A wake-up call to action for smoking cessation interventions

Farahnak Assadi 1

Recent data obtained through analysis of the World Health Organization (WHO) on Tobacco epidemic 2019 indicate that about 5 million people (65%) of the world’s population are now covered by at least by one MPOWER measure (Monitor tobacco use and prevention policies; protect people from tobacco smoke; offer help to quit tobacco use;warn about the dangers of tobacco; enforce bans on tobacco advertising, promotion and sponsorship; raise taxes on tobacco) at the highest achievement levels, which has been quadrupled since 2007, when one billion people (15%) were covered [ 1]. Of the 5 million people protected by at least one complete POWER measure, 3.9 billion live in low- and middle-income countries. Brazil and Turkey are the only two middle-income countries that have adopted all POWER measures at the highest level.

However, despite the significant progress in global tobacco control, there are 59 countries that have yet to adopt a single POWER measure at the highest achievement level. In terms of population, only one third of the world’s population (2.4 billion people in 23 countries) have access to quit smoking services. The global targets for the prevention of tobacco exposure will be achieved only and if only all tobacco users quit [ 1].

In the United States, Centers for Disease Control and Prevention (CDC) report on the tobacco epidemic finds that about 14% of the U.S. population aged 18 years and older are tobacco smokers and that nearly 500,000 American die each year as a result of smoking-related illness [ 2]. The burden of disease is paralleled by the enormous cost for delivering healthcare. The smoking-related costs are staggering.According to the Centers for Medicare and Medicaid Services (SMS), the annual healthcare expenditures caused by smoking in the United States are estimated to be over $300 billion and greater than $156 billion in lost productivity related to premature death and exposure to second-hand smoking (SHS) [ 2].

The diseases largely contributing to tobacco are pulmonary diseases, including emphysema, bronchitis, pneumonia,chronic obstructive pulmonary disease (COPD), nonalcoholic fatty liver disease and lung cancer [ 3- 6]. Smokers are at increased risk of hypertension, cardiovascular and neurologic complications (impaired cognition, learning and memory function, stroke) [ 7- 9]. Further, tobacco smoking can lead to osteoporosis and other types of cancer, including oral, pharyngeal and nasal cavity, larynx, esophageal,urinary tract, cervix, breast, endometrial, prostate, and leukemia [ 10- 16]. Sadly, there is a rise in use of smokeless tobacco use, including e-cigarettes, cigars, hookahs, kreteks,bidis, and pipes especially among youth, which is as dangerous as use of cigarette smoking [ 5, 8, 9].

Women smokers are more likely to have a delay in conception and higher risk of infertility and miscarriage [ 17].Men who smoke are at increased risk of erectile dysfunction and impaired sperm quality and mobility [ 17, 18].Maternal cigarette smoking before and during pregnancy may adversely affect the health of both mother and their off-spring [ 18]. Maternal smoking increases the risk of preterm deliveries, low birth weight for gestational age deliveries,sudden infant death syndrome (SIDS) and the risk of off-spring being born with, cleft lip and/or cleft palate [ 19- 22].

Passive smoking or second-hand smoking (SHS) during childhood is even more hazardous than prenatal tobacco exposure during gestation [ 5, 8, 9, 23, 24]. SHS is known to increase the incidence of SIDS, exacerbate asthma attacks,neurobehavior dysfunction, and cause hypertension, dyslipidemia, glucose intolerance, respiratory illness and even cancer.

Up to 80% of nicotine is metabolized to cotinine and is the most sensitive and specific biomarker for environmental tobacco exposure, including tobacco smoke contamination of dust, air in a room where smoking previously occurred,or residual tobacco smoke contamination on surfaces. Cotinine can be measured in hair, nails, blood, saliva, or urine samples [ 25, 26].

Interventions for tobacco cessation

We do have prevention plan and treatment regimens that are safe, relatively simple, and if not perfect, quite effective [ 27, 28]. However, the clinical delivery of the known therapy for preventing or smoking cessation is sadly inadequate. Studies show that clinicians inconsistently assess tobacco smoking and offer intervention to quit smoking in clinical practice [ 1, 29]. More distressing is that many smokers are not awaring of the smoking-related health hazards [ 1, 29].

About 75% of patients who smoke say they would like to quit smoking but only less than 10% are able to do so on their own [ 30]. Healthcare providers, including the primary care physicians, nursing staff and social workers must work together as a team to increase awareness of all tobacco users about the serious health-related consequences of smoking and to advise all them to seriously consider making a quit attempts. Healthcare professionals must ensure that all smokers who come in contact to receive basic intervention and support. The types of interventions include behavioral modifications, pharmacologic, and alternative methods such as hypnosis and acupuncture [ 27, 28].

