In areas where smoke free laws are in effect, it can be easy to think that the war on cigarette smoking has been won. After all, the dangers of smoking are widely known, and it doesn’t appear that many people are smoking. This hides a dangerous discrepancy. Tobacco smoking is still the leading cause of preventable disease, disability, and death in the United States. In order to reduce these deaths, both public health professionals and clinicians have to redouble their efforts to promote cessation and prevent initiation of tobacco use.
We now know that behavioral counseling and cessation medication interventions are more effective in smoking cessation than self-help materials or no treatment. Although a majority of cigarette smokers make an attempt to quit every year, less than one-third use FDA-approved cessation medications or behavioral counseling to support these attempts. By opening up the conversation about smoking cessation, healthcare providers can provide their patients with resources that we know will make them more successful. Additionally, we know that the public health “tobacco vaccine,” - the combined policies of smoke free environments, access to cessation resources, increased tobacco products and hard hitting media campaigns - can drastically reduce cigarettes use rates. Only through health care professionals and public health professionals continuing the conversation around evidence-based strategies can we reduce and eliminate the needless healthcare and economic burden that smoking creates (resources for healthcare providers and public health officials).
In 2018, 13.7% of U.S. adults (34.2 million people) were current cigarette smokers. While this is incredible progress since the 1960s, these individuals still account for a quarter of all coronary heart disease deaths and nearly 9 out of 10 lung cancers. More than 16 million Americans are living with a disease caused by smoking. On average, smokers die 10 years earlier than nonsmokers. What these numbers add up to is a huge, preventable disease burden and ongoing needless death. Secondhand smoke is also an ongoing and very real health risk. Secondhand smoke exposure contributes to approximately 41,000 deaths among nonsmoking adults and 400 deaths in infants each year.
In addition to the physical toll of smoking, as of 2014 the annual total economic costs due to tobacco is over $289 billion. including at least $130 billion for direct medical care, over $150 billion for lost productivity due to premature death, and more than $5 billion for lost productivity from premature death due to exposure to secondhand smoke.
While it is no surprise that smoking causes disease, and the economic burden of that disease, for many, the size of its impact does not correlate with what they see daily. In many areas of the country, restrictions on smoking in public locations pushes cigarettes out of sight and out of mind. Where these restrictions have been put in place, they have very successfully reduced the normalization of smoking. But they have also led to a reduced sense of urgency to talk to both patients and policy makers about smoking.
Four out of every nine adult cigarette smokers who saw a health professional during the past year did not receive advice to quit, but 68% of current smokers say they want to quit smoking. About two thirds of smokers even try to quit each year. But the majority of these people try to quit completely on their own, without using strategies that we know drastically increase success at quitting. Healthcare providers are positioned to fill the gap between who wants to quit and who has the resources to succeed, first by starting the conversation, and then by providing follow up and accountability.
Public health specialists also cannot become complacent when it comes to smoking. The concept of the “Tobacco Control Vaccine,” or the combination of different public health policies that have been shown to reduce tobacco use, is certainly not new. These policies include increasing tobacco product prices, enacting smoke free policies for restaurants, bars, and other public places, access to cessation resources such as quit lines, and media campaigns to promote smoking prevention and cessation. In states where this model has been followed, it has been shown to be extraordinarily effective. However, it is easy to overestimate how many places have actually implemented these actions. 40% of Americans are not covered by any public smoke-free policies. Right now, not a single state out of 50 funds smoking cessations programs at CDC’s “recommended” level. Three states (Connecticut, Tennessee, and West Virginia) give no state funds for prevention and quit-smoking programs. By comparison, tobacco companies spend about $26 million each day on marketing.
The good news is that with adequate promotion, comprehensive, barrier-free, evidence-based cessation insurance coverage increases the availability and utilization of treatment services for smoking cessation. But we cannot let ourselves revel in our accomplishments and become complacent. In order to reduce tobacco morbidity and mortality, clinicians and public health officials must continue to address smoking as a serious and urgent health concern.
U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020 [accessed 2020 April 25].
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2020 April 25].
Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs–2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2020 April 25].
King BA, Graffunder C. The Tobacco Control Vaccine: a population-based framework for preventing tobacco-related disease and death. Tobacco Control. 2018 Mar;27(2):123-124. doi: 10.1136/tobaccocontrol-2018-054276.