(Chest. 1999;116:490S-492S.)
© 1999
American College of Chest Physicians
Smoking Cessation and Tobacco Control*
An Overview
Karen M. Emmons, PhD
*
From the Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, MA.
Correspondence to: Karen M. Emmons, PhD, Dana-Farber Cancer Institute, Center for Community-Based Research, 44 Binney St, Boston, MA 02115; e-mail: karen_emmons{at}dfci.harvard.edu
 |
Abstract
|
|---|
Cigarette smoking is an intractable public health problem and the
single largest risk factor for a variety of malignancies, including
lung cancer. Worldwide, about 3 million people die each year of
smoking-related disease, and this is expected to increase to > 10
million deaths per year. The Agency for Health Care Policy and Research
has published a clinical practice guideline detailing available outcome
data for various smoking cessation strategies. In particular, it has
been recommended that all patients be screened for smoking status on
every health-care visit, and that all patients who smoke be strongly
advised to quit and offered assistance to do so. Health-care providers
play a vital role in the effort to reduce the prevalence of smoking by
delivering smoking cessation advice, supporting community-based efforts
to control tobacco, and becoming involved in the tobacco control
debate.
|
Introduction
|
|---|
Cigarette
smoking is an intractable public health problem that poses a great
threat to the health of the entire population. Smoking is the single
largest risk factor for a variety of malignancies, including lung
cancer. Although there has been a large and ongoing body of work in the
area of smoking during the past 30 years, in the past decade tobacco
control efforts have played an unprecedented role in the national
debate about public health. This paper provides a brief background on
tobacco control, as well as an overview of current work in the areas of
tobacco control and smoking cessation.
|
Tobacco Control: A Historical Perspective
|
|---|
In 1906, the first federal food and drug law was passed. A drug
was defined as any medicine listed in the U.S. Pharmacopoeia at the
time of the law’s passage. Tobacco was included in the U.S.
Pharmacopoeia until 1905, and thus it escaped regulation and set a
precedent related to the protection of tobacco from regulation. For
example, in 1938, the U.S. Food and Drug Administration (FDA) was given
jurisdiction over food, drugs, medicinal devices, and cosmetics. This
provided the FDA with jurisdiction over only those tobacco products for
which specific medicinal claims were made. Although claims were made
about some products, changes in advertising strategies and brand
products maintained the virtually regulation-free status of tobacco.
Tobacco has generally escaped strong government regulation; when laws
have been passed, they have frequently been accompanied by compromises
that weakened the public health effects of the legislation and
ultimately benefited the tobacco industry.1
2
The late
1990s, however, have presented a very different scenario, and for the
first time in U.S. history, it appears likely that tobacco will be
regulated in some manner.
|
Smoking Prevalence
|
|---|
In 1965, approximately 60% of men and 30% of women in the United
States smoked; in 1996, 24% of the U.S. population were
smokers.3
Although the gender gap in smoking
prevalence has narrowed considerably, men still smoke at a slightly but
significantly higher rate than women. Smoking prevalence is highest
among individuals categorized as American Indian or Alaskan Native;
overall, smoking prevalence is virtually equivalent among whites and
African Americans. However, sex and race interactions have also been
observed, with smoking prevalence being higher among African American
than white men, and lower among African American than white women.
Education level is the primary predictor of smoking4
;
35.6% of individuals with 9 to 11 years of education smoke, compared
with 16.5% of those with a college degree.3
Although the prevalence of cigarette smoking has decreased in the
United States and much of the developed world during the past two
decades, it is increasing in many developing countries. There are an
estimated 1.1 billion smokers worldwide. The changes in social norms
regarding smoking and the accompanying changes in policies that have
provided widespread access to smoke-free environments in the United
States have not been observed in other countries. However, the
socioeconomic disparity in smoking status observed in the United States
is also seen worldwide. Estimates suggest that by 2025, only 15% of
the world’s smokers will live in developed countries.
|
Health Consequences of Smoking
|
|---|
Smoking is a major contributor to preventable morbidity and
mortality. Worldwide, about 3 million people die each year of
smoking-related diseases.6
By 2025, this figure is
expected to increase to > 10 million deaths per year. In 1990,
> 430,000 smokers in the United States alone died of smoking-related
diseases, accounting for 26% of all deaths among men and 17% of
deaths among women.6
Lung cancer has now replaced breast
cancer as the leading cancer killer of women. In 1993, the estimated
smoking-attributed costs for medical care, lost work, and productivity
exceeded $97 billion. If these costs were borne by smokers in the form
of cigarette taxes, the price of each pack of cigarettes would have to
rise to $4 (from the current price of $2.49).7
|
Factors Influencing Smoking
|
|---|
It is clear that smoking results from multiple determinants,
including physiologic, psychological, social, and community factors
(Fig 1 ).8
9
10
11
Social factors have typically been considered of
most importance in the initiation of smoking. However, recent evidence
focusing on smoking among lower income populations, where smoking
prevalence remains the highest, suggests that social factors are also
very important in the maintenance of smoking behavior. Community
factors include access to material resources as well as smoking
cessation services. At the psychological level, the habitual aspects of
smoking are well-documented. Research in the past decade has also
examined the relationship between smoking and psychological factors,
most notably depression.12
13
Individuals with a history
of mood disorder are more likely to smoke, and the incidence of current
depression and severity of depression have been found to have a linear
relationship with smoking status. Among all smokers, dysphoric mood is
a common antecedent of relapse.12
14
The physically addictive properties of nicotine are also well known.
