Chapter 40 - Tobacco Use

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Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e
Chapter 40: Tobacco Use
Maya Vijayaraghavan; Steven A. Schroeder
OBJECTIVES
Objectives
Review the epidemiology of patients who smoke tobacco.
Describe other types of tobacco used by vulnerable populations.
Describe the health consequences of tobacco use and its impact on the healthcare system.
Describe the challenges that tobacco use poses to patients, clinicians, and communities.
Identify strategies to treat tobacco dependence including clinical, policylevel, and systemslevel interventions.
Clarence Jones is a 44yearold man brought to the emergency room via ambulance in respiratory distress. He has had five admissions within the
past year for chronic obstructive pulmonary disease (COPD) exacerbations and has been intubated during each admission. He has been smoking
since he was 8 years old and smokes up to two packs a day.
INTRODUCTION
Cigarette smoking is the leading cause of preventable, premature morbidity and mortality in the United States and in many countries around the world.
Smokers, on average, die 10 years earlier than nonsmokers.1 Tobacco use is a major cause of death from cancer, cardiovascular disease, and
pulmonary disease. Smoking accounts for 6% or more of total American medical costs.2 Patterns of tobacco use are the result of the complex
interactions of a multitude of factors, including socioeconomic status, culture, acculturation, poor access to medical care, targeted advertising, relative
affordability of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives. It is clear that helping smokers
quit may be the most important act healthcare providers do. This chapter reviews the epidemiology, the health effects of cigarette smoking and other
tobacco use, and the challenges to treating tobacco dependence, particularly among vulnerable populations where tobacco use is concentrated. It
discusses some strategies for confronting these challenges.
EPIDEMIOLOGY OF TOBACCO USE

GENERAL EPIDEMIOLOGY
In 2012, an estimated 42.1 million Americans were smokers.3 Of these, about threefourths were daily smokers, and about onefourth intermittent
smokers. Over time, the prevalence of smoking has declined, from a high of 42.7% in 1965 to the current level of 18%. The decrease in male smoking
prevalence is even more dramatic, falling from a high of 54% in 1955 to the current level of 20.5%.4 Smoking among women rose to a high of 34% in
1964, before its decline to the current level of 16%.3
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that number began to fall, and today the average smoker smokes about 13 cigarettes per day, with about 22% of all smokers not smoking every day
(Figure 401). Although 70% of smokers state that they would like to quit, only about 5% are able to do so, with the number being higher for those
seeking medical assistance with quitting. For most smokers who want to quit, it takes as many as 10–12 attempts before they succeed.
In 2012, an estimated 42.1 million Americans were smokers.3 Of these, about threefourths were daily smokers, and about onefourth intermittent
Trinity in
smokers. Over time, the prevalence of smoking has declined, from a high of 42.7% in 1965 to the current level of 18%. The decrease School of Medicine
male smoking
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prevalence is even more dramatic, falling from a high of 54% in 1955 to the current level of 20.5%.4 Smoking among women rose to a high of 34% in
1964, before its decline to the current level of 16%.3
It was initially hypothesized that quitting smoking would be easier for light and intermittent smokers, and thus as a result the remaining smokers
would be more hardcore. But that has not turned out to be the case. Until 1995, smokers consumed, on average, 20 cigarettes daily. Beginning in 1995
that number began to fall, and today the average smoker smokes about 13 cigarettes per day, with about 22% of all smokers not smoking every day
(Figure 401). Although 70% of smokers state that they would like to quit, only about 5% are able to do so, with the number being higher for those
seeking medical assistance with quitting. For most smokers who want to quit, it takes as many as 10–12 attempts before they succeed.
Figure 401.
Smoking prevalence and average number of cigarettes smoked per day per current smoker, 1965–2010. (Adapted from Schroeder SA. How clinicians
can help smokers to quit. JAMA 2012. 308(15):15861587.)50
RACIAL/ETHNIC MINORITIES
Differences in smoking prevalence exist among racial and ethnic groups, with Native Americans having the highest rate (31.5%), followed by whites
(20.6%), African Americans (19.4%), Hispanics (12.9%), and Asians (9.9%). Substantial differences exist within these broad groups. For example,
smoking rates among Americans of Korean descent are much higher than those of Filipino ancestry.5 It may seem paradoxical that AsianAmerican
men have relatively low smoking rates, since in their home countries (China, Korea, Japan, and Vietnam) male smoking rates exceed 50%. There is no
evidence of selective immigration by nonsmoking Asian men, and studies have found that Asian immigrant smokers have high postimmigration
cessation rates as a process of acculturating to a nation that stigmatizes smoking.
GENDER
In the period before World War II and up until the 1960s, men smoked at a much higher rate than women. Since then, the gap has narrowed but
persisted. In 2012, men’s smoking prevalence was 20%, compared with women’s rate of 16%.3 For youth, however, girls now have equal or higher
smoking rates than boys.
PREGNANCY
A steady decline in smoking prevalence during pregnancy has followed the warnings that smoking is the most important contributor to premature
delivery. However, only about onethird of women who stop smoking during pregnancy are still abstinent 1 year later. The highest rates of smoking
during pregnancy occur among younger women, white or Native American women, and women of lower socioeconomic classes.
VULNERABLE POPULATIONS
Once a badge of sophistication, tobacco use is now disproportionately concentrated among marginalized populations. These include persons with
mental illness, substance use disorders including alcohol and illicit drugs, incarcerated populations, the homeless population, and the LGBT
community. As smoking has become stigmatized, it is also increasingly concentrated among those with low socioeconomic status. There are very high
rates among those with General Educational Development (GED) diplomas, for example. Compared with the general population (18%), smoking
prevalence rates among these groups are two to four times as high, despite the fact that the steep price of a pack of cigarettes exerts a substantial
financial toll on many of these vulnerable persons. By contrast, the rate of smoking among US physicians is between 1% and 2%, among the lowest in
the world.
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MIDDLEINCOME COUNTRIESSteven A. Schroeder Page 2 / 22
Smoking prevalence in low and middleincome countries is generally higher than in developed nations, and much higher among men than among
women. Rates are especially high among Asian men and the former Soviet Republics, including Russia, and relatively low among women in Africa,
mental illness, substance use disorders including alcohol and illicit drugs, incarcerated populations, the homeless population, and the LGBT
community. As smoking has become stigmatized, it is also increasingly concentrated among those with low socioeconomic status.TrinityThere
School
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high
rates among those with General Educational Development (GED) diplomas, for example. Compared with the general population (18%),
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prevalence rates among these groups are two to four times as high, despite the fact that the steep price of a pack of cigarettes exerts a substantial
financial toll on many of these vulnerable persons. By contrast, the rate of smoking among US physicians is between 1% and 2%, among the lowest in
the world.
LOW AND MIDDLEINCOME COUNTRIES
Smoking prevalence in low and middleincome countries is generally higher than in developed nations, and much higher among men than among
women. Rates are especially high among Asian men and the former Soviet Republics, including Russia, and relatively low among women in Africa,
South East Asia, and most of Latin America, except for Chile and Paraguay. Although overall worldwide smoking prevalence decreased between 1980
and 2012 from 41% to 31% for men and from 11% to 6% for women, because of population growth the absolute numbers of smokers globally actually
increased, from 718 million to 966 million. The highest rates of smoking for men include Russia and Indonesia (>50%) and for women Greece and
Bulgaria (>30%).6
OTHER TYPES OF TOBACCO

