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Cigarettes became popular after 1915. Today, approximately 1.1 billion people aged 15 years and over smoke: about one-third of the global population. This research paper provides an overview of health eﬀects, and methods for smoking prevention and cessation.
1. Health Eﬀects
In the late 1940s, epidemiologists noticed that annual death rates due to lung cancer had increased ﬁfteenfold between 1922 and 1947 in several countries. Since the middle of the twentieth century, tobacco products contributed to more than 60 million deaths in developed countries. The estimated annual mortality is 540,000 in the European Union, 461,000 in the USA, and 457,000 in the former USSR (Peto et al. 1994). Tobacco is held responsible for three and a half million deaths worldwide yearly: about seven percent of all deaths per year. This ﬁgure will grow to ten million deaths per year by the 2020s; about 18 percent of all deaths in developed countries and 11 percent of all deaths in developing countries. Half a billion people now alive will then be killed by tobacco products; these products will have killed more people than any other single disease (WHO 1998).
More than 40 chemicals in tobacco smoke cause cancer. Tobacco is a known or probable cause of about 25 diseases. Tobacco is recognized as the most important cause of lung cancer, but it kills even more people through many other diseases, including cancers at other sites, heart disease, stroke, emphysema, and other chronic lung diseases. Smokeless tobacco and cigars also have deadly consequences, including lung, larynx, esophageal, and oral cancer (USDHHS 1994). Lifetime smokers have a 50 percent chance of dying from tobacco. Half of these will die in middle age, before age 70, losing 22 years of normal life expectancy.
Exposure to environmental tobacco smoke (ETS) has been found to be an established cause of lung cancer, ischemic heart disease, and chronic respiratory disease in adults. Reported eﬀects for children are sudden infant death syndrome, bronchial hyper-responsiveness, atopy, asthma, respiratory diseases, reduced lung function, and middle ear disease. Barnes and Bero (1998) demonstrated from 106 reviews that conclusions on ETS were associated with the aﬃliations of the researchers. Overall, 37 percent concluded that passive smoking was not harmful to health. However, 74 percent of these were written by researchers with tobacco industry aﬃliations. The only factor associated with concluding that passive smoking is not harmful was whether the author was aﬃliated with the tobacco industry.
Declining consumption in developed countries has been counterbalanced by increasing consumption in developing countries. Globally, 47 percent of men and 12 percent of women smoke. In developing countries 48 percent of men and 7 percent of women smoke, while in developed countries 42 percent of men smoke as do 24 percent of women. Tobacco use is regarded as the single most important public health issue in industrialized countries.
2. Smoking Prevention
The process of becoming a smoker can be divided into several stages: preparation (never smoking), initial smoking, experimental or occasional (monthly) smoking, and regular (weekly and daily) smoking. In the preparatory stage attitudes towards smoking are formed. While at least 90 percent of the population has ever smoked a cigarette, the likelihood of becoming a regular smoker increases if initial smoking is repeated several times. In the third stage, a child learns how to smoke and the perceived advantages of smoking start to outweigh the disadvantages. In the fourth stage smoking becomes a routine. Most onset of smoking takes place during adolescence between age 10 and 20. Smoking onset as well as cessation are inﬂuenced by a variety of cultural (e.g., availability, litigation, smoke free places), biological (addiction), demographic (e.g., socioeconomic status, parent education), social factors (e.g., parental and peer smoking, parental and peer pressure, social bonding), and psychological factors (e.g., self-esteem, attitudes, self-eﬃcacy expectations).
Various eﬀorts have been undertaken to prevent youngsters to start to smoke (see e.g., Hansen 1992, Reid et al. 1995, USDHHS 1994).
2.1 School-Based Prevention Programs
Three types of school programs can be distinguished. Knowledge programs were not eﬀective. The social inﬂuence approaches result in reduced onset ranging from 25 to 60 percent; eﬀects may persist up to four years. Long term eﬀects are found with programs embedded in more comprehensive community approaches. The method includes ﬁve to ten lessons, emphasizes short-term consequences of smoking, discusses social (mostly peer) pressures, and includes refusal skills training. Life skills approaches focus on the training of generic life skills. Their eﬀects are less strong than those of the social inﬂuence approaches.
2.2 Out-Of-School Approaches
Youngsters can also be reached out of school. Mass media approaches and nonsmoking clubs are popular methods. They attract attention to the subject and may inﬂuence attitudes. A review of 63 studies about the eﬀectiveness of mass media found small eﬀects on behavior (Sowden and Arblaster 1999). Targeting smoking parents is important as well; children are almost three times as likely to smoke if their parents do. Helping parents to quit smoking may prevent their children from starting to smoke and may encourage adolescent cessation.
A range of policy interventions can be used to stimulate the prevention of smoking.
