A multi-factorial approach to the endgame of the tobacco epidemic in Italy

The word “endgame” of the tobacco epidemic evokes many emotions, especially in researchers and clinicians. In the history of medicine only 2 times this goal has been achieved: on the 8th of May 1980, the WHO declared that smallpox was eradicated, and in June 2011, the United Nations FAO confirmed that rinderpest (cattle plague) was fully wiped out! Unfortunately, the declaration of polio eradication in 1999 was soon contradicted by the finding of some epidemic foci  which have caused more than 200 cases worldwide in 2012.

Unlike infectious diseases, addictions are diseases that don’t depend only on the presence of the pathogen, but have a multi-factorial etiology. Thus, we must not fall into the trap of thinking that nicotine addiction can be simply “eradicated” by restrictive policies towards tobacco. They are not sufficient to ensure its disappearance. The latest classifications in psychiatry and psychology show us how, in some cases, addiction is manifested by behaviors without use of any substance, such as gambling, compulsive shopping or sex addiction. Moreover, the physical detoxification by drug use does not heal the addiction which can be switched to other substances or behaviors. Experience teaches that we cannot eradicate addictions with a magic pill or with the invention of a medical device. In the field of addiction to drugs it was often thought that a single drug could solve the problems. Examples of this are naltrexone for heroin and disulfiram for alcohol. After the first experiences they were accepted as useful tools, but not sufficient to cure an addiction.

An example of a multi-factorial view about tobacco addiction is provided by the way in which people start smoking. The first attempt by young people to smoke cigarettes is usually unpleasant, it causes negative symptoms and generally does not produce pleasure. The need to begin to smoke is thus based on a variety of social and individual stimuli. The availability of tobacco is only a part of this problem. The beginning of tobacco smoking among young people, for example, is related to their social and economic status, their educational level, the presence of smokers in the family. Our un-published data showed a correlation in adolescents, already known in the literature, between smoking and school failure, antisocial disorders, intra-family conflicts, a tendency to anxiety, low self-esteem and avoidant behavior.

The economic aspects of the tobacco market are also complex. The tobacco lobbies turn over hundreds of billions of dollars and this business, although it produces enormous harm to human health, supports a part of the economy of various countries. If you balance economic gains and losses, the losses are higher in terms of human lives, health and social costs. Nevertheless, the transition from this deleterious business to a positive and health generating economy is not immediate. The strategies should oppose the production and sale of tobacco, and should encourage conversion to other agricultural crops and replacement of cigarettes trade with products that do not cause damage to health. We need urgently to develop and promote viable alternatives with appropriate projects dedicated to financing and human resources.

Another important factor is the production of tobacco derivatives that produce less dependence. It is worth exploring, but probably this will not be the decisive factor. In recent years some products, such as electronic cigarettes (ENDS), have changed the tobacco market and look set to provide new options to consumers. This phenomenon came as a surprise to experts, who were forced to investigate this novel product, to study its effects and try to understand how it could be useful in smoking cessation. Economists’ forecasts were optimistic towards the development of this business and the same tobacco companies have allocated resources to be ready in the coming years for promoting the sale of electronic cigarettes.

The impression of many experts, though, is that this device can be, at best, an aid to smoking cessation. If and when it will be possible to produce a completely risk free electronic cigarette, the problem of the addiction of nicotine will remain. It should be remembered that beyond the pack (cigarette, pipe, cigar, snus …), the true object of the sale is nicotine, which alone is also responsible for cardiovascular disease and addiction, although it avoids the harmful effects of smoking.

The governments of Western countries are ambivalent about this. On the one hand they have issued very restrictive rules on electronic cigarettes, but on the other, continue to leave the traditional cigarettes freely on sale. The fear of an open market additional to that of the cigarettes has prevailed, but the fact that electronic cigarettes could be a less harmful alternative to smoking has been underestimated. The laws and raising taxes on electronic cigarettes in Italy, for example, have brought down sales recently. The introduction of European standards that limit the amount of nicotine in electronic cigarettes will further contribute to greatly reduce their use. Indeed, restrictive and undifferentiated regulations for electronic cigarettes may not necessarily lead to favorable health outcomes. If electronic cigarettes were to establish an additional independent market which, in the long run, would not substitute the traditional tobacco trade but would be added to it, restrictive laws, which reduce electronic cigarette use, could have positive health effects, especially among young people. This will be achieved because electronic cigarettes losing their appeal, will not constitute the first step towards traditional tobacco addiction. But the reduction in electronic cigarette use, induced by restriction, could also have negative health effects. Indeed, those who use this device to reduce the deadly effect of tobacco smoke, may later return to their previous habits. Since we cannot tell the future, we need to be cautious. Certainly we will need to have clear rules and laws for the safety of the product, but also to leave the door open to consider harm reduction strategies.

Indeed, the perception of many professionals working in the centers for smoking cessation is that – after a first trial – many consumers of electronic cigarettes return to traditional smoking or continue to consume both products.

For these reasons, we believe that research on alternative forms of administration of nicotine or tobacco with lower nicotine content, although useful, cannot constitute the crucial element of the endgame of tobacco.

It’s also impossible to base all our expectations on the effects of restrictive laws and increased taxation. These elements are very effective, but not sufficient.

In Italy, as in many Western countries, the prevalence of smoking has had a modest but progressive reduction in recent years. It declined gradually from 32% in 1990 to 20.8 % in 2012. This epidemiological observation was achieved thanks to a combination of factors including legislative measures (“Sirchia’s law” – Law 3, 16/01/2003), cultural changes and personal decisions.

Important pillars of a comprehensive strategy are:

  1. The adoption of policies for health promotion especially for the new generations, which encourage protective factors in regard to social problems and addictions, through the improvement of young people’s life skills and that of their families, and through specific prevention projects.
  2. Financial support for projects for the conversion of tobacco cultivation to the production of healthier products.
  3. Restrictive legislation on sales of tobacco and a progressive increase in taxation.
  4. The diffusion of treatments for tobacco addiction, with a layered approach that sees minimal interventions, medical counseling  and specialists of centers for smoking cessation. The treatment has to be free and easily accessible to the entire population.
  5. Support for research in the field of new therapies or products for harm reduction to achieve, step- by-step, the goal of eradication.

In a nutshell, we think we should look forward and plan for the end of tobacco, but meanwhile we must work every day on things that are concretely feasible, remembering that great achievements are the result of an ambitious vision that may be realized by a multi-factorial approach.


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