Although cigarettes are the most common form of tobacco product used in the United States, a wide variety of other tobacco products exist. Non
cigarette forms of tobacco can be categorized into three groups: other combustible tobacco, smokeless forms of tobacco, and electronic nicotine
delivery systems.7
COMBUSTIBLE TOBACCO
Cigars, pipes, water pipes, and rollyourown tobacco comprise the major forms of other combustible tobacco used in the United States. Cigars contain
shredded tobacco, wrapped in a tobacco leaf, and are produced as little cigars (manufactured and packaged as cigarettes), cigarillos, or large cigars.
Pipes consist of a bowl that holds the tobacco, and an attached stem, where smoke is drawn, whereas water pipes (otherwise known as shisha,
hookah, or narghile) use an indirect heating mechanism where smoke from the burned tobacco is passed through a container filled with water before
reaching the user via a hose. Bidis and kreteks are made from looseleaf tobacco, and are used frequently in other parts of the world including South
Asia and SouthEast Asia, and among US immigrants from these regions. While the exclusive use of these products is low in the United States, dual use
of cigarettes and other combustible tobacco products is common among youth, persons with low incomes, and those with low educational
attainment.8 The lower prices of these products compared to cigarettes, the wide variety of flavors, and the perception that these products are less
harmful than cigarettes have contributed to the increase in the use of other combustible forms of tobacco.
SMOKELESS TOBACCO
Smokeless tobacco is a broad term for tobacco products that are used orally or nasally, and include chewing tobacco, snuff, snus, and newer
dissolvable tobacco products. Chewing tobacco is sold as long strands of tobacco, which are chewed or placed in between the cheeks, gums, or teeth.
The nicotine is absorbed through the tissues of the mouth, and the user spits out the tobacco after its use. Snuff and snus are finely ground tobacco
that are sold in their dry or moist forms, and used in a manner similar to chewing tobacco, without the need for spitting. Other types of newer
dissolvable tobacco products include tobacco lozenges or pellets or toothpick like strips, which are produced in a wide variety of flavorings that appeal
to youth and young adult populations. Exclusive use of smokeless tobacco is more common among men than among women, and is highest among the
young adult population (18–24 years) and those with less than a high school education. Dual use of cigarettes and smokeless tobacco is more
prevalent among youth and young adults, those with low incomes, and low educational attainment.
ELECTRONIC NICOTINE DELIVERY SYSTEMS
Electronic nicotine delivery systems originated in China in 2006, and became available worldwide between 2008 and 2009. Otherwise known as e
cigarettes, these devices are constructed to resemble cigarettes, and deliver a vaporized solution of nicotine. They come in a wide variety of flavorings
(e.g., licorice, chocolate, and strawberry), which appeal to youth and young adults. Consequently, use of ecigarettes among the youth and young adult
population has increased substantially in recent years. The prevalence of ecigarette use doubled between 2011 and 2012 from 3.3% to 6.8% among
youths in grades 6 through 12, and from 6.2% in 2011 to 3.3% in 2010 among adults.9
HEALTH CONSEQUENCES OF TOBACCO USE

TOBACCO USE
Chapter
Tobacco 40:
use Tobacco
accountsUse, Maya480,000
for about Vijayaraghavan; Steven
deaths annually inA.
theSchroeder Page 3 / 22
United States and more than 5 million worldwide. An additional 8 million persons
suffer from diseases caused by smoking in the United States alone. The list of diseases caused by tobacco use is large, and it continues to expand over
time. For some illnesses, such as lung cancer, the risks are staggering. But all of the conditions listed in Table 401 are more likely to occur if a person
population has increased substantially in recent years. The prevalence of ecigarette use doubled between 2011 and 2012 from 3.3% to 6.8% among
youths in grades 6 through 12, and from 6.2% in 2011 to 3.3% in 2010 among adults.9 Trinity School of Medicine
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HEALTH CONSEQUENCES OF TOBACCO USE

TOBACCO USE
Tobacco use accounts for about 480,000 deaths annually in the United States and more than 5 million worldwide. An additional 8 million persons
suffer from diseases caused by smoking in the United States alone. The list of diseases caused by tobacco use is large, and it continues to expand over
time. For some illnesses, such as lung cancer, the risks are staggering. But all of the conditions listed in Table 401 are more likely to occur if a person
uses tobacco, especially combustible tobacco.
Table 401.
Health Hazards of Smoking
Cancer Cardiovascular Pulmonary Gastrointestinal
Lung Coronary heart disease and acute Lung cancer Peptic ulcer
Oral cavity and pharyngeal MI Chronic bronchitis Esophageal
Larynx Cerebrovascular disease and Emphysema reflux
Nasal cavity, sinuses, and stroke GI cancers
nasopharynx Peripheral arterial
Bladder and kidney disease/impotence
Cervix Abdominal aortic aneurysm
Colon
Liver
Pancreas
Esophagus
Stomach
Acute myeloid leukemia
Prostate
Infection Other Reproductive
Tuberculosis Type II DM Reduced fertility in women

Worse recovery from pulmonary Early menopause Premature birth
infections Osteoporosis Poor birth outcomes
Pneumococcal pneumonia Cataract Congenital anomalies, low birth
Legionnaires disease Macular degeneration weight
Meningococcal disease Rheumatoid arthritis Abruptio placentae
Periodontal disease Alzheimer disease Spontaneous abortion
H. pylori Poor surgical outcomes Childhood obesity
Influenza Sleep disorders
HIV Premature skin wrinkling
Altered drug metabolism
SECONDHAND SMOKE
In addition to the health consequences of active smoking, inhalation of secondhand smoke is also dangerous, accounting for an estimated 50,000 of
the annual 480,000 deaths in the United States. The major causes of death from secondhand smoke exposure are diseases of the cardiovascular and
cerebrovascular systems. Persons with these conditions can be harmed from minimal exposure to passive smoking, because even very low exposure to
cigarette smoke causes changes in platelet adhesiveness and arterial endothelial function. Secondhand smoke can also increase the odds of lung
cancer, nasal sinus cancer, exacerbations of asthma and other respiratory conditions, and decreased hearing in teenagers. Reproductive and
developmental
Chapter problems
40: Tobacco Use,from
Mayasecondhand smoke exposure
Vijayaraghavan; Steven A.include premature delivery, lowbirthweight infants, sudden infant death syndrome,
Schroeder Page 4 / 22
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communities, it is illegal to smoke in an automobile if children are
present. Cigaretteinduced fires cause burns, smoke inhalation damage, and death. Pediatricians have publicized the risk of thirdhand smoke
exposure, which occurs when infants and young children orally ingest tobacco smoke residues that have accumulated on the clothes and furniture of
In addition to the health consequences of active smoking, inhalation of secondhand smoke is also dangerous, accounting forTrinity School 50,000
an estimated of Medicine
of
the annual 480,000 deaths in the United States. The major causes of death from secondhand smoke exposure are diseases ofAccess
the cardiovascular
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cerebrovascular systems. Persons with these conditions can be harmed from minimal exposure to passive smoking, because even very low exposure to
cigarette smoke causes changes in platelet adhesiveness and arterial endothelial function. Secondhand smoke can also increase the odds of lung
cancer, nasal sinus cancer, exacerbations of asthma and other respiratory conditions, and decreased hearing in teenagers. Reproductive and
developmental problems from secondhand smoke exposure include premature delivery, lowbirthweight infants, sudden infant death syndrome,
childhood depression, and childhood middle ear disease. In some states and communities, it is illegal to smoke in an automobile if children are
present. Cigaretteinduced fires cause burns, smoke inhalation damage, and death. Pediatricians have publicized the risk of thirdhand smoke
exposure, which occurs when infants and young children orally ingest tobacco smoke residues that have accumulated on the clothes and furniture of
smokers. These chemicals can exacerbate respiratory and middle ear infection and are potentially carcinogenic.
SMOKELESS TOBACCO AND OTHER ELECTRONIC NICOTINE DELIVERY SYSTEMS
Smokeless tobacco, while not as harmful as combustible products, also carries health risks, most notably oral and pharyngeal cancers, and also
leukoplakia, gingivitis and gingival recession, poor recovery from oral surgery, and staining of teeth. Ingestion of tobacco products, including the
nicotine found in electronic cigarettes, is an increasingly common cause of childhood poisoning. Data on the risks of using electronic cigarettes are
emerging, as this product increases in popularity. The contents of ecigarettes include propylene glycol, nicotine, nitrosamines and other known
carcinogens, and ultrafine particles. While less harmful than combustible tobacco products, ecigarettes have led to burns, explosions, and nicotine
toxicity among children who ingest the contents of the cartridges.
Whether the ecigarette is—on balance—helpful or harmful has stirred much debate in the tobacco control community. Opponents cite predatory
marketing practices, packaging of the product in ways that appeal to youth, such as adding fruit or chocolate flavoring, the concern that ecigarette
usage will prove a gateway to combustible tobacco for youth, and that it will deter smoking cessation activities among established smokers. Others see
the potential for great health benefit if smokers switch to ecigarettes, which, although not proven to be safe, are likely safer than combustible tobacco.
There is general consensus, however, around three points: there should be regulation of marketing practices so that the product is not marketed to
youth; there should be no tolerance for ecigarette vapor in public places; and we need to know more about the safety profile, the risk of serving as a
gateway, and the potential for helping smokers quit. In April 2014, the Food and Drug Administration (FDA) issued a proposed rule that would extend
to currently unregulated tobacco products including electronic cigarettes. Under the proposed rule, makers of these tobacco products would need to
register with the FDA and report product ingredients, only market new tobacco products after FDA review, make direct and implied claims of reduced
risk only after the FDA has confirmed scientific evidence, and not distribute free samples. In addition, makers of these products would be prohibited
from selling their products to underage youth and would need to include health warnings on packaging. The FDA is expected to make a decision on its
proposed rule in the near future.
IMPACT ON THE HEALTHCARE SYSTEM