(a) Price policies can have preventive eﬀects. Higher prices encourage cessation among current smokers and discourage initiation among young smokers. A price elasticity of -0.05 implies that a ten percent increase in price reduces consumption or prevalence by ﬁve percent. Price elasticity ranges between -0.20 to -0.50.
(b) School policies can stimulate smoking prevention. When examining the impact of school smoking policies over 4,000 adolescents in 23 Californian schools, it was found that schools with many smoking prevention policies had signiﬁcantly lower smoking rates than schools with fewer policies and less emphasis on smoking prevention.
(c) Public smoking restrictions can contribute to adolescents’ beliefs that nonsmoking is normative and that smoking creates health problems. Smoking regulations are more eﬀective in preventing teenagers from starting to smoke than in reducing their consumption. Restriction of sales to minors often results in noncompliance: between 60 to 90 percent of the adolescents succeeded to buy tobacco products in situations where this was not allowed.
3. Smoking Cessation
Physical addiction is caused by the pharmacological eﬀects of nicotine. Psychological addiction occurs because smoking becomes linked with numerous daily circumstances and activities (e.g., eating, drinking) and emotional and stressful events. A person becomes motivated to quit if he has a positive attitude, encounters social support, and has high self-eﬃcacy expectations towards quitting (De Vries and Mudde 1998).
Cessation is a process: a smoker in precontemplation is not considering to quit within six months; a smoker in contemplation is, but not within a month; a smoker in preparation is considering to quit within a month; a person in action has quit recently; a person in maintenance has quit for more than six months (Velicer and Prochaska 1999).
Three outcome measures can be used to assess smoking cessation: point prevalence (having smoked during the preceding seven days), prolonged abstinence (not smoked during six or twelve months), and continuous abstinence (not smoked at all since the time of intervention). In longitudinal experimental designs more smokers than quitters may drop out, thus resulting in too optimistic estimates of successes of treatments. To correct for this bias, dropouts are coded as smokers; this is referred to as the ‘intention to treat procedure.’ This procedure may, however, result in conservative eﬀect estimates. The desirability of biochemical validation is still controversial. Misreporting seldom exceeds ﬁve percent. Detection of occasional smoking in youngsters is diﬃcult and expensive. Biochemical validation of self-reports should be considered when high demand situations are involved. A random subsample can be used to estimate bias and correct reported cessation rates. Cotinine has emerged as the measure of choice, with carbon monoxide as a cheaper but less sensitive alternative (Velicer et al. 1992).
Comparing the results of cessation studies is hindered by diﬀerences in outcome measures, populations (e.g., the percentage of precontemplators), and follow-up periods. This overview includes methods that have evidence for success. The numerous studies assessing and reviewing the eﬃcacy of smoking cessation interventions provide diﬀerent success rates. Hence, the ﬁgures reported below are estimates derived from various studies that are reported below, as well as from inspection of other publications.
Pharmacotherapeutic interventions increase quit rates approximately 1.5 to 2-fold. The absolute probability of not smoking at 6–12 months is greater when additional high intensity support is provided (Hughes et al. 1999, Silagy et al. 1999).
Nicotine Replacement Therapy (NRT) products are available in a number of forms, including gum, transdermal patch, nasal spray, lozenge, and inhaler. NRT is recommended to be part of the core treatment package oﬀered to all smokers. There are few instances in which the use of NRT is contraindicated. A meta analysis including 49 trials found signiﬁcant eﬀects when applying gum, patches, nasal spray, inhaled nicotine, and sublingual tablet. These eﬀects were largely independent of the intensity of additional support provided or the setting in which the NRT was oﬀered. The eﬃcacy of NRT appears also to be largely independent of other elements of treatment although absolute success rates are higher with more intensive behavioral support. The NRT cessation eﬀects range from 6 to 35 percent, mostly ranging between 15 and 25 percent.
Bupropion is an atypical antidepressant that has both dopaminergic and adrenergic actions. Unlike NRT, smokers begin bupropion treatment one week prior to cessation. The recent evidence shows that cessation rates are comparable to those by NRT, between 15 and 25 percent (Hurt et al. 1997, Jorenby et al. 1999). One study found that the nicotine patch was less eﬀective than bupropion (Jorenby et al. 1999). The drug appears to work equally well in smokers with and without a past history of depression.
3.2 Motivational Strategies
Various studies report on the eﬀectiveness of group courses, self-help materials, computer tailoring, and competitions (e.g., Eriksen and Gottlieb 1998, Fisher et al. 1993, Matson et al. 1993, Skaar et al. 1997, Strecher 1999, Velicer and Prochaska 1999).
Group courses can be eﬀective. Studies suggest 10 to 30 percent abstinence rates. The disadvantage is that they attract mostly smokers who are highly motivated to quit, and that many smokers want to quit on their own.
Self-help cessation interventions use diﬀerent for-mats such as brochures, cassettes, and self-help guides. Point prevalence quit rates at one-year follow-up range between 9 and 15 percent.
