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To be most effective, tobacco control efforts should be truly comprehensive, and include a variety of interventions.

Tobacco control interventions can have a wide number of effects, as reported by the US Department of Health and Human Services (2000), summarized as: strengthening motivation to quit; reducing impediments to quitting; creating a non-smoking norm; and reducing stimuli to smoke. The interactions and synergy between these efforts may be more important than their individual effects (US Department of Health and Human Services, 2000). For example, in New York City, the combination of a large tobacco tax increase, a comprehensive smokefree law, and programs to encourage smokers to quit, including the provision of NRT, led to a 14.4% decline in adult smokers in two years (CDC, 2007). Similarly, the US Task Force on Community Preventive Services found a positive impact on cessation from increasing the unit price of tobacco; providing multi-component cessation services, including telephone quitlines; and mass media campaigns as a part of the comprehensive effort.  Workplace/public place smoking bans were found to decrease per capita consumption.  A review of these issues across several nations in 2006 by Jha and colleagues concurred with these conclusions and more recently a landmark article by Jha and Peto advocates for significant global price increases on tobacco, calling for doubling or tripling the inflation-adjusted price as the most effective policy to reduce worldwide consumption by a third (Jha, Peto 2014). A recent study using sophisticated modeling techniques demonstrated the positive impact that policies such as monitoring tobacco use and tobacco control policies (protecting people from the dangers of tobacco smoke, offering help to quit tobacco, warning the public about the dangers of tobacco, enforcing bans on tobacco advertising, promotion and sponsorship; and raising tobacco taxes) could have (Levy et al., 2013). Overall, a review of the impact that tobacco control policies have had on smoking rates concluded that the most successful campaigns included a combination of such interventions (Levy et al., 2004).

It is important to recognize that different individuals may respond to different approaches and that approaches must be relevant and feasible with consideration given to the population and the country or region.  The key guiding principle should be to achieve a diverse mix of evidence-based principles to the greatest extent possible, e.g., combining education, taxation, clean air laws, and providing access to treatment.

Specific components of comprehensive policies are described in greater detail immediately below:

Packaging and labeling. There is evidence that misleading descriptions on cigarettes such as ‘light’, ‘mild’ and ‘ultralight’ have dissuaded some smokers from quitting (Giovino et al., 1996; Weinstein, 2001; Shiffman et al., 2001a; Shiffman et al., 2001b). Further research by Tindle and colleagues indicates that smokers who switch to light cigarettes are less likely to succeed in smoking cessation (Tindle et al., 2006; 2009). Hamilton et al. (2004) showed that many smokers not only think these messages imply less risk to health, but that a government agency controls the veracity of advertising for regular and “light” products, including the health claims.  Adolescents hold similar misperceptions about the addictiveness, health risks, and ease of quitting “light” cigarettes (Kropp & Halpern-Felsher, 2004).  Hughes (2001) summarizes the results of experimental studies in this area and concluded that advertisements correcting false beliefs about ‘lights’ increased self-reported interest in quitting, the likelihood of quitting or interest in obtaining treatment. Recent initiatives in Australia, New Zealand and some nations of the European Union to limit cigarette packaging to plain, generic packs without brand logos or colors are another strategy that may be shown to reduce consumption.  Since Australia began its policy of plain packaging in October 2012, initial research on its effect is quite promising, with increased calls to the Quitline, diminished positive perceptions of cigarettes among youth, and observations that there may be fewer people smoking in outdoor areas of cafes, bars, etc and a reduction in personal pack display.

Access to treatment. Treatment programs complement other tobacco control policies by enhancing/creating the access to cessation support, thereby increasing the chances that a quit attempt will be successful. Health care providers at all levels should receive appropriate training  to motivate and facilitate cessation attempts using evidence-based methodology. As the number of former tobacco users increases, support for tobacco control measures increases, with a positive impact on national health. Such tobacco control efforts are promoted through FCTC Articles 6-14 which are in Part III describing measures relating to the reduction of demand for tobacco, as well as Articles 15-17 in Part IV describing measures to reduce the supply of tobacco (WHO FCTC, 2005).

