The 2024 WHO Clinical Treatment Guideline for Tobacco Cessation in Adults has just been published. This scholarly endeavour starts with the usual mantra: ‘Tobacco kills more than 8 million people per year.’ The problem, then, is what should be done about this dreadful situation? It’s put in a nutshell by WHO:

Although globally there are still 1.25 billion people who use tobacco, and of the adults among this number, over 60 per cent want to quit, but around 70 per cent of them have no access to comprehensive tobacco cessation services.

So that’s what smokers need: access to comprehensive tobacco cessation services!

It’s clear in this document that WHO regards tobacco smoking as a chronic disease in need of treatment. The most effective treatments, according to the evidence they examined, are behavioural interventions, whatever that means; nicotine maintenance therapy; and drugs, namely, varenicline, bupropion, and cytisine.

When doctors treat a disease, they need to counteract or remove the cause, if this is possible. For example, bacterial pneumonia should be treated with antibiotics, and type 1 diabetes with the provision of insulin. What, then, is the cause of tobacco use? The answer, obviously, is tobacco. And how do the world’s 1.25 billion tobacco users obtain tobacco? They buy it in the shops where it’s on open sale! I’ll come back to this absurdity shortly.

Why do people start smoking?
The short answer is because they can. The vast majority of smokers start in their teen years because their parents or friends smoke and it appears cool and grown up; or they want to try it out of curiosity; or some start from rebelliousness, especially if they’re below the legal age to buy cigarettes; and a few may start because of the misperception that it can help reduce stress.

The usual initial experience of sucking poisonous tobacco fumes into one’s lungs it unpleasant. It makes you cough and you might feel dizzy or nauseated. Nonetheless, around two-thirds of teenagers who try smoking go on to do it again – and again and again. Then they find they can’t stop, or think they can’t, so they pop down to the local supermarket or convenience store and buy another pack of cigarettes!

Tobacco control
The current focus of ‘tobacco control’ is to discourage people from buying cigarettes. That’s what the horrible pictures and health warnings on cigarette packs are for. Or perhaps increasing the price will put people off. But why are cigarettes on sale in the first place? They serve no useful purpose in people’s daily lives. The perceptions that smoking is relaxing, pleasurable, or rewarding in some way are illusory. This can easily be demonstrated in a simple non-judgemental conversation with smokers. It’s not a matter of trying to persuade smokers they ought not to do it – they already know that – but of helping them to quit even though they think it will be hard.

The idea of the difficulty of stopping smoking is unwittingly reinforced by the orthodox approach to smoking cessation. You need to be mindful of the evidence-based most effective treatments offered by comprehensive tobacco cessation services, namely, behavioural interventions, nicotine maintenance therapy, and prescription drugs! And while smokers struggle to get their heads around these discouraging official pronouncements, if they listen to them at all, they can pick up further supplies of cigarettes from the local shops whenever they feel like it.

This absurd situation is encouraged by the belief that ‘over 60 per cent of smokers want to quit.’ They want to quit but they can’t, so they need help. In the UK, how come that 60 per cent of the 6.4 million adult smokers, that is 3.84 million people, are not clamouring for access to comprehensive tobacco cessation services? The answer is that they don’t really want to quit. And even if they do want to quit, the prospect of submitting to behavioural interventions, nicotine maintenance therapy, and taking prescription drugs may put people off. They’re defeated before they start.

Edifying statements
In this document we find such edifying statements as the following:

The term health-care provider includes, but is not limited to, doctors, nurses, pharmacists, dentists, physical therapists, counsellors, community health workers and other health-care providers.

There is high-certainty evidence that more-intensive individual behavioural counselling is more effective than less-intensive individual behavioural counselling.

Well, fancy that.

Throughout this document smoking is considered as a disease, which manifestly it is not, for which sufferers will be glad to submit to any treatment or ‘intervention’ that has a reasonable hope of success. The various forms of counselling, nicotine products, and drugs are assessed by the ‘evidence’ and graded by their perceived degrees of effectiveness. But these interventions are only potentially of benefit for those smokers who choose to submit to them, and even for those who do, willpower is still required to refrain from smoking.

Furthermore, what does it mean that ‘over 60 per cent of smokers want to quit’? As I explain in Chapter 2 of my book, Stop Smoking: Real Help at Last, depending on how you ask the question, you will get answers indicating that everyone, or no one, wants to quit. And even if the 60 per cent figure is true, what about the 40 per cent who apparently don’t want to quit? What can we do to help them? Or are they beyond help? Furthermore, as I also describe in the above-mentioned book, in Chapter 3 called ‘The Magic Wand Dilemma’, we could have a situation like this:

I could say to the smoker: ‘I have here a magic wand which, with your permission, I shall wave while making a ritual incantation. There will be a puff of smoke (!), the spell will immediately take effect, and you will never want to smoke again, but everything else in your life will be unchanged. Shall I wave the magic wand?’ The answer will be no.’

WHO, governments, and smoking cessation counsellors should stop fooling themselves that what we need is more evidence-based interventions for smoking cessation. What we need is legislation to make tobacco products unavailable by banning their manufacture and sale.

Simple smoking cessation
In the meantime, for smokers who really do want to quit but find it difficult and are looking for help, the complicated and discouraging approach set out in the above document is unnecessary. I have found with the hundreds of my smoker patients I have successfully treated over the years, that returning to the happy state of being a non-smoker is much easier than most people imagine.

The Symonds Method consists in helping smokers to demonstrate to themselves two things: why they really smoke, as opposed to why they think they smoke, and why quitting seems so hard. With this understanding smokers can soon develop an attitude to smoking such that they won’t want to do it anymore. So they won’t.

Text © Gabriel Symonds

Picture credit: Wikimedia Commons