Keywords

Introduction

Tobacco use in the United States (US) has fallen over the last half-century but remains the leading preventable causes of death and disability [1]. From a peak of over 40% in 1965, cigarette smoking has declined to 12.5% among adults in 2020 [2]. When other tobacco products such as chewing tobacco, cigars, and e-cigarettes are included, 19% of adults in the US (47 million people) currently use a tobacco product [2]. Globally, smoking caused nearly 8 million deaths and 200 million disability-adjusted life years in 2019 [3].

Up to one out of three cardiovascular deaths and four out of ten cancer deaths are due to tobacco use [4, 5]. Sites of tobacco-related cancers include the lung, bladder, cervix, gastrointestinal tract, liver, pancreas, stomach, esophagus, larynx, oropharynx, and blood (myeloid leukemia) [1]. In addition, for every person who dies from tobacco-related disease, 30 more people suffer debilitating chronic illnesses, including diabetes, decreased immune function, rheumatoid arthritis, hip fractures, vascular disease, chronic obstructive pulmonary disease (COPD), blindness, cataracts, strokes, and pneumonia. [6] Exposure to secondhand smoke (SHS) increases risk of premature death and disease for people who have never smoked, and negatively impacts fetal development as well as the health of infants and children [7, 8]. In the US, tobacco use costs $600 billion (in 2018 dollars), including $240 billion in direct medical care, lost productivity from smoking-related illnesses and health conditions, lost productivity from early death related to smoking, and $7 billion in lost productivity due to death from secondhand tobacco exposure [6, 9,10,11].

Large disparities in tobacco use exist by region, state, age, race and ethnicity, social economic status, occupation, mental health, gender, and sexual orientation. In medical practice, smoking by people with one or more chronic diseases, including mental health and substance use, remains significantly higher than those with no comorbidities [12]. One of the largest factors in tobacco use is educational attainment, with tobacco use ranging from 40% among people with a high-school degree or equivalent to 8.6% among those with a graduate degree [2]. Income follows a similar trend, with smoking rates ranging from 25% among people with an annual household income of under $35,000 to 14% among people with an income of over $100,000 [2]. Mental health is also an important predictor, with tobacco use more common among people with generalized anxiety (30% use), major depression (36% use), and bipolar or psychotic disorders. People who identify as lesbian, gay, or bisexual also have a higher prevalence of tobacco use (25%) [2]. Cigarillo use, one of the most popular of all cigar types, is disproportionately higher among young adults and African American adults [13].

Since the 1964 US Surgeon General’s report on smoking and health, a comprehensive tobacco control strategy has sought to decrease the initiation and prevalence of smoking through public health policy initiatives such as clean air statutes, media campaigns, taxes on cigarettes, and comprehensive state programs, including quitlines, websites, and apps. Despite advocacy for health care system change that supports treatment, evidence-based interventions remain under-prescribed by providers and under-utilized by patients [1, 14, 15].

Tobacco Use and Chronic Disease

Tobacco Use as a Chronic Disease

The US Public Health Service’s Guidelines on Treating Tobacco Use and Dependence includes 10 key recommendations (Table 4.1). The first recommendation emphasizes that tobacco use and addiction are chronic diseases that often require repeated intervention and multiple attempts to quit and that effective treatments exist that can significantly increase rates of long-term abstinence [16]. Only a minority of people who use tobacco are able to achieve long-term abstinence in an initial attempt; rather, the experience of most patients involves multiple quit attempts, with periods of abstinence followed by periods of relapse, hence the ongoing, chronic nature of tobacco addiction. Like managing hypertension or diabetes, clinicians who acknowledge tobacco use as a chronic disease should include brief interventions in every patient encounter, give patients realistic expectations about achieving success, use behavioral therapy, encourage use of various approved pharmacotherapy agents and monitor compliance, refer patients to treatment specialists, and view relapse without judgment.

Table 4.1 US Public Health Service’s ten guidelines on treating tobacco use and dependence [16]
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While over two-thirds of smokers want to quit smoking, and over one half try to quit each year, less than 10% who try on their own are successful in any given year, which is lower than successful abstention from heroin or alcohol [17, 18]. Tobacco cessation doubles with strong advice from the clinician to quit and achieves successful quit rates of 20–30% of patients when behavioral counseling is combined with pharmacotherapy [19].

Tobacco dependence is a chronic illness that involves changes in brain chemistry from the effects of nicotine and other compounds involved in the upregulation of nicotine receptors. When people stop using tobacco, physiologic changes in the brain cause urges and withdrawal symptoms. Like other chronic illnesses, tobacco dependence merits effective treatment and should be covered by health insurance [20].

Patients who smoke often feel isolated and tend to under-report or deny their tobacco use if they anticipate judgment from their doctor. Patients are more likely to successfully quit if their clinicians offer empathy and an acknowledgment of the difficulty of stopping tobacco use while providing resources for cessation [21].

Impact on Other Chronic Diseases

Tobacco use, especially smoking, damages nearly every organ in the body and has a significant impact on chronic diseases [6] (Fig. 4.1). From 2005 to 2013, adults with asthma, diabetes, heart disease, hypertension, and substance abuse did not reduce their rate of smoking as much as that of adults without chronic conditions, and those with substance use disorder or mental health problems continue to smoke at higher rates than the general population [12]. Almost half of cigarettes are consumed by those with serious mental illness, and smoking rates for individuals with schizophrenia and bipolar disorder are increasing. The stress of trying to stop a highly addictive behavior like smoking while living with a chronic disease can feel overwhelming to patients, who may struggle to give up the one thing that comforts them. Patients may also dislike the weight gain associated with stopping smoking. Still, most people are willing to contemplate stopping and understand that doing so will decrease the adverse outcomes of their chronic disease [22, 23].

Fig. 4.1
An anatomy diagram of the human labeled with types of cancer and chronic diseases. Cancers in the oropharynx, larynx and esophagus, lungs, stomach, liver, kidney, cervix, and colorectal are marked. Chronic diseases include stroke, blindness, cataracts, pneumonia, diabetes, and rheumatoid arthritis.

The health consequences causally linked to smoking. Notations in red were newly added to the 2014 Surgeon General’s Report. Reprinted from public domain: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/

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Types of Tobacco Products

Tobacco use disorder involves tobacco use on a regular basis for which abstinence produces withdrawal symptoms, meeting criteria for addiction (Table 4.2). Tobacco products, defined and regulated by the US Food and Drug Authority (FDA), include smoked, smokeless, and heated/vaporized. About one in five tobacco users use more than one product, which is referred to as poly-tobacco use and is especially prevalent in young adults (ages 18–24 years). Most poly-tobacco users use two products (“dual-use”), the most common of which are cigarette and e-cigarette use, followed by cigarettes and another combustible product (e.g., cigars), followed by cigarettes and smokeless tobacco [2]. It is important to ask about all tobacco product use.

Table 4.2 Tobacco use disorder definitions [24]
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Smoked (Combustibles)

All combustible tobacco products are carcinogenic and promote multiple respiratory and cardiac diseases. Cigarettes contain tobacco wrapped in a paper, usually with a filter to reduce the harshness (but not the toxicity) of the inhaled smoke. Cigarettes are a highly effective and efficient drug delivery system, delivering a bolus of nicotine to the brain within 10 seconds of inhalation [25]. A pack includes 20 cigarettes and can be sold as single packs or in cartons of 10 packs. Sale of single cigarettes (“loosies”) is illegal, but common in some places. Previous attempts by tobacco companies to brand cigarettes as safer included “light” and “low tar” designations. These misleading labels are now prohibited, but still identifiable by color labels, for example, light products are often in gold packaging. Terms such as “natural” and “organic” have also been used to convey a less harmful product [26]. Congress banned all characterizing flavors in US cigarettes in 2009, with the notable exception of menthol, even though it may be the most harmful flavor. Menthol masks the harsh taste and feel of inhaled smoke and allows for deeper inhalation, with the ability to deliver higher levels of nicotine in fewer cigarettes. In 2020, 37% of all cigarettes sold in the US were mentholated [27]. Use of menthol makes it easier to start smoking and more difficult to stop [28]. Young people smoke menthol cigarettes at higher rates than adults and almost 75% of African Americans who smoke use menthol cigarettes [29]. The FDA announced in 2022 plans to ban menthol in cigarettes, a move that could dramatically decrease cigarette consumption if combined with increased support for cessation [30].

Cigars and cigarillos use tobacco leaf as the wrapper and range in size from cigarette-size (little cigars) to an intermediary size (cigarillos), to large cigars. Someone who smokes 20 cigarettes a day (one pack) and who switches to cigarillos will typically use about three cigarillos per day, stubbing them out and relighting them frequently to maintain nicotine levels. Because there are no minimum pack sizes, cigarillos can be sold individually or in small packages at inexpensive prices (e.g., 3 for $0.99). Currently no federal flavor limitations exist for cigar products, allowing a wide array of flavors, such as apple, grape, and cherry, which are popular with youth and young adults. The FDA may ban flavors in cigar products [30].

Pipe smoking involves use of different blends of tobacco stuffed into the pipe bowl, lit, and inhaled through the pipe stem. While it has the lowest prevalence among combustible tobacco products, it still delivers nicotine and carcinogens throughout the lungs and most organ systems.

Hookah or water pipe, originally from the Middle East, has become more popular in the US, particularly among youth and young adults, often in group settings [31]. Hookah use among college students is high, with over 20% of college students using hookah in any given year [32]. In a hookah, burned tobacco passes through a water pipe which filters out some chemicals, but the inhaled smoke still contains high levels of toxins that come from the burning of the charcoal, tobacco, and flavoring; hence, it is not a safe alternative to smoking cigarettes [31].

Smokeless (Non-combustibles)

Smokeless tobacco is placed in the mouth, where nicotine and other chemicals are absorbed through the oral mucosa. Smokeless tobacco includes chew, dip, snuff, and snus, and newer products like nicotine pouches. Smokeless tobacco (especially Swedish snus), while harmful, is substantially less harmful than cigarette use [33]. Chew and dip (also sometimes called moist snuff) [34] usually require expectoration of the liquid that pools in the lower jaw, hence the name spit tobacco. Nasal snuff may be sniffed up the nose. Snus, based on a Scandinavian product, contains tobacco in a small teabag-like pouch that does not require spitting. Nicotine pouch products also use a small pouch, but rather than containing ground tobacco leaves use a white powder that is a mix of nicotine, flavoring, sweeteners, and binding agents. Smokeless tobaccos contain a number of carcinogens and cause oral cancer, esophageal cancer, and pancreatic cancer [34]. Smokeless tobacco use can also lead to leukoplakia, gum disease, tooth decay, and tooth loss. Use of smokeless tobacco increases the risk of death from heart disease and stroke and use during pregnancy increases the risk of pre-term delivery and stillbirth and affects fetal brain development [35].

E-Cigarettes (Vapes) and Heated Tobacco Products

E-cigarettes (also called vape pens) deliver nicotine by using a battery to heat a solution of nicotine, flavoring, and carrier chemicals (propylene glycol and/or glycerin) to create an aerosol that is inhaled or “vaped.” The small, discrete size of e-cigarettes, the variety of flavors available, and social media marketing make e-cigarettes popular among youth.

Heated tobacco products (also called “heat-not-burn” tobacco products, for example, Philip Morris’s IQOS brand) use a battery-powered device to heat a heavily modified type of tobacco cigarette. These products are increasingly popular internationally and are recently available in the US.

While people who use e-cigarettes and heated tobacco products are not exposed to the carbon monoxide, tars, or carcinogens of smoked tobacco, these products are not harmless and research is underway to determine their carcinogenicity and toxicity. The FDA has started the process of regulating e-cigarettes.

Second- and Thirdhand Smoke Exposure

While those who use combustible tobacco products receive the most concentrated exposure to toxic chemicals, the effects can be experienced by others. Secondhand smoke (SHS) is a combination of smoke that comes directly from burning cigarettes, cigars, or pipes, called “side-stream smoke,” and smoke that is exhaled by the person smoking, or “main-stream” smoke. Side-stream smoke comprises 85% of SHS. SHS can remain in the air for hours which increases the time others are vulnerable [7]. Nonsmokers who are exposed to SHS increase their risk of developing heart disease by 25–30%, yet providers rarely ask nonsmokers about SHS exposure [6].

Thirdhand smoke (THS) refers to the residual nicotine and carcinogens found in tobacco smoke adhering to surfaces long after a cigarette has been finished. [36] These lingering toxins are found in hair, skin, clothes, carpets, furniture, walls, insulation, and vehicles. The molecules react with oxidants in the air and other compounds in the environment to generate secondary contaminants that can be more toxic to humans than the original contaminants [37]. These toxic effects have been shown in cells, animal models, and children, including in neonates. While more research is needed to understand long-term effects of these exposures, it is prudent to decrease such exposure [38].

Individuals exposed to SHS and THS can suffer the same adverse health effects as those who smoke voluntarily [7]. Adults exposed to tobacco smoke in the environment have increased adverse effects on their cardiovascular system and can develop lung cancer. In the US, SHS annually causes about 3,400 lung cancer deaths and 42,000 heart disease deaths in people who do not smoke. Children who are exposed to smoke have elevated risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear infections, and asthma [7]. In the US, this translates to hundreds of thousands of lower respiratory tract infections in children younger than 18 months. Approximately 14% of US children live in a household with at least one person who smokes, which increases their vulnerability to tobacco smoke and the resulting consequences [39].

African Americans, children, people with incomes below the poverty level, and those who rent their homes are more likely to be exposed to SHS than other populations. Especially vulnerable are people living in multi-unit housing like apartments and condominiums. Even if they adopt smoke-free policies for their own living units, they can be exposed to smoke from nearby units and shared areas. Tobacco-free policies in workplaces and public places, including public housing, have contributed to reducing exposure to SHS and THS for many people in the US, but such policies vary widely by state and locality [40].

Children are at the greatest risk of exposure to THS, as they more frequently touch surfaces on which the toxic particles reside. They also can be exposed over long periods of time, from in utero until leaving home as young adults. Exposure to nicotine and tobacco-specific nitrosamines is of particular concern [41]. Thirdhand smoke is not easily removed and can take months to years to dissipate [42]. Although the risks of exposure are not fully known, human and in vitro animal studies link THS to DNA damage, altered fibroblast migration involved in wound healing, and impaired respiratory development [43,44,45].

Public health experts advocate that all clinicians ask adults and children if they are or have been exposed to smoke from tobacco products in their usual environment [46]. Secondhand smoke exposure is an ICD 10 code (Z77.22) that can be used to indicate a diagnosis for reimbursement purposes [47].

Benefits of Cessation in Patient Populations

Asymptomatic Patients and Disease Prevention

People who stop using tobacco decrease the risk for cancer, lung disease, and cardiovascular disease and add years to life expectancy [48] (Fig. 4.2). They report increased sense of taste and smell, overall well-being and sense of accomplishment, a new-found freedom, and increased self-efficacy for making other behavior changes. The 2020 report of the US Surgeon General summarizes the health benefits of smoking cessation on multiple health systems and diseases (Table 4.3) [1]. The benefits of stopping tobacco use on individual chronic conditions are discussed below [22, 23].

Fig. 4.2
A timeline features the ways to a healthy life after quitting smoking. Within 20 minutes, the heart rate and blood pressure drops. After 5 years, the risk of mouth and throat cancer is cut in half. After 15 years, the risk of coronary heart disease is the same as non-smokers.

Positive outcomes from stopping tobacco use. Reprinted from public domain: www.BeTobaccoFree.gov

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Table 4.3 Smoking cessation: a report of the surgeon general—2020, key findings [1]
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Cardiovascular Disease

For patients at risk for or with current cardiovascular disease (CVD), stopping smoking can be the single best intervention for improving cardiovascular health and has greater cost-effectiveness than treatment for hypertension and hyperlipidemia [49]. Benefits begin immediately, including decrease in sudden cardiac death, and within a few years the risk for acute myocardial infarction is decreased (Fig. 4.2) [50]. Cessation also decreases the risk of stroke [51]. All FDA-approved tobacco use treatment medications can be effectively used with patients who have CVD. While misconceptions about use of nicotine replacement therapy (NRT) persist, no clinical evidence links NRT and CVD, even if patients smoke while using NRT [52]. Intensive behavioral therapy can significantly increase quit rates in patients with CVD [53].

