Since the first Surgeon General’s report in 1964 more than 20 million premature deaths can be attributed to cigarette smoking. Due to sustained efforts in the United States, the prevalence of current cigarette smoking among adults has declined from 42% in 1965 to 18% in 2012. However, more than 42 million Americans still smoke.1 This year approximately half a million people will die due to tobacco related causes. Thus smoking remains the leading preventable cause of premature disease and death in the United States.1 Annually, the total economic costs due to tobacco are now over $289 billion. And if we continue on our current trajectory, 5.6 million children alive today who are younger than 18 years of age will die prematurely as a result of smoking.1
Since the 1964 Surgeon General’s report, cigarette smoking has been causally linked to diseases of nearly all organs of the body, to diminished health status, and harm to the fetus. Research continues to link smoking to other common diseases, including diabetes mellitus, rheumatoid arthritis, and colorectal cancer. Other critical information we learned in the past 50 years is that exposure to secondhand tobacco smoke causes cancer, respiratory, and cardiovascular diseases, and adverse effects on infants and children. Now the evidence is sufficient to infer that nicotine activates multiple biological pathways through which it increases risk for disease. Finally, this latest report highlights that very large disparities in tobacco use remain across racial/ethnic groups and between groups defined by educational level, socioeconomic status, and region.1
In spite of serious efforts by physicians, government, the Center for Disease Control (CDC) and community organizations we are still not able to eliminate this serious threat to health of the public.2 While we have witnessed a significant decrease in smoking rates in adult population there is a significant increase in tobacco and nicotine product use by young people.1 There are still myriad tobacco products and nicotine in various forms available to the public including minors. The most recent surge in use of tobacco related products containing nicotine in the form of electronic cigarettes is alarming.3 Despite the progress we made in decreasing smoking rates, we still have innumerable threats to public health due to tobacco and tobacco derived products flooding the markets and some of those products are freely available to minors for use. Under these changing circumstances family physicians have a tremendous opportunity to make a significant impact on the tobacco use behavior of Americans. The American Academy of Family Physicians (AAFP) outlines its position on prevention and treatment of tobacco use and nicotine dependence beginning with a call to action for all family physicians.
The AAFP urges all national, state, federal, and private sector institutions involved in tobacco prevention and cessation activities to increase and coordinate their efforts. Bold new initiatives are necessary to rapidly decrease the harm caused by tobacco and nicotine use. The AAFP has joined with American Academy of Pediatrics, American Cancer Society, Cancer Action Network, American Heart Association, American Lung Association, Americans for Nonsmokers’ Rights, Campaign for Tobacco-Free Kids and Legacy® to call for action by all levels of government to achieve three bold goals.4
Family physicians should become active in advocating for tobacco and nicotine control measures at the patient, community, state, and national levels. In order to reach these bold goals, the AAFP calls for action in the following areas:
Through these and other actions, the AAFP, its constituent chapters, and its individual members will work in partnership to help eliminate the epidemic of tobacco-related death and disease.
The 2014 Health Consequences of Smoking--50 Years of Progress: A Report of the Surgeon General states that due to the impact of tobacco use on specific populations, the changing cigarette, nicotine addiction, specific smoking-related diseases, and dangerous secondhand smoke, a steady movement away from smoking as an acceptable social norm emerged. The prevalence of smoking among adults is now less than one-half of what it was in 1964.1 Despite this milestone, each year, more people in the United States die from smoking than from acquired immunodeficiency syndrome, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires combined.1 Tobacco use remains the leading preventable cause of disease, disability, and death in the United States. There are remarkable changes currently underway in tobacco and nicotine dependence with transformation in products, prevention, disparities, and treatment.