The nicotine withdrawal syndrome, which is now well
characterized,15
includes nicotine craving, irritability,
anxiety, difficulty concentrating, restlessness, and increased
appetite. Nicotine addiction is pervasive among smokers and can be a
key barrier to long-term abstinence. This is an area in which
health-care providers can play a critical role in assisting patients to
evaluate and use pharmacologic aids for smoking cessation, including
nicotine replacement and newer non-nicotine products. Pharmacotherapy
for smoking cessation represents a key innovation in tobacco control
during the past decade.16
|
Smoking Cessation Counseling by Health-Care Providers
|
|---|
The Agency for Health Care Policy and Research (AHCPR) has
published a clinical practice guideline on smoking that details
available outcome data for various smoking cessation
strategies.16
The smoking cessation guideline makes
several recommendations that are relevant to all types of health-care
providers (Table 1
). In particular, it has been recommended that all patients be screened
for smoking status on every health-care visit, and that all patients
who smoke be strongly advised to quit and offered assistance to do so.
Consideration of smoking status as a vital sign would ensure that this
assessment is uniformly conducted (Fig 2
). It is further recommended that providers use the "4 As" model for
delivery of brief smoking cessation counseling (Table 2
). The AHCPR guideline provides a compendium of evidence demonstrating
that smoking cessation counseling should be part of standard medical
practice, and further makes recommendations for how to implement
counseling strategies.
|
Summary
|
|---|
We are at a historic crossroads in tobacco control. Never before
has there been as much attention focused on this very important public
health issue, particularly from forces that span legislative,
regulatory, federal, local, and state interests. In this climate, there
is an unprecedented opportunity to reduce the prevalence of smoking in
this country to historic lows. Health-care providers play a vital role
in this effort by delivering smoking cessation advice and counseling to
their patients, supporting community-based efforts at tobacco control,
and becoming involved in the tobacco control debate at the national
level.
|
Footnotes
|
|---|
Abbreviations: AHCPR = Agency for Health Care Policy and
Research; FDA = U.S. Food and Drug Administration
Supported in part by grants from the National Cancer Institute
(1RO1CA77780, 1RO1CA73242 and 1RO1HL50017), the National Heart, Lung,
and Blood Institute (5RO1HL54351), the Robert Wood Johnson Foundation
Smoke-Free Families Initiative, NYNEX, Liberty Mutual Insurance
Company, Aetna, and the Boston Company.
|
References
|
|---|
-
Kluger R. Ashes to ashes. New York, NY: Alfred A. Knopf, 1996
-
Emmons, KM, Kawachi, I, Barclay, G (1997) Tobacco control: a brief review of its history and prospects for the future. Hematol Oncol Clin North Am 11,177-195[CrossRef][ISI][Medline]
-
Centers for Disease Control and Prevention. Cigarette smoking among adults: United States, 1994. MMWR Morb Mortal Wkly Rep 1996; 45:588–590
-
Escobedo, L, Anda, R, Smith, P (1990) Sociodemographic characteristics of cigarette smoking initiation in the United States: implications for smoking prevention policy. JAMA 264,1550-1555[Abstract]
-
Glanz, K, Brekke, M, Harper, D, et al (1992) Evaluation of implementation of a cholesterol management program in physicians’ offices. Health Educ Res 7,151-163[Abstract/Free Full Text]
-
Peto, R, Lopez, AD, Boreham, J, et al (1994) Mortality from smoking in developed countries 1950–2000: indirect estimates from national vital statistics. Oxford University Press Oxford, UK.
-
US Department of Health, and Human Services. Reducing the health consequences of smoking: 25 years of progress; a report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989
-
Orleans, CT, Slade, J (1993) Nicotine addiction: principles and management. Oxford University Press Oxford, UK.
-
Abrams, DB, Emmons, KM, Niaura, RD, et al (1991) Tobacco dependence: an integration of individual and public health perspectives. Nathan, PE Langenbucher, JW McCrady, BSet al eds. The annual review of addictions treatment and research ,391-436 Pergamon Press Elmsford, NY.
-
Emmons KM. Health behaviors in a social context. In: Berkman LF, Kawachi I, eds. Social epidemiology. Oxford, UK: Oxford University Press, in press
-
Graham, H (1993) When life’s a drag: women, smoking and disadvantage. Her Majesty’s Stationery Office London, UK.
-
Anda, RF, Williamson, DF, Escobedo, LG, et al (1990) Depression and the dynamics of smoking: a national perspective. JAMA 264,1541-1545[Abstract]
-
Glassman, AH, Helzer, JE, Covey, LS, et al (1990) Smoking, smoking cessation, and major depression. JAMA 264,1546-1549[Abstract]
-
Shiffman, S (1982) A relapse prevention hotline. Bull Soc Psychol Subst Abuse 1,50-54
-
Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994
-
The Smoking Cessation Clinical Practice Guideline Panel. Smoking cessation clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1996. AHCPR publication 96-0692
TOP
Abstract
Introduction