According to the 2014 report of the Surgeon General on the Health Consequences of Smoking, annual smokingattributable costs in the United States
were about $300 billion, including about $150 billion for medical care, about $150 billion from lost productivity due to premature deaths, and close to
$6 billion from lost productivity due to secondhand smoke exposure.10
BENEFITS OF QUITTING
No matter how old a smoker is, she will accrue health benefits from quitting compared to what would have happened had she continued to smoke. For
example, a smoker who quits at ages 25–34 saves an estimated 10 years of life. Benefits from quitting in the 35–44 years age group are 9 years, in the
45–54 years age group 8 years, and in the 55–64 years age group 4 years. Even for smokers older than 65 years, the risk of getting lung cancer or
cardiovascular disease declines after stopping smoking.11 Return of function and reduction of risk following smoking cessation follow a predictable
course. Within weeks to months, respiratory and circulatory function improves. By 1 year, the risk of coronary heart disease decreases to one half that
of a continuing smoker and by 15 years the risk is at the level of neversmokers. For cerebrovascular disease, after 5 years, the risk is similar to never
smokers. Although the risk of lung cancer persists, by 10 years it is half that of a continuing smoker.
CHALLENGES TO MANAGING TOBACCO USE

NICOTINE ADDICTION
Nicotine is a naturally occurring alkaloid found in combustible and noncombustible forms of tobacco. It is highly addictive and induces physical
dependence and tolerance in a manner similar to other illicit substances, such as cocaine or heroin. In the brain, nicotine binds to nicotinic
acetylcholine receptorsUse,
Chapter 40: Tobacco andMaya
triggers the activation of
Vijayaraghavan; brain circuits
Steven that are involved in the reward system and habit formation. Chronic exposure
A. Schroeder Page 5to/ 22
nicotineMcGraw
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widespread alterations
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Termsneurotransmission that sustains
of Use • Privacy Policy • Noticeand promotes addiction. Smoking cessation disrupts these neuro
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adaptations and leads to nicotine withdrawal. Symptoms of nicotine withdrawal such as depressed mood, insomnia, irritability, and anxiety act as
potent deterrents to smoking cessation, and lead to maintenance of the smoking habit.
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NICOTINE ADDICTION
Nicotine is a naturally occurring alkaloid found in combustible and noncombustible forms of tobacco. It is highly addictive and induces physical
dependence and tolerance in a manner similar to other illicit substances, such as cocaine or heroin. In the brain, nicotine binds to nicotinic
acetylcholine receptors and triggers the activation of brain circuits that are involved in the reward system and habit formation. Chronic exposure to
nicotine leads to widespread alterations in brain neurotransmission that sustains and promotes addiction. Smoking cessation disrupts these neuro
adaptations and leads to nicotine withdrawal. Symptoms of nicotine withdrawal such as depressed mood, insomnia, irritability, and anxiety act as
potent deterrents to smoking cessation, and lead to maintenance of the smoking habit.
Nicotine dependence and the severity of nicotine withdrawal symptoms tend to be higher among persons with mental health disorders or substance
use disorders; these individuals have higher rates of smoking than that of the general population. Many years of twin and adoption studies have
demonstrated that nicotine dependence is a heritable trait. Genomewide linkage and association studies have identified numerous genes (e.g.,
cholinergic nicotinic receptor subunit genes) associated with nicotine dependence that are located on chromosomes in close proximity to others
linked with psychiatric illnesses such as schizophrenia or bipolar disorder.12 These genetic factors are one of the many reasons for the increased
severity of nicotine addiction among individuals with mental health and substance use disorders.
SOCIAL NORMS
The first reports on the harmful effects of secondhand smoke were published in the 1980s. In the United States, legislation to ban smoking in the
workplace was passed in 1994 and enacted in 1998, with California being the first state to implement smokefree policies in the workplace.13 While the
protection of nonsmokers was the primary intent of these policies, studies have shown that such policies are also associated with reduced prevalence
of smoking and increased cessation among smokers.14,15 Since the mid1990s, there has been a gradual expansion of smokefree policies into public
places, hospitality establishments, and hospitals. Until recently, correctional facilities, psychiatric hospitals, substance use recovery programs, public
housing, and homeless shelters—settings that serve populations that are disproportionately affected by tobacco use—had a culture permissive of
smoking. However, with changing norms around smoking in favor of stricter smoking restrictions and to protect nonsmokers from exposure to
secondhand smoke, correctional facilities,16 psychiatric hospitals,17 and public housing18 have moved toward implementing indoor and outdoor
smokefree policies. Less is known about smokefree policies in homeless shelters and substance use recovery programs. The absence of a consistent
policy around smoking in facilities that serve marginalized populations reinforces the culture of tobacco use in these settings, and may contribute to
the higher rates of tobacco use among these populations.
TOBACCO INDUSTRY MARKETING AND SOCIAL MEDIA

YOUTH
Television and movies promote tobacco use as a socially acceptable activity. Tobacco companies spend billions of dollars annually to market their
products,19,20 and these marketing strategies are directed specifically toward youth and young adults, women, racial/ethnic minorities, and other
vulnerable populations. The three most heavily advertised cigarette brands, Marlboro, Newport, and Camel, were the preferred brands of cigarettes
smoked by adolescents and young adults between 2008 and 2011.21 Indeed, studies have shown the causal association between exposure to tobacco
industry advertising and initiation of cigarette smoking among adolescents.22 Storefront cigarette advertising is more common in lowincome
communities, and these retail establishments are often situated within 1000 feet of a school.23 The close proximity of these convenience stores to
schools increases children’s exposure to a wide variety of tobacco products, potentially leading to increased experimentation and sustained use.
WOMEN
The tobacco industry is estimated to spend more than $5 billion dollars annually in creating brands and marketing strategies that appeal to women.24
Products such as Virginia Slims, for example, associated their cigarettes with independence, success, and sex appeal to create brand loyalty in young
women in the 1970s. Lowincome women have been particularly vulnerable to tobacco industry tactics.25 Military wives; women belonging to
racial/ethnic minorities who live in urban, innercity areas; “discountsusceptible” older female smokers; and less educated white women have been
targeted by the industry since the 1970s.25 Some of the strategies used by the tobacco industry include distributing discount coupons with food
stamps, discount offers at point of sale, developing new brands for lowincome women, and promoting luxury images to lowincome AfricanAmerican
women.25
Chapter 40: Tobacco Use, Maya Vijayaraghavan; Steven A. Schroeder Page 6 / 22
Racial/ethnic
©2023 McGraw minorities
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Rights been targeted
Reserved. Termsheavily
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Policy Marketing
• Notice to Latinos and American Indians/Alaskan Natives has
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included the advertising and the promotion of cigarette brands with names such as Rio, Dorado, and American Spirit. Tobacco industry advertising at
the point of sale is most common among gas stations, convenience stores, liquor stores, and tobacco stores; the density of these retail establishments
racial/ethnic minorities who live in urban, innercity areas; “discountsusceptible” older female smokers; and less educated white women have been
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targeted by the industry since the 1970s.25 Some of the strategies used by the tobacco industry include distributing discount coupons of Medicine
with food
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stamps, discount offers at point of sale, developing new brands for lowincome women, and promoting luxury images to lowincome AfricanAmerican
women.25
Racial/ethnic minorities have also been targeted heavily by the tobacco industry. Marketing to Latinos and American Indians/Alaskan Natives has
included the advertising and the promotion of cigarette brands with names such as Rio, Dorado, and American Spirit. Tobacco industry advertising at
the point of sale is most common among gas stations, convenience stores, liquor stores, and tobacco stores; the density of these retail establishments
is much higher in communities inhabited by racial/ethnic minorities.26 Communities that have a higher African/American population, people on public
assistance, or people living below 150% of the federal poverty line are more likely to have advertisements featuring menthol brands of cigarettes.27 The
specific targeting of lowincome racial/ethnic minorities in combination with the tobacco industry efforts in establishing relationships with leaders
from these communities (e.g., by providing employment opportunities to community leaders from these minority groups) has significantly
undermined tobacco control efforts in these populations.
VULNERABLE POPULATIONS
Other vulnerable populations that have been targeted by the tobacco industry include the homeless population and persons with mental health
disorders. These populations have among the highest rates of smoking, and their extreme economic, psychological, and social vulnerability has made
them particularly susceptible to tobacco industry marketing tactics. Capitalizing on these circumstances, the tobacco industry has marketed heavily to
these “downscale clients” by directtoconsumer marketing strategies such as donating free cigarettes to shelters or soup kitchens, by advertising
“value” brands that appeal to “street people,” and by promoting a positive image through advocacy and largescale donations to organizations that
serve these population.28 As an example, R. J. Reynolds Tobacco Company developed a marketing campaign entitled, “Project SCUM (Subculture
Urban Marketing),” which was intended to increase sales of Camel cigarettes to specific consumer populations in San Francisco (e.g., gay men and
homeless persons). A review of tobacco industry documents illustrates that the rationale for targeting these populations was a belief that these
individuals may be “more impressionable or susceptible to marketing/advertising … .” and an underlying knowledge that the incidence of tobacco and
substance use was higher among these populations.28 Such strategies have contributed to the very high rates of smoking observed in these
populations.
REGULATORY CLIMATE
While tobacco industry marketing influences the diffusion and acceptance of tobacco products, the regulatory climate is another factor that governs
uptake of tobacco products. Regulation of tobacco products includes counterindustry strategies employed by the FDA to control the manufacturing,
advertising, marketing, and distribution of tobacco products to the public. The FDA’s public health framework for tobacco regulation includes eight
elements: understand regulated products; restrict product changes to protect public health; prohibit modified risk claims that state/imply reduce risk
without evidence; restrict marketing and distribution to protect public health; decrease harms of tobacco products; ensure industry compliance with
FDA regulation through education, inspections, and enforcement; educate the public about FDA’s regulatory actions; and expand the science base of
regulatory action and evaluation. Such measures taken by the FDA are expected to minimize the harms of tobacco use on a population level.29
CHALLENGES IN THE HEALTHCARE SYSTEM
Despite the fact that smoking cessation treatments are available and equally efficacious for all populations, disparities exist in access to smoking
cessation treatment (Box 401). More than 70% of smokers report a desire to quit, and smokers cite a physician’s advice to quit as an important
motivator for attempting to stop smoking.30 The majority of smokers see at least one or more health professionals each year; however, most smokers
are not asked about their smoking status, urged to quit, or offered effective assistance in quitting.2 Persons who belong to racial/ethnic minorities and
low socioeconomic status as well as individuals who are older, disabled, or have mental illness may be less likely to receive advice to quit smoking from
healthcare providers.31,32,33,34
Box 401. Common Pitfalls
Failing to ask about tobacco use in clinical encounters.
Inadequate training about addressing smoking cessation in clinical encounters.
Lack of knowledge about available community resources for tobacco cessation.

Not encouraging the adoption of smokefree homes.
Not understanding how mental illness and substance use influence tobacco use and cessation.
motivator for attempting to stop smoking.30 The majority of smokers see at least one or more health professionals each year; however, most smokers
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are not asked about their smoking status, urged to quit, or offered effective assistance in quitting.2 Persons who belong to racial/ethnic of Medicine
minorities and
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low socioeconomic status as well as individuals who are older, disabled, or have mental illness may be less likely to receive advice to quit smoking from
healthcare providers.31,32,33,34
Box 401. Common Pitfalls
Failing to ask about tobacco use in clinical encounters.
Inadequate training about addressing smoking cessation in clinical encounters.
Lack of knowledge about available community resources for tobacco cessation.
Not encouraging the adoption of smokefree homes.
Not understanding how mental illness and substance use influence tobacco use and cessation.
Many healthcare providers are unfamiliar with the available treatments for smoking, or their efficacy, administration, and side effects.30 Many
physicians harbor fears that they do not have enough time and their counseling will be ineffective.35 Training is often lacking, further adding to the
hopelessness of physicians in addressing smoking cessation in their clinics. This is particularly true of providers counseling adolescents, arguably the
most important group to target for prevention efforts.36 Even when a healthcare provider is armed with adequate knowledge, conflicting priorities
and time pressures make it extremely difficult to address tobacco use and cessation.
Systemwide barriers include limited resources for smoking cessation (e.g., counseling and pharmacotherapy) among patients seeking care in safety
net settings, where a large majority of uninsured and underinsured patients seek care, and limited exposure to educational messages around smoking
cessation. Compounding these health systems barriers is the fact that reimbursements for smoking cessation counseling is valued less than a
procedure and is either not reimbursed or poorly reimbursed by many health payers.37 This may act as a disincentive for some healthcare providers to
devote time to this important task. These patient, provider, and systemsrelated barriers significantly curb efforts in promoting widespread access to
tobacco cessation resources for all smokers, and especially to those who are affected disproportionately by tobacco use.
STRATEGIES FOR MANAGING TOBACCO ABUSE

PRIMARY PREVENTION
The vast majority of smokers initiate tobacco use before the age of 18 years30 Delaying the age when children first experiment with smoking can reduce
the risk that they become regular smokers and increase their chances of quitting if they do become regular smokers. All adolescents should be asked
about tobacco use among their peers as well as within their home environment. Risk factors for youth smoking include peer more than parental
smoking, behavioral problems, poor school performance, low selfesteem, rebelliousness or risktaking behaviors, depression, anxiety, lack of ability
to resist influences to tobacco use, and living in families of lower socioeconomic status or singleparent homes.
Counseling and behavioral interventions used in adults are useful in adolescents. However, given their developmental stage, many teens do not
respond to warnings about the longterm adverse health outcomes of tobacco use, but may respond to shortterm effects such as halitosis, skin
wrinkling, and erectile dysfunction. Messages pertaining to the dangers of secondhand smoke and the addiction potential of nicotine along with anti–
tobacco industry messages are the most highly effective messages to use when trying to reach teen smokers.38 Policies such as prohibiting sales to
minors and high cigarette taxes are also very effective components of decreasing youth smoking.
TREATING TOBACCO DEPENDENCE
Screening
Asking and recording smoking status as another vital sign has been suggested as one method of assuring that smoking does not drop off providers’
radar as a problem, so those who have relapsed will be discovered and assisted. Guidelines recommend that clinicians begin by using the five A’s
mnemonic to initiate a brief intervention in every patient presenting to the clinical setting (Box 402; Figure 402).
Figure 402.

