Hiroki Tateno: Recommendation for Smoking Cessation Clinics — Quitting Smoking with a Smartphone App?!

2020/04/20

Nowadays, there is likely no one who believes that smoking cigarettes is not bad for the body. In the last few years, the market for heated tobacco products such as IQOS, glo, and Ploom TECH has also heated up, and the number of people switching from combustible cigarettes is increasing. The primary reason, above all else, is "thinking about health."

For those who cannot quit smoking, smoking cessation treatment has been covered by health insurance in Japan since 2006. One can receive treatment using medication with a co-payment of around 30%, and the success rate is high. Treatment at a so-called smoking cessation clinic is a program involving five visits over three months; for those who complete all five visits, the success rate after three months actually exceeds 80%. Quitting smoking at a smoking cessation clinic is currently considered the most scientifically supported and easiest method to succeed.

It is said that up to 70% of smokers think, "Tobacco doesn't seem good for my body, I'll have to quit someday." While tobacco is sold as a luxury item, unlike other luxury items such as tea or aromatherapy, why is it that only tobacco is so difficult to quit, and why does the government need to go to the trouble of using tax money to set up smoking cessation clinics?

The medical name for the condition when smoking cessation treatment is covered by insurance is the chronic disease "nicotine dependence." It is often called nicotine addiction, but the fact that nicotine has "dependence (= addictiveness)" is the key to everything.

Nicotine and tar. These are words often heard and displayed on cigarette packs, but nicotine is actually a very rare substance that hardly exists in nature. It can only be produced by the tobacco plant, a member of the nightshade family, and is thought to be a toxic component to protect itself from pests. Columbus brought the custom of smoking this plant, native to South America, back to Europe from the Americas. Later, automatic rolling machines were created in North America, making mass production possible and spreading nicotine dependence throughout the world. If one were to dry weeds from the roadside, chop them up, roll them in paper, and try to smoke them, no one would continue smoking them. It is precisely because it contains nicotine that people continue to smoke.

The addictiveness of tobacco is said to be stronger than that of narcotics. The nicotine contained in tobacco smoke reaches the brain within seconds of taking a puff, giving the dependent person a sense of relief. It is a product that makes one feel, "I smoke because I want to," "It is indispensable to my life," or "I don't want to quit if possible," but it is also a product that people stock up on so they don't run out, or go out to buy even in the middle of a typhoon if they do run out. Is this truly a luxury item smoked of one's own free will? Rather, wouldn't it be closer to say one is "being made to smoke"?

Thus, the nicotine business is profitable; once someone starts smoking, it becomes a lucrative product that they will continue to consume for decades. Furthermore, the government, which levies a 60% tax on it, also depends on tobacco revenue, making it a product that cannot be easily banned from sale.

However, the health damage from tobacco is serious. Smoking properly (?) every day shortens one's lifespan by 10 years and doubles the mortality rate. If someone starts smoking at age 20 and dies at 75 when they could have lived to 85, they are calculated to be throwing away two months of life every year. The fact that the mortality rate doubles for diseases that could have been avoided by not smoking is the same as playing a high-risk gamble, like loading one bullet into every two chambers of a revolver in Russian roulette and pulling the trigger.

It is known that even with such tobacco, positive effects appear immediately upon quitting. The risk of myocardial infarction decreases within 24 hours, and emphysema stops progressing. Lifespan is extended, and one becomes less likely to develop dementia. In all cases, the earlier you quit, the greater the benefits, but it is effective no matter what age you quit, and it is never too late to stop smoking.

It's not just about health. How peaceful and comfortable is a life where you don't have to smoke! You don't need to remember to carry a whole set of smoking gear when going out, and you don't need to look for places where you can smoke in advance at your destination. Worries about fire hazards disappear, and there's no need to pop a Frisk in your mouth out of concern for bad breath. Yes, quitting smoking is full of good things for you; there is nothing to fear.

Recently, the number of places where one can smoke has decreased significantly. Japan's smoking population has fallen below 20%, and smoking in front of others is accompanied by a considerable sense of awkwardness. Establishments where smoking was previously allowed may become non-smoking from this April due to legal changes and ordinances, and smoke-free shops will likely increase further. This is to suppress health damage to others, known as "secondhand smoke." The damage from secondhand smoke is also serious, with an estimated 15,000 people dying every year in Japan alone due to secondhand smoke.

Recently, the term "thirdhand smoke" has also emerged. This refers to the health effects received from tobacco smoke substances remaining in rooms, even if one is not smoked in front of directly. Nicotine released from tobacco sticks to furniture and carpets in a room and remains there. When it reacts with substances in the atmosphere, carcinogens are also produced. For infants in particular, by putting hands that have touched these surfaces into their mouths while crawling, they ingest these harmful substances at higher concentrations than adults.

