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• W2640228049 abstract "Article 14 of the Framework Convention on Tobacco Control recommends provision of evidence-based support for tobacco cessation. However, it is being implemented very slowly in most countries, so that by 2014 only a small minority of the world's tobacco users had access to appropriate cessation support, according to the World Health Organization (WHO). This editorial, endorsed by more than 70 global leaders in tobacco cessation as it went to press (see online version; contact the lead author for the latest list of endorsers), sets out actions that countries can take to remedy the situation, focusing on low-cost, broad-reach interventions. Stopping tobacco use is a vital element in any comprehensive approach to tobacco control. It saves lives, prevents debilitating illnesses and is beneficial economically 1, not least by reducing health-care costs 2. Recognizing this, the World Health Organization (WHO) oversaw the development of the world's first global health treaty, the Framework Convention on Tobacco Control (WHO FCTC), which entered into force in 2005, and includes an Article on tobacco cessation (Article 14). The FCTC is one of the most widely supported of all United Nations (UN) treaties. At the time of writing 179 countries (180 Parties), representing 90% of the world's population, have ratified the Treaty 3. In 2010 the fourth Conference of the Parties to the Treaty adopted guidelines to assist Parties in implementing Article 14 of the Treaty on tobacco dependence and cessation 4. Thus, there is strong international support to strengthen and accelerate full implementation of the WHO FCTC. While preventing people from starting smoking and using other forms of tobacco will save lives 20 years and more from now, only effective tobacco cessation will have a sufficient effect on mortality in the few years left to reach the UN/WHO goal of a 25% reduction in premature mortality from NCDs by 2025. Failure on that front will surely thwart the global aspiration for success in NCD control and fail to save millions of current smokers’ lives 8. The 2014 WHO Global Progress Report notes that, in general, good progress is being made in FCTC implementation (although it notes that only 19% of Parties have implemented it to the ‘highest level’), but that some Treaty articles are being implemented more quickly than others 9. The report shows that by 2014 the strongest focus was on Articles 8 (restrictions on smoking in public places), 16 (restrictions on sales to minors), 11 (large health warnings) and 12 (educational programmes), which motivate tobacco users to seek treatment for tobacco dependence. Only half of Parties reported that they were implementing Article 14 on tobacco dependence and cessation, a finding consistent with that of another survey suggesting slow implementation of Article 14 10. Evidence from the survey suggests that perceived cost may be one reason for hesitation in addressing tobacco treatment support. Another reason may be lack of clarity about the effectiveness and cost-effectiveness of tobacco dependence treatment. There is little doubt that implementation of FCTC Article 14 and its guidelines will bring health and economic benefits to countries 1. Helping smokers to stop is a highly cost-effective health-care intervention which saves lives 11-15, improves population health by reducing both morbidity and mortality 16-18 and can reduce health-care costs 2. Every day that smokers aged more than 35 years continue to smoke they lose approximately 3–6 hours of life 19, so for the world's estimated 1 billion current smokers 1, approximately half of them aged more than 35 20, 62 million days of life are lost every day. Some of these will stop unaided. Many others will stop only after repeated attempts over time. Many more smokers will never stop and will die before they can stop 21, mainly because tobacco use is so addictive 4, 22-24. Arguably treatment support should be provided, along with measures such as restrictions on smoking in public places and other measures mentioned in the FCTC 25. While other tobacco control policies, such as tax increases and smoke-free air laws, primarily increase quit attempts, evidence shows that comprehensive cessation treatment policies primarily affect quit success 12. Combining cessation treatment with other policies creates a synergistic impact that improves the effect of other policies. The unaided tobacco cessation rate at 6–12 months is low, only approximately 3–5% 26. Adding comprehensive cessation support can increase this considerably, at least doubling it 12, 18, 27, 28, but even brief advice improves cessation rates significantly. Its long-term rate is much lower, but applied at population level it would still result in significant population health gain 27. One reason why so many people who eventually end up as ex-smokers have stopped without help is not because attempting to quit without help is the most effective method, but simply because many of them had no access to help. If they had had access to support they may have stopped sooner, and many life years could have been saved. Additionally, many smokers who never stopped might have managed to do so if support had been available and accessible. According to WHO, just 15% of the world's population have access to appropriate cessation support 29, and even among this 15% many do not use the support that is available 30. Although less is known about smokeless tobacco use, clearly a comprehensive approach is required for cessation 31, 32. There is thus a significant unmet need for tobacco cessation support. Although some tobacco users stop unaided, many more would stop if they had access to effective support. The FCTC Article 14 Guidelines recommend how to address this need in a way that is appropriate to the situation of the country, and which makes best use of existing resources. Improving cessation support need not be expensive, and helping smokers stop sooner rather than later will not only save many lives but improve the quality of life of those who do stop. Because of these considerations, and because the FCTC Article 14 Guidelines contain clear and feasible recommendations, we believe the time has come to re-evaluate the role of cessation support, especially because effective, low-cost, broad-reach approaches exist that can be implemented quickly 27. Revenue could be raised for tobacco control and cessation from tobacco tax increases 1, 33, 34 and evidence from some countries suggests that public support for such tax increases is stronger if some of the money is spent offering support to tobacco users who need it, many of whom are poor and for whom tobacco use is a financial strain 35. FCTC Article 14 states that ‘each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence’. The FCTC Article 14 Guidelines set out detailed recommendations for implementation of this Article, including on developing infrastructure, the key components of a national treatment system and a stepwise