Algorithm for treating tobacco dependence.
Asking and recording smoking status as another vital sign has been suggested as one method of assuring that smoking does not drop off providers’
radar as a problem, so those who have relapsed will be discovered and assisted. Guidelines recommend that clinicians begin Trinity
by usingSchool of A’s
the five Medicine
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mnemonic to initiate a brief intervention in every patient presenting to the clinical setting (Box 402; Figure 402).
Figure 402.
Algorithm for treating tobacco dependence.
Box 402. The Five A’s Mnemonic
Ask
Screen patients for smoking at each and every visit. Consider making it a vital sign.
Advise
Clearly advise patients to quit at every visit.
Personalize the message: Tie tobacco use to a current health problem, its cost, or the impact on others.
Stress total abstinence as the goal.
Assess
Assess each smoker’s willingness to quit at every visit.
If willing, offer behavioral and pharmacologic treatment, including intensive treatment if available.
If unwilling, provide a motivational intervention (see five R’s).
Provide information/resources tailored to the patient (adolescent, pregnant smoker, racial/ethnic minority).
Assist
Assist patient in making a quit attempt (see STAR mnemonic).
Arrange
Arrange followup tailored to the patient.
Smoking Cessation
There is great variability in the addictive nature of smoking, in the number of daily cigarettes consumed, and in the ease of quitting for different
people. Only about 4% of people quit spontaneously. Trials of counseling, coupled with pharmacotherapy, can produce higher rates (Figure 403),
though it must be remembered that volunteers for smoking cessation drug trials are likely
©2023 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility to be more motivated and thus more likely to quit, and the
counseling provided in drug trials for both the active and placebo arms is likely to be more intensive and of higher quality than what exists in the real
world. Thus, the smoking cessation results shown in the drug arms (16–28%) as well as in the placebo arms (8–12%) are likely higher than when
Arrange followup tailored to the patient.
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Smoking Cessation
There is great variability in the addictive nature of smoking, in the number of daily cigarettes consumed, and in the ease of quitting for different
people. Only about 4% of people quit spontaneously. Trials of counseling, coupled with pharmacotherapy, can produce higher rates (Figure 403),
though it must be remembered that volunteers for smoking cessation drug trials are likely to be more motivated and thus more likely to quit, and the
counseling provided in drug trials for both the active and placebo arms is likely to be more intensive and of higher quality than what exists in the real
world. Thus, the smoking cessation results shown in the drug arms (16–28%) as well as in the placebo arms (8–12%) are likely higher than when
counseling, with and without pharmacologic aids are used in realworld settings. A strong dose–response relationship between length of personto
person contact and quit rates has been shown, and treatment delivered in four or more sessions has been shown to increase abstinence rates.
Treatments delivered by multiple types of providers and in multiple types of formats are more effective than interventions by a single type of clinician
in a single type of format.30 Nevertheless, even brief interventions have been shown to have a significant benefit in helping patients quit smoking.
Although daily costs of pharmacotherapies are comparable to the cost of a pack of cigarettes, most vulnerable patients will have difficulty coming up
with the price of a packet of the overthecounter products or the cost of the prescription product. Thus, providing ways to pay for these products is
essential.
Figure 403.
Longterm quit rates for available cessation medications. This chart summarizes the longterm (≥6 month) quit rates observed with the different
nicotine replacement therapy products, bupropion SR, and varenicline based on data derived from 145 different randomizedcontrolled trials. It is not
appropriate to compare the active medications with respect to clinical efficacy; however, the quit rates from each of the methods is approximately
twice that of its corresponding placebo control treatment arm. (Data adapted from Cahill et al,51 Stead et al,52 and Hughes et al.53) (Adapted from “Rx
for Change”—developed through a collaboration of the American Society for Anesthesiologists and the Rx for Change: ClinicianAssisted Tobacco
Cessation Program. Funded by the National Cancer Institute and the Robert Wood Johnson Foundation.)
Smokers’ Willingness to Quit
When it is determined that a patient is ready to quit, the provider should help with a quit plan. The STAR mnemonic may be used to address all the
major components to an effective quit plan (Box 403).
Box 403. STAR Mnemonic
S et a quit date.
Set a quit date, ideally within 2 weeks.
The goal is for total abstinence.
T ell family, friends, and coworkers.
Elicit support by telling family, friends, and coworkers about the quit plan. Request understanding and support.
ChapterSolidify resolve. Use, Maya Vijayaraghavan; Steven A. Schroeder
40: Tobacco Page 10 / 22
A nticipate challenges.
Smokers’ Willingness to Quit
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When it is determined that a patient is ready to quit, the provider should help with a quit plan. The STAR mnemonic may be used to address all the
major components to an effective quit plan (Box 403).
Box 403. STAR Mnemonic
S et a quit date.
Set a quit date, ideally within 2 weeks.
The goal is for total abstinence.
T ell family, friends, and coworkers.
Elicit support by telling family, friends, and coworkers about the quit plan. Request understanding and support.
Solidify resolve.
A nticipate challenges.
Ask openended questions and discuss past quit attempts to elicit the triggers for smoking.
Identify strategies to overcome triggers to smoking.
Create a plan to prevent relapse and orchestrate support.
Encourage housemates to quit with patient or not smoke in the patient’s presence.
Review nicotine withdrawal symptoms.
Recommend abstention from alcohol during quit attempt.
Recommend pharmacologic treatment.
Encourage the patient to seek help before relapse.
R emove tobacco products.
Before the quit date, get rid of all cigarettes and tobacco products.
Avoid smoking in places where the smoker spends a lot of time (home/car/work).
Followup for quit attempt
Followup 1 week after quit date.
Followup 1 month after quit date.
Phone interventions may be helpful.
Congratulate successes.
If relapse occurs, review circumstances and recommit to the quit process by setting a new quit date.
Use the relapse as an opportunity to assure success.
Review medication use and side effects.
Consider referral to more intensive treatment.
The Smoker Who Is Unwilling to Quit

Smokers 40:
Chapter mayTobacco
lack information
Use, Maya about the harmful effects
Vijayaraghavan; StevenofA.
tobacco because of poor health literacy or language barriers, or because no one
Schroeder has11ever
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©2023the
taken McGraw
time toHill. All Rights
tell them. Reserved.
Additionally, theyTerms of Use
may lack the•required
Privacy financial
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resources, may have concerns about quitting including fears of
withdrawal symptoms, or may be demoralized because of previous relapse.
Review medication use and side effects.
Consider referral to more intensive treatment. Access Provided by:
The Smoker Who Is Unwilling to Quit
Smokers may lack information about the harmful effects of tobacco because of poor health literacy or language barriers, or because no one has ever
taken the time to tell them. Additionally, they may lack the required financial resources, may have concerns about quitting including fears of
withdrawal symptoms, or may be demoralized because of previous relapse.
Disinterest in quitting or protest that smoking is enjoyable may mask a profound doubt in ability to overcome the habit. Reasons for continued
smoking may be expressed in a number of ways, from indifference to anger. However, challenging this assumption prematurely may be met with
resistance to quitting. Promoting motivation to quit is most likely to be successful when the clinician is empathic, promotes patient autonomy, avoids
arguments, and supports the patient’s selfefficacy by identifying previous success in behavior change efforts (Box 404) (see Chapter 12).
Box 404. The Five R’s
Relevance
Encourage the patient to reflect on why quitting is p

ersonally relevant.
Use reflective listening and openended questions.
Risks (Cons: see “Health Consequences of Tobacco Use” section)
Ask the patient to identify the negative consequences of tobacco use.
Highlight the risks that are most relevant to the patient.
Discuss shortterm, longterm, and environmental risks.
Rewards (see Pros and Cons in “Core Competency” section)
Ask the patient to identify the benefits of smoking.
Highlight the benefits that are most relevant to the patient. Discuss the pros of smoking for the patient.
Add health benefits of quitting if the patient does not articulate these.
Roadblocks
Ask the patient to identify barriers and impediments to quitting.
Solve problem with the patient by noting elements of treatment that could address barriers.
Repetition
Perform a motivational intervention at every encounter.
If past failure is a concern, notify the patient that most people make repeated quit attempts before success.
Stress relapse as an opportunity to plumb for success.
Schedule followup.
The Smoker Who Has Recently Quit: Preventing Relapse
Mr. Jones abstains from smoking for over 15 years and does well. However, when his daughter dies unexpectedly, he relapses and needs to be
hospitalized2023724
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exacerbation.
A Your At
IP first, he is ashamed of smoking again, but when he returns to facilitating the group, he discusses his
is 24.248.8.126
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relapse 40: Tobacco Use,
as predictable. HisMaya
doctorVijayaraghavan;
does not ask about Steven A. Schroeder
the smoking relapse as she assumes he no longer smokes, but when Mr. Jones bringsPage
up12 / 22
what
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Schedule followup.
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The Smoker Who Has Recently Quit: Preventing Relapse
Mr. Jones abstains from smoking for over 15 years and does well. However, when his daughter dies unexpectedly, he relapses and needs to be
hospitalized for a COPD exacerbation. At first, he is ashamed of smoking again, but when he returns to facilitating the group, he discusses his
relapse as predictable. His doctor does not ask about the smoking relapse as she assumes he no longer smokes, but when Mr. Jones brings up what
happened, they decide to restart nicotine patches and bupropion.
Often in busy clinical practices, it is easy to assume that once the provider has successfully helped a smoker quit, smoking no longer needs to be
addressed. However, it is essential to continue to address the issue of smoking with the patient to prevent relapse. Most relapses occur within the first
3 months after quitting, although some relapses occur months or even years after the quit date.30 Consequently, followup through clinic visits and
telephone calls is critical during the first 3 months. Encourage patients to report any difficulties promptly, including lapses, depression, and
medication side effects while continuing efforts to quit. Congratulate the recovering smoker on success and encourage continued abstinence.
Smokers respect the opinions of healthcare providers and these short interventions are well received.
When to Intervene
Although providers should not wait for special circumstances to discuss smoking cessation, there may be times when a patient is more motivated to
quit, such as at the onset of new medical symptoms, a hospitalization, a myocardial infarction, impending surgery, a friend recently diagnosed with
lung cancer, pregnancy, the recent birth of a child, a new child at home, or diagnosis of asthma in a child. Tailoring any event to a patient’s
circumstances can be used as a motivating factor. For instance, smoking cessation before middle age is associated with a more than 90% reduction in
tobaccoattributable cancer risk39; hence, the midlife birthday of a patient is a perfect time to bring up quitting.
Pharmacotherapy
In addition to counseling, all smokers making a quit attempt should receive pharmacotherapy, except in the presence of special circumstances.
Additionally, longterm smoking cessation pharmacotherapy can be considered as a strategy to reduce the likelihood of relapse. It is important to
remember when choosing a pharmacotherapeutic regimen that patient preference and expectations regarding outcome are important. Seven firstline
pharmacotherapies are approved by the FDA to be safe and effective for tobaccodependence treatment: bupropion SR, varenicline, nicotine gum,
nicotine patch, nicotine lozenge, nicotine nasal spray, and nicotine inhaler. See Table 402 for a summary of the dosing, recommended usage, cost,
contraindications, side effects, and other notes.
TABLE 402.
Review of Clinical Use of Pharmacotherapies for Smoking Cessationa
Precautions,
Pharmacotherapy Adverse effects Dosage Duration Availability
contraindications
First line History of seizure Insomnia 150 mg every morning for 3 days, then 150 7–12 weeks Prescription
Sustained release History of eating Dry mouth mg twice daily (begin treatment 1–2 weeks Maintenance only
bupropion disorders Seizures prequit) up to 6
hydrochloride months
Nicotine gum Mouth soreness 1–24 cigarettes/day; 2 mg gum (up to 24 Up to 12 OTC only
Dyspepsia pieces/day) weeks
≥25 cigarettes/day; 4 mg gum (up to 24
pieces/day)
Nicotine inhaler Local irritation of 6–16 cartridges/day Up to 6 Prescription

