Cigarette smoking is the leading preventable cause of death in the United States, responsible for an estimated 443,000 deaths per year, or one in every five deaths. Physicians often care for the health consequences of their patients’ tobacco use, and it is equally important for them to prevent smoking-related disease. There is no safe level of tobacco use. Smoking as few as one to four cigarettes per day increases the risk of myocardial infarction and cardiovascular mortality. Smoking cigarettes with reduced tar and nicotine content does not protect against the health hazards of smoking. Smoking cessation treatment is one of the most cost-effective actions available to clinicians.

The prevalence of cigarette smoking in the United States rose rapidly in the first half of the twentieth century and peaked in 1965, when 40% of adult Americans smoked cigarettes. Since then, smoking prevalence has been cut in half, reaching 19% of adults in 2011. This dramatic decline reflects growing public awareness of the health risks of tobacco and decades of public health efforts to discourage tobacco use. More recently, smoking prevalence has stabilized but the pattern of tobacco use has changed. Twenty percent of current smokers do not smoke every day, and the average smoker smokes only 15 cigarettes daily. Combining cigarette smoking with other tobacco products, especially smokeless tobacco, is increasingly reflecting the impact of expanding restrictions on places where smoking is allowed. The rising cost of cigarettes has led increasing number of smokers to use small cigars that have lower tobacco excise taxes and to buy tobacco in bulk and roll their own cigarettes.

Tobacco smoking starts during childhood and adolescence. Nearly 90% of smokers begin to smoke before the age of 18 years and 99% start by the age of 26 years. The rates of tobacco use in men and women, once very different, are now similar, with 16.5% of adult women and 21.6% of adult men smoking cigarettes in 2011. In the United States, smoking is more closely linked to education than it is to age, race, occupation, or any other sociodemographic factors. Educational attainment is a marker for socioeconomic status, and these data indicate that smoking is a problem that is concentrated in lower socioeconomic groups. Smoking is also more prevalent among individuals with comorbid psychiatric disorders and substance abuse disorders.

Cigarette smoking increases overall mortality and morbidity rates and is a cause of cardiovascular disease (including myocardial infarction and sudden death), cerebrovascular disease; peripheral vascular disease; chronic obstructive pulmonary disease; and cancers at many sites, including the lung, larynx, oral cavity, esophagus, bladder, kidney, pancreas, and uterine cervix. Approximately 30% of tobacco-related deaths are due to cardiovascular disease. Lung cancer, once a rare disease, increased dramatically during the twentieth century, becoming the leading cause of deaths due to cancer among men in 1955 and among women in 1986. Lung cancer incidence is now declining among both men and women, reflecting the decline in smoking prevalence by US adults that occurred decades earlier.

Smoking is associated with many pregnancy complications, especially low birth weight (<2500 g). This is primarily attributable to intrauterine growth retardation (IUGR), although smoking in pregnancy also increases the risk of preterm delivery. Other adverse pregnancy outcomes linked to smoking are miscarriage (spontaneous abortion) and stillbirth. Smoking during pregnancy affects children even after birth. Sudden infant death syndrome is two to four times more common in infants born to mothers who smoked during pregnancy. Cognitive deficits and developmental problems in childhood are also linked to maternal smoking during pregnancy.

Cigarette smoking also increases a woman’s risk of postmenopausal osteoporosis and fracture. Smokers have higher rates of upper and lower respiratory infections, diabetes, peptic ulcer disease, cataracts, macular degeneration, and sensorineural hearing loss than nonsmokers. Smokers have more prominent skin wrinkling than nonsmokers, independent of sun exposure. Smoking causes the majority of residential fire deaths.

The health hazards of smoking are not limited to those who smoke. Nonsmokers are harmed by exposure to the smoke produced by nearby smokers, a phenomenon called secondhand smoke (SHS). According to the 2006 US Surgeon General’s Report, there is no safe level of exposure to SHS. The children of parents who smoke have more serious respiratory infections during infancy and childhood, more respiratory symptoms, and a higher rate of chronic otitis media and asthma than the children of nonsmokers. Among adults, chronic SHS exposure increases a nonsmoker’s risk of lung cancer and coronary heart disease. An estimated 3400 lung cancer deaths and 69,000 heart disease deaths in US nonsmokers are attributable to SHS exposure. Even after tobacco smoke has dissipated it leaves a residual of chemicals on clothing and surfaces in the area where tobacco was smoked. This phenomenon, called thirdhand smoke, allows for even more prolonged exposure to tobacco toxins.

Smoking cessation has health benefits for men and women of all ages, even for those who stop smoking after the age of 65 years or who quit after the development of a smoking-related disease. Smoking cessation decreases the risk of lung and other cancers, heart attack, stroke, chronic lung disease, and peptic ulcer disease. After 10–15 years of abstinence, overall mortality rates for smokers approach rates of those who never smoked. The risk reduction for cardiovascular disease occurs more rapidly than the risk reduction for lung cancer or overall mortality. Half of the excess risk of cardiovascular mortality is eliminated in the first year of quitting, whereas for lung cancer, 30–50% of the excess risk is still evident 10 years after quitting and some excess risk remains after 15 years.

The benefits of stopping smoking translate into a longer life expectancy for former smokers compared with continuing smokers. Smokers who benefit the most are those who quit when they are younger, have fewer pack-years of tobacco exposure, and are free of smoking-related disease. The health benefits of smoking cessation far exceed any risks from the small weight gain that occurs with cessation.

Cigarettes and other tobacco products are addictive because they contain nicotine, a drug that creates tolerance and physical dependence in habitual users with symptoms of nicotine withdrawal when smoking stops. Nicotine withdrawal symptoms include: (1) cravings for a cigarette; (2) irritability; (3) restlessness; (4) anger and impatience; (5) difficulty concentrating; (6) anxiety; (7) depressed mood; (8) excessive hunger; and (9) sleep disturbance. These symptoms begin within a few hours of the last cigarette, are strongest during the first 2–3 days after quitting, and gradually diminish over a month or more. Other than craving for a cigarette, the symptoms are nonspecific, and many smokers fail to recognize them as nicotine withdrawal. The severity of nicotine withdrawal is variable across smokers and is related to the level of prior nicotine intake. Smokers who smoke more than 20 cigarettes daily or smoke their first cigarette within 30 minutes of awakening are likely to suffer from nicotine withdrawal symptoms when they try to quit.

The discomfort of nicotine withdrawal is one reason smokers fail in their efforts to stop. However, the attractiveness of smoking is attributable to more than nicotine dependence. Smoking is also a habit, a behavior that has become an integral part of a daily routine. Smokers come to associate cigarettes with enjoyable activities, such as finishing a meal or having a cup of coffee. These actions trigger the desire for a cigarette in smokers who are trying to quit. Smokers also use cigarettes to cope with stress and negative emotions, such as anger, anxiety, loneliