Many cigarette smokers are trying to kick the habit—or would at least like to. Among current users in 2000, 70% expressed a desire to quit smoking, according to the National Health Interview Survey. In addition, 41% had managed to quit smoking for more than a day in the year prior to the survey. In 2002, 64.4% of smokers tried to quit (Morbidity and Mortality Weekly Report, January 9, 2004). In a 2004 Gallup Poll, 224 smokers were asked if they would like to give up smoking. Eighty-two percent answered yes. This figure is up from 76% in 1999 and from 66% in 1977 ("Tobacco and Smoking," The Gallup Organization, 2004).
In an effort to help people stop smoking, the federal government began a massive antismoking campaign in
TABLE 5.6
Leading tobacco indicators in Healthy People 2010
[In percentages]
| Tobacco use | 1997 baseline | 2010 |
| Cigarette smoking adults | 24 | 12 |
| American Indian/Alaskan Native | 34 | 12 |
| Family income, poor level | 34 | 12 |
| Current tobacco use by youth (past 30 days) | 43 | 21 |
| Smoking cessation attempts | ||
| Adults | 43 | 75 |
| Pregnant women | 12 | 30 |
| Adolescents (grades 9-12) | 73 | 84 |
1991, intended to prevent 1.2 million smoking-related deaths. The goal of the multiyear program was to help 5.5 million adults stop smoking, prevent two million youths from starting, and reduce the number of smokers to 15% of the population. One of the national health objectives for the year 2010 (Healthy People 2010, 2nd ed., Washington, DC: U.S. Department of Health and Human Services, November 2000) is to reduce the prevalence of cigarette smoking among adults to no more than 12%. Table 5.6 shows other tobacco-related goals of the program.
The government reports Reducing Tobacco Use and Tobacco Control State Highlights say that drug treatment for nicotine addiction, combined with other treatment methods, will enable 20 to 25% of users to refrain from smoking one year after treatment. Even physicians who advise their patients to quit smoking can produce a cessation increase of 5 to 10%.
Global Efforts to Reduce Tobacco Use
An estimated 1.1 billion adults worldwide are believed to use tobacco. According to the World Health Organization (WHO), tobacco causes 4.9 million deaths per year. In May 2003 member states of WHO adopted the world's first international public health treaty for global cooperation in reducing the negative health consequences of tobacco use. The WHO Framework Convention on Tobacco Control is designed to reduce tobacco-related deaths and disease around the world.
In February 2005 the treaty came into force after being ratified by member countries. Each of the 168 countries that have signed on to the treaty must now pass it into law. Although the United States signed the treaty in 2004, indicating its general acceptance, by spring of 2005 it had not yet been sent to the Senate for ratification but was undergoing legal review at the State Department. The treaty has many measures, which include requiring countries to impose restrictions on tobacco advertising, sponsorship, and promotion; establishing new packaging and labeling of tobacco products; establishing clean indoor air controls; and promoting taxation as a way to cut consumption and fight smuggling.
The Benefits of Stopping
The Health Benefits of Smoking Cessation: A Report of the Surgeon General, 1990 (Washington, DC: 1990) noted that quitting offers major and immediate health benefits for both sexes and for all ages. This first comprehensive report on the benefits of quitting showed that many of the ill effects of smoking can be reversed.
The Surgeon General's report of 2004, The Health Consequences of Smoking: A Report of the Surgeon General, revealed that deaths attributable to smoking can be reduced dramatically if the prevalence of smoking is cut. Table 5.7 shows the projected number of smokers by age group in 2010 based on three scenarios: (1) the rates at which people begin to smoke (initiation) and stop smoking (cessation) remain unchanged from 1998 rates (status quo prevalence); (2) the rates of initiation decline by one-third and cessation increases by 50% from the 1998 rates; and (3) youth smoking prevalence declines from 35 to 16% and adult prevalence is cut in half for all age groups (i.e., the Healthy People 2010 objectives are met). The Surgeon General's report notes that if scenario 2 occurred, approximately 2.5 million expected premature deaths from smoking would be prevented compared with the status quo group (scenario 1). If scenario 3 occurred, approximately 7.1 million deaths would be prevented.
