Counseling to Prevent Tobacco Use

Recommendation

Tobacco cessation counseling on a regular basis is recommended for all persons who use tobacco products. Pregnant women and parents with children living at home also should be counseled on the potentially harmful effects of smoking on fetal and child health. The prescription of nicotine patches or gum is recommended as an adjunct for selected patients. Anti-tobacco messages are recommended for inclusion in health promotion counseling of children, adolescents, and young adults (see Clinical Intervention).

Burden of Suffering

Smoking accounts for one out of every five deaths in the U.S.1 It is the most important modifiable cause of premature death, responsible annually for an estimated 5 million years of potential life lost.1,2 About 420,000 Americans die each year as a result of smoking.1 Since early studies in the 1950s and 1960s, a large body of epidemiologic evidence has accumulated regarding the health effects of smoking. Major cohort studies, many case-control studies, and other data sources provide consistent, convincing evidence linking the use of tobacco with a variety of serious pulmonary, cardiovascular, and neoplastic diseases. The scope of this report does not permit an examination of each study of the health effects of smoking or the nature of the risk relationship (e.g., relative risk, dose-response relationship) between smoking and each disease. Detailed reviews of this extensive literature have been published elsewhere.1-6 A number of consistent findings from this body of evidence are well established. First, tobacco is one of the most potent of human carcinogens, causing an estimated 148,000 deaths among smokers annually due to smoking-related cancers.1 The majority of all cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, and esophagus are attributable to the use of smoked or smokeless tobacco.2,6 Smoking also accounts for a significant but smaller proportion of cancers of the pancreas,3,7-9 kidney,2 bladder,3,10 and cervix.3,11-13 Second, smoking promotes atherosclerosis and is a leading risk factor for myocardial infarction and coronary artery, cerebrovascular, and peripheral vascular disease.2,3 It is responsible for about 100,000 deaths from coronary heart disease and 23,000 deaths due to cerebrovascular disease each year.1 Third, smoking is an important risk factor for respiratory illnesses, causing 85,000 deaths per year from pulmonary diseases such as chronic obstructive pulmonary disease (COPD) and pneumonia.1,3 Children and adolescents who are active smokers have an increased prevalence ad severity of respiratory symptoms and illnesses, decreased physical fitness, and potential retardation of lung growth.14 Fourth, the nicotine in tobacco is an addictive drug, and the pharmacologic and behavioral processes that determine nicotine addiction are similar to those that determine addiction to drugs such as heroin and cocaine.15,16 The initiation of tobacco use at an early age is associated with more severe addiction as an adult. Fifth, tobacco use may be associated with an increased risk of osteoporosis.17,18 Sixth, smoking affects the health of nonsmokers. Smoking during pregnancy causes about 5-6% of perinatal deaths, 17-26% of low-birth-weight births, and 7-10% of preterm deliveries,2,3 and it increases the risk of miscarriage and fetal growth retardation.3 It may also increase the risk for sudden infant death syndrome (SIDS).19,20 Passive smoking (or environmental tobacco smoke) increases the risk of lung cancer in nonsmokers,4,21 causing approximately 3,000 lung cancer deaths each year.4 It may also increase the risk of coronary heart disease in otherwise healthy nonsmokers.22-25 Environmental tobacco smoke exposure increases the frequency of middle ear effusions and lower respiratory infections in children, causing an estimated 150,000-300,000 cases of lower respiratory tract infections leading to 7,500-15,000 hospitalizations.4 In children, passive smoking is also associated with a small but measurable reduction in lung function4 and exacerbates asthma,4,26,27 causing symptoms in 200,000 to 1,000,000 asthmatics in addition to as many as 8,000-26,000 new cases of asthma a year.4 Passive smoking has also been associated with an increased risk of SIDS.19,20,27a Finally, cigarettes are responsible for about 25% of deaths from residential fires, causing some 1,000 fire-related deaths and 3,300 injuries each year.28 Estimated smoking-attributable costs for medical care in 1993 were $50 billion,29 and excess lifetime medical expenditures for the current cohort of smokers may be as high as $500 billion.30

Although smoking has declined in the past three decades, 25% of adults in the U.S. continue to smoke.31 Among adults, cigarette smoking is more common among men, Native Americans and Alaska Natives, and persons of low socioeconomic status or with 9-11 years of education.31 Due to an increase in smoking by women during the period between 1940 and the early 1960s, lung cancer mortality in females has risen steadily since the mid-1960s; lung cancer is now the leading cause of cancer death in women.32 Two thirds of female smokers continue to smoke during pregnancy.33 Most smokers begin tobacco use as teenagers.14 Currently, 19% of all high school seniors smoke on a regular basis; among black high school seniors, however, only 4% smoke regularly.33a Of persons aged 18-24, 26% are current smokers.31 Smokeless tobacco is regularly used by 3% of adults (5.3 million persons)34 and by about 20% of male high school seniors.14