Smoking Cessation

Tremendous progress has been made in reducing the incidence of tobacco abuse. This is partly the result of the health care profession educating and counseling smokers, but is also undoubtedly related to the increasing inconvenience and social stigma of smoking. The rising cost of cigarettes and the increasing prohibitions against smoking in public places have clearly been shown to decrease the incidence of smoking. Although the problem of tobacco abuse has seen much improvement in the last 50 years, with the prevalence of smoking decreasing by about half in the past 50 years, tobacco abuse remains the largest preventable cause of death in the United States. It is estimated that roughly a third of cancer and cardiovascular deaths, and virtually all of the chronic obstructive pulmonary disease (COPD)-related deaths, can be attributed to tobacco abuse. It is estimated that the cumulative impact on our economy, in terms of health care costs and lost productivity, approaches $200 billion per year.

The opportunity for affecting patients’ behavior through interaction that is inherent in the health care system is significant. Most smokers see a primary care physician each year and can be identified with the routine inclusion of tobacco use as one of the vital signs. In spite of this opportunity, treating tobacco dependence remains challenging. Most smokers are not ready or interested in quitting at any given time. This may be partly because of the high failure rate of unaided, cold turkey attempts to quit smoking. However, successful interventions to treat smoking patients are clearly possible.

A great deal is known about the science of smoking cessation. It is important to understand some of these basic facts and to approach smoking cessation in an organized fashion based on these principles. Smoking remains the leading cause of avoidable death in the United States. Most smokers are not asked about, or counseled about, smoking when they are seen in the health care setting, and these interactions are poorly documented. The rate of recidivism among those who attempt to quit smoking is high initially, but a number of interventions, including counseling and repeated attempts, can improve this. Patients who are willing to quit smoking should be identified, because they have the best chance of quitting smoking. Counseling plays an important role in the treatment of smokers, both in trying to recruit those who are unwilling to quit and in supporting and improving the chances of quitting among the willing. Pharmacologic interventions, including nicotine-replacement therapy, have been shown to improve likelihood of smoking cessation.