A distinct change in the landscape of tobacco and nicotine use is the variety of products that have flooded the market. While cigarette smoking is the predominant form of tobacco use in the United States, other tobacco products include cigars, pipes, and smokeless tobacco products (e.g., chewing tobacco, dipping tobacco, and snuff). Newer tobacco products which in many ways are targeted to appeal directly to children and young people include bidis, smoking tobacco through the use of a hookah (i.e., waterpipe), snus, dissolvables, electronic nicotine delivery systems (e-cigarettes), and little cigars/cigarillos.7
There is also increasing awareness regarding the need for strong tobacco prevention initiatives. According to Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General 2012, very few people initiate smoking after age 26; 99% of adult smokers start to smoke by age 26.3 The AAFP’s tobacco prevention program seeks to keep youth from using tobacco and nicotine products. Other initiatives include the FDA’s national public education campaign to prevent youth tobacco use and reduce the number of kids who become regular smokers. “The Real Cost” campaign is the FDA’s first campaign targeted at 10 million young people ages 12-17 who have never smoked a cigarette and youth who are already experimenting with cigarettes including e-cigarettes and are at risk of becoming regular smokers.8 The AAFP’s Tar Wars tobacco education and prevention program, FDA’s youth campaign, Campaign for Tobacco-Free Kids, Legacy® and many other local and national initiatives continue to work towards reinforcing prevention.
Perhaps the most intriguing way that treatment has evolved is the focus on nicotine dependence and behavioral health, as well as health disparities. The integration of behavioral health into primary care has been instrumental in effective treatment. People with mental illnesses smoke at rates that are twice as high as the general population.9 Nearly half the cigarettes smoked in the United States are used by people with co-occurring psychiatric disorders; the smoking prevalence rates are even higher (60-80%) for those who are diagnosed with depression, bipolar disorder, or schizophrenia.9 In spite of the overall decline in tobacco-use, higher rates persist in certain population groups. These groups are defined by educational level and socioeconomic status, geographic region, sexual identity (including individuals who are gay, lesbian, bisexual, and transgender), and presence of severe mental illness.1
Nicotine and tobacco dependence is a chronic disease that often requires repeated intervention by health care professionals and takes multiple attempts to quit.10 Family physicians have a tremendous opportunity to make a significant impact on the tobacco use behavior of Americans because approximately 70% of the people who use tobacco products see a physician each year.11
Recent evidence reinforces the impact primary care physicians can have by addressing tobacco use with their patients. The Morbidity and Mortality Weekly Report: Quitting Smoking Among Adults 2001-2010, indicates that 68.8% of current cigarette smokers said they would like to stop smoking, and 52.4% had tried to quit smoking in the past year.12 However, 68.3% of the smokers who tried to quit did so without using evidence-based cessation counseling or medications, and only 48.3% of those who had visited a health-care provider in the past year reported being advised to quit smoking.12 If physicians would advise 90% of smokers to quit and offer them medication or other assistance, 42,000 lives could be saved each year.13
Of the 42.1 million people in the United States who smoke cigarettes, only 5 % are able to quit without assistance from healthcare providers.10, 14 Less than one half of smokers make a quit attempt each year. Most smokers who try to quit do so on their own, without participating in evidence-based programs; more than 95 % relapse.2 The use of evidence-based programs can more than double success rates.2 The 2008 Update of the U.S. Public Health Service (USPHS) Clinical Practice Guideline, Treating Tobacco Use and Dependence, calls on physicians to change clinical culture and practice patterns to ensure that every patient who uses tobacco is identified, advised to quit, and offered scientifically proven treatments.10 This update also calls for systems-level interventions to ensure that tobacco and nicotine use is systematically assessed and treated at every clinical encounter. The current rates of comprehensive intervention by physicians are well below what is desirable and effective.10 Tobacco dependence is a chronic disease characterized by remission and relapse, and family physicians should approach treatment for tobacco use with this in mind.10
To ensure comprehensive intervention, medical practices need to establish a team-based system to implement the following:
The AAFP encourages its members to use behavioral intervention techniques to address tobacco and nicotine dependence, such as motivational interviewing, the use of brief interventions, and group visits. Further issues surrounding tobacco use and dependence involve the existence of barriers to successful intervention and treatment. These barriers exist at both the physician-patient level as well as system-wide issues. There are many barriers to successful implementation of interventions to help prevent tobacco use and nicotine dependence as well as help patients quit tobacco use and nicotine dependence. These barriers can be separated into two categories one at the physician-patient level and the second at the system level.