According to the National Center for Health Statistics, heart disease was the number one killer of Americans in 2003 and cancer was the number two killer. Of all cancers, lung cancer is the number one killer of both men and women. People who quit smoking in middle age or prior to middle age avoid more than 90% of the lung cancer risk attributable to tobacco. Results of a study published in the British Medical Journal ("Smoking, Smoking Cessation, and Lung Cancer in the UK since 1950: Combination of National Statistics with Two Case-Control Studies," August 5, 2000) revealed the extent to which smoking cessation lowers lung cancer risk. For men who stopped smoking at ages sixty, fifty, forty, and thirty, the cumulative risks of lung cancer by age seventy-five were 10%, 6%, 3%, and 2%, respectively. These results were supported by the findings of a 2004 study that led to the conclusion that, for long-term smokers, giving up smoking in middle age allows people to avoid most of the subsequent risk of lung cancer (A. Crispo et al., "The Cumulative Risk of Lung Cancer among Current, Ex- and Never-Smokers in European Men," British Journal of Cancer, Vol. 91, no. 7, 2004).
TABLE 5.7
Smoking prevalence in 2010, based on three scenarios, by age
| Age | Status quo prevalencea | Modest reductionsb | Healthy People 2010 reductionsc |
| Current smoking prevalence (%) | |||
| 10-17 years | 36.0 | 24.4 | 16.0 |
| Adults | 19.5 | 18.1 | 12.0 |
| 18-24 years | 26.9 | 22.6 | 14.0 |
| 25-44 years | 24.1 | 23.8 | 13.8 |
| 45-64 years | 17.4 | 15.8 | 12.5 |
| ≥65 years | 9.3 | 7.9 | 5.5 |
| Number of smokersd | |||
| 10-17 years | 11,714,200 | 7,948,200 | 5,210,400 |
| 18-24 years | 8,104,100 | 6,803,600 | 4,207,700 |
| 25-44 years | 18,896,800 | 18,640,400 | 10,765,400 |
| 45-64 years | 13,821,400 | 12,599,000 | 9,948,600 |
| ≥65 years | 3,682,400 | 3,132,500 | 2,164,500 |
| Total | 56,218,900 | 49,123,600 | 32,296,600 |
| Note: Figures for the number of smokers are rounded and hence do not add up. | |||
| aAssumes constant youth smoking prevalence of 35% (1998 data) and adult cessation rates of 0.21%, 2.15%, and 5.96% for ages 18-30, 31-50, and ≥51 years, respectively. Smoking prevalence estimates for adults are from the 1998 National Health Interview Survey. Data from the 1999 Youth Risk Behavior Survey were used to project the percentage of 10-17-year-olds expected to become smokers (Centers for Disease Control and Prevention [CDC] 2001b). | |||
| bAssumes constant annual changes: by 2010, youth initiation rates will decline by one-third and adult cessation rates will increase by 50%. | |||
| cAssumes Healthy People 2010 goals are met: reducing youth smoking prevalence among persons aged <18 years to 16% and prevalence among persons aged ≥18 years and for each age group by 50% overall (U.S. Department of Health and Human Services 2000). | |||
| dBased on U.S. Census Bureau population projections (U.S. Census Bureau 2002). | |||
For smokers who quit, the news is even better for their risk of heart disease, because the risk drops rapidly after smoking cessation. After one year's abstinence from smoking, the risk of heart disease is reduced by about 50% and continues to decline gradually. After five to ten years of smoking cessation, the risk has declined to that of a person who has never smoked. In addition, stopping smoking reduces the risk of stroke to that of a nonsmoker after five years of smoking cessation (G. Sutherland, "Smoking: Can We Really Make a Difference?," Heart, vol. 89, Supplement 2, 2003).