mouth and throat months only
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Nausea/heartburn Time to 1st cigarette >30 min: 2 mg lozenge Up to 12 OTC only
Chapter 40: Tobacco Use, Maya Vijayaraghavan; Steven A. Schroeder Time to 1st cigarette ≤30 min: 4 mg lozenge weeks
Page 13 / 22
Between 4 and 20 lozenges/day
remember when choosing a pharmacotherapeutic regimen that patient preference and expectations regarding outcome are important. Seven firstline
pharmacotherapies are approved by the FDA to be safe and effective for tobaccodependence treatment: bupropion SR, varenicline, nicotine gum,
Access Provided by:
nicotine patch, nicotine lozenge, nicotine nasal spray, and nicotine inhaler. See Table 402 for a summary of the dosing, recommended usage, cost,
contraindications, side effects, and other notes.
TABLE 402.
Review of Clinical Use of Pharmacotherapies for Smoking Cessationa
Precautions,
Pharmacotherapy Adverse effects Dosage Duration Availability
contraindications
First line History of seizure Insomnia 150 mg every morning for 3 days, then 150 7–12 weeks Prescription
Sustained release History of eating Dry mouth mg twice daily (begin treatment 1–2 weeks Maintenance only
bupropion disorders Seizures prequit) up to 6
hydrochloride months
Nicotine gum Mouth soreness 1–24 cigarettes/day; 2 mg gum (up to 24 Up to 12 OTC only
Dyspepsia pieces/day) weeks
≥25 cigarettes/day; 4 mg gum (up to 24
pieces/day)
Nicotine inhaler Local irritation of 6–16 cartridges/day Up to 6 Prescription

mouth and throat months only
Nicotine lozenge Nausea/heartburn Time to 1st cigarette >30 min: 2 mg lozenge Up to 12 OTC only
Time to 1st cigarette ≤30 min: 4 mg lozenge weeks
Between 4 and 20 lozenges/day
Nicotine nasal spray Nasal irritation 8–40 doses/day 3–6 months Prescription
only
Nicotine patch Local skin reaction Ex. 21 mg/24 h 4 weeks Prescription

Insomnia 14 mg/24 h Then 2 and OTC
7 mg/24 h weeks
Ex. 15 mg/16 h Then 2
weeks
8 weeks
Varenicline Significant kidney Nausea/trouble 0.5 mg/day for 3 days 3–6 months Prescription
disease sleeping 0.5 mg twice/day for 4 days only
Patients on dialysis Abnormal or Then, 1 mg twice/day
Severe psychiatric vivid/strange dreams (Begin treatment one week prequit)
disease Depressed mood and
other psychiatric
symptoms
Abbreviation: OTC, over the counter.
aThe information contained in this table describes the prescribing instructions for the seven FDAapproved firstline medications. This information is not
comprehensive. See package inserts for additional information, including safety information.
Source: Adapted from Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for
treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med. 2008;35(2):158176.40
Pregnancy 2023724 10:21 A Your IP is 24.248.8.126

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©2023 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility 40
Use of pharmacotherapy is controversial during pregnancy, because none of the medications have been tested in pregnant women. A number of
studies have shown that nicotine presents risks to the fetus, including neurotoxicity. Treating a woman with nicotine replacement, however, may
comprehensive. See package inserts for additional information, including safety information.
Source: Adapted from Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline
Access Provided by: for
treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med. 2008;35(2):158176.40
Pregnancy
Use of pharmacotherapy is controversial during pregnancy, because none of the medications have been tested in pregnant women.40 A number of
studies have shown that nicotine presents risks to the fetus, including neurotoxicity. Treating a woman with nicotine replacement, however, may
actually reduce the amount of nicotine she is absorbing if she is a heavy smoker and avoids exposing the fetus to the other toxic compounds found in
smoke. Intermittently dosed nicotine products are probably safer in pregnancy than the patch, with its continuous release of nicotine. Thus, the ideal
smoking cessation strategy for a pregnant woman would be intensive counseling. If that approach does not work, adding nicotine replacement,
though not without theoretical risk, is preferable to continuing to smoke. Many pregnant smokers who quit during pregnancy resume smoking after
delivery, thereby putting themselves and their infant at risk. Intensive smoking cessation efforts should continue after pregnancy is terminated.
Harm Reduction
In harm reduction strategies, tobacco users alter or decrease, rather than eliminate, their use of nicotine or tobacco. Although total abstinence from
cigarettes is a goal, as increased health risks have been documented even in smokers who smoke less than five cigarettes per day,41 there is evidence
that reduction in smoking is helpful. Patients who reduce smoking may eventually quit,42 and in the meantime asthma symptoms,43 worsening lung
function, and risk of lung cancer have all been shown to decrease.39 Shifting to lowtar and lownicotine cigarettes show no reduction in risk because
smokers compensate by increasing the frequency or depth of inhalation per cigarette.44 Switching to smokeless tobacco products or electronic
nicotine delivery devices in order to facilitate cessation has not been shown to increase smoking cessation rates on a population level.45
SYSTEMBASED APPROACHES TO SMOKING CESSATION