In the early 1990s the National Cancer Institute developed the publication: How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians.20 The guide recommended that physicians Ask, Advise, Assist and Arrange follow-up to help smokers quit. These four A’s were expanded to five in the 1996 Agency for Health Care Policy and Research guidelines.10 The USPHS guideline also encourages five A’s (i.e., Ask, Advise, Assess, Assist, and Arrange) as a “brief intervention” for patients who smoke.10 Many physicians have found the five A’s cumbersome, hard to remember, and not practical for every patient at every visit. Several medical specialty organizations have integrated components of the five A’s into an abbreviated intervention: “Ask, Advise, Refer.” In this model, health professionals ask patients about tobacco use, advise them to quit, and refer them to quitlines or web-based or local cessation programs.
The AAFP encourages its members and their practice teams to Ask all patients about tobacco use, and then to Act to help them quit. The AAFP Ask and Act Tobacco Cessation program (www.askandact.org) is an evidenced-based strategy based upon the USPHS guideline. This easy-to-remember approach provides the opportunity for every member of a practice team to intervene at every visit. Interventions can be tailored to a specific patient based on his or her willingness to quit, as well as to the structure of the practice and each team member’s knowledge and skill level. Interventions can include any combination of these:
AAFP’s Office Champions model has proven successful in integrating system changes into the clinic workflow to support tobacco cessation efforts. Office Champions is a quality improvement project systems-change model. Visit http://www.aafp.org/askandact/officechampions for additional information.
The transformation of primary care offices into patient-centered medical homes (PCMH) offers a significant opportunity to improve the rate of interventions for nicotine and tobacco dependence. This new model of care is based on an expanded relationship between the patient, the physician, and the practice health care team, where each takes collective responsibility for the patient's ongoing healthcare needs.
Electronic health records (EHRs) allow for integration of the USPHS guideline recommendations into the practice workflow, facilitating system-level changes to reduce tobacco use. The AAFP and the American Academy of Pediatrics developed a joint statement advocating that:
The wide availability of smartphones and advances in mobile health and other digital technologies have resulted in a dramatic increase in mobile applications (“apps”) for health behavior change, including those for smoking cessation. However, a recent review of 47 iPhone apps for smoking cessation revealed that most ‘apps” did not adhere to best practices or USPSTF evidence-based guidelines.21 The AAFP encourages its members to take note of some of the more popular smoking cessation “apps” and discuss the pros and cons of their use with their patients. For example, the U.S. Department of Health and Human Services (HHS) has a “Quitstart App” which is a free smartphone app that can help track cravings and moods, monitor progress toward achieving smoke-free milestones, identify smoking triggers, and upload personalized "pick me ups" and text message reminders to use during challenging times to assist smokers in quitting. It was created to target teens, but can be used by adults as well. For more information, visit http://smokefree.gov/apps-quitstart(smokefree.gov).
