Smoking cessation

Smoking Cessation Smoking causes damage to more than just the lungs.

Definition

Smoking cessation means "to quit smoking," or "withdrawal from nicotine." Because smoking is highly addictive, quitting the habit often involves irritability, headache, mood swings, and cravings associated with the sudden cessation or reduction of tobacco use by a nicotine-dependent individual.

Purpose

There are many good reasons to stop smoking; not the least is that smoking cessation may speed post-surgery recovery. Smoking cessation helps a person heal and recover faster, especially in the incision area, or if the surgery involved any bones. Research shows that patients who underwent hip and knee replacements, or surgery on other bone joints, healed better and recovered more quickly if they had quit or cut down their tobacco intake several weeks before the operation. Smoking weakens the bone mineral that keeps the skeleton strong and undermines tissue and vessel health. One study suggested that even quitting tobacco for a few days could improve tissue blood flow and oxygenation, and might have a positive effect on wound healing. If a patient has had a history of heart problems, his chances of having a second heart attack will be lowered. Quitting may also reduce wound complications, and lower the risk of cardiovascular trouble after surgery. If surgery was performed to remove cancerous tumors, quitting will reduce the risk of a second tumor, especially if cancer in the lung, head, or neck has been successfully treated.

Description

Quitting smoking is one of the best things a person can do to increase their life expectancy. On average, male smokers who quit at 35 years old can be expected to live to be 76 years old instead of 69 years if they were still smoking. Women who quit would live to be 80 years old instead of 74 years.

Effects of Smoking on the Body

Nicotine acts as both a stimulant and a depressant on the body. Saliva and bronchial secretions increase along with bowel tone. Some inexperienced smokers may experience tremors or even convulsions with high doses of nicotine because of the stimulation of the central nervous system. The respiratory muscles are then depressed following stimulation.

Nicotine causes arousal as well as relaxation from stressful situations. Tobacco use increases the heart rate about 10–20 beats per minute; and because it constricts the blood vessels, it increases the blood pressure reading by 5–10 mm Hg.

Sweating, nausea, and diarrhea may also increase because of the effects of nicotine upon the central nervous system. Hormonal activities of the body are also affected. Nicotine elevates the blood glucose levels and increases insulin production; it can also lead to blood clots. Smoking does have some positive effects on the body by stimulating memory and alertness, and enhancing cognitive skills that require speed, reaction time, vigilance, and work performance. Smoking tends to alleviate boredom and reduce stress as well as reduce aggressive responses to stressful events because of its mood-altering ability. It also acts as an appetite suppressant, specifically decreasing the appetite for simple carbohydrates (sweets) and inhibiting the efficiency with which food is metabolized. The fear of weight gain prevents some people from quitting smoking. The addictive effects of tobacco have been well documented. It is considered mood-and behavior-altering, psychoactive, and abusable. Tobacco's addictive potential is believed to be comparable to alcohol, cocaine, and morphine.

Health Problems Associated With Smoking

In general, chronic use of nicotine may cause an acceleration of coronary artery disease, hypertension, reproductive disturbances, esophageal reflux, peptic ulcer disease, fetal illnesses and death, and delayed wound healing. The smoker is at greater risk of developing cancer (especially in the lung, mouth, larynx, esophagus, bladder, kidney, pancreas, and cervix); heart attacks and strokes; and chronic lung disease. Using tobacco during pregnancy increases the risk of miscarriage, intrauterine growth retardation (resulting in the birth of an infant small for gestational age), and the infant's risk for sudden infant death syndrome.

The specific health risks of tobacco use include: nicotine addiction, lung disease, lung cancer, emphysema, chronic bronchitis, coronary artery disease and angina, heart attack, atherosclerotic and peripheral vascular disease, aneurysms, hypertension, blood clots, strokes, oral/tooth/gum diseases including oral cancer, and cancer in the kidney, bladder, and pancreas. Nicotine is also associated with decreased senses of taste and smell. During pregnancy, nicotine may cause increased fetal death, premature labor, low birth weight infants, and sudden infant death syndrome.

Nonsmokers who are regularly exposed to second hand smoke also may experience specific health risks including:

• Increased risk of lung cancer.
• An increased frequency of respiratory infections in infants and children (e.g. bronchitis and pneumonia), asthma, and decreases in lung function as the lungs mature.
• Acute, sudden, and occasionally severe reactions including eye, nose, throat, and lower respiratory tract symptoms.