Diabetes

Long-term effects of stopping smoking for people with diabetes include improved blood lipid levels and rates of inhaled insulin absorption that approach those of people who do not smoke [54, 55]. Varenicline is well tolerated in people with diabetes and can help achieve continuous abstinence rates of 18%, which is double that of placebo, with an average weight gain in those who stopped smoking similar to study participants who did not have diabetes (around 2 kg) [56].

Chronic Obstructive Pulmonary Disease

In early chronic obstructive pulmonary disease (COPD), people who stop smoking can reduce disease progression [57]. Even in advanced COPD, decreasing lung function can be slowed, and risk of death decreases compared to continued smoking [58, 59]. Interventions that include pharmacotherapy, educational materials, and behavioral strategies demonstrate significant abstinence rates and effectiveness in patients, regardless of perceived readiness or motivation [60].

Asthma

Smoking cessation improves asthma control, with significant reductions in chest tightness and nighttime symptoms, improved lung function, decreased sputum neutrophil count, and reduced inhaled steroid use [61]. People with asthma can quit, but they may experience slower declines in nicotine withdrawal symptoms and cravings compared to people without asthma [62]. Promising treatment approaches include peer interventions with adolescents, mobile applications, and tailoring for specific needs of asthma patients [63].

Cancer

With increasing survival following cancer diagnosis, the need for addressing continued tobacco use in cancer care is critical. Surgery, radiation, and chemotherapy treatments are more effective when patients stop using tobacco, and patients who are tobacco free have lower rates of cancer recurrence and higher quality-of-life measures [6, 64]. Effective interventions include pharmacotherapy and intensive behavioral strategies [65,66,67,68].

HIV/AIDS

While effective treatments for people living with human immunodeficiency virus (HIV) have extended life expectancy, those who smoke have twice the decreased life expectancy as HIV itself [69]. People with HIV smoke at higher rates (42%) and are less likely to quit than the general population [70]. Those who stop smoking in the course of HIV treatment can gain up to 5.7 years of life by decreasing risks of pneumonia, thrush, and hairy leukoplakia, as well as cancer, cardiovascular disease, and respiratory disease [69]. Pilot studies on treatment that include adherence-focused interventions, such as peer counseling, prepaid cell phones, or texting, have demonstrated effectiveness [71,72,73].

Mental Health and Substance Use

Having a mental health or substance use problem is associated with significantly higher rates of tobacco use compared to the general population [74]. Such conditions often occur in environments that normalize smoking, with concomitant less access to tobacco use treatment [75]. People with mental health disorders who stop smoking experience decreased depression, anxiety, and stress, with improved mood and quality of life compared to those who continue to smoke [76]. Studies also show increased abstinence from illicit drug and alcohol use in those who stop smoking [75, 77]. Effective treatment includes intensive pharmacotherapy and behavioral interventions, often over a long period of time. Peer counseling and integrated treatment models are also effective.

Inpatients

The inpatient setting, which is invariably smoke-free, is an ideal environment for patients to receive tobacco cessation counseling [78]. The Joint Commission has implemented inpatient tobacco treatment measures (TTMs) which involve identifying patients who have used tobacco within 30 days, offering nicotine replacement therapy and counseling while inpatient, and providing nicotine replacement therapy and referral for outpatient tobacco cessation counseling at discharge. Standardized pathways in an electronic medical record can improve inpatient ordering of nicotine replacement therapy, tobacco cessation counseling, and care coordination of tobacco cessation treatments [79]. Evidence-based inpatient tobacco treatment programs are successful, easy to access, offer appropriate smoking cessation medications, and save the inpatient team time [80]. Patients who receive bedside cessation counseling as an inpatient followed by 6 months of outpatient counseling after hospital discharge have abstinence rates of 78% at 4 weeks and 59% at 6 months [81]. In contrast, patients who only receive counseling while in the hospital have low (less than 20%) success rates of smoking cessation at 3 or 6 months [82]. Patients on inpatient psychiatry services randomized to receive group counseling, free nicotine patches at time of hospital discharge, free post-discharge counseling (quitline, text- or web-based), and post-discharge automatic interactive calls and/or texts are more likely to use smoking cessation treatments than a control group (74.6 vs 40.5%) and to achieve abstinence from tobacco use (8.9 vs 3.5%) [83]. Patients with admission for cardiovascular diagnoses have higher smoking cessation rates than patients admitted with respiratory or neurologic diagnoses after enrollment in an inpatient smoking cessation program, suggesting that some diagnoses provide better teachable moments than others [84]. One pharmacist-led smoking cessation program during hospital stays did not improve smoking cessation rates, which may be due to the “Hawthorne effect,” in which participants in the control group of a study modify their behaviors due to an awareness of being observed [85]. Still, hospitalizations may serve as an entry point to tobacco cessation education and counseling, and further studies may determine what strategies have the most impact.

The Chronic Care Model and Tobacco Dependence

Effective chronic care management requires understanding of the chronic nature of tobacco dependence and utilization of effective evidence-based treatments. The Chronic Care Model (CCM) improves health outcomes through system changes that include patient-centered and evidence-based care, team care, planned interventions, self-management, community resources, decision support, patient registries, and information technology [86].

A Comprehensive Approach

Effective approaches such as the 5As model for tobacco use (described below) should be utilized at every health care visit [87]. Effective use of information technology to support this model includes integrating the 5As into electronic health records (EHRs). Most EHRs include Ask in vital signs. If Assess and Advise are also in the vital signs, counseling rates for smoking cessation increase [88]. The American Academy of Family Physicians recommends an abbreviated version known as Ask and Act [89].

