in public places, the prevalence of smoking has not dropped considerably in Ireland. Some experts have advocated a more radical approach.
If everyone who smoked was to quit smoking, then one third of all cancer deaths would be prevented. Respiratory disease is the second highest cause of death in Ireland and one in three cancers is due to smoking. Nearly all cases of lung cancer, about 90%, occur in smokers and are due to smoking.
Preventing cancer due to smoking is key to lowering death rates. In 2004, the introduction of the smoking ban in places of work in Ireland was a revolutionary act and put the country at the forefront of cancer prevention. However, despite the ban smoking levels in the country have not decreased substantially.
Levels did initially fall by about 2-3% but they have rise over a percentage point since.
Despite this disappointing fall, there is good evidence that it has changed the attitude of many smokers with a lot more people wanting to quit and even more in favour of the smoking ban.
Also there is proof that when you quit, no matter how late you do it, it can have profoundly positive effects on your health and life expectancy. If you quit before you are 40, then you will have a similar lifespan to those who have never smoked. Even if you quit in your 60s then you are still likely to see improvements in terms of how long you live.
Global respiratory disease and cancer caused by smoking is likely to increase over the next decades. In the so-called Western World, levels of smoking are likely to decrease, but in the developing world levels are increasing dramatically.
In heavily populated countries, such as China, India and Indonesia, more people are smoking. This explains why there is expected to be a ten fold projected increase in tobacco related deaths in the future during this century. The World Health Organisation Framework on Prevention and Tobacco Control (FTPC) has been ratified by 160 countries out of 168 member countries to try and tackle this global epidemic.
In a way in Ireland we are heading towards the end of this epidemic with cigarette related deaths falling. It is still difficult to tackle 50-years of tobacco industry marketing.
The three strategies that have been recommended are to get people who are addicted to quit, pressure on the tobacco industry to prevent the encouragement of new smokers, and media campaigns.
To date there has not been enough in terms of mass media campaigns to get people to quit in Ireland. In some countries, such as Australia, TV advertising with more graphically shocking and blunt messages have been used to good effect.
Innovative methods need to be used to fund ads, as government does not always see the benefit of the cause and effect of healthcare promotion. In California, they have put a tax on each pack with one fifth of the tax used to fund a sustained media campaign for a decade.
Worded cautions on packs are not as effective as they could be. In Thailand, they have put pictorial warnings on packs instead of text and it was found to increase smoker’s desire to quit. By placing a call to action or a quit line number on packs in Australia, this increased the number of calls for quit advice.
Advertising by cigarette companies and use of attractive looking packs at the point of sale is still permitted in Ireland despite other restrictions. Most people would support a ban on these promotional activities by cigarette companies.
Education is key and it is vital to get across the message the smoking cigarettes is not a lifestyle choice but is an addiction. Most smokers regret starting but find it difficult to quit quit despite trying.
Free nicotine patches given out to smokers in New York and this helped some quit. There was over 400,000 calls made looking for free patches.
It is very difficult to force people to quit smoking, but there is evidence that if a doctor or nurse keeps reinforcing a quit message each time they see a smoker that it does impact on their desire to quit.
In some cases the desire may not be enough and it is important to understand how the smoker hit works. Dopamine is released in the brain about 10 seconds after a drag and there is an anticipation of this. So taking medication can help people quit. If a smoker who is trying to quit gets counselling then this improves there chance of quitting by about 30% and if they also get medication then it improves to 50%. Combining treatments works best in those who are more heaving addicted or those who have many previous failed attempts.
Nicotine addiction varies from one smoker to another depending on the release of chemicals in the brain. The best measure of the severity of addiction is the first cigarette and needing to smoke a few minutes after waking up.
If nicotine replacement therapy is used then it is better to start a few weeks before quitting as this results in higher quit rates.
A nicotine vaccine is in development but is still a long way off.
Low tar light cigarettes are ineffective because they generally have greater filter ventilation so smokers are deluded into thinking they are getting less. Many smokers block the holes or take bigger and more puffs to counteract the lower concentration of nicotine. Banning filter vents could overcome this.
Other ways that have been mooted to control smoking are to limit profits from growing tobacco, banning sales of tobacco, such as has been instituted in Bhutan, and giving tobacco companies accountability quotas. This would work by giving the companies a quota of smokers per country and fine them if they exceed that number. A quota on tobacco sales would reduce deaths and the massive healthcare costs associated with smoking dramatically.
One good way to regulate companies is to use product licensing and only renewing it when companies are seen to be introducing and promoting cleaner and healthier products. New products could only be introduced if they are shown to meet the conditions of the license.
Box: Key requirements of WHO FPTC include a variety of policies known to reduce tobacco consumption.
- Inflate the price and keep it higher
- Protect the public from secondhand smoke
- Regulate ingredients of tobacco and how it is labelled
- Institute education and communication programs
- Ban tobacco advertising
- Offer dependency quit treatments to addicts
© Conor Caffrey 2011
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