Another study ("Effects of Multiple Attempts to Quit Smoking and Relapses to Smoking on Pulmonary Function," Journal of Clinical Epidemiology, December 1998) investigated whether short periods of quitting were beneficial to smokers' health. Results revealed that those who made several attempts to quit smoking had less loss of lung function than those who continued to smoke. Therefore, even intermittent lapses in smoking are beneficial.
QUITTING AND PREGNANCY.
The 2003 National Survey on Drug Use and Health found that, of the sample
TABLE 5.8
Tobacco use in the past month among females aged 15-44,
by pregnancy status, average of percentages, 2002 and 2003
| Pregnancy status | |||
| Drug | Totala | Pregnant | Not pregnant |
| Any tobaccob | 31.3 | 18.9 | 31.7 |
| Cigarettes | 30.2 | 18.0 | 30.7 |
| Smokeless tobacco | 0.3 | 0.3 | 0.3 |
| Cigars | 3.0 | 1.4 | 3.1 |
| Pipe tobacco | 0.3 | 0.3 | 0.3 |
| aEstimates in the Total column are for all females aged 15 to 44, including those with unknown pregnancy status. | |||
| bAny tobacco product includes cigarettes, smokeless tobacco (i.e., chewing tobacco or snuff), cigars, or pipe tobacco. | |||
of females ages fifteen to forty-four who were surveyed, 31.3% used tobacco in the month prior to the survey. Of the pregnant women in this sample, 18.9% had smoked cigarettes in the prior month, 1.4% smoked cigars, and 0.3% smoked pipes. (See Table 5.8.)
Smoking during pregnancy can compromise the health of the developing fetus. The 2004 Surgeon General's report The Health Consequences of Smoking noted that evidence suggests the possibility of a causal relationship between maternal smoking and ectopic pregnancy, a situation in which the fertilized egg implants in the fallopian tube rather than in the uterus. This situation is quite serious and is life-threatening to the mother. Smoking by pregnant women is also linked to an increased risk of miscarriage, stillbirth, premature delivery, and sudden infant death syndrome (SIDS), and is a cause of low birth weight in infants. A woman who stops smoking, either before she becomes pregnant or during her first trimester (three months) of pregnancy, significantly reduces her chances of having a low-birth-weight baby. Research has found that it takes smokers longer to get pregnant than nonsmokers, but that women who quit are as likely to get pregnant as those who have never smoked.
Complaints about Quitting
A major side effect of smoking cessation is nicotine withdrawal. The short-term consequences of nicotine withdrawal may include anxiety, irritability, frustration, anger, difficulty concentrating, and restlessness. Possible long-term consequences are urges to smoke and increased appetite. Nicotine withdrawal symptoms peak in the first few days after quitting and subside during the following weeks. Improved self-esteem and an increased sense of control often accompany long-term abstinence.
One of the most common complaints among exsmokers is that they gain weight when they stop smoking. Many reasons explain this weight gain, but two primary reasons are: (1) the metabolism changes when nicotine is withdrawn from the body, and (2) many former smokers use food in an attempt to manage their withdrawal cravings. To combat weight gain, some ex-smokers start exercise programs.
Ways to Stop Smoking
Nicotine-replacement treatments can be effective for many smokers. Nicotine patches and gum are both types of nicotine replacement therapy (NRT). The nicotine in a patch is absorbed through the skin, and the nicotine in gum is absorbed through the mouth and throat. NRT helps a smoker cope with nicotine withdrawal symptoms that discourage many smokers trying to stop. Nicotine patches and gum are available over-the-counter (without a prescription). Other NRT products are the nicotine nasal spray and the nicotine inhaler, which are available by prescription.
The non-nicotine therapy bupropion (e.g., Zyban, Wellbutrin) is also available by prescription for the relief of nicotine withdrawal symptoms. In addition, behavioral treatments, such as formal smoking-cessation programs, are successful for some smokers who want to quit. Behavioral methods are designed to create an aversion to smoking, develop self-monitoring of smoking behavior, and establish alternative coping responses.
Figure 5.10 shows the one-year success rates for smoking cessation. Only 1 to 2% of smokers trying to
FIGURE 5.10
Expected one-year success rates of quitting smoking with various interventions
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