There are several behavioral interventions, such as coping response therapy, problem-focused treatment, relapse prevention training, and cognitive behavioral therapy. The main limitation of this approach is that a very few smokers are interested in attending specific classes at any given time.

Nicotine replacement therapy (NRT), bupropion, and varenicline are the first-line pharmacologic intervention for tobacco cessation [ 28, 31, 32]. However, these drugs have not been approved for use among pregnant or nursing women [ 33]. NRT are commercially available in forms of patch, chewing gum, lozenge, nasal spray, and inhaler.

Annual screening for lung cancer with low-dose computed tomography is highly recommended in adults 55 years or older who have a 30-pack-year smoking habit or have quit smoking within the last 15 years.

Strategic plan

Recognizing the magnitude of the problem, the availability of effective intervention for tobacco cessation, and deficiency of its use, this call to action is for all healthcare professionals who have an impact on tobacco smoking cessation to take action to create a smoke-free future.· Prioritize tobacco exposure as a national health action by developing an infrastructure to support tobacco cessation and treatment of tobacco dependence.

· Prioritize education programs that are science driven and meet the needs of patient care in communities,schools, health care facilities, worksites, and mass communications campaign that educate the public about the POWER measure to prevent tobacco-related illness.

· Outreach into communities with diverse cultural specificity, modify public opinion, expose adverse environmental conditions, challenge unhealthy norms, reduce operational barriers so that the education can be executed in a timely, cost-effective manner, and empower consumers to improve their own environment.

· Identify deficiencies in tobacco exposure prevention and treatment research, clinical care, education, and training that have yet to be adequately addressed.

· Collaborate internationally to develop and implement new effective cessation measures.

· Identify people at high risk requiring testing and treatment. Those at risk include all first-hand and secondhand exposures to tobacco. The risks in these categories are markedly amplified in youth and pregnant women groups.

· Create a center in which to conduct state-of the-art,patient-oriented education, including neurobehavioral analysis to support public and healthcare providers and serve as a magnet facility to foster collaboration with extramural researchers that address disparities in the prevalence of tobacco users among racial and ethnic,gender, socioeconomic, and age groups.

· Adapt and promote a multi-stakeholder approach to identifying and implanting practical solution for taking individuals who smoke tobacco.

· Secure sufficient funding to support a leadership infrastructure plan for standardization of tools and procedures for education design, data capture, data sharing,and administrative functions to minimize duplication of efforts, and to facilitate development of a shared infrastructure to support an integrated national tobacco smoking cessation network.

· Develop educational programs for primary care professionals, including physicians, nursing staff and social workers to become engaged in addressing this problem.Further, the strategic plan recommend to include policy makers in organizations engaged in health education for public awareness.

· The key element in the success of the strategic program will be collaboration with groups already interested in the intervention of tobacco smoking cessation,including nonprofit professional organizations as well as a number ofindustry partners whose business focus on this patient population. Provide leadership for a national education program in smoking-related diseases targeting areas such as lung cancer, high blood pressure, cardiovascular, and neurocognitive disorders.

· Other areas of cutting-edge education include prevention and treatment to foster multidisciplinary approaches to tobacco exposure during pregnancy and its adverse effects on the developing fetuses.

Conclusions

It is widely recognized that tobacco smoking can reduce the length and quality of life. Effective prevention and treatment are widely available but not adequately utilized. Disparities in tobacco users prevalence based on race and ethnicity,socioeconomic status, gender and age ought to be eliminated. Environment must be modified to promote healthy life style. The social stigmatism associated with tobacco smoke must be eradicated. Raising tobacco-related illness awareness among public and policy makers should be encouraged.The value of public education and mass communication is really hard to overestimate. A preventive strategy policy can provide the opportunity to have a beneficial impact on the national education agenda in areas related to tobacco smoking. This vision should be approached vigorously.

Primary care professionals are obliged to ask all schoolaged children, adolescents and adults about tobacco use during their initial clinic visits. They must advise all tobacco users to seriously consider to stop smoking and provide them behavioral interventions, including education and consoling. WHO 2019 objectives are to reduce the prevalence of tobacco smoking among school-age children, adolescents and adults. Tobacco-attributable health care costs is staggering. Tobacco-related illnesses have also a major impact on the cost of health care and lost work productivity. The long-term consequences are most dire for children and if the current trends continue, children may live shorter lives as adults.Although many organizations have called for action to stop tobacco smoking, but yet, no national action plan has been emerged to provide the urgent action required to reverse these critical public health improvements.

FundingNone to declare.

Compliance with ethical standards

Conflict of interestThe author declares no conflict of interest.