Cigarette Smoking

Cigarette smoking

Cigarette smoking remains the most important cause of preventable morbidity and early mortality. In 2000, there were an estimated 4.8 million premature deaths in the world attributable to smoking, 2.4 million in developing countries and 2 million in industrialized countries. More than three-quarters (3.8 million) of these deaths were in men. The leading causes of death from smoking were cardiovascular diseases (1.7 million deaths), chronic obstructive pulmonary disease (COPD) (1 million deaths), and lung cancer (0.9 million deaths). Nicotine is highly addictive, raises brain levels of dopamine, and produces withdrawal symptoms on discontinuation. Cigar smoking has also increased; there is also continued use of smokeless tobacco (chewing tobacco and snuff), particularly among young people. Tobacco dependence may have a genetic component.

Cigarettes are responsible for one in every five deaths in the United States, yet smoking prevalence rates have been increasing among high school and college students. Currently, 23% of US adults and 26% of US young adults are smokers.

Smokers have twice the risk of fatal heart disease, 10 times the risk of lung cancer, and several times the risk of cancers of the mouth, throat, esophagus, pancreas, kidney, bladder, and cervix; a twofold to threefold higher incidence of stroke and peptic ulcers (which heal less well than in nonsmokers); a twofold to fourfold greater risk of fractures of the hip, wrist, and vertebrae; four times the risk of invasive pneumococcal disease; and a twofold increase in cataracts. In the United States, over 90% of cases of COPD occur among current or former smokers. Both active smoking and passive smoking are associated with deterioration of the elastic properties of the aorta (increasing the risk of aortic aneurysm) and with progression of carotid artery atherosclerosis. Smoking has also been associated with increased risks of leukemia, of colon and prostate cancers, of breast cancer among postmenopausal women who are slow acetylators of N-acetyltransferase-2 enzymes, osteoporosis, and Alzheimer's disease. In cancers of the head and neck, lung, esophagus, and bladder, smoking is linked to mutations of the P53 gene, the most common genetic change in human cancer. Patients with head and neck cancer who continue to smoke during radiation therapy have lower rates of response than those who do not smoke. Olfaction and taste are impaired in smokers, and facial wrinkles are increased. Heavy smokers have a 2.5 greater risk of age-related macular degeneration. Smokers die 5–8 years earlier than never-smokers.

The children of smokers have lower birth weights, are more likely to be mentally retarded, have more frequent respiratory infections and less efficient pulmonary function, have a higher incidence of chronic ear infections than children of nonsmokers, and are more likely to become smokers themselves.

In addition, exposure to environmental tobacco smoke has been shown to increase the risk of cervical cancer, lung cancer, invasive pneumococcal disease, and heart disease; to promote endothelial damage and platelet aggregation; and to increase urinary excretion of tobacco-specific lung carcinogens. The incidence of breast cancer may be increased as well. Of approximately 450,000 smoking-related deaths in the United States annually, as many as 53,000 are attributable to environmental tobacco smoke.

Smoking cessation reduces the risks of death and of myocardial infarction in people with coronary artery disease; reduces the rate of death and acute myocardial infarction in patients who have undergone percutaneous coronary revascularization; lessens the risk of stroke; slows the rate of progression of carotid atherosclerosis; and is associated with improvement of COPD symptoms. On average, women smokers who quit smoking by age 35 add about 3 years to their life expectancy, and men add more than 2 years to theirs. Smoking cessation can increase life expectancy even for those who stop after the age of 65.

Although tobacco use constitutes the most serious common medical problem, it is undertreated. Almost 40% of smokers attempt to quit each year, but only 4% are successful. Factors associated with successful cessation include having a rule against smoking in the home, being older, and having greater education. Persons whose physicians advise them to quit are 1.6 times as likely to attempt quitting. Over 70% of smokers see a physician each year, but only 20% of them receive any medical quitting advice or assistance.