Systembased approaches—referral to telephone quit lines or smoking cessation specialists or group classes to help patients quit smoking—are most
useful. Creating smoking cessation consult services; implementing systematic screening and tobaccouser identification systems; and ensuring
adequate training in smoking cessation for personnel and availability of appropriate resources are important interventions. Healthcare facility chart
audits, electronic medical records, and computerized patient databases can be used to evaluate the degree to which healthcare providers are
identifying, documenting, and treating smokers. Feedback can be provided to providers in the form of “report cards” to remind providers about the
importance of addressing tobacco use in their practices. Guaranteeing that pharmacotherapies are covered or provided for patients at minimal cost is
particularly important.
Finally, reimbursement for tobacco cessation programs is essential. Insurers and purchasers of insurance must make certain that all insurance plans
include a reimbursement benefit for smoking cessation counseling and pharmacotherapy as well as a reimbursement for clinicians providing tobacco
dependence treatment. The Affordable Care Act provides for reimbursement of all US Preventive Service Task Force–recommended treatments,
including smoking cessation counseling and pharmacotherapy.
TELEPHONE QUITLINES
Tollfree telephone quitlines connect smokers with trained counselors who take an individual smoking history, prepare a customized cessation plan
that includes pharmacotherapy, and provide followup telephone calls to assess progress. Access to tollfree telephone quitlines is available in all
states.1 The Department of Health and Human Services has a national number (1800QUITNOW) that forwards callers to services in their area. In many
states, clinicians can directly fax referral forms from their offices or from the hospital, so that the state quitline can proactively contact the smoker.
Telephone counseling is effective in promoting cessation. In a large, randomized controlled trial of more than 3000 patients, telephone counseling
through the California state quitline (1800NOBUTTS) nearly doubled abstinence rates.46 Many smokers who call the telephone quitline suffer from
major depression, suggesting a need for targeted interventions for this population. Telephone quitlines offer convenience, the ability to serve diverse
and multilingual populations, and anonymity. The majority of patients also prefer using quitlines to clinic visits.1 Internet programs to help people quit
smoking are a newer variation on telephone counseling, and evidence is emerging that they are effective.
POLICYBASED APPROACHES TO SMOKING CESSATION
As healthcare providers and patient advocates, providers have the opportunity to take part in many communitybased and broader initiatives to
combat the epidemic
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the United States. Many of these policybased initiatives have been shown to be more effective in tobacco cessation
IP is 24.248.8.126
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than any clinicbased intervention practitioners canSteven
40: Tobacco Use, Maya Vijayaraghavan; A.Therefore,
provide. Schroederit is useful to review some of these policybased initiatives. Page 15 / 22
Primary Prevention and PolicyBased Approaches in Children
and multilingual populations, and anonymity. The majority of patients also prefer using quitlines to clinic visits. Internet programs to help people quit
smoking are a newer variation on telephone counseling, and evidence is emerging that they are effective. Trinity School of Medicine
Access Provided by:
POLICYBASED APPROACHES TO SMOKING CESSATION
As healthcare providers and patient advocates, providers have the opportunity to take part in many communitybased and broader initiatives to
combat the epidemic of tobacco in the United States. Many of these policybased initiatives have been shown to be more effective in tobacco cessation
than any clinicbased intervention practitioners can provide. Therefore, it is useful to review some of these policybased initiatives.
Primary Prevention and PolicyBased Approaches in Children
Primary prevention of smoking in US youth is the focus of many legislative and programmatic interventions. Effective legislative methods useful in
decreasing initiation of smoking among youth include use of federal, state, and local excise taxes to increase the cost of cigarettes, restricting tobacco
advertising and promotional activities (including bans on point of purchase and print advertising as well as sponsorship of events by tobacco
companies), mandating tobacco education in schools, banning representation of smoking on television, giving films with smoking an R rating, and
making tobacco access laws for minors more strict (including requirements to keep tobacco products behind the counter and bans on cigarette
vending machines). CVS pharmacy has recently announced that it will no longer sell tobacco products, and other chain pharmacies may follow CVS’s
lead.47 Antismoking media campaigns and counteradvertising, merchant education and training, schoolbased tobacco use prevention programs that
help model for children the identification and resistance of social influences that lead to smoking, and bans on smoking on school grounds have all
been shown to be effective. Restrictions on indoor smoking, campaigns to discourage family and friends from providing cigarettes to youth, and
promoting smokefree homes also work.48 Evidence supports the use of multiple modalities in combination with a comprehensive program against
tobacco use and initiation. The prevalence of smoking among youth has declined most rapidly in states that have used the most extensive paid media
campaigns in combination with other antitobacco activities in their comprehensive antitobacco campaigns.48
PolicyBased Approaches to Smoking Cessation in Adults
Policybased interventions used to decrease smoking in adults are also important interventions. In addition to the policies described in the preceding
section, such as tobacco excise taxes, tobaccofree work places are an example of an effective policybased intervention in adults. In addition to
protecting both workers and patrons from secondhand smoke exposure, smokefree workplace policies are associated with decreased cigarette
consumption and possibly with increased cessation rates among workers and members of the general public. These measures are supported by the
general public and do not decrease business revenues in restaurants and bars.49 Smokefree homes, another policybased approach, not only reduce
exposure to secondhand smoke but also promote cessation among smokers.14 Smokefree homes have been shown to be associated with increased
successful quit attempts among smokers, increased efficacy of pharmaceutical aids for cessation, and reduced relapse to smoking.
Languageappropriate, culturally competent, targeted education campaigns are being waged to combat tobacco company advertising and
promotional activities in minority and low socioeconomic status populations. Continued monitoring of tobacco industry attempts to target these
populations is necessary to develop a comprehensive understanding of the influences that encourage individuals in these highrisk populations to
smoke and design effective countermarketing campaigns.
CONCLUSION
Tobacco use is a scourge on health. Although cigarettesmoking rates have declined in the past three decades, the rate of decline has slowed in the
recent years. Among vulnerable populations, cigarettesmoking rates remain very high. Without efforts to increase access to cessation aids for
vulnerable populations, the rate of smoking among the general population may not decline to the goal set by the Healthy People 2020. Tobacco use
has also evolved to include a range of novel products, which have been marketed heavily to youth and vulnerable populations. Whether these products
result in a net public health benefit by increasing cessation rates remains unknown. However, the potential for augmenting addiction by promoting
dual and polyuse is a concern, and poses a risk to current populationwide efforts to reduce tobacco use. Helping current smokers quit and keeping
people, particularly young people, from starting should be top priorities for all health professionals. Achieving these goals will require a spectrum of
responses from efforts of individual providers, clinics, hospitals, and healthcare systems to antismoking media campaigns, and legislative restrictions
on promotion and sale of tobacco products and smoking in public places.
KEY CONCEPTS
Smoking is the leading cause of preventable death in the United States.
The poor, the mentally ill, and those with substance use disorders bear the brunt of poor health caused by cigarette smoking.
Primary
Chapter prevention
40: Tobacco Use,inMaya
the young is best tackled
Vijayaraghavan; through
Steven comprehensive public policies and medical counseling of children, teens, and
A. Schroeder their
Page 16 / 22
©2023parents.
McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
All health professionals should address smoking cessation at every opportunity.