The specific health risks for smokeless tobacco users include many of the diseases of smokers, as well as a 50-fold greater risk for oral cancer with long-term or regular use.

In diabetics taking medication for high blood pressure, it has been reported that smoking may increase the risk of kidney disease and/or kidney failure.

Making a Plan to Quit

Long lead times for elective procedures like joint operations offer a good opportunity for doctors to encourage their patients to quit smoking, but only the smoker has the power to stop smoking. Before a smoker decides to quit, he should make sure he wants to quit smoking for himself, and not for other people. The following are some questions as well as some suggestions the smoker may want to consider:

• When is the best time to quit smoking? The answer may be different for women and men. Women should set their quit date to begin at the end of their period for best results. The first step is to set a quit date.
• Make a written list of why you want to quit smoking.
• Will you use an aid to help you quit? Will it be the patch, nicotine gum, Zyban, nicotine spray, soft laser therapy, nasal inhaler, or some other method? If you plan to use Zyban, set your quit date for one week after you begin to use it.
• smoke only in certain places, preferably outdoors
• switch to a brand of cigarettes that you don't like
• do not buy cigarettes by the carton
• cut coffee consumption in half (You will not need to give it up.)
• practice putting off lighting up when the urge strikes
• go for a walk every day or begin an exercise program
• stock up on non-fattening safe snacks to help with weight control after quitting
• enlist the support of family and friends
• clean and put away all ashtrays the day before quitting

Smokers who are trying to quit should remind themselves that they are doing the smartest thing they have ever done. Because of the preparation for smoking cessation, the smoker won't be surprised or fearful about quitting. The quitter will be willing to do what's necessary, even though it won't be easy. Remember, this will likely add years to the lifespan. The quitting smoker should be prepared to spend more time with nonsmoking friends, if other smokers don't support the attempt to quit.

Since hospitals are smoke-free environments, if a smoking patient is in the hospital for elective surgery, it may be a good opportunity to quit smoking. It might be best to set the quit date around the time of the surgery and let the attending doctor know. As the smoker takes the first step, professional hospital staff will be there to give the support and help needed. Medical staff can start the patient on nicotine replacement therapy to help control the cravings and increase the chances of quitting permanently.

Methods of Quitting

Cold turkey, or an abrupt cessation of nicotine, is one way to stop smoking. Cold turkey can provide cost savings because paraphernalia and smoking cessation aids are not required; however, not everyone can stop this way as tremendous willpower is needed.

Laser therapy is an entirely safe and pain-free form of acupuncture that has been in use since the 1980s. Using a painless soft laser beam instead of needles the laser beam is applied to specific energy points on the body, stimulating production of endorphins. These natural body chemicals produce a calming, relaxing effect. It is the sudden drop in endorphin levels that leads to withdrawal symptoms and physical cravings when a person stops smoking. Laser treatment not only helps relieve these cravings, but helps with stress reduction and lung detoxification. Some studies indicate that laser therapy is the most effective method of smoking cessation, with an extraordinarily high success rate.

Acupuncture—small needles or springs are inserted into the skin—is another aid in smoking cessation. The needles or springs are sometimes left in the ears and touched lightly by the patient between visits.

Some smokers find hypnosis particularly useful, especially if there is any kind of mental conflict, such as phobias, panic attacks, or weight control. As a smoker struggles to stop smoking, the conscious mind, deciding to quit, battles the inner mind, which is governed by habit and body chemistry. Hypnosis, by talking directly to the inner mind, can help to resolve that inner battle.

Aversion techniques attempt to make smoking seem unpleasant. This technique reminds the person of the distasteful aspects of smoking, such as the smell, dirty ashtrays, coughing, the high cost, and health issues. The most common technique prescribed by psychologists for "thought stopping"—stopping unwanted thoughts—is to wear a rubber band around the wrist. Every time there is an unwanted thought (a craving to smoke) the band is supposed to be pulled so that it hurts. The thought then becomes associated with pain and gradually neutralized.

Rapid smoking is a technique in which smoking times are strictly scheduled once a day for the first three days after quitting. Phrases are repeated such as "smoking irritates my throat" or "smoking burns my lips and tongue." This causes over-smoking in a way that makes the taste and sensations very unpleasant.

There are special mouthwashes available, which, when used before smoking, alter the taste, making cigarettes taste awful. The aim is for smoking to eventually become associated with this very unpleasant taste.

Smoking cessation aids wean a person off nicotine slowly, and the nicotine can be delivered where it does the least bodily harm. Unlike cigarettes, they do not introduce other harmful poisons to the body. They can be used for a short period of time. However, it should be noted that nicotine from any source (smoking, nicotine gum, or the nicotine patch) can make some health problems worse. These include heart or circulation problems, irregular heartbeat, chest pain, high blood pressure, overactive thyroid, stomach ulcers, or diabetes.

The four main brands of the patch are Nicotrol, Nicoderm, Prostep, and Habitrol. All four transmit low doses of nicotine to the body throughout the day. The patch comes in varying strengths ranging from 7 mg to 21 mg. The patch must be prescribed and used under a physician's care. Package instructions must be followed carefully. Other smoking cessation programs or materials should be used while using the patch.

Nicorette gum allows the nicotine to be absorbed through the membrane of the mouth between the cheek and gums. Past smoking habits determine the right strength to choose. The gum should be chewed slowly.

The nicotine nasal spray reduces cravings and withdrawal symptoms, allowing smokers to cut back slowly. The nasal spray acts quickly to stop the cravings, as it is rapidly absorbed through the nasal membranes. One of the drawbacks is a risk of addiction to the spray.

The nicotine inhaler uses a plastic mouthpiece with a nicotine plug, delivering nicotine to the mucous membranes of the mouth. It provides nicotine at about one-third the nicotine level of cigarettes.

Zyban is an oral medication that is making an impact in the fight to help smokers quit. It is a treatment for nicotine dependence.

The nicotine lozenge is another smoking cessation aid recently added to the growing list of tools to combat nicotine withdrawal.

Withdrawal Symptoms

Generally, the longer one has smoked and the greater the number of cigarettes (and nicotine) consumed, the more likely it is that withdrawal symptoms will occur and the more severe they are likely to be. When a smoker switches from regular to low-nicotine cigarettes or significantly cuts back smoking, a milder form of nicotine withdrawal involving some or all of these symptoms can occur.

These are some of the withdrawal symptoms that most ex-smokers experience in the beginning of their new smoke-free life:

• dry mouth
• mood swings
• irritability
• feelings of depression
• gas
• tension
• sleeplessness or sleeping too much
• difficulty in concentration
• intense cravings for a cigarette
• increased appetite and weight gain
• headaches

These side effects are all temporary conditions that will probably subside in a short time for most people. These symptoms can last from one to three weeks and are strongest during the first week after quitting. Drinking plenty of water during the first week can help detoxify the body and shorten the duration of the withdrawal symptoms. A positive attitude, drive, commitment, and a willingness to get help from health care professionals and support groups will help a smoker kick the habit.

Researchers from the University of California San Diego strongly suggest that any of the above cessation aids should be used in combination with other types of smoking cessation help, such as behavioral counseling and/or support programs. These products are not designed to help with the behavioral aspects of smoking, but only the cravings associated with them. Counseling and support groups can offer tips on coping with difficult situations that can trigger the urge to smoke.

Even a New Heart Can't Break a Bad Habit

Why do some people who have heart transplants continue to smoke? In a three-year study at the University of Pittsburgh of 202 heart transplant recipients, 71% of the recipients were smokers before surgery. The overall rate of post-transplant smoking was 27%. All but one of the smokers resumed the smoking habit they had before the transplant. The biggest reason for resuming smoking was addiction to nicotine. Smoking is a complex behavior, involving social interactions, visual cues, and other factors. Those who smoked until less than six months before the transplant were much more likely to resume smoking early and to smoke more. One of the major causes of early relapse was because of depression and anxiety within two months after the transplant. Another strong predictor of relapse was having a caretaker who smoked. The knowledge of these risk factors could help develop strategies for identifying those in greatest need of early intervention. According to European studies, the five-year survival rate for post-transplant smokers is 37%, compared to 80% for nonsmoking recipients. Smokers can develop inoperable lung cancers within five years after a transplant, thus resulting in a shorter survival rate. There is an alarming incidence of head and neck cancers in transplant recipients who resume smoking.

Overall, there is a 90% relapse rate in the general population but, the more times a smoker tries to quit, the greater the chance of success with each new try.

Resources

Books

Dodds, Bill. 1440 Reasons to Quit Smoking: 1 For Every Minute of the Day. Minnetonka, MN: Meadowbrook Press, 2000.

Jones, David C. and Derick D. Schermerhorn, eds. Yes You CanStop Smoking: Even if You Don't Want To. Dolphin Pub., 2001.

