Inequalities in cessation and critique of possible contributing factors: taking stock of a perseveration with current treatment approaches, uptake of promising treatments and limited upscaling of interventions with positive equity impact

Jackson et al. provide an estimate of the effectiveness of commonly used smoking cessation aids in England [6]. Although the data are specific to England, they provide useful information for readers in other countries. We highlight three areas relevant to many countries.

First, the traditional telephone support-based approach to smoking cessation may not be the best option for low socio-economic (low SES) and/or disadvantaged smokers. Guidelines, including that for Article 14 [2], typically stress the importance of providing proactive telephone support through Quitlines, primarily because of their reach [2]. Globally, however, in countries where Quitlines are available, coverage and utilization are low [7]. Further, communications technology and the ways it is used have evolved considerably. As demonstrated by Jackson et al., technology-based interventions, e.g. websites for cessation, are having a positive equity impact [6]. Technology-based interventions can support tailoring to users’ needs, be adapted according to literacy and overcome barriers to treatment engagement, including the financial and time factors that exist for traditional cessation approaches [8]. Low SES compared to smokers from high SES groups have cited additional obstacles, such as guilt, shame and stigma, that deter them from accessing existing telephone or face-to-face services [9]. Alternative technology-based platforms, such as mobile phone text messaging, could provide an outlet that overcomes these barriers [9].

Secondly, in England, varenicline or electronic cigarette (EC) use appear to be the best first-line options for smoking cessation. At the time of Jackson et al.’s final data analysis, use of nicotine replacement therapy (NRT) purchased over-the-counter (OTC) had dwarfed varenicline and EC use in a quit attempt (27.5, 5.5 and 12.7%, respectively) [6]. However, this has since shifted, with EC use now the most commonly used smoking cessation aid. While the necessity for a medical consultation may be a barrier to accessing prescription medicines, ECs are as readily available as NRT OTC. The Action on Smoking and Health UK survey estimates that more than 3 million adults in Great Britain use ECs, and the most commonly cited reason for use is for cessation purposes [10]. Concern has been expressed that smoking cessation has been overly medicalized [11, 12], perhaps leading to a perception that smoking cessation medications are a bona fide approach to quitting, whereas the switch to vaping is seen as something different. Monitoring systems and survey data (similar to the UK Smoking Toolkit Study) play an important role in evaluating population-level impacts of EC use, both positive and negative. Many countries could go further to implement systems that enable the capture of EC use (and other alternative nicotine delivery systems) and distinguish it from smoking in electronic medical records. This may allow future quantification of the health benefits, versus risks, associated with long-term EC use.

Our final observation is that the findings bring into question, again, the effectiveness of NRT purchased OTC. Despite initial wide-scale predictions of advantages of switching NRT to OTC [13], population-level surveys have generally demonstrated minimal gains related to prolonged cessation [13, 14]. While ready access to NRT is important, countries that subsidize OTC NRT may be wise to ensure that the provision of subsidized NRT is coupled with some behavioural support, or at least advice from a trained work-force.

Although the findings from Jackson et al. are specific to England, they provide data relevant to stakeholders in other countries involved in tobacco control policy and service commissioning. While many aspects of smoking cessation guidelines remain just as relevant today as they did a decade ago, there is a need to review and refresh current approaches to help people stop smoking. As the inequalities trend persists throughout Europe [15] and other countries among varying SES indicators, we need to re-evaluate best practice in smoking cessation aids. As demonstrated by Jackson et al., some interventions are having a positive equity impact and stronger focus must be placed on these from now onwards. There is a need to develop new strategies with demonstrated cost-effectiveness and higher reach, uptake and sustainability. Future improvements in the upscaling and adaptations of existing technology-based interventions are a priority for low SES and disadvantaged smokers. Their implementation may be the catalyst required to ebb the tide in smoking inequalities.

Declaration of interests

H.M. has received honoraria for speaking at smoking cessation meetings and attending advisory board meetings that have been organized by Johnson & Johnson and Pfizer.