dual and polyuse is a concern, and poses a risk to current populationwide efforts to reduce tobacco use. Helping current smokers quit and keeping
people, particularly young people, from starting should be top priorities for all health professionals. Achieving these goals will require a spectrum of
Access Provided by:
responses from efforts of individual providers, clinics, hospitals, and healthcare systems to antismoking media campaigns, and legislative restrictions
on promotion and sale of tobacco products and smoking in public places.
KEY CONCEPTS
Smoking is the leading cause of preventable death in the United States.
The poor, the mentally ill, and those with substance use disorders bear the brunt of poor health caused by cigarette smoking.
Primary prevention in the young is best tackled through comprehensive public policies and medical counseling of children, teens, and their
parents.
All health professionals should address smoking cessation at every opportunity.
Systemsbased interventions are essential to support tobacco cessation efforts.
Public policies and regulations are needed to combat the powerful and pervasive promotion of tobacco products by cigarette companies.
CORE COMPETENCY
Practical Smoking Cessation Tips and Exercises
General approach
Avoid “shoulds.” Use alternatives, such as, “Consider becoming smoke free.”
Be empathetic and respectful about the difficulty of quitting.
—Remember: Shame about smoking may actually inhibit cessation.
—Acknowledge smoking as an addiction, not a filthy habit or deficit in the person.
—Fearbased motivation may cause feelings of powerlessness and hopeless.
—Fear may break a person out of denial, but as a constant motivational tool is often counterproductive.
—Desirebased motivation can be more powerful than avoidance.
—Smoking cessation takes time and is a process. Do not get discouraged.
Exercises
Awareness
Ask patients to pay attention to how they feel when inhaling the cigarette.
Rate the four components of addiction to cigarettes on a scale of 1 to 5 in importance:
—Nicotine (although remember that nicotine effects and psychological reasons for smoking may be intertwined and impossible to
distinguish)
—Hand and mouth stimulation
—Psychological and emotional impulses for smoking
—Review conditioned cues: smoking after meals, during break times, when angry or upset, etc.
Use this information to focus interventions such as stress management.
Deep breathing
Deep breathing can help manage stress and eliminate cigarettes.
Deep breathing instruction: Purse lips and exhale as though blowing out a candle. Keep blowing until you can no longer exhale, and then allow
a natural inhalation. The inhalation will be deep and go to the abdomen. Practice a minimum of three times daily with 5–10 deep breaths each
—Psychological and emotional impulses for smoking
—Review conditioned cues: smoking after meals, during break times, when angry or upset, etc. Access Provided by:
Use this information to focus interventions such as stress management.
Deep breathing
Deep breathing can help manage stress and eliminate cigarettes.
Deep breathing instruction: Purse lips and exhale as though blowing out a candle. Keep blowing until you can no longer exhale, and then allow
a natural inhalation. The inhalation will be deep and go to the abdomen. Practice a minimum of three times daily with 5–10 deep breaths each
time. Use this to postpone or eliminate cigarettes.
Delaying
Cut drinking straws into the length of a cigarette. Put several into your cigarette pack. When you pull up a straw, deep breathe instead of smoke.
Pros and Cons
Reviewing an individual’s reasons for smoking provides the basis for exploring new responses to important needs. For example:
—Smoking helps a woman establish boundaries with men. She can use the lit cigarette to indicate “don’t come closer than this.”
—Smoking gives a person a reason to go outside and take a break from being with people, especially if he or she tends to be shy.
—Smoking lets you feel cool and rebellious.
—Smoking helps keep you awake, relaxed, and calm, and controls anger, hunger, and loneliness.
Desirebased motivation: List the cons about smoking. Turn the cons into the pros about being smoke free. For example, feeling like a bad
mother and nurse because of smoking can be turned into, “I am devoted to my children and health and can be fearless and proud and smoke
free.”
DISCUSSION QUESTIONS
1. Why do you think that healthcare professionals in your field do not tackle smoking cessation as frequently as they should? What strategies could
you use in your setting to improve smoking cessation efforts?
2. Discuss ways in which novel tobacco products may change current patterns of tobacco use. Discuss how the regulation of these products might
affect patterns of tobacco use.
3. Some argue that without the production and sale of tobacco, our economy would suffer tremendously and that public policies to restrict tobacco
use hurt the economy. Discuss.
4. Practice and roleplay with your neighbor using the five A’s, five R’s, and STAR techniques.
5. Compare and contrast the health benefits of quitting smoking with other treatments that are often prescribed.
RESOURCES
Smoking cessation leadership site: http://smokingcessationleadership.ucsf.edu.
Smoking cessation leadership site provides information on research on tobacco use and cessation, information on tobacco use among persons with
mental health and substance use disorders, resources for healthcare providers and smokers on smoking cessation, webinars, and other tools for
smoking cessation.
http://www.cdcgov/tobacco/
http://www.ahrq.gov/
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Many hospitals 2023724 10:21cessation
have smoking A Your services
IP is 24.248.8.126
available that enable referral of smokers as necessary. Many states have toll free quit lines (e.g., in
Chapter 40: Tobacco Use, Maya Vijayaraghavan; Steven
California, 1800NOBUTTS), and the national number A. Schroeder forwards callers to services in their area.
(1800QUITNOW)
Page 18 / 22
Comprehensive information from patient aides to clinical recommendations to information on how to develop or fund comprehensive tobacco
programs are available on the Centers for Disease Control and Prevention and the Agency for Health Care Research and Quality Web sites.
smoking cessation.
Access Provided by:
http://www.cdcgov/tobacco/
http://www.ahrq.gov/
Many hospitals have smoking cessation services available that enable referral of smokers as necessary. Many states have toll free quit lines (e.g., in
California, 1800NOBUTTS), and the national number (1800QUITNOW) forwards callers to services in their area.
Comprehensive information from patient aides to clinical recommendations to information on how to develop or fund comprehensive tobacco
programs are available on the Centers for Disease Control and Prevention and the Agency for Health Care Research and Quality Web sites.
Internetbased programs such as QuitNet can provide online chat rooms and can give smokers with access to a computer a sense of community with
other smokers. If patients do not have their own computer, the public library is a smoke free environment in which they can access computers.
http://www.quitnet.com.
The American Lung Association has significant information and an online program called “Seven Steps to a SmokeFree Life” to which patients can be
referred. http://www.lungusa.org/tobacco.
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Trinity School of Medicine

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Chapter 40: Tobacco Use

Maya Vijayaraghavan; Steven A. Schroeder

Review the epidemiology of patients who smoke tobacco.

Describe other types of tobacco used by vulnerable populations.

EPIDEMIOLOGY OF TOBACCO USE

LOW­ AND MIDDLE­INCOME COUNTRIES

OTHER TYPES OF TOBACCO

ELECTRONIC NICOTINE DELIVERY SYSTEMS

HEALTH CONSEQUENCES OF TOBACCO USE

HEALTH CONSEQUENCES OF TOBACCO USE

Cancer Cardiovascular Pulmonary Gastrointestinal

Infection Other Reproductive

Tuberculosis Type II DM Reduced fertility in women

SMOKELESS TOBACCO AND OTHER ELECTRONIC NICOTINE DELIVERY SYSTEMS

IMPACT ON THE HEALTH­CARE SYSTEM

CHALLENGES TO MANAGING TOBACCO USE

TOBACCO INDUSTRY MARKETING AND SOCIAL MEDIA

CHALLENGES IN THE HEALTH­CARE SYSTEM

Box 40­1. Common Pitfalls

Failing to ask about tobacco use in clinical encounters.

Inadequate training about addressing smoking cessation in clinical encounters.

Lack of knowledge about available community resources for tobacco cessation.

Box 40­1. Common Pitfalls

Failing to ask about tobacco use in clinical encounters.

Inadequate training about addressing smoking cessation in clinical encounters.

Lack of knowledge about available community resources for tobacco cessation.

Not encouraging the adoption of smoke­free homes.

STRATEGIES FOR MANAGING TOBACCO ABUSE

TREATING TOBACCO DEPENDENCE

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Algorithm for treating tobacco dependence.

Box 40­2. The Five A’s Mnemonic

Clearly advise patients to quit at every visit.

Stress total abstinence as the goal.

Assess each smoker’s willingness to quit at every visit.

If unwilling, provide a motivational intervention (see five R’s).

Assist patient in making a quit attempt (see STAR mnemonic).

Arrange follow­up tailored to the patient.

Smokers’ Willingness to Quit

Box 40­3. STAR Mnemonic

Set a quit date, ideally within 2 weeks.

The goal is for total abstinence.

T ell family, friends, and coworkers.

Box 40­3. STAR Mnemonic

Set a quit date, ideally within 2 weeks.

The goal is for total abstinence.

T ell family, friends, and coworkers.

Identify strategies to overcome triggers to smoking.

Create a plan to prevent relapse and orchestrate support.

Review nicotine withdrawal symptoms.

Recommend abstention from alcohol during quit attempt.

Recommend pharmacologic treatment.

Encourage the patient to seek help before relapse.

R emove tobacco products.

Follow­up for quit attempt

Follow­up 1 week after quit date.

LOW AND MIDDLEINCOME COUNTRIES

IMPACT ON THE HEALTHCARE SYSTEM

CHALLENGES IN THE HEALTHCARE SYSTEM

Box 401. Common Pitfalls

Box 401. Common Pitfalls

Not encouraging the adoption of smokefree homes.

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Box 402. The Five A’s Mnemonic

Arrange followup tailored to the patient.

Box 403. STAR Mnemonic

Box 403. STAR Mnemonic

Followup for quit attempt

Followup 1 week after quit date.

Followup 1 month after quit date.

Box 404. The Five R’s

Use reflective listening and openended questions.

Discuss shortterm, longterm, and environmental risks.

Pregnancy 2023724 10:21 A Your IP is 24.248.8.126

SYSTEMBASED APPROACHES TO SMOKING CESSATION

POLICYBASED APPROACHES TO SMOKING CESSATION

Primary Prevention and PolicyBased Approaches in Children

PolicyBased Approaches to Smoking Cessation in Adults

Systemsbased interventions are essential to support tobacco cessation efforts.

—Fearbased motivation may cause feelings of powerlessness and hopeless.

—Desirebased motivation can be more powerful than avoidance.

13. IARC. Evaluating the Effectiveness of Smokefree Policies. WHO, 2009.

13. IARC. Evaluating the Effectiveness of Smokefree Policies. WHO, 2009.

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