Several effective interventions are available to promote smoking cessation, including counseling, pharmacotherapy, and combinations of the two. The five steps for helping smokers quit are summarized in Table 1–3. Common elements of supportive smoking cessation treatments are reviewed in Table 1–4. A system should be implemented to identify smokers, and advice to quit should be tailored to the patient's level of readiness to change. Pharmacotherapy to reduce cigarette consumption is ineffective in smokers who are unwilling or not ready to quit. Conversely, all patients trying to quit should be offered pharmacotherapy except those with medical contraindications, women who are pregnant or breast-feeding, and adolescents.

Actions and strategies for the primary care clinician to help patients quit smoking.

Action Strategies for Implementation Step 1. Ask—Systematically Identify All Tobacco Users at Every Visit  Implement an officewide system that ensures that for every patient at every clinic visit, tobacco-use status is queried and documented1 Expand the vital signs to include tobacco use.   Data should be collected by the health care team.   The action should be implemented using preprinted progress note paper that includes the expanded vital signs, a vital signs stamp or, for computerized records, an item assessing tobacco-use status. Alternatives to the vital signs stamp are to place tobacco-use status stickers on all patients' charts or to indicate smoking status using computerized reminder systems. Step 2. Advise—Strongly Urge All Smokers to Quit  In a clear, strong, and personalized manner, urge every smoker to quit  Advice should be   Clear:"I think it is important for you to quit smoking now, and I will help you. Cutting down while you are ill is not enough."    Strong:"As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your current and future health."     Personalized: Tie smoking to current health or illness and/or the social and economic costs of tobacco use, motivational level/readiness to quit, and the impact of smoking on children and others in the household.   Encourage clinic staff to reinforce the cessation message and support the patient's quit attempt. Step 3. Attempt—Identify Smokers Willing to Make a Quit Attempt  Ask every smoker if he or she is willing to make a quit attempt at this time If the patient is willing to make a quit attempt at this time, provide assistance (see step 4). If the patient prefers a more intensive treatment or the clinician believes more intensive treatment is appropriate, refer the patient to interventions administered by a smoking cessation specialist and follow up with him or her regarding quitting (see step 5). If the patient clearly states he or she is not willing to make a quit attempt at this time, provide a motivational intervention. Step 4. Assist—Aid the Patient in Quitting  A. Help the patient with a quit plan Set a quit date. Ideally, the quit date should be within 2 weeks, taking patient preference into account.   Help the patient prepare for quitting. The patient must:     Inform family, friends, and coworkers of quitting and request understanding and support.     Prepare the environment by removing cigarettes from it. Prior to quitting, the patient should avoid smoking in places where he or she spends a lot of time (eg, home, car).     Review previous quit attempts. What helped? What led to relapse?     Anticipate challenges to the planned quit attempt, particularly during the critical first few weeks.   B. Encourage nicotine replacement therapy except in special circumstances Encourage the use of the nicotine patch or nicotine gum therapy for smoking cessation (see Table 1–5, Table 1–6, and Table 1–7 for specific instructions and precautions). C. Give key advice on successful quitting Abstinence: Total abstinence is essential. Not even a single puff after the quit date.   Alcohol: Drinking alcohol is highly associated with relapse. Those who stop smoking should review their alcohol use and consider limiting or abstaining from alcohol use during the quit process.   Other smokers in the household: The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. Patients should consider quitting with their significant others and/or developing specific plans to maintain abstinence in a household where others still smoke.   D. Provide supplementary materials Source: Federal agencies, including the National Cancer Institute and the Agency for Health Care Policy and Research; nonprofit agencies (American Cancer Society, American Lung Association, American Heart Association); or local or state health departments.  Selection concerns: The material must be culturally, racially, educationally, and age appropriate for the patient.   Location: Readily available in every clinic office.  Step 5. Arrange—Schedule Follow-Up Contact  Schedule follow-up contact, either in person or via telephone1 Timing: Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.  Actions during follow-up: Congratulate success. If smoking occurred, review the circumstances and elicit recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience and is not a sign of failure. Identify the problems already encountered and anticipate challenges in the immediate future. Assess nicotine replacement therapy use and problems. Consider referral to a more intense or specialized program.