More than 60% of tobacco users worldwide want to quit. But since help is often fragmented and hard to access, only a small fraction have access to evidence-based help. A new report from Vital Strategies, developed in collaboration with the World Health Organization, examines why—and what it will take to change that.
The report proposes an “ecosystem” approach that treats cessation support not as a single program or clinic but as an inter-related system. The tobacco cessation ecosystem model addresses resource management, stakeholder involvement, monitoring, and health care delivery system improvement to make cessation help more accessible, affordable and effective. Aimed at policymakers, healthcare workers, managers and advocates, the report highlights global examples and offers helpful resources.
To unpack the findings, we spoke with Dr. Tim McAfee, lead author of the report, titled “Strengthening the Tobacco Cessation Ecosystem: Strategies for Improving Access, Use, Success, Synergy and Impact at the National, Subnational and Organizational Levels.”
“We’re trying to create an impact, we’re trying to decrease tobacco use at the population level,” says McAfee. “That includes ensuring there are high-quality services available for individuals that are delivered in ways that are accessible and effective.”
Read on for more from Dr. McAfee.
What is one of the most effective ways to help people quit?
The core approach from a tobacco cessation ecosystem perspective is to “consistently address tobacco use and dependence in all patients as a standard of care, providing evidence-based support,” McAfee says. Tobacco treatment should include routine screening for tobacco use, diagnosis, brief advice to quit, and offering assistance or referral with follow-up in all healthcare settings for those interested in quitting. What does this mean at the individual level? Especially in countries where the rate of trying to quit is very low, the most impactful of all the different interventions is something called the “delivery of brief advice in healthcare sites,” says McAfee.
Every time a patient interacts with the healthcare system—primary care, a specialty visit, a hospital, a community health clinic or outreach worker—they should be asked about tobacco use. If ,using any form of tobacco they are advised that quitting is critical to their health, and provided additional assistance on-site or through referral, if they show interest in quitting. “This is an incredibly powerful and underutilized way to address tobacco use at the population and individual level through cessation interventions. It sounds straightforward, but it takes a lot of effort on the part of multiple people and institutions in different parts of the cessation ecosystem to make that happen on a regular basis.” Even a 20- to 30-second message, delivered consistently, creates measurable increases in quitting, says McAfee.
How is technology—including AI—changing what’s possible in cessation?
Quit support is increasingly augmented by digital modalities, including interactive texting programs, and other emerging tools such as cessation apps, both free-standing and embedded in larger platforms such as WeChat in China. Increasingly, “call” centers established over the past few decades to provide live, more accessible counseling support over the phone are integrating digital options into their service offerings. This can provide opportunities to further scale up support to large populations efficiently.
Many digital cessation tools—like texting programs and apps—now use AI in the background to analyze users’ questions and provide tailored, interactive chat support rather than canned messaging. The recent WHO cessation guideline found emerging evidence that AI-powered chatbots can increase quit success. “But both the World Health Organization guidelines and the ecosystem report emphasize that we don’t think of digital solutions, including AI, as being the total solution,” McAfee says. Highly effective, well-established tools for increasing quit success include medications and human-based counseling programs delivered in person or by phone. Ensuring barrier-free access to these established means of more intensive support is also vital.
What are some of the challenges the tobacco cessation ecosystem faces when it comes to helping people quit?
Tobacco cessation doesn’t exist in a vacuum, says McAfee. Over the last 10 to 15 years, there’s been an uptick in aggressive activity from the commercial tobacco and nicotine industry that can impede the positive work in the tobacco cessation ecosystem. This includes the “tobacco harm reduction” framework being aggressively pushed by the industry that focuses on encouraging cigarette users to switch to the new suite of more profitable products, like electronic cigarettes, heated tobacco products and oral nicotine pouches, rather than to quit. “They’ve gone so far at this point where they’re ingratiating themselves into medical education events and [funding] medical education programs so they can influence the messaging,” says McAfee. There’s an example in the report that walks through how Philip Morris International (PMI) donated $3 million to a leading continuing medical education provider to create a smoking cessation curriculum. Unsurprisingly, the curriculum promoted switching to noncombustible tobacco products over traditional cessation.
What are some of the key findings on the tobacco cessation ecosystem?
Policies that make the overall environment more conducive to cessation emphasize systematic advice to quit and offer evidence-based assistance to all tobacco users in healthcare and community settings.
The principles for a thriving cessation ecosystem include:
- Increase reach, including to those at greatest risk and in populations with high prevalence.
- Provide reliable, sufficient funding, leadership messaging and system support.
- Protect against tobacco industry misinformation, manipulation, marketing and access; an ecosystem analogy is of an invasive species.
- Foster cross-institutional and cross-modality collaboration, coordination and support to create a fully integrated, resilient cessation ecosystem.
- Maximize environmental support to increase quit attempts and decrease relapses.
For more detail and analysis: