T Parish. Smoking Cessation: Not just patches, gum, pills, and stern warnings anymore!. The Internet Journal of Academic Physician Assistants. 2002 Volume 3 Number 2.
Cigarette smoking remains the single most important preventable cause of death and disability in this country. It is responsible for some 440,000 deaths a year in smokers, another 35,000 deaths in non-smokers, and costs Americans more than $150 billion per year in health care costs and lost productivity. Smoking rates have declined from 65% of adults in the 1960's to about 23% in 1990. That level of smoking has remained stagnant in the last 13 years. There is ample evidence to believe that rates could be decreased further if; in addition to employing patches, gum, pills, and stern warnings, we changed the social milieu to make it less accommodating to smokers.
We all have patients who smoke cigarettes. Many of us have found it frustrating to counsel them on the dangers of smoking, and benefits of stopping, only to see most of them continue to smoke. We have continued to offer the same gum, pills, patches, and stern admonitions in spite of our frustrations with the poor success rates of these therapies. Even though studies have suggested that 70% of smokers want to quit, and approximately 34% of smokers attempt to quit each year, only about 2.5% are able to successfully quit (defined as cigarette abstinence for more than a year).1
The reasons that people start smoking and continue to smoke in spite of the mountain of evidence of tobacco's harm to themselves and to others is complex. A multifactorial approach to smoking cessation has the best chance to diminish the medical, social, and economic costs to all Americans. As providers and as citizens, we must consider a more global approach to smoking cessation. Smokers are frequently victims of an addiction, social indifference to smoking, and clever marketing. Any measures suggested here should not be construed as punishment of smokers or a restriction of their freedom. Smoking is not a freedom; it is a social burden and a danger to all Americans who live, work, or play in the same environment as smokers.
Cigarette smoking remains the single most important preventable cause of death, disease, and disability in the Unites States. It results in “more deaths each year than AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires – combined”.2 It is estimated that cigarette smoking kills more than 440,000 people a year in the U.S.1 and that the burden of smoking on society in terms of excess health care costs and lost productivity is “at least” 150 billion dollars.1 These statistics do not adequately portray the individual smoker's slow agonizing loss of mobility or increasing dependence caused by progressive lung, heart, or vascular diseases. Or the emotional price paid by family members who must watch a loved one endure the slow but steady progression of these debilitating diseases. Or the fact that a smoker's family suffers the loss of their smoking family member, on average, 13 to 14 years earlier than if they had not been smokers.
Environmental Tobacco Smoke (ETS) is another source of exposure to irritant and carcinogenic compounds from the cigarettes of others. It is commonly referred to as second hand smoke or passive smoking. A study conducted in 1992 by the EPA concluded that “each year approximately 3,000 lung cancer deaths in nonsmoking adults are attributable to ETS”.3 The American Lung Association estimates that ETS causes another 35,000 deaths from heart disease in nonsmokers2. They also estimate that 150,000-300,000 cases every year of infections like bronchitis and pneumonia in infants and children less than 18 months of age are caused by ETS. Additionally, ETS represents an occupational health hazard for bartenders and wait staff in bars and restaurants. It is suggested that the average bartender breathes the equivalent of one pack of cigarettes during each eight-hour shift1, without ever lighting a cigarette!
Cigarettes are one of the most heavily marketed consumer products in America. In 2001 tobacco companies reportedly spent nearly $9.7 billion to advertise their products, the largest sum ever reported by the major cigarette manufacturers. 2 In spite of the 1970 ban imposed on television and radio advertising, the tobacco companies are still able to sell their products by sponsoring high visibility sporting activities, erecting large billboards, strategically placing magazine ads, and “product placement” in television and movies.
The rate of adult smoking in this country was about 60% in 1965 and declined to 23% by 1990 and remains at that rate currently.2 This lack of progress in the past 13 years suggests that we need to examine our current strategies and consider additional methods for getting people to stop smoking. Our interventions have largely been directed at getting individual smokers to quit. Progress in this area will likely require interventions that are more global in nature than most of our current efforts.
Opportunities exist to change the above statistics and the enormous social, emotional, medical, and economic burdens that cigarettes place on this society. A coordinated, multi-factorial effort to change our society is in order, making it less accommodating to smokers.
Smoking cessation programs that employ a combination of nicotine replacement therapies, medications, and counseling will remain an important part of any campaign to encourage smokers to quit. A number of valuable resources from the CDC and US Public Health Service exist that guide clinicians in selection of appropriate therapies4. In addition, there is national support for increasing access to such programs5.
The most encouraging information relating to successfully decreasing smoking comes from the state of California. In 1988 they passed legislation that increased cigarette taxes and established a tobacco control program. They have spent 90 million dollars a year since then with one third of the funds operating a school based tobacco use prevention program and two thirds going toward a comprehensive anti-tobacco health education effort. This program included local education programs, a statewide media campaign, and a surveillance and evaluation plan6. California's program has embraced the “social norm change model” for public health intervention. “The goal of this... approach is to indirectly influence current and future tobacco users by creating a social milieu and legal climate in which tobacco becomes less desirable, less acceptable, and less accessible.” Tobacco companies have acknowledged that this strategy represents a threat to their companies. An R.J. Reynolds memo reportedly indicated: “The California campaign, and others like it, represents a very real threat to the industry in the intermediate term”7. This comprehensive approach began in 1988 with an increase in tobacco taxes, and culminated with legislation to ban indoor smoking approved by voters in 1996 and implemented in January of 1998. Since 1988, when the first increase in tobacco taxes was implemented, “per capita cigarette consumption in California has declined by 60%. During the same period, per capita cigarette consumption in the entire nation (including California) declined by 34%”7.
A Suggested Comprehensive Plan
Any comprehensive strategy should continue to provide individual smokers with education and an increase in the availability of smoking cessation medications and counseling. At the same time our society must be changed to make it less accommodating to smokers.
Tobacco control efforts should include legislative and other measures that embrace the Social Norm Change Model mentioned previously. This should be a grass-roots effort begun by interested citizens, providers, and public health professionals. Below are my ten suggestions for a comprehensive, community based, smoking cessation plan.
As health care providers we must demand that all health plans continue to provide smoking cessation programs and increase availability for any smokers who are interested. These programs should be freely available for repeated attempts at smoking cessation.
Health care providers should seize every opportunity to counsel smokers to quit. Every patient chart should record the smoking status of the patient. In addition, each encounter should include an encouragement to quit with an offer of medical support, or an encouragement to quit again.
Require continued education of the public via funding of anti-smoking campaigns. Particularly those directed at middle and high schools. It is estimated that lifelong smokers generally begin smoking between the ages of 14 and 18. Approximately 3,000 teenagers become regular smokers every day in this country.1
Letter writing and e-mail campaigns in three areas. (a) A campaign by non-smokers to inform their state and national representatives that smoking in public places matters. Reminding them that 77% of Americans do not smoke, but that they do vote. De-normalize smoking in the minds of legislators at the local, state, and national levels. (b) Obtain information on tobacco company contributions to political parties and individual legislators. Target them to receive letters asking them to refuse contributions from tobacco companies. Make it politically irresponsible for politicians to accept funds from tobacco company interests (growers, manufacturers, and retailers). (c) Urge mutual funds, retirement plans and 401k's to divest themselves of tobacco company securities. Make it clear to fund managers that you do not want your investment portfolio to support companies that gain from the death and misery of millions of Americans.
Help lawmakers at all levels craft legislation that would establish severe penalties for selling or providing cigarettes to minors and establish severe penalties. Most states have some form of legislation restricting sales of cigarettes to minors, however most remain poorly enforced.
Promote legislation to ban cigarette vending machines in all venues. They remain an easy source of cigarettes for minors and an un-necessary convenience for smokers.
Support continued increases in tobacco taxes. Healthy People 2010 calls for increases of state and federal taxes on a pack of cigarettes to equal 2 dollars by 2010.2 Price appears to be particularly effective in deterring teen smoking.
In my view, the most important initiative is a ban on indoor smoking. This has an obvious effect on non-smokers, as they would no longer be exposed to ETS in bars, or restaurants. ETS is clearly a workplace health hazard for bartenders, waitresses and waiters. The health interests of 77% of the adult population should not be overshadowed by the 23% who smoke.
Lobby film and television companies to stop allowing product placement of cigarettes. These placements glamorize smoking, or at least portray it as the norm, defeating the intent of the ban on cigarette advertising on television imposed in 1970.
Require that tobacco company settlement funds paid to the state are largely used to treat tobacco related illnesses, provide counseling and medications for current smokers, and fund public health campaigns against smoking. It should particularly fund anti-smoking campaigns in the schools. It is fundamentally dishonest to use these funds in any other way.
The implementation of these initiatives collectively addresses the desire to affect a social norm change. The goal is to protect non-smokers from the effects of ETS, make smoking less acceptable in our society, and ultimately save Americans from the tremendous economic, medical, social, and emotional burdens that smoking imposes.
We must directly support continued efforts to get individual smokers to quit and educate providers to seize every opportunity to encourage and support smokers who want to quit. We must indirectly exert an effect on smokers and potential smokers by changing society to a place that gradually becomes less accommodating to smokers. This de-normalization of smoking has the best chance to produce an enduring effect on Americans.
The power and reach of tobacco companies in this country must be fought with education, truth, and resolve. They have been able to overcome and attack the essential rightness of previous legislation and regulations with untruth, political influence, and greed, at the expense of generations of smokers and non-smokers alike. The time has come for the 77% of Americans who do not smoke to exercise their right to clean indoor air and relief from the staggering economic, medical, social, and emotional burdens that smoking imposes.
Smoking is not a freedom; it is a social burden and a danger to all Americans who live, work, or play in the same environment as smokers.
A valuable resource for those interested in further information, education, and treatment guidelines is available on a CDC web site called the “Tobacco Information and Prevention Source (TIPS)”. It can be found at http://www.cdc.gov/tobacco/.
Thomas G. Parish, PA-C, MPH Assistant Professor Department of PA Studies Medical College of Ohio Toledo, Ohio (W) 419-383-6624 (fax) 419-383-5880 email@example.com