Physicians and other health care providers must view tobacco use as a long-term condition and routinely assess motivation and interest in medications and referral to specialized or community resources, utilizing shared decision making. Clinicians should address patient concerns such as failure, boredom, addiction, weight gain, and loss of a social circle, and understand the barriers to the use of medications, such as cost, availability, or misinformation.

Team Approach

While providers are in the best position to relate tobacco use to health outcomes, the involvement of clinic staff and other health care professionals increases delivery and success rates of treatment [89,90,91]. Team-based care demonstrates the importance of addressing tobacco use and increases efficiency by introducing the topic before the physician sees the patient. Supportive, non-judgmental comments such as “We are happy that you are trying to quit, and our team looks forward to seeing you again soon.”

Family and Social Support

Social networks and families can support a person’s cessation efforts and increase the intention and success rate of smoking cessation [92,93,94]. Having family or friends who are quitting tobacco increases the probability that patients will also quit [95]. Interactions with former smokers or peer-support groups increase successful quit attempts in patients with less social support, such as those experiencing homelessness or historically marginalized populations [96, 97]. Since smoking behavior is often similar in family and friends, it is important to determine who in the patient’s social network is willing and able to support the patient [98, 99]. Partners often undertake behavior changes together, including smoking cessation [100]. Optimizing support for the patient’s quit attempt often means working with family members on cessation including discussing how a tobacco-free environment improves everyone’s health and saves money [101]. Children who live in tobacco-free homes are less likely to initiate use.

Social connections can also negatively influence a person’s attempt to quit. Family or friends may not believe that tobacco use is a chronic disease and may not be empathetic or supportive of patients who struggle with continued use despite health complications [102]. If others in the family smoke, the patient may change the status quo in the home which may result in conflict or family stress regarding continued smoking in a family member [103, 104]. Clinicians can try to motivate family members to consider cessation or supportive behaviors such as not smoking in the home [105].

Public Health Interventions

Tobacco’s massive cost to society for health care and lost productivity is a public health concern. Public health initiatives can counter efforts that promote smoking. The tobacco industry spends billions of dollars in advertising and promotion or nearly $22 million per day in the US [106]. In addition to direct advertising and coupons, marketing dollars are paid directly to retailers or wholesalers to reduce the price of cigarettes and fund promotions such as two for one pricing. Much of the advertising is historically targeted to younger populations, women, racial and ethnic communities. Community-based coalitions across the US can advocate for federal, state, and local policy initiatives, including youth empowerment efforts, taxes, or minimum prices to raise the cost of tobacco products, strong clean air regulations, preventing youth access to tobacco products, smoke-free homes and cars, banning flavored tobacco products, promoting strong warnings on tobacco products, and supporting comprehensive state funding for tobacco-free initiatives.

Emotional Support

When individuals understand that tobacco use is a chronic disease, they may feel less of a sense of failure if they struggle to quit. Understanding the relapsing nature of the addiction, while knowing that support and effective treatment exist, can increase self-efficacy. Misperceptions can be barriers to successful management of this chronic condition. One misperception is that the responsibility for change rests entirely on the individual who uses tobacco, viewing tobacco use as “just a bad habit” or “just a mind thing.” This view reinforces judgment and shame. In fact, the highly addictive nature of tobacco products, which deliver nicotine to the brain in less than 10 seconds, makes tobacco use an automatic, ingrained repetitive behavior. Effective abstinence requires continued practice to relearn new behaviors while dealing with the difficult symptoms of withdrawal. Willpower alone rarely succeeds, especially with patients who deal with multiple chronic diseases, financial insecurity, or other life stress.

Another misperception is the association of smoking with stress relief. Nicotine triggers the release of dopamine, leading to a temporary feeling of well-being and enhanced cognitive performance. However, this is a “cruel illusion.” [107] While the immediate hit of nicotine causes feelings of well-being, it also puts stress on the heart by increasing heart rate and blood pressure and, after a few hours, adds the stress of withdrawal that can only be relieved by smoking again. It is important that both patient and provider understand this phenomenon as they work to find effective strategies to improve health.

The 5As Model for Tobacco Cessation

Effective systems addressing tobacco dependence follow a strong theoretical intervention, such as the 5As model for tobacco use: Ask, Advise, Assess, Assist, and Arrange, which should be addressed at every health care visit (Fig. 4.3). [21, 87, 108, 109]

Fig. 4.3
A table titled clinical practice guideline recommendation 5 As. It lists the 5 As models for treating tobacco use, such as ASK, ADVISE, ASSESS, ASSIST, and ARRANGE.

The Five A’s for treating tobacco use (Reprinted from public domain)

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Ask

Team-based care starts with Ask, meaning a nurse or medical assistant inquiries about tobacco use while taking vital signs. Asking about smoking behaviors in a non-judgmental manner acknowledges the chronic nature of tobacco dependence and that tobacco cessation is not a linear accomplishment for most patients [110]. A straight forward “Have you ever used tobacco products?” with a positive response followed by “Do you currently smoke or use any other tobacco products, including e-cigarettes?” has a very different feel than the accusatory tone of “Are you (still) a smoker?” or “You don’t smoke, do you?” Asking the patient if they are exposed to secondhand smoke allows for conversations on ways to reduce that exposure. Patients may be embarrassed or reluctant to be truthful regarding tobacco use. The term “smoker” reinforces judgment and stigmatization, labeling a person by the disease or addiction. Alternative language such as “a person who smokes” labels the behavior instead of the person, allowing clinicians to see patients who use tobacco as people who are caught in a cycle of addiction that has both individual and societal determinants. This reframing can increase empathy toward the patient who is being asked to change daily routines that revolve around smoking, while fighting off cravings and irritability.