Competitions were eﬀective in three out of ﬁve workplace studies. No study showed enhanced smoking cessation past six months. Net eﬀects for cessation rate of competition plus group cessation program over group program alone in three studies varied between 1 to 25 percent.
Computer tailoring results in personalized materials for smokers which are based on the (cognitive) characteristics of a person that were measured by a questionnaire. Large segments of smokers can be reached (De Vries and Brug 1999). A review of ten randomized trials found signiﬁcant eﬀects up to 25–30 percent.
3.3 Policy Interventions
Policy interventions can eﬀect cessation (Cummings et al. 1997, Eriksen and Gottlieb 1998, Glantz et al. 1997, Meier and Licari 1997, Zimring and Nelson 1995).
Price policies, as with adolescents, inﬂuence cessation rates. Price elasticity rates for adults range between -0.3 and – 0.55. Increases in cigarette prices may place a greater burden on those with lower incomes who tend to have greater diﬃculty in stopping smoking.
Smoke-free areas can be eﬀective as well, although evidence is not unequivocal. Smoking bans in workplaces resulted in reduced tobacco consumption or cessation at work, results ranging from 12 percent to 39 percent. The ﬁndings on reductions on prevalence were not consistent.
Advertising, including tobacco sponsorship of events, is believed to stimulate the uptake of smoking and to reinforce the habit. This ﬁnding was supported by results from the COMMIT trial. The use of health warnings, however, has been found to be able to reduce tobacco consumption. Litigation by states and other groups may change the way tobacco is advertised and sold.
3.4 Special Settings For Cessation
Multiple smoking cessation interventions can be applied in speciﬁc settings. The goal is to attract large segments of smokers, or particular segments of smokers.
Advice by health intermediaries (physicians, nurses, midwives) is eﬀective. A review describing the eﬃcacy of 188 randomized controlled trials reported a two percent cessation rate resulting from a single routine consultation by physicians. While modest, the results were cost-eﬀective. The eﬀects are most salient among special risk groups, such as pregnant women and patients with cardiac diseases, although the additional cessation rates range from approximately 5 to 30 percent (Law and Tang 1995). In workplace settings cessation rates were four percent for a simple warning, eight percent for short counseling. They were highest among high-risk groups: 24 percent among workers at high risk for cardiovascular problems and 29 percent among asbestos exposed workers (Eriksen and Gottlieb 1998).
Community interventions have the potential to reach all segments of a community. They combine diﬀerent methods, such as mass media approaches, counseling, and self-help materials. Both the broader cardiovascular risk reduction interventions and those focusing solely on smoking had very small eﬀects (1–3 percent cessation rates), although somewhat larger eﬀects may be reached when combining them with mass media approaches (Fisher et al. 1993, Velicer and Prochaska 1999).
Workplace programs also often combine methods. They can reach large and diverse groups of smokers and may produce an average long-term quit rate of 13 percent (ranging from 1.5 percent to 37 percent) at an average of 12 month’s follow-up regardless of the intervention methods (Eriksen and Gottlieb 1998). Group programs were more eﬀective than minimal programs, although less intensive treatments when combined with high participation rates can inﬂuence the total population as well.
School-based smoking prevention can prevent or delay smoking onset. It is unrealistic to expect long-term eﬀects with short programs when prosmoking norms are communicated through multiple channels. Consequently, at least ten lessons are needed during adolescence in several grades. Outside of school, programs are needed, since adolescents with the highest rates of tobacco use are least likely to be reached through school based programs (Stanton et al. 1995). Innovative cessation interventions are needed as well, because youth cessation programs show no long-term success. Since multiple interventions are found to be most eﬀective, priority should be given to broad-based interventions aimed at both the youngsters, the schools, the parents, and the community as a whole, including mass campaigns for all age groups, ﬁscal policies, restrictions on smoking, and bans on advertising.
Pharmacotherapy, motivational strategies, and policies are eﬀective tools to promote cessation. The potential of other antidepressants (e.g., nortriptyline) on smoking cessation need attention as well. Innovative media strategies, such as computer tailoring, may reach less motivated smokers. Speciﬁc attention for underprivileged populations (e.g., ethnic populations, low socioeconomic groups) is needed as well. The combination of multiple methods given by multiple health care providers on multiple occasions will result in the greatest impact. Future research should assess the eﬀectiveness of programs in smokers diﬀering in motivational stages, since the most eﬀective methods mostly attract smokers who are motivated to quit.
Eﬀective methods that only reach a small segment of motivated smokers have a low impact. Less eﬀective methods that reach large segments of the population have a higher impact. Velicer and Prochaska (1999) suggest the greatest impact for computer-tailored programs. Finally, cost-eﬀectiveness studies reveal that cessation methods are most cost-eﬀective when aimed at a particular subgroup, multiple interventions, and at maintaining abstinence.
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