Smoking rates continue to decrease with only 15.5% to 37% identifying as smokers in 2016; however, significant disparities exist among the smoking population. Those below the poverty line are more likely to be smokers (25.3%), as well as those on Medicaid (25.3%), and those who are uninsured (28.4%). Individuals with serious psychological distress are even more likely (35.8%) to be identified as smokers. Programs have been implemented within populations with higher smoking prevalence by public health services, and the National Commission on Prevention Priorities continues to rank smoking cessation as a top three priority (Bailey, Heintzman, Jacob, Puro, & Marino, 2018; Bailey et al, 2018 & Sharma et al., 2018).
Smoking cessation programs within primary care is a standard of care, yet these programs are highly variable from clinic to clinic. The Affordable Care Act’s mandate for smoking cessation assistance for patient’s with certain insurance coverage may help implement smoking cessation programs more readily, as might implementation of the Meaningful Use of Electronic Health Records initiative, as the latter implements smoking cessation measures (Bailey, Heintzman, Jacob, Puro, & Marino, 2018, p 1082).
Those not assessed for readiness to quit have demonstrated the lowest odds of success. Desire to quit is vital. When evaluating those provided smoking cessation aides, studies have found that older age and co-morbidities increases the number of prescriptions written for pharmaceutical aides. Those with Medicaid have 17% higher odds of being referred to a comprehensive smoking assistance program, with the uninsured having the lowest odds. Household income has not been associated with smoking cessation assistance and evidence seems clear that safety-net clinics are providing smoking cessation assistance equally to patients with varying levels of socioeconomic status (Bailey, Heintzman, Jacob, Puro, & Marino, 2018).
People with a mental illness and substance dependence die 25 years earlier than those without those disorders (Guillaumier et al., 2018). The main causes of tobacco-related deaths are cancer, cerebrovascular diseases, and chronic respiratory diseases. Interestingly, smokers who have other substance abuse dependence are more likely to die from tobacco-related causes than from the effects of any of their other vices. When smokers cease smoking, it helps them recover from their other addictions for longer periods (Guillaumier et al., 2018).
The large majority (85%) of those who make the decision to quit smoking and use standard medication and behavioral support, do not succeed for twelve months or more. Those with alcohol addiction have even less success which is believed to be due to not having effective coping skills to replace the cigarette smoking habit when triggers present and their social network which supported their drinking and smoking remains (Guillaumier et al., 2018).
Those who quit, tend to do so on their own efforts, and due to the growing market of alternative options, consumers are seeking deliverance in nicotine in ways that avoids the damaging effects of nicotine. Consumers generally perceive little cigars or cigarillos, e-cigarettes, and hookah as less harmful than cigarettes; however, studies are conflicting with some evidence putting into question if they are equally harmful as cigarettes. There is also the perception that e-cigarettes and hookah are less addictive. Interestingly, study participants are able to name specific diseases related to the use of cigarettes, but are unable to do the same with e-cigarettes and hookah (Getachew et al., 2018).
The e-cigarette contains a liquid, that may or may not contain nicotine, for either vaporizing or inhalation. There are several varieties, including: aerosol generator, flow sensors, battery, and a cartridge containing e-liquid. These liquids may be a solution with propylene glycol or vegetable glycerine, or flavorings and nicotine. This market has exploded and is predicted to achieve a market value of more than $50 billion by 2025. Most users don’t use daily, as most are infrequent users, but more than 20% are using daily and these users represent those who have recently quit smoking cigarettes (Goldberg & Cataldo, 2018).
Safety and effectiveness are still up for debate regarding the e-cigarette. Proponents argue they are substantially less harmful than cigarettes and are an effective way to quit smoking. There is significant data that supports this claim based on a large systematic review of 57 studies and 5 previous systematic studies (Malas, van Der Tempel, & Schwartz, 2016; & Guillaumier et al., 2018). However, there is also a substantial amount of conflicting information. One meta-analysis found e-cigarette users to be less likely to be able to quit smoking than those not using e-cigarettes (Kalkhoran & Glantz, 2016; & Glantz & Bareham, 2018). Frequency of use and e-cigarette type seem to be the variable impacting cessation outcomes (Glantz & Bareham, 2018).
Opponents of the e-cigarette do agree that they deliver fewer carcinogens than conventional cigarettes. However, there is strong evidence that they contribute ultra fine particles and toxins that can significantly raise the risk of cardiovascular and lung disease, although non-cancerous (Glantz & Bareham, 2018). A 2018 systematic review on the safety of e-cigarettes demonstrated that levels of heavy metals, volatile organic compounds, and tobacco-specific nitrosamines were higher in e-cigarettes than in conventional cigarettes (Malas, van Der Tempel, & Schwartz, 2016).