Advise

Many patients report that their doctor told them to quit smoking but did not offer any help or information about how to quit. Patients do not like being preached to or having fingers wagged or hearing about all the bad things that will happen if they continue to smoke. Instead, they benefit from specific information related to individual circumstances, for example, “Stopping all tobacco use is one of the best things you can do for your health. You will notice significant reductions in your asthma symptoms, without having to rely on higher doses of medications. I understand how difficult this change can be. We have effective medications and resources for supporting you in becoming tobacco-free.” In this brief message, the clinician voices belief in positive outcomes of stopping tobacco use, demonstrates empathy, and offers resources to the patient. Positive messaging or “gain-framed” statements, such as the benefits that will accrue after stopping tobacco use for 1 day, 1 month, or 1 year, may be positive moderators of treatment [111].

Assess

Assessment has typically been framed as a yes/no question such as “Are you ready to quit?” with an affirmative answer required for further assistance. This is insufficient. Seventy percent of people who smoke say they want to stop, but may not say they are ready to quit because of perceived stress, lack of success in previous efforts, or not knowing how. An open-ended prompt, such as “I’d like to hear your thoughts about cutting down or stopping smoking” or “Tell me about your smoking and your interest in making any changes,” is better and allows patients to state their concerns and give clinicians clues about how to best approach efforts to become tobacco free. The clinician can listen for patient fears and perceived difficulties, then address those with empathy, education, and resources.

If the patient is not interested in quitting, motivational interviewing using empathetic open-ended questions is an evidenced-based strategy to help patients consider treatment [112, 113]. Effective motivational interviewing creates teachable moments when a patient may be more receptive to considering a behavior change due to a health scare (e.g., chronic disease diagnosis, hospitalization, or cancer diagnosis related to complications from smoking) or due to renewed interest in health optimization (e.g., annual physical exam) [114,115,116,117,118]. Teachable moments occur in the inpatient, outpatient, and emergency department setting but are often lost opportunities to increase patient motivation and commitment to change [119, 120].

The OARS framework can guide motivational interviewing:

  • Open-ended questions to invite further dialogue with the patient, such as “What has worked when you have tried to stop smoking in the past?”

  • Affirming to identify positive attributes in the patient, such as “That is great that you were able to cut down by 5 cigarettes.”

  • Reflective or active listening to communicate back to patient that their message was heard and they have your attention, such as “I hear that it has been difficult for you to quit tobacco and that you have tried many different approaches to quitting.”

  • Summarizing the conversation to gather important points within the current session and/or link salient information from prior sessions, transition to a new topic, or signal the end of a session, such as “It sounds like you’re saying that despite many previous attempts to quit on your own that were not fully successful, you are ready to try medications and counseling.”

Asking the patient open-ended questions such as “Help me understand why you are not ready to quit given what you know about the health effects of tobacco use” or “What would it take to get you interested in quitting?” often elicits information that motivates change. Follow-up questions might help overcome resistance, such as “If we could relieve your cravings, would you consider quitting?” or “Knowing that it is not easy, how can I best help you do so?” Physician-delivered motivational interviewing is associated with a 3.5-fold increased rate of quitting tobacco compared to usual care or limited brief advice [121].

Motivational interviewing can elicit both strengths and challenges to quitting. Strengths can be found even in statements such as “I’ve tried a hundred times and failed,” which can be countered with the statement “You’ve had a lot of practice and it sounds like you can be quite persistent.” The patient may reference a past situation that prevented abstinence such as “I quit for a few months but then my husband lost his job” and the clinician can reply “You were able to quit, and a very stressful situation set you back.” Finding strengths can be useful in suggesting strategies to deal with the challenge of changing tobacco habits. Some patients end up stopping smoking even when they do not indicate a readiness to quit. When provided treatment, patients who said they were not ready to quit had higher rates of six-month abstinence than those stating they were planning to quit [122, 123].

Assist

Evidence-based treatment includes a combination of pharmacotherapy and behavioral counseling. The strength of the addiction to nicotine and other substances means that changing behavior immediately and without intervention (“cold turkey”) will be extremely difficult for most people [19].

Cutting-Down-to-Quit (Nicotine Fading)

The traditional advice is that a person using tobacco should set a quit date and abruptly quit on that date [124]. An alternative approach is to gradually reduce the amount of tobacco used (e.g., cutting down from 10 cigarettes per day to 1 cigarette per day over the course of a few weeks) as both abrupt and gradual cessation approaches are similarly effective [125]. Clinicians should support the approach that the patient believes will work best for them.

Behavioral Counseling

Even brief behavioral interventions for tobacco dependence treatment can promote abstinence [126]. Given the chronic nature of tobacco dependence, repeated, longitudinal interventions and multiple quit attempts may be necessary for long-term cessation. Comprehensive treatment strategies benefit most people who use tobacco, and intensive counseling increases patient satisfaction even in those patients who are not ready to quit smoking [127,128,129]. Individual, group, and telephone counseling can all be effective strategies. There is a dose-response between counseling and effectiveness suggesting that increasing the duration or frequency of counseling will improve outcomes. While even 3 minutes of counseling can have impact, 10 or more minutes is ideal, with increasing effectiveness with four or more sessions. Counseling via different strategies (i.e., problem-solving skills vs social support), by different personnel (both clinicians and non-clinicians) and inclusion of nicotine replacement therapies and/or non-nicotine pharmacologic management compliment tobacco cessation counseling and increase abstinence rates.