Kleinman, Lowell, Deborah Messina-Kleinman, and Mitchell Nides. Complete Idiot's Guide to Quitting Smoking. London, UK: Alpha Books, 2000.

Mannoia, Richard J. NBAC Program: Never Buy Another Cigarette: A Cigarette Smoking Cessation Program. Paradise Publications, 2003.

Shipley, Robert H. Quit Smart: Stop Smoking Guide With theQuitsmart System, It's Easier Than You Think! Quitsmart, 2002.

Periodicals

Landman, Anne, Pamela M. Ling, and Stanton A. Glantz. "Tobacco Industry Youth Smoking Prevention Programs: Protecting the Industry and Hurting Tobacco Control." American Journal of Public Health 92, no. 6 (June 2002): 917–30.

Ling, Pamela M. and Stanton A. Glantz, "Forum on Youth Smoking, Why and How the Tobacco Industry Sells Cigarettes to Young Adults: Evidence From Industry Documents." American Journal of Public Health 92, no. 6 (June 2002): 908–16.

Taylor, Donald H., Jr., Vic Hasselblad, S. Jane Henley, Michael J. Thun, and Frank A. Sloan. "Research and Practice, Benefits of Smoking Cessation for Longevity." American Journal of Public Health 92, no. 6 (June 2002): 990–6.

Other

Illig, David. Stop Smoking. Audio CD. Seattle: WA: Success-world, 2001.

Mesmer. Stop Smoking With America's Foremost Hypnotist. Audio CD. Victoria, BC: Ace Mirage Entertainment, 2000.

Organizations

Action on Smoking and Health. 2013 H Street, NW, Washington, DC 20006. (202) 659-4310. http://ash.org.

American Lung Association. 61 Broadway, 6th Floor, New York, NY. 10006. (800) 586-4872. www.lungusa.org.

— Crystal H. Kaczkowski, M.Sc.

Key Terms: Bupropion, Buspirone.

Definition

Smoking cessation is the medical term for quitting smoking. It is a vital part of cancer prevention because smoking is the single most preventable cause of death from cancer. As early as 1982, the Surgeon General reported that tobacco causes more cancer deaths in the United States than any other factor–30% of all cancer deaths, including 87% of deaths from lung cancer. Although people think of smoking most often in connection with lung cancer, smoking is also associated with cancers of the mouth, throat, voice box (larynx), esophagus, pancreas, kidney, and bladder. Women who smoke increase their risk of cancer of the cervix. Quitting smoking, however, significantly reduces the risk of cancer; 15 years after quitting, a former smoker's risk is almost as low as that of someone who has never smoked.

Description

Smoking cessation covers several different approaches, ranging from medications and psychotherapy to special classes and programs. Smoking is a habit difficult to break because it involves many different aspects of a person's emotions and social life as well as physical addiction to nicotine. Most people who quit smoking successfully use a combination of treatments or techniques for quitting.

Special Concerns

People who are trying to quit smoking are often concerned about:

• Withdrawal symptoms. Nicotine, the substance in tobacco that gives smokers a pleasurable feeling, is as addictive as heroin or cocaine. Withdrawal from nicotine may produce depression, anger, fatigue, headaches, problems with sleep or concentration, or increased appetite for food. These symptoms usually start several hours after the last cigarette. They may last for several days or several weeks.
• Weight gain. Many people, particularly women, gain between two and 10 pounds after giving up smoking. This mild weight gain, however, is not nearly as great a danger to health as continuing to smoke. Getting more exercise can help.

• Stress. Many smokers started to smoke as a way to cope with stress and tension. Finding other methods—exercise, meditation, biofeedback, massage, and others, can reduce the temptation to smoke when stress arises.
• Side effects of nicotine replacement products. Smokers who are using these products to help them quit may experience headaches, nausea, sore throat, or long-term dependence. Side effects can often be reduced or eliminated by using a lower dosage of the product or switching to another form of nicotine replacement.

Treatments

Nicotine Replacement Therapy

Nicotine replacement therapy gives the smoker a measured supply of nicotine without the other harmful chemicals in tobacco. It reduces the physical craving for cigarettes so that the smoker can handle the psychological aspects of quitting more effectively.