Increasing accessibility to treatment complements all these other measures by enhancing the availability of help in stopping and by increasing the chances of quit attempts succeeding. Shiffman and colleagues (2008) demonstrated that many smokers are grossly misinformed about the risks of nicotine replacement therapy (NRT) and therefore are less likely purchase NRT, or to use less than recommended if they do use, or fail to use for a sufficiently long period of time. Thus, providing coherent information to the public concerning treatment options can attenuate this negative perception and have a significant impact on public health.

Taxation. Tax increases have a direct effect on tobacco prevalence and encourage cessation.  From the US to New Zealand (Wilson & Thompson, 2005) and Taiwan (Lee et al., 2005), this seems to be an economic truism. While tax/price increases have a significant effect on tobacco consumption, an international study of the affordability of tobacco products points to this dimension as being another important financial consideration of tobacco pricing policy (Blecher & von Walbeek, 2004). More specifically, tax/price increases encourage people to quit smoking, and may be the single most effective policy intervention to do so (Biener et al., 1998, 2000; Tauras, 1999).

Tax increases also stimulate smokers to use nicotine replacement therapy (Chaloupka, 2000; Tauras & Chaloupka, 2003). Worksite restrictions also encourage smokers to reduce per capita consumption of cigarettes, and to stop and use treatment (Fichtenberg & Glantz, 2002; Sorensen et al., 1991; Glasgow et al., 1997; Tauras & Chaloupka, 1999). Tobacco advertising bans have also been shown to promote cessation (Saffer & Chaloupka, 2000). 

Education. Promotional and education campaigns have been shown to play a role in stimulating smokers to make quit attempts and there is some evidence of their effectiveness and cost-effectiveness (World Health Organization, 2009; World Bank, 1999; National Cancer Institute, 2000). News media coverage of smoking and health issues has been shown to be related to adult quitting behavior (Pierce & Gilpin, 2001). Comprehensive programs, such as The California Tobacco Control Program. have also been demonstrated to promote cessation (e.g. Messer et al., 2007), particularly among young adults. Nevertheless, smokers in industrialized countries are still misinformed about the health consequences of some aspects of smoking, e.g. low tar cigarettes, filter cigarettes, compensation, ingredients, etc. (e.g. Shiffman et al., 2001).

Smoke free policies. Although smoke-free policies are intended to reduce exposure to second hand smoke, they also provide the opportunity for smokers to quit. Fichtenberg and Glantz (2002) estimated that some 15% of smokers give up altogether and others cut down when smoke-free laws are implemented. There is also evidence of quitting activity around the time of implementation of smoke-free laws, including increases in calls to quitlines (Wilson et al., 2007) and increases in sales of smoking cessation medications (Metzger et al., 2005). However, a recent review of outdoor smoke-free regulation across 48 European countries found that such policies were rare (Martinez et al., 2014). Thus, although progress is being made with regard to smoke-free policies, there is room for improvement.

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Chaloupka FJ. The taxation of tobacco products. In: Tobacco Control in Developing Countries. 2000. Edited by Prabhat Jha and Frank Chaloupka. Oxford: Oxford University Press.

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Levy DT, Chaloupka F, Gitchell J. The effects of tobacco control policies on smoking rates: a tobacco control scorecard. Journal of public health management and practice : JPHMP. 2004;10: 338-353.

Martinez C, Guydish J, Robinson G, Martinez-Sanchez JM, Fernandez E. Assessment of the smoke-free outdoor regulation in the WHO European Region. Prev Med. 2014; 64: 37-40.

Messer K, Pierce JP, Zhu SH, Hartman AM, Al-Delaimy WK, Trinidad DR, Gilpin EA. The California Tobacco Control Program’s effect on adult smokers: (1) Smoking cessation. Tob Control. 2007; 16: 85-90.

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National Cancer Institute. Population Based Smoking Cessation: Proceedings of a Conference on What Works to Influence Cessation in the General Population. Smoking and Tobacco Control Monograph No. 12. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2000. NIH Publication No. 00-4892.

Pierce JP, Gilpin EA. News media coverage of smoking and health is associated with changes in population rates of smoking cessation but not initiation. Tob Control. 2001; 10: 145-153.

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US Task Force on Community Preventive Services

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