Furthermore, harmful substances continue to be emitted from exhaled breath for 45 minutes after smoking. The fact that this does not disappear after a few deep breaths is evident from the fact that you can immediately tell by the smell when a colleague returns from a smoking area and sits in the next seat. For this reason, some places have begun to prohibit entry into the premises or elevators for 45 minutes after smoking.

While such a restricted life may become even stricter in the future, the prospect of it being relaxed is slim. Yes, if you quit smoking, these social awkwardness issues will be resolved at once.

As mentioned at the beginning, sales competition for heated tobacco products from various companies has intensified in recent years. The selling point is the "reduction of harmful substances," and pamphlets show graphs suggesting that toxic substances have been cut by 90%. Manufacturers hope that people will think, "If this is the case, it might not be that bad for my health, and I might not have to quit tobacco itself."

Since they have only been on the market for a few years, no one knows how much heated tobacco affects lung cancer or emphysema, which take 20 or 30 years to develop after starting to smoke. However, medical professionals are unanimous in saying that it is better to quit heated tobacco as well. In fact, IQOS pamphlets state in fine print that expressions like "approximately 90% reduction in the amount of harmful components" do not mean that the adverse health effects of this product are smaller compared to other products, and that the best way to reduce tobacco-related health risks is to quit both combustible cigarettes and IQOS.

What is known at this point is that the same amount of nicotine can be ingested from heated tobacco (which is natural in a sense, as the purpose of the new product is to maintain nicotine dependence and keep people buying tobacco products), that there are many substances that are more abundant than in combustible cigarettes, that many people cannot switch completely to only heated tobacco and end up smoking combustible cigarettes as well, and that even if harmful components could be cut by 90%, the health impact would not decrease by even 50%. In experiments conducted on Japanese subjects, even if they switched completely to heated tobacco for three months, although the toxic substances detected in the body decreased, the biological response to toxic substances did not improve.

E-cigarettes containing nicotine are not sold in Japan due to legal regulations, but in the United States, they have become a problem after it was discovered that they cause lung damage comparable to severe coronavirus pneumonia.

The aldehydes (one type of harmful substance) detected from these new types of tobacco are indeed about one-tenth of those in combustible cigarettes, but if you quit smoking and breathe only the atmosphere, the aldehydes entering the body decrease to one-hundred-thousandth. Yes, the orders of magnitude are different. If you are going to think about your body, stopping at heated tobacco is a waste; now is the chance to quit smoking!

The success rate of quitting smoking at smoking cessation clinics is high. However, the aforementioned data of over 80% is limited to those who completed all five visits over three months. If we include those who stopped visiting midway and track them up to one year later, the smoking cessation rate drops to around 30%.

Smoking cessation medications suppress the "nicotine withdrawal symptoms" that appear as soon as you start quitting. This is also effective for heated tobacco. Thus, one can quit smoking easily, but another important element in the clinic—receiving counseling from doctors and nurses—only happens once every two to four weeks. During the periods between visits, one continues their own coping strategies while using medication and recalling the content of the counseling.

Furthermore, while smoking cessation treatment ends in three months, there are cases where people resume smoking afterward.

The Department of Pulmonary Medicine at the Keio University School of Medicine supervised the joint development of a smartphone app for smoking cessation treatment, to be used by patients at smoking cessation clinics, with the company CureApp. When clinical trials were conducted with nearly 600 smokers who visited about 30 smoking cessation clinics in Japan, high effects comparable to smoking cessation medications were obtained.

The app is equipped with powerful tools: it has an automatic response function where users can chat daily with a nurse icon to receive advice, animated videos that can be viewed in a few minutes are delivered to help master smoking cessation strategies, a portable exhaled carbon monoxide measuring device is included for daily measurement at home so users can feel the values improving as they quit, and recorded smoking cessation diaries can be shown to the doctor at the next visit. When used together with smoking cessation medication and continued until the sixth month even after the medication ended, the smoking cessation rate remained high even after one year. Currently, an application is being made so that the app can be "prescribed" under health insurance, aiming for realization within this year.

The success rate of quitting smoking at smoking cessation clinics will likely become even higher in the future. If you visit, you can say goodbye to a high-risk life much more cheaply and easily than continuing to smoke. I would like to conclude this article by conveying once again the peace and comfort of a life where you don't have to worry about tobacco, including my own self-reflection as a former smoker.