The AAFP encourages its members to be extra vigilant in screening members of high-risk populations for nicotine and tobacco use. Higher rates of tobacco and nicotine use in these populations puts them at increased risk for the harmful health effects. This poses an immediate and increased health threat to tobacco users in the following populations:
According to 2014 Report of the Surgeon General, each day more than 3,200 youth under age 18 in the United States try their first cigarette; another 2,100 who are occasional smokers become daily smokers and more than 700 kids under age 18 become daily smokers.1 If current rates continue, 5.6 million children alive today will ultimately die prematurely from smoking-caused disease.1 In addition to the well-known, long-term health effects, children who smoke may immediately experience increased heart beat and blood pressure, respiratory problems, reduced immune function, increased illness, tooth decay, gum disease, and precancerous gene mutations.35
In 2011, cigarette companies spent $8.37 billion on advertising and promotional expenses in the United States, an increase from $8.05 billion in 2010.36 In addition, the five major U.S. smokeless tobacco manufacturers spent $451.7 million on smokeless tobacco advertising and promotion in 2011, up from $442.2 million spent in 2010.37 There is clear evidence to conclude that there is a causal relationship between Tobacco Company advertising and the influence, initiation, and progression of tobacco use among youth.3 This pattern of predatory marketing brings results as high school students and young adults now smoke cigars at far higher rates than all adults.38-41
The AAFP encourages its members to talk to children and adolescents about the risks of using tobacco and nicotine products, and to participate in community awareness and prevention activities, such as Tar Wars (http://www.aafp.org/about/initiatives/tar-wars.html). Developed by a family physician and a health educator in 1988, Tar Wars is an educational program that teaches children about effects of tobacco use, the cost associated with using tobacco products, and the advertising techniques used by the tobacco industry to market their products to children. Tar Wars provides an opportunity for family physicians, family medicine residents, and medical students to introduce family medicine to their community. These health professionals serve as role models in their communities as volunteer presenters in elementary schools. Tar Wars is the only tobacco prevention program for children offered by a medical specialty organization in the United States, and has reached more than 10 million children. It has been active in all 50 states, several territories, and 16 other countries.42
Electronic Cigarettes—the relatively new nicotine delivery devices also known as e-cigarettes—have become increasingly popular in the past few years. According to the CDC, use and experimentation among US middle and high school students in 2011-2012 has doubled from 3.3% to 6.8% of children in grades 6-12, leading to approximately 1.78 million students having reported ever-using an electronic cigarette as of 2012.43 Several studies have recently described “rapid expansion” in their use among adolescents, high school and college students, as well as among adults.44-48 Sales of electronic cigarettes, also known as e-cigarettes, Personal Electronic Vaporizing Units, and Electronic Nicotine Delivery Systems (ENDS), more than doubled in the last few years and are projected to be 10 billion dollar industry by 2015.49
Manufacturers and marketers tout e-cigarettes as cheaper and safer alternatives to traditional cigarettes.50 These claims are being made despite a general lack of evidence for their potential benefits, and a number of studies that show several harmful effects such as increases in blood nicotine level51, multiple physical symptoms52, and negative effects on indoor air.53-54 The most significant danger, however, is the increased focus—by manufacturers, marketers and retailers—on their use as a smoking cessation tool. Critics note these major issues with studies on e- cigarettes as smoking cessation devices: They are inherently biased, methodologically flawed, or they do not provide adequate evidence to draw a conclusion about e-cigarettes’ efficacy as a smoking cessation method.56-58
The AAFP recognizes the alarmingly increased use of e-cigarettes, especially among youth and those attempting to quit smoking tobacco.6 E-cigarettes are unregulated, battery-operated devices that contain nicotine-filled cartridges. The resulting vapor is inhaled as a mist that contains flavorings and various levels of nicotine and other toxic substances. Although e-cigarettes may be less toxic than smoking combustible tobacco cigarettes, currently there is no evidence supporting the efficacy of e-cigarettes as a smoking cessation device. Nevertheless, some physicians and public health groups consider the use of these devices as a viable harm-reduction strategy. Many are concerned that e-cigarettes may contribute to nicotine dependence, promote dual use of both products (cigarettes and e-cigarettes), and encourage nicotine consumption. E-cigarettes may also introduce children to nicotine leading to potential addiction. Reports are increasing of nicotine-related toxicity and poisoning, especially among children, associated with the nicotine refill cartridges (“nicotine juice”). The CDC has reported a dramatic increase in calls to poison centers, from one per month in September 2010 to 215 per month in February 2014.60-61 A recent concern is the ability to replace the nicotine liquid with hashish oil in order to smoke marijuana. Reports have surfaced of people about using e-cigarettes to smoke marijuana, particularly in public places, and there are numerous websites providing instruction on how to convert e-cigarette cartridges to smoke marijuana.62 Additionally, there have been instances of e-cigarettes and their batteries exploding resulting in damage to persons and property.63
Due to the current lack of good evidence and regulation of manufacturing, marketing and sales, the AAFP has established a formal policy on e-cigarettes which calls for rigorous research in the form of randomized controlled trials of e-cigarettes to assess their safety, quality, and efficacy as a potential cessation device. The AAFP also recommends that the marketing and advertising of e-cigarettes to children and youth should cease immediately until e-cigarette’s safety, toxicity, and efficacy are established.6 The AAFP encourages all members to screen for e-cigarette use in all age groups, to discuss the potential harms of e-cigarette use, and to recommend evidence-based smoking cessation interventions with e-cigarette users.