Pharmacotherapy

Physical and psychological tobacco use dependence is most effectively managed with medications that alleviate nicotine withdrawal symptoms and reduce the strength and frequency of urges to use tobacco. Medications can double initial quit rates but sustained abstinence requires behavioral interventions that address the routines, stressors, and psychological factors that reinforce tobacco use.

The Food and Drug Administration (FDA) has approved varenicline, bupropion, and various types of nicotine replacement therapy (NRT) for tobacco cessation treatment (Table 4.4). The two most effective pharmacotherapy approaches are single-use varenicline or combination NRT, such as a long-acting patch plus short-acting gum or lozenge. Varenicline is a nicotine agonist and is proven safe, even in people with mental health diagnoses [130]. Patients do not need to quit smoking before starting varenicline. Combination NRT allows for self-dosing of nicotine to reduce withdrawal symptoms, which is the most common cause for relapse or inability to stop use. Step-down dosing of the patch strength over weeks to months is a common approach, with use of NRT gum or lozenge dosing as needed for cravings. Informing patients of medication cost and potential side effects improves compliance with therapy.

Table 4.4 FDA-approved tobacco cessation medications; table adapted from Duke-UNC Tobacco Treatment Specialist Training Program Manual
Full size table

The amount of nicotine delivered per cigarette has increased in the past decades, which makes quitting more difficult and NRT less effective. E-cigarette use practices make this clear, as patients liberally self-dose. Nicotine withdrawal symptoms include agitation, anhedonia, anxiety, depression, foggy thoughts, irritability, cravings for tobacco, and restlessness. Over medicating with nicotine can also cause symptoms such as nausea, dizziness, light-headedness, and insomnia. Effective management of withdrawal symptoms allows the energy and focus necessary to develop the behavioral changes that will support long-term abstinence, such as strategies to manage triggers and cues, cognitive therapy to reframe feelings of weakness or lack of willpower, and nutritional and physical activity to reduce resultant weight gain.

Arrange

As with any chronic illness, long-term follow-up improves outcomes. Immediate follow-up to new quit attempts helps patients adhere to medications and manage side effects and improves cessation outcomes [131]. Patients may be referred to a quitline or a tobacco treatment specialist or other behavioral health provider. Quitlines are free, live, evidence-based, and are available in every US state by calling 1-800-QUIT NOW (1-800-784-8669). Automated text-messaging interventions are effective, but smartphone apps remain unproven.

Referrals to quitlines can be integrated into EHRs or faxed. Hospitals, clinics, and other organizations may employ certified tobacco treatment specialists who undergo evidence-based training, including didactic sessions on the biomedical and psychosocial aspects of tobacco dependence, counseling techniques, and 240 hours of documented tobacco cessation counseling with patients, prior to becoming certified [132]. They skillfully provide short- and long-term follow-up with patients including counseling, coaching, and medication management.

Long-term follow-up focuses on relapse prevention, reinforces the positives of a tobacco-free life, and anticipates challenges or cause for return to tobacco use. Inquiring as to progress in cessation takes only a few moments at follow-up visits. This individual care along with community resources increases the success rate of tobacco cessation.

Telehealth

The COVID-19 pandemic increased virtual care delivery including tobacco cessation treatment. Telehealth for smoking cessation is efficient and effective [133,134,135,136,137]. It has potential as an effective tool for tobacco cessation but disparities in access to telehealth tools (i.e., computers, cell phones, tablets, and/or broadband) exacerbate inequities in care delivery [138,139,140]. In the US, the Federal Communication Commission is investing billions of dollars to improve broadband connectivity to rural and lower-income regions [139, 141, 142]. Greater access will help overcome barriers to virtual tobacco treatment [143]. Ongoing research and implementation evaluations regarding best practices have the potential to improve effective access to tobacco use treatment, ensuring equitable access for all populations [143, 144].

Population Health and the Health Care System

Tobacco use is so detrimental to the health of individuals that efforts to promote cessation should be prominent in the health care system. Addressing tobacco use may be a consideration in recognition as a Patient-Centered Medical Home (PCMH). Tobacco use treatment should be streamlined into patient visits, including integration of protocols into EHRs which can assist with patient and cohort identification, care documentation, patient follow-up, guideline adherence, and benchmarking. EHR registries can identify patients with a disease of interest and facilitate population health tracking and interventions for these patients [145]. Dashboards use demographic data from registries and associated interventions to track process, financial, quality, and clinical outcome measures. Dashboards that present data in an accessible and comprehensible way to clinicians improve care processes and outcomes [146]. Visualization dashboards present data to clinicians in graphic formats that are easy to read and time efficient, thereby reducing clinician errors and cognitive load and improving evidence-based guideline adherence [147].

The Centers for Disease Control and Prevention (CDC) recommends use of tobacco registries and treatment tracking in all patients who smoke though it is not yet clear which types of digital support are used and which are most effective [148]. Tobacco registries standardize tobacco use treatment leading to increased referrals to quitlines, tobacco use counseling, and medication prescriptions [149]. EHRs can send Best Practice Advisories to clinicians during an encounter, reminding them to Ask, Advise, Assess, Assist, and Arrange, while providing decision support, pharmacotherapy guidance, and behavioral treatment referrals which can include access to community resources [145]. These digital supports provide population-level interventions to standardize outreach and tracking of patients who use tobacco, send targeted messages to patients (via patient portals or mailings), and provide billing prompts for rendered services [149].

Federal population-based tobacco use treatment efforts include the National Cancer Institute’s smokefree.gov initiative, which offers free evidence-based support to the public [150]. These digital supports augment traditional quitlines and individual counseling sessions with websites, text-messaging programs, and mobile applications that can target the general population or specific populations such as military veterans, women, adolescents, Spanish-speakers, and older adults. With over 7 million users a year, the benefits of multiple intervention modalities are apparent [150].

Quality Improvement

Quality improvement (QI) efforts can dramatically increase tobacco use treatment [101, 151]. QI processes such as Lean continuous improvement to systematically evaluate workflows and processes can improve care delivery [152, 153]. QI studies may use Plan-Do-Study-Act (PDSA) cycles to iteratively evaluate, implement, and test patient care improvement efforts. Systematic methods to improve workflows and patient care processes in tobacco use can improve site-specific tobacco treatment and inform similar work at other institutions resulting in shared knowledge and continuous process improvements across institutions [154,155,156].

Insurance Changes

The 2010 Affordable Care Act requires insurance companies to cover evidence-based services that have a rating of “A” or “B” from the US Preventive Services Task Force (USPSTF), an independent panel of clinicians and scientists commissioned by the Agency for Healthcare Research and Quality, including tobacco use counseling and medication. Treatment is covered up to four sessions twice a year with 12 weeks of pharmacotherapy coverage. While these provisions are a start, they do not acknowledge the long-term nature of behavioral change, especially in people who are trying to address mental health or other substance use at same time, or for whom smoking is a coping strategy for grief, stress, discomfort, and loneliness.

Future Directions

Social Media, mHealth, and eHealth

Mobile health interventions, such texting, may increase quitting success. There are numerous smartphone cessation apps but their quality varies and evidence is still lacking on their efficacy or effectiveness [157]. Online and text-based interventions are common with peer recruiting through social media showing some promise with one online social network (Share2Quit) quadrupling peer recruitment [158]. Given the ubiquity of social media and digital devices, more options for tobacco cessation support are likely to develop.

New Pharmacotherapies

There are several novel pharmacotherapies in clinical trials [159]. Nicotine vaccines and galenic formulations of varenicline may be effective in producing antibody levels that reduce side effects. Efforts should also continue to address misperceptions about the currently available medications, including the low risk of these agents compared to the enormous health risks of continued smoking.

E-Cigarettes for Quitting Cigarettes

Electronic cigarettes have grown in popularity, and some people who smoke use them to try to quit cigarette smoking even those that are not an approved cessation product. While likely less harmful than cigarettes, e-cigarettes are not harmless and the long-term health effects remain unknown [160]. E-cigarettes may be more effective than nicotine replacement therapy in randomized clinical trials, but evidence is conflicting, especially in the long term (more than 1 year) [161, 162]. Observational studies of consumer e-cigarette use have not found them to be associated with smoking cessation [163]. Rather than using e-cigarettes to completely quit smoking, many smokers use e-cigarettes as a supplement, for example, vaping in places where they can’t smoke [164]. About half of e-cigarette users still smoke cigarettes with the associated ongoing health risks [165]. E-cigarette users should be encouraged to fully quit cigarettes and only use e-cigarettes or, better yet, use an approved cessation product.

Behavioral Therapies

Mindfulness, as both primary and adjunct therapy for becoming tobacco free, can reduce craving and manage stress, which may improve smoking abstinence and relapse prevention [166,167,168]. This approach may be especially helpful when combined with other established treatments.

Genetics

Research on the human genome has opened a new dimension for understanding tobacco use and dependence. An association between the nicotinic receptor alpha 5 (CHRNA5) and increased risk of addiction-associated phenotypes may explain why some people smoke more heavily than others. The potential for using genetic data includes individualized treatment as well as the ability to target prevention efforts [169,170,171].

Adolescents and Young Adults

Tobacco use and habituation usually start in adolescence or young adulthood [172, 173]. In 2020, 24% of high-school students and 7% of middle-school students reported use of a tobacco product in the previous 30 days. Primary treatment for tobacco use in adolescents focuses on behavioral interventions with little research showing efficacy of pharmacotherapy in youth [174]. Characteristics of effective behavioral cessation programs include voluntary and fun sessions, motivational interviewing focused on intrinsic and extrinsic motivations to quit, frequent counseling sessions (10 sessions have been efficacious), using social and community support for cessation, extrinsic rewards for quitting, and education on handling stress, social situations, and peer pressure [175]. The National Cancer Institute’s Smokefree Teen website provides online resources for teens including text messaging, apps, and access to counselors with age-appropriate cessation support [176]. Several resources are also available for parents and caregivers to support adolescents in cessation efforts [177, 178]. The Truth Initiative has a texting program for youth and young adult vaping called “This is Quitting” that has been shown effective. [179]

Prenatal Treatment

Behavioral treatment is also emphasized during pregnancy, given the concerns of medication use. A 2021 USPSTF guideline recommends (grade A recommendation) that clinicians ask and advise cessation for pregnant people who smoke and provide behavioral counseling to assist in cessation [131]. This guideline also states there is insufficient evidence (grade I recommendation) to adequately determine the risks and benefits of cessation medication use in pregnancy.

Education to Health Care Team Members

Team-based care is a growing concept in our health care system. All health care providers in practice or training, including physicians, nurses, dentists, physical and occupational therapists, and advanced practice practitioners, should be well-versed in the harms of tobacco use and taught the skills to address this leading cause of preventable disease and death.