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'Consonant' smokers know and accept the risks associated with tobacco consumption, and do not wish to change their smoking, whereas 'dissonant' smokers are tobacco consumers whose attitudes differ from their behavior. Dissonant smokers have several options: to quit smoking (the optimal solution), reduce their smoking, switch products or brands, or do nothing. To date, nicotine replacement therapy (NRT) is the best-established medical aid to smoking cessation, but several important factors impact on NRT use. As smokers constitute a diverse group there is a need for various different formulations, some of which will suit certain smokers better than others. Smokers should be allowed to select their preferred products in order to increase compliance, and should also be permitted to combine various products if desired. Adequate dosage regimens should be stressed in order to avoid under-dosing, which is common with NRT. It is also essential that the medical system focuses increasingly on the diagnosis and treatment of those smokers who are unable or unwilling to quit smoking. High nicotine dependence correlates with a high risk of pulmonary and cardiovascular disease; because these smokers cannot quit, cessation efforts have little impact on the incidence of tobacco-related diseases in this population. Additional smoking control interventions, such as smoking reduction therapy, are therefore required to treat this group. Our experience in Vienna shows that these smokers can be targeted through approaches that utilize new messages offering alternatives to cessation.
To date, prevention of onset of smoking has been considered the primary goal in tobacco control; however, current smoking prevalence figures indicate that such programs have not been particularly successful. There are now an estimated 1.1 billion existing smokers worldwide, 50% of whom will die prematurely as a result of tobacco use. As prevention of onset has no effect whatsoever on minimizing tobacco-related death and disease in existing smokers, increasing efforts must be made to eliminate or substantially reduce tobacco use among this population.
Smoking populations can be divided into various subgroups. Consonant smokers are those whose attitude and behavior are in agreement: they do not profess to have any concerns about smoking and they continue to smoke. As these smokers are unwilling to change their smoking behavior, little can be done with this population other than to attempt to motivate them to stop, which is often discouraging for both the smoker and the counselor. In contrast, dissonant smokers express a desire to alter their smoking behavior, and these individuals are the primary target group at whom to target smoking control efforts. One survey of dissonant smokers in Austria revealed that 28% wanted to quit smoking and 14% wanted to switch to a different tobacco product or brand, whereas the largest group (56%) expressed a desire to reduce smoking. Irrespective of the end-point, there needs to be a change in the way smokers are counseled. Traditionally, smokers are told emphatically that they must stop smoking, but this autocratic approach may be counterproductive. Physicians and other health professionals involved in smoking control should aim to inform (rather than tell) smokers about available intervention techniques, such as therapy for smoking reduction and how to manage withdrawal symptoms during periods of temporary abstinence. In addition, better diagnostic techniques and treatment are also needed. Certain dissonant smokers are at very high risk of developing tobacco-related disease, either because of their smoking patterns and/or because of other risk factors, which might be prevalent in individual smokers.
Quit or reduce?
An alternative approach that can be used to treat highly dependent smokers who are unable or unwilling to quit smoking is advice to reduce smoking. Based on the dose-response relationship for many tobacco-related diseases, this novel concept is gaining acceptance among experts in the field of tobacco control. Treatment often involves concomitant use of nicotine from alternative nicotine delivery devices and smoking fewer cigarettes. Non-nicotine therapies such as bupropion could also be used to achieve smoking reduction, but there is no experience with this to date.
In the clinic, it is important not be too authoritative when smokers are being counseled with regard to the 'best' NRT product for them; patients must be allowed free choice to make their own decisions. For example, if a patient is doing well with the nicotine inhaler combined with a transdermal patch on the solar plexus, there is no need to insist that the patch be sited elsewhere.
Achievement of complete abstinence involves a combination of pharmacological and behavioral modification methods. Behavior modification is also important in attaining smoking reduction. In Austria, cigarettes are often combined with a nicotine inhaler. Although this may differ in other countries, behavior modification techniques could involve smokers alternating between cigarettes and inhalers.
From a scientific perspective, the concept of reduced smoking as an alternative strategy for the heavy smoker who cannot quit is simple and pragmatic. It is also ethical and reflects practices in other fields of health care. For example, in a hypertensive patient with a blood pressure of 220 mmHg on presentation, reduction to 160 mmHg, although not optimal, would be considered a significant clinical improvement. Similarly, a patient in whom the blood cholesterol level could be reduced from 420 to 280 mg/dL would be considered to have made progress. Therefore, smokers who significantly reduce exhaled carbon monoxide levels over prolonged periods may also represent treatment success by reducing the risk to health.
Furthermore, a reduction in the number of cigarettes smoked creates interest, allows the smoker to regain control of their smoking and may facilitate the next cessation attempt.
Aiding dissonant smokers
Baseline analysis of nicotine dependence, rated using the Fagerstrom Test for Nicotine Dependence (FTND),[ 18] revealed that more than half the participants (54%) were 'highly' or 'very highly' dependent (Fig. 1). This was corroborated by expired CO levels; 69% of participants had levels >20 ng/ml (Fig. 2), reflecting high daily cigarette consumption and high levels of nicotine dependence. Thus, this initiative attracted smokers in whom smoking reduction therapy should be considered a valid treatment approach. The majority (56%) had made > 1 serious, failed quit attempt; a further 21% had tried to quit once and 23% had never made a previous quit attempt. One explanation for the extent of interest shown in this initiative is the change in message, i.e. offering smokers an alternative to cessation. As previous research has shown that there is a correlation between the incidence of lung cancer and cigarette consumption, this population can no longer be left to 'quit or die'.
As the novel concept of harm reduction may genuinely benefit dissonant smokers who are not adequately helped by existing approaches, smoking reduction is gaining acceptance. However, this concept also requires a significant change in significant change in thinking surrounding the control of tobacco-related diseases. One way to achieve smoking reduction is through concomitant use of NRT and smoking fewer cigarettes. Smoking reduction may also be a step on the way to complete tobacco abstinence. Historically, the options for dissonant smokers have largely been 'quit or die'. However, smoking reduction and improved diagnostic techniques mark the first steps in maximizing help for dissonant smokers.
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