As of 2001, the Food and Drug Administration (FDA) had approved four forms of nicotine replacement therapy:

• Transdermal patches. Patches, which are non-prescription items, supply measured doses of nicotine through the skin. The doses are lowered over a period of weeks, thus helping the smoker to reduce the need for nicotine gradually.
• Nicotine gum. Nicotine gum provides a fast-acting nicotine replacement that is absorbed through the mouth tissues. The smoker chews the gum slowly and then keeps it against the inside of the cheek for 20 to 30 minutes. The gum is also available without prescription.
• Nasal spray. Nicotine nasal spray provides nicotine through the tissues that line the nose. It acts much more rapidly than the patches or gum, but requires a doctor's prescription.
• Inhalers. Nicotine inhalers are plastic tubes containing nicotine plugs. The plug gives off nicotine vapor when the smoker puffs on the tube. Some smokers prefer inhalers because they look more like cigarettes than other types of nicotine replacement. They also require a doctor's prescription.

Other Medications

Bupropion, which is sold under the trade name Zyban, is an antidepressant medication given to lower the symptoms of withdrawal from nicotine. Bupropion by itself can help people quit smoking, but its success rate is even higher when it is used together with nicotine replacement therapy. Another drug that is sometimes given for nicotine withdrawal is buspirone (BuSpar), which is an antianxiety medication.

Stop-Smoking Programs and Groups

Stop-smoking programs help by reinforcing a smoker's decision to give up tobacco. They teach people to recognize common problems that occur during quitting and they offer emotional support and encouragement. While stop-smoking programs do not have as high a success rate by themselves as medications or nicotine replacement therapy, they are very helpful as part of an overall quitting plan. The most effective programs include either individual or group psychological counseling. Many state Medicaid plans now cover the costs of smoking cessation programs; further information is available from the American Association of Respiratory Care at

The Great American Smokeout has been held annually since 1977 on the third Thursday in November to call attention to the high human costs of smoking. Smokers are asked to quit for the day and donate the money saved on cigarettes to high school scholarship funds.

Nicotine Anonymous is an organization that applies the Twelve Steps of Alcoholics Anonymous (AA) to tobacco addiction. Its group meetings are free of charge.

Alternative and Complementary Therapies

Some people find that hypnosis helps them to quit. Acupuncture has also been used, but there are no largescale studies comparing it to other stop-smoking treatments. A list of physicians who are also licensed acupuncturists is available from the American Academy of Medical Acupuncture at (800) 521-2262.

Questions to Ask the Doctor

• What methods would you recommend to help me quit smoking?
• How can I cope with withdrawal symptoms and other side effects of quitting?
• Are there any stop-smoking programs in this area that you would recommend?

Other complementary approaches that have been shown to be useful in quitting smoking include movement therapies like yoga, t'ai chi, and dance. Prayer and meditation have also helped many smokers learn to handle stress without using tobacco.

Resources

Books

American Cancer Society. Quitting Smoking. New York: American Cancer Society, 2000. [cited June 29, 2001].

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Smoking Cessation.". In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

United States Public Health Service. You Can Quit Smoking. Consumer Guide, June 2000. [cited June 29, 2001]. Government Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. htm./">

Organizations

American Association for Respiratory Care. 11030 Ables Lane, Dallas, TX 75229. [cited June 29, 2001]. .

American Cancer Society (ACS). 1599 Clifton Road, NE, Atlanta, GA 30329. (404) 320-3333 or (800) ACS-2345. Fax: (404) 329-7530. [cited June 29, 2001]. .

American Lung Association. 1740 Broadway, 14th Floor, New York, NY 10019. (212) 315-8700 or (800) 586-4872 (LUNG USA).

National Cancer Institute, Office of Cancer Communications. 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 4-CANCER (1-800-422-6237). TTY: (800) 332-8615.[cited June 29, 2001]. .

National Heart, Lung, and Blood Institute. Information Center, P. O. Box 30105, Bethesda, MD 20824. (301) 251-1222.

Nicotine Anonymous. (415) 750-0328.[cited June 29, 2001]. .

Other

United States Public Health Service Fact Sheet. Treating Tobacco Use and Dependence. June, 2000. [cited June 29, 2001]. .

—Rebecca J. Frey, Ph.D.

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 smoking cigarettes 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):

• Community programs to reduce tobacco use.
• Chronic disease programs to reduce the burden of tobacco related disease.
• 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.

(SEE ALSO: Addicition and Habituation; Adolescent Smoking; Advertising of Unhealthy Products; Media Advocacy; Office on Smoking and Health; Tobacco Control)

Bibliography

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— CORINNE G. HUSTEN; ABBY C. ROSENTHAL; MICAH H.