Those who vape have stated the ability to control the amount of nicotine they are smoking is a huge advantage, allowing them to initiate weaning. They also prefer the smell, and even the aesthetic. Vaping allows smokers the advantage in smoke-free areas where cigarette smokers would be prohibited. “Vaping is almost more politically correct if you will - cooler… It just seems to be more socially accepted,” (Goldberg & Cataldo, 2018, p 58). The flavors have allowed some to curve their cravings and lose weight. They chose to vape rather than eat a snack. However, others recognize the flavors as a risk, containing chemicals that should not be inhaled (Goldberg & Cataldo, 2018).
Lack of satisfaction however, often leads to dual use of e-cigarettes and continued smoking of conventional cigarettes. Users have reported using the e-cigarette after smoking a cigarette to cover the odor, while others share that because they can use it anywhere without restriction, they end up vaping all the time. This convenience seems to many to create an even greater addiction than cigarettes did in the first place. Others state they just want a cigarette when they are stressed. One user states in the Goldberg & Cataldo (2018) study, “An e-cigarette is like eating tofu [when] alls [sic] you [want to] do is eat meat,” (p 59). Users have also reported the e-cigarette device can be too complex and ultimately unreliable, which causes them to return to cigarettes (Goldberg & Cataldo, 2018).
Smoking cessation quit lines connect callers with important cessation resources such as coaching, counseling, information on best practices for quitting, written literature, and free nicotine replacement therapy. These lines can be offered for low cost, are convenient, tailored to the individual, and accessible to most everyone. They help address barriers associated with seeking cessation treatment such as lack of transportation, having to arrange for childcare, and not having financial means to see a clinician which is critical as smokers tend to be within the lower socioeconomic group. Quit lines are also one of the few ways smokers can learn about lung cancer screening (Sharma et al., 2018).
A Cochrane review found that quit lines are effective for the general population and when proactive, these counselors can be even more successful (Guillaumier et al, 2018; Sharma et al., 2018). However, their implementation is poorly utilized with as few as 3% taking advantage (Guillaumier et al., 2018). Other studies find them utilized as much as 14.2%, but continue to support their implementation as cost-effective, easily accessible, and effective in creating smoking cessation (Weng et al., 2018).
Clinician Effort towards Smoking Cessation
Despite decades of public health education and interventions for smoking cessation, tobacco use remains the number one cause of preventable deaths worldwide (Weng et al., 2018). More than half who smoke confess they would like to quit but have been unsuccessful, and more than half have tried in the past year (York, Kane, Beaton, Keown, & McMahan, 2018; & Bailey et al., 2018). Fear of anxiety, mood swings, fear of failure, and weight gain are among the more common barriers. However, the most significant barrier to smoking cessation identified in the literature is lack of awareness of treatment available and lack of knowledge about drug therapy. Challenges to program success include lack of transportation and lack of time (Stead, Buitrago, Preciado, Sanchez, Hartmann-Boyce, & Lancaster, 2013).
One study found that physicians who offer simple advice on smoking cessation to their patients do have an impact, although small. Brief advice increases quitting by 1% to 3% only, while more intensive interventions were somewhat more helpful. Providing follow-up support increases success even further (Pereira, Gritsch, Passos, & Furtado, 2018; & Stead, Buitrago, Preciado, Sanchez, Hartmann-Boyce, & Lancaster, 2013).
Most smokers quit on their own without smoking cessation services, but research demonstrates that active referral to such programs does increase the rate of abstinence at six months compared with brief general advice (17.2% compared to 11.5%). Even text messaging has demonstrated cessation of smoking was 1.37 times higher (Weng et al., 2018). When in an environment where smoking is prohibited, such as during hospitalization, rates of cessation are at their highest. Smokers need support and encouragement as well. Fearing failure and then being judged by their family and peers has been identified as a significant barrier as well (Karas, Troxell & Snyder, 2018).
Primary care providers have a unique opportunity to impact smoking cessation rates. Clinical practice guidelines for treating tobacco use and dependence in primary care settings include a brief intervention: the “5 As” including: ask, advise, assess, assist, and arrange. Adhering to the first two is fairly well achieved, but clinicians aren’t fabulous at offering resources, assisting in quitting and following up. Sadly, more than half of all smokers report their healthcare provider even talking to them about quitting (Bailey et al., 2018).
Offering the option of smoking cessation assistance at most or all outpatient visits substantially improves the odds of reaching at patient at the point of readiness to change. Long-term quit rates are also improved over four years when cessation services can be provided and consistent discussion occurs in follow-up visits, even as infrequent as the annual wellness visit (Bailey et al., 2018).
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