The available budgets in the public and private sectors for development of new technologies and approaches to screening and treatment are not commensurate with the size of the tobacco and nicotine use epidemic. The AAFP encourages increased funding for the pursuit of innovative approaches to identifying those at risk for tobacco and nicotine use and helping people quit, including providing medications, counseling, policy change, and improvements in primary care clinic systems.
Not all health care professionals are aware of the evidence-based guidelines for treating tobacco dependence.64 The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and the USPHS guideline recommend that all health care professionals, including students in health care training programs, receive education in the management of tobacco use and dependence.10, 65 Despite these recommendations, students in the health professions receive inadequate training for treating tobacco use and dependence. In an international survey assessing the tobacco-related content in medical school curricula, only 34% of schools reported that they provide training on smoking cessation techniques.66
The AAFP strongly advocates in-depth, effective education in prevention and cessation of tobacco use in medical schools and residency programs, and encourages family physicians to participate in CME activities and programs related to prevention or cessation of tobacco use. The AAFP also strongly encourages organizations involved in the creation of CME to integrate tobacco and nicotine use screening, prevention and treatment into their curricula. Organizations involved in the ongoing credentialing of primary care physicians, such as the American Board of Family Medicine, should include questions about tobacco dependence treatment in examinations and test preparation materials. The AAFP provides educational materials for members at www.askandact.org.
The AAFP recognizes that most states and the federal government tax cigarettes and numerous reports have demonstrated that increasing taxes on tobacco products provides a major disincentive to potential buyers, especially youth.67 The AAFP encourages the development of health education and other tobacco control programs funded by the taxes collected on cigarettes.
Furthermore, the AAFP supports its constituent chapters as they seek to ensure that funds from the Master Settlement Agreement (MSA) or excise taxes on tobacco products be used for tobacco prevention, cessation, education, and other elements of comprehensive tobacco control. Suggested spending levels from the CDC’s Best Practices for Comprehensive Tobacco Control Programs should be followed in funding of these activities across the nation. Despite the fact that states receive massive amounts of revenue annually from tobacco taxes and state tobacco lawsuit settlements with cigarette companies, the vast majority of states fail to invest the amounts recommended by the CDC to reduce tobacco use and minimize its health harms and costs.68 Between 2007 and 2014 the percentage of state funds spent on such tobacco prevention programs fell from a 2008 high of $717.2 million, 44.8% of the CDC’s recommended minimum, to a low in 2014 of $481.2 million, 13.0% of the CDC’s recommended minimum. This compares to $8.37 billion spent in advertising and promoting tobacco in 2011. The 2014 Surgeon General’s report estimates the annual economic costs of nicotine addiction at $300 billion annually, with direct medical costs of at least $130 billion, more than $150 billion of lost productivity due to premature death, and $5.6 billion in lost productivity due to secondhand smoke exposure.1 Despite progress in educating the public on the harms of tobacco use, it remains a deadly and costly health threat due, in part, to low utilization of cost-effective, evidence-based treatments, which could be subsidized by allocation of more MSA funds to tobacco control and prevention.
