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
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.
EFFECTIVE INTERVENTIONS
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.
CLINICAL INTERVENTIONS
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.
HEALTH CARE SYSTEM SUPPORT FOR TREATMENT OF TOBACCO-USE
Several guidelines recommend that health care systems institutionalize the consistent identification, documentation, and treatment of every tobacco users. Another recommendation is to provide full insurance coverage for medication and counseling related to tobacco use. Data show that reducing cost barriers not only increases the use of more effective treatments but also increases the number of people who successfully quit.
Tobacco-dependence treatments are both clinically effective and highly cost-effective relative to other medical and disease prevention interventions. Treatment of tobacco use costs $2,600 per year of life saved compared with $62,000 for mammograms and $23,000 for the treatment of hypertension.
Model Clinical Treatment Programs. Group Health Cooperative (GHC) of Puget Sound, a Seattle-based managed care organization, provides comprehensive coverage for smoking cessation. Treatment includes telephone or group behavioral counseling and medications to support the quit process. This program enrolls 8 percent of all smokers in GHC into the treatment program each year and has a 30 percent long-term quit rate. Smoking has declined at a faster rate among GHC enrollees than among the general population of Washington State. It is estimated that this program paid for itself within four years.
SPECIAL POPULATIONS
Pregnant Women. If a woman is pregnant or nursing it is especially important for her to quit smoking—to protect her own health and the health of the baby. Counseling is the primary treatment recommended for pregnant women. A pregnant woman who is a heavy smoker and unable to quit should consult her physician about the possible use of medication.
Young People. Since most tobacco use begins during adolescence, it is important to prevent onset of tobacco use and to encourage cessation at a young age. Half of adolescent smokers say they want to stop smokingcigarettes completely and about six of ten report that they seriously tried to quit in the past year. Unfortunately, adolescent tobacco users can become addicted to nicotine within the first weeks of use, and most adolescents experience symptoms of nicotine withdrawal when they try to quit. Therefore, adolescents are as likely to relapse as adults are. It is unclear which interventions will help adolescents quit. However, some adolescent prevention and cessation programs show promise in increasing quit rates.
POPULATION APPROACHES TO CESSATION
The Community Preventive Services Task Force reviewed the effect on cessation of population approaches, including media campaigns, cigarette tax increases, and clean indoor air laws, and found that media campaigns and price increases promoted cessation. Clean indoor air policies decrease the number of cigarettes smoked per day; though the impact on cessation is less clear.
CESSATION ACTIVITIES IN THE UNITED STATES
California and Massachusetts have developed comprehensive programs that include media campaigns, community interventions, and state-sponsored telephone quit lines. These programs have been successful in increasing smoking cessation. Oregon has collaborated with managed care organizations to improve treatment and also provides telephone counseling and medication to Medicaid clients. Florida has developed a very successful media campaign and community intervention that reduced smoking by young people.
Comprehensive programs directed at both young people and adults that focus on decreasing initiation, increasing cessation, and decreasing exposure to ETS have proven effective. In California, comprehensive tobacco-control programs and policies have been associated with accelerated declines in cardiovascular disease and deaths from lung cancer compared to the rest of the nation.
State Roles. The Center for Disease Control and Prevention's 1999 Best Practices for Comprehensive Tobacco Control Programs suggests that comprehensive state programs include the following (1999):
School programs to reduce tobacco use by young people.
Enforcement of clean indoor air and minors' access laws.
Statewide programs.
Counter-marketing campaigns.
Cessation programs.
Surveillance and evaluation.
Administration and management.
Combining individual, systems, and population-based approaches that increase cessation offers the best opportunity to reduce morbidity and mortality from tobacco use, which is the leading preventable cause of death in the United States. The clinician's role is to assess every patient's tobacco use and interest in quitting, advise those who smoke to stop, offer individual, group, or telephone counseling, and encourage patients to use effective medications. The role of the health care system is to implement system changes to support routine tobacco treatment by clinicians and to monitor the effect of treatment through quality performance measures.
Employers also play a role, which consists of providing insurance coverage for cessation services, providing treatment services at the worksite, and establishing smoke-free buildings or campuses. Finally the role of the government is to increase the price of tobacco products, implement media campaigns, enact clean indoor air policies and laws, regulate tobacco products, and ensure insurance coverage of tobacco use treatment.
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