EDITORIAL

Smoking cessation - challenges to be faced

Ubiratan de Paula Santos

Coordenador do Ambulatório de Cessação de Tabagismo da Disciplina de Pneumologia do InCor- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HCFMUSP, São Paulo, SP

Current estimates indicate that smoking is responsible for approximately 5.4 million of deaths/year all over the world,¹ and it is one of the highest risk factor for death, being second only to hypertension.^1,2 Smokers live an average of 10 years shorter than non-smokers and have a worse quality of life.³ In spite of the information available about the harmful effects of smoking, 1.3 billion people still smoke worldwide.¹ In Brazil, around 23% of the population older than 18 years old smokes.⁴ The main reasons for such a high prevalence rate of smokers are as follows: tobacco-related diseases are chronic, the tobacco industry is allowed to produce marketing campaigns, tobacco is inexpensive, and quitting smoking is difficult, since most smokers are nicotine-dependent and social, economic, and cultural aspects are associated with that difficulty.

The prevalence of smokers is much higher among individuals with psychiatric diseases (above 50%). These individuals are usually heavy smokers and are at higher risk for relapses after quitting smoking, which should not prevent them from receiving attention from programs aimed at helping smokers to stop smoking.

In the current issue of the journal, Azevedo et al.⁵ present the results of a treatment offered to smokers at a psychiatric outpatient clinic; 47% of the subjects had symptoms of anxiety and depression and 28% had a history of drug abuse and alcoholism. In this study, despite only part of the group could be medicated, the combined use of group therapy and medication in 171 patients achieved a success rate of 62% after 25 weeks of follow-up, which is much higher than the previous studies published in the literature.⁶ The authors suggest that this success rate is related to the large number of motivational sessions attended by the group of patients. However, these data need to be confirmed, since a meta-analysis including 46 studies revealed a success rate between 18% and 24% for a similar number of sessions.⁶ In addition to the limitations mentioned in the article, the facts that it was not a controlled study and that the confirmation of smoking cessation was checked only by telephone restrict the interpretation of the results. The most important aspect of this study is related to the emphasis on the need of offering treatment to patients with psychiatric disorder, except for situations in which there are severe symptoms and smoking cessation may exacerbate the disease. In such cases, patients should be more closely controlled before beginning the treatment.

Also in the current issue of the journal, Souza et al.⁷ present a study using the Brazilian version of the Modified Reasons for Smoking Scale, comprising 21 structured questions grouped in several different combinations that characterize seven motivational domains associated with smoking. This is the first Brazilian study to be published using this scale, which has been recently validated for the Portuguese language by the same authors.⁸

The authors based the importance of the study⁷ on the fact that the reasons leading individuals to smoke are not restricted to nicotine dependence, since there are also behavioral and psychosocial components which have not been well understood yet and whose dimension could be better measured by this scale, thus serving as an additional supportive component for the programs of smoking cessation. The study revealed that the scale presented adequate factorial structure and psychometric properties, showing the lowest scores in the following domains: dependence, tension reduction/relaxation, and hand-mouth activity, which were significantly associated with lower scores on the Fagerström nicotine dependence test.

In spite of the evidence that smoking nicotine-free cigarettes does not cause dependence, reinforcing the role played by nicotine in the addiction,⁹ there are not doubts regarding the obscure aspects related to the pharmacology of nicotine and the presence of other factors involved in smoking persistence.^9,10

Panday et al., in a study conducted in South Africa,¹¹ revealed that 11.6% of the smokers aged 14-16 years, who smoked an average of 6-10 cigarettes/week, had high dependence and 56% of them reported more than two symptoms of abstinence. The reasons why individuals with high dependence or presenting with abstinence symptoms are able to smoke less than 10 cigarettes a week are not clear yet. Furthermore, there are studies evidencing failure in the use of medication, such as nicotine replacement and bupropion, to aid young people to quit smoking.⁶

On the other hand, Volpp et al.¹² presented new data in a recently published study involving 878 smoking employees of a large company, with approximately 50% of them receiving counseling and financial incentives to quit smoking and the other half receiving only information. Those smokers who received financial incentives achieved a success rate after 12 months of 14.7% compared to 5% in the group that received only information (odds ratio 3.28-fold higher). The success rate was confirmed using urinary cotinine measurement. The reasons for that result have not been well explained, but this finding can serve as a stimulus for this type of treatment, since it is less expensive and smokers do not need to use medication, which makes them less vulnerable to adverse effects.

The reasons for smoking scale used by Souza et al.,⁷ as stated by the authors, has been rarely used outside the United States, and few studies on its use have been published even in the United States. The actual clinical usefulness of its administration in programs and actions aimed at smoking cessation still need to be demonstrated. The validation for the Portuguese language⁸ and the consistent data regarding its use, as demonstrated in the study by Souza et al.,⁷ open this opportunity to Brazilian researchers.

The difficulties faced by smokers to quit smoking make it very important to improve the methods to help them, which is the objective of the studies published in the current issue.

References

• 1. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Geneva: Word Health Organization; 2008.
• 2. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367:1747-57.
• 3. Doll R, Peto J, Borehan J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male british doctors. BMJ. 2004;328:1519-28.
• 4. Monteiro CA, Cavalcante TM, Moura EC, Claro RM, Szwarcwald CL. Population - based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Org. 2007;85:527-34.
• 5. Azevedo RCS, Higa CMH, Mira IS, et al. Grupo terapeutico para tabagistas: resultados após seguimento de dois anos. Rev Assoc Med Bras. 2009;55(5):593-96.
• ⁶
  U.S. Department of Health and Human Services. Quick Reference Guide for Clinicians. Treating tobacco use and dependence; 2008. Update. [cited 2009 ago]. Available from: http://www.ahrq.gov/clinic/tobacco/tobaqrg.pdf
• 7. Souza EST, Crippa JAS, Pasian SR, Martinez JAB. Estrutura fatorial da versão brasileira da escala de razões para fumar modificada. Rev Assoc Med Bras. 2009;55(5).
• 8. Souza EST, Crippa JAS, Pasian SR, Martinez JAB. Escala de razões para fumar modificada: tradução e adaptação cultural para o português para uso no Brasil e avaliação da confiabilidade teste-reteste. J Bras Pneumol. 2009;35:683-9.
• 9. Benowitz NL. Clinical pharmocology of nicotine: implications for understanding, preventing, and treating tobacco addiciton. Clin Pharmacol Ther. 2008;83:531-41.
• 10. Jarvis MJ. Why people smoke. BMJ. 2004;328:277-9.
• 11. Panday S, Reddy SP, Ruiter RAC, Bergström E, de Vries H. Nicotine dependence and withdrawal among ocasional smokers. J Adolesc Health. 2007;40:144-50.
• 12. Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, et al. A Randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360:699-709.

Cessação de tabagismo

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desafios a serem enfrentados

Publication Dates

• Publication in this collection
  17 Nov 2009
• Date of issue
  2009