Smoking prevalence has been declining in countries such as the United States, Australia, Canada, and the United Kingdom, but these declines are matched by increasing rates in most other countries. The Healthy People 2010 goal in the United States is to decrease prevalence from 24 percent to 12 percent by the year 2010. This goal can only be achieved by helping current smokers to quit. Increasing the incidence of quitting is achieved through medications, counseling strategies, and public health approaches.
IMPACT OF SMOKING
In the United States smoking became increasingly popular from the early 1900s through the mid-1960s, but it then declined substantially. During the 1950s, the link between smoking and respiratory diseases and cancer became known. In 1964, the first Surgeon General’s Report on smoking noted the substantial health hazards associated with smoking. Cigarette smoke contains more than 4,000 chemicals, of which forty-three are known to cause cancer. Among the more toxic chemicals in tobacco are ammonia,arsenic, carbon monoxide, and benzene. Cigarette smoking is now known to cause chronic obstructive pulmonary disease (COPD), heart disease, stroke, multiple cancers (including lung cancer), and adverse reproductive outcomes. Smoking causes about 21 percent of all deaths from heart disease, 86 percent of deaths from lung cancer, and 81 percent of all deaths from chronic lung disease.
Nicotine is highly addictive and causes persistent and compulsive smoking behavior. Most users make four to six quit attempts before they are able to remain nicotine-free.
Smoking cessation produces major and immediate health benefits by reducing mortality and morbidity from heart disease, stroke, cancer, and various lung diseases.
Secondhand smoke, or environmental tobacco smoke (ETS), causes lung cancer and cardiovascular disease in nonsmoking adults. About 43 percent of U.S. children are exposed to cigarette smoke by household members. Childhood exposure to ETS has been shown to cause asthma and to increase the number of episodes and severity of the disease. ETS exposure of very young children is also causally associated with an increased risk of bronchitis, pneumonia, and ear infections. For these reasons, the importance of smoking cessation extends beyond the health benefit of the smokers themselves.
In general, clinical interventions to treat tobacco use double unassisted quit rates. Effective interventions include the provision of advice to quit by a health care provider, the provision of behavioral counseling, and medications. Since the 1980s, efforts to reduce tobacco use have shifted away from an exclusive focus on clinical interventions to include a broader public health approach. This broader approach increases quitting by changing societal norms around tobacco use and increasing the motivation and support for people to attempt to quit.
Tobacco dependence is a chronic relapsing condition that often requires repeated intervention. The U.S. Public Health Service’s “Treating Tobacco Use and Dependence” Clinical Practice Guideline describes the strong science base behind current treatment recommendations. Guidelines from Canada and the United Kingdom provide similar recommendations.
Brief advice to quit smoking from a health care provider increases quit rates by 30 percent. Every person who uses tobacco should be offered at least brief advice to quit smoking because failure to do so becomes a reason for smokers to assume their doctor does not consider it important to their health. More intensive counseling (individual, group, and telephone counseling) and medications are even more effective and should be provided to all tobacco users willing to use them.
Counseling. All patients should be asked at every visit to their physician whether they smoke, and this information should be recorded in the patient chart. Providers are encouraged to incorporate the five As: Ask, Advise, Assess, Assist, and Arrange into their treatment strategy. Asking if a person smokes prompts the provider to give advice to quit. The assessment process determines whether the person is ready to quit in the near future; the clinician’s message can then be tailored either to provide advice about quitting or to a motivational message to increase interest in quitting. Assistance is given by reviewing information on the quitting process, providing more intensive counseling and by encouraging the use of medications. Arranging means following up with the patient to determine the effectiveness of treatment.
Medication. Five medications have been approved by the U.S. Food and Drug Administration for treating nicotine dependence. All produce approximately a doubling of quit rates. Bupropion SR works on the nicotine receptors in the brain and seems to curb the craving for nicotine. Nicotine replacement therapy (NRT) products are produced in four forms in the United States: gum, patch, nasal spray, and inhaler. Nicotine tablets are also available in Europe. These products provide nicotine without the toxic chemicals that one inhales with smoke or absorbs through the mouth with chew or spit tobacco. Currently, the patch and gum are available in over-the-counter form; the nasal spray and inhaler are available by prescription.