approach to developing cessation support. We urge all stakeholders to use these guidelines to guide their thinking about cessation support. Eventually, all Parties should implement all aspects of the FCTC, and the FCTC Article 14 Guidelines encourage Parties to implement measures beyond those recommended by the guidelines (in accordance with the provisions of Article 2.1 of the Convention). However, they also acknowledge clearly that different countries will be at different stages and will need to implement Article 14 according to their own priorities and resources. Thus, we recommend measures that we believe all countries can begin implementing now, and then measures to be implemented as resources become available. Some of these measures are relatively low cost 27, and we believe some are essential if healthcare systems are to play an active role in helping tobacco users to stop. For example, healthcare workers raising the issue and giving brief advice will be more likely if tobacco use is recorded in medical notes, yet only 20% of countries mandate this 10. The Article 14 Guidelines emphasize strongly using existing infrastructure as far as possible, both to keep costs down and to ensure as broad a coverage as possible. They mention infrastructure such as the primary healthcare system and services to treat tuberculosis and HIV/AIDS, and in some countries dental services and NCD programmes could also be involved. The first WHO Report on the Global Tobacco Epidemic (the MPOWER package) recommends that tobacco cessation advice be incorporated into primary health-care services 36. We believe that whatever stage countries are at in implementing other articles of the FCTC, they could be implementing these six core measures. The FCTC Article 14 Guidelines urge Parties to follow the evidence base, keep under review the emerging scientific evidence and be open to innovative approaches to promote tobacco cessation 4. Since the Article 14 Guidelines were adopted in 2010, for example, new research has emerged on text messaging and on less harmful forms of nicotine delivery. Thus national cessation guidelines need to be reviewed and updated periodically to include new interventions. An increasing body of evidence demonstrates the effectiveness of text messaging, a measure with enormous potential because of its possible population reach and low cost. Research is also developing on different forms of nicotine delivery. Clearly, any cessation guideline published in 1980 would be seriously out of date by 1990 because of the advent of nicotine replacement therapy (NRT)—itself an alternative form of nicotine delivery when it was first licensed, and now affordable in many countries—and on the WHO Essential Medicines List 37. Two recent authoritative publications recognize the continuum of risk from using nicotine products 38, 39. Based on this idea, differential taxes have been proposed that discourage use of the most dangerous forms of nicotine-yielding products 40. We therefore urge countries to remember that it is the nicotine in tobacco products that keeps people using them, but it is primarily the toxins in the tobacco and tobacco smoke that cause the illness and death, and to keep under review all potential options for tobacco cessation including, for some, the continued use of nicotine. Many tools exist to help countries implement or improve their provision of tobacco cessation support, including the recommendations of the FCTC Article 14 Guidelines themselves (for example to include the quitline number on tobacco packaging) 4, WHO resources 41-43 and tools to help countries conduct a national situation analysis—recommended in the Article 14 Guidelines—and access other related resources 44. West and colleagues have published a review of effectiveness and affordability, which includes an Excel calculator that permits a country to input its own national data in order to calculate the affordability of a cessation intervention 27. Potentially low-cost evidence-based medications are available 45; countries should also examine how to make medications more affordable, through bulk buying for example, and by including some on their national essential medicines lists. Many countries base their national lists on WHO's essential medicines list 37, which includes nicotine chewing gum and nicotine patch. We also urge countries to consider increasing funding for tobacco control and cessation support through earmarked tax increases 34, a measure recommended in the FCTC Article 6 Guidelines. Obviously, a key challenge in providing specialist face-to-face cessation support is cost, but another issue is reach. Even in some countries that provide specialist support it is only accessible to a small fraction of the population. This is why the Article 14 Guidelines encourage Parties to consider using existing, rather than creating new, infrastructures. However, many countries have the resources to offer specialist support, and the Article 14 guidelines include a number of recommendations for these, including that it could be delivered by a variety of healthcare or other trained workers, in a wide variety of settings, should be easily accessible to tobacco users and where possible should be provided free or at an affordable cost. The guidelines also emphasize the importance of mass communication programmes that promote cessation. Implementation of FCTC Article 14 has been slow. Accelerating its implementation to complement implementation of other Articles, including those promoting tax increases, smoke-free public places and graphic health warnings, will save lives, prevent numerous debilitating illnesses and bring economic benefits. The availability of effective, broad-reach, low-cost interventions and tools to help countries select affordable treatments 27 will remove significant barriers to the development of tobacco cessation support and make Article 14 implementation both eminently feasible and a significant contributor to global health. M.R. was funded by Global Bridges, Mayo Clinic, to lead the writing of this article; T.G. was funded by Global Bridges, Mayo Clinic during the writing of this article; O.A.Y., F.C., M.F., F.H., J.M., A.M. and S.R. declare no conflicts of interest. The Global Bridges project at Mayo Clinic is partially funded by Pfizer, but managed independently. We gratefully acknowledge help from Brent Bell, Alice Grainger-Gasser, Ehsan Latif, Kapka Nilan, Kamran Siddiqi and Francis Thompson in the preparation of this paper. Appendix S1 Contains the list of organizations and individuals who had endorsed these recommendations when they went to press. The latest version, which is being continuously updated, can be obtained from the first author. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article." @default.
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• W2640228049 title "Recommendations for the implementation of WHO Framework Convention on Tobacco Control Article 14 on tobacco cessation support" @default.
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