Commentary on Peretti-Watel et al. (2009): The cost of a chronic disease


In this issue of Addiction, Peretti-Watel et al.[1] highlight the relationship between tobacco initiation, cessation and poverty in France. Their study demonstrates that tobacco dependence is an economically driven disease.

Tobacco dependence is a disease which does not spread naturally or accidentally. The spread is planned and orchestrated by the tobacco industry, and for decades the industry has implemented different strategies for dissemination aimed at targeted populations [2].

For example, investments made to promote teenagers' smoking habits are financially profitable, because by enriching nicotine receptors in the brain [3] a ‘nicotine dependency centre’ is created and reinforced. This then leads to a cycle of dependence whereby the urge to buy tobacco is sustained as a daily need; thus, the industry's initial investment is financially profitable.

The tobacco industry's global strategy has been first to target the wealthy male population, and thereafter all levels of the male and female population. A subsequent decrease in use has occurred in reverse order, as each group has become aware of the tobacco disaster which resulted in the well-known ‘bell-shaped’ epidemic curve [4].

In many western countries the most privileged classes are in the process of a rapid decline in smoking, intermediate classes are at the beginning of a decrease, while the most disadvantaged show no little or no decrease in smoking rates. This shift of the bell-shaped curve of the tobacco epidemic according to income may be a first explanation of the results of Pereti-Wattel et al.'s study [1]. The authors report no decline in smoking rates among the unemployed during 2000–07, when France had increased the price of tobacco by 42% and implemented a total indoor smoking ban. During the same period, the smoking rate declined by 22% in the more affluent groups and 11% in manual occupational groups. This is the opposite of what might be expected, given that in other countries price rises have had more of an effect on poorer smokers [5,6].

A second explanation could be the high price in France of smoking cessation medication for poorer people. The poorest populations are also those who have less access to smoking cessation clinics, which are not free of charge in France. Unlike the laws of a traditional market, where the purchase of a product by the consumer is in competition with other household expenditures and consumption of these products is limited to allow for other basic expenditures, the purchase of addictive products does not follow logical reason. The addicted subject will reduce expenditure on other products in order to purchase his substance. This would explain how 15% of the smoking French population spends more than 20% of their budget on tobacco, as reported by Pereti-Wattel et al.[1]. In France, medication and health care are covered by medical insurance and as a result consumers are often not prepared to pay the health costs for chronic disease. To explain to a smoker with few resources that it is cheaper to buy nicotine replacement therapy (NRT) for €1/day or prescription drugs for smoking cessation for €3–4/day than a packet of cigarettes for €5.30 is logical economically, but often goes against the decision-making processes of an addicted person. Indeed, in an addicted person the common relationship between available financial resources and consumption of the product is broken down and the biological need to feed the nicotine receptors drives the decision to purchase the product.

Smoking is a cause of poverty and creates social inequality; quitting smoking is shown to be more difficult for poorer smokers [7]. These social inequalities justify the allocation, as recommended by the Framework Convention for Tobacco Control (FCTC) [8], of a fraction of tobacco taxes to support smoking cessation, particularly among the most deprived, in order to reduce the economic inequalities caused by smoking.

The wealth of the tobacco industry is one of the major causes of the tobacco epidemic. The lack of wealth of the population increases the risk and severity of tobacco dependence and contributes in turn to the development of a poverty cycle. States are urged to protect their population from the tobacco industry's efforts to spread the tobacco epidemic by implementing higher taxes in order to put into place free or reduced-cost access to smoking cessation for the poorest populations.

Declaration of interest

Bertrand Dautzenberg is Principle Investigator for a smoking cessation trial funded by Pfizer.