Secondhand smoke is a mixture of gases and fine particles that includes smoke from a burning tobacco product as well as smoke that has been exhaled by the person. More than 7,000 chemicals, including hundreds that are toxic and about 70 that can cause cancer are present in second hand smoke.1 Most exposure to secondhand smoke occurs in homes and workplaces and continues to occur in public places such as restaurants, bars, and casinos, as well as multiunit housing and vehicles.69 Since 1964, 2.5 million nonsmokers have died from exposure to secondhand smoke.1 Eliminating smoking in indoor spaces is the only way to fully protect nonsmokers as simply separating smokers from nonsmokers within the same air space, cleaning the air, opening windows, or ventilating buildings does not completely eliminate secondhand smoke exposure.69 The AAFP strongly supports prohibiting the use of tobacco and nicotine products in all public places. Family physicians should advise their patients, especially those with cardiovascular diseases or other chronic conditions, to avoid establishments that permit smoking and to request that family members not smoke in their home or vehicle. Family physicians should specifically address the problems of exposing children to tobacco smoke, and encourage cessation for all adult household members. The AAFP urges all employers to provide smoke-free work environments and incentives for employees who participate in cessation programs. Family physicians and AAFP constituent chapters are encouraged to work with local governments and agencies to advocate for clean indoor air ordinances and regulations.
Repeated clinical tobacco-cessation counseling is one of the three most important and cost-effective preventive services that can be provided in a medical practice.15 The AAFP strongly advocates for health plan coverage and appropriate payment for evidence-based physician services for screening and treatment of tobacco use. Consistent with the United States Preventative Services recommendations,70 the AAFP recommends that all tobacco users in the United States be aware of the existence of and have access to all evidenced-based FDA approved therapies and counseling as described in the USPHS guideline. The Centers for Medicare and Medicaid Services (CMS) pays for physician services related to smoking cessation counseling provided to Medicare beneficiaries since 2005. In 2014, the Affordable Care Act (ACA) requires insurance plans to cover many clinical preventive services including tobacco-use screening and counseling. A coding reference is available online at www.askandact.org.
The AAFP believes the FDA should have authority to regulate the manufacturing, sale, labeling, distribution and marketing of all tobacco products including cigars of all sizes and flavors.71 It should also regulate nicotine delivery devices, including e-cigarettes. The FDA is currently considering expanding its jurisdiction to include e-cigarettes.72 The AAFP supports this proposed rule change as outlined in a letter to the FDA.73
Across the world, tobacco use claims more than 5 million lives each year, with projections that by 2030, the toll will rise to about 8 million annual deaths.74 Because of shifts in consumption trends away from developed nations like the United States, most of this pandemic will occur in developing nations in Asia, South America, and Africa, where health care systems may be too challenged to adequately address prevention, cessation, and chronic disease management issues.75 The FCTC is the world’s first global public health treaty that requires nations to adopt a comprehensive range of measures designed to reduce the devastating health and economic impact of tobacco use. Work on the treaty began in 1999 at the World Health Organization (WHO), and in 2003 was unanimously adopted by the World Health Assembly and opened for signature.76 Among many other medical and health care organizations, the FCTC is supported by the American Medical Association, the American Cancer Society, the American Thoracic Society, and the American Society of Clinical Oncologists. The World Organization of Family Doctors added its support to the FCTC in 2004.77
The FCTC calls for the following reduction provisions:
The core supply reduction provisions address:
The United States signed the treaty in 2004, but it has yet to be sent to the Senate for ratification. The AAFP supports the FCTC, and urges Senate ratification and presidential signature of the treaty.
(2009 COD) (July 2014 BOD)
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Preventing and Treating Nicotine Dependence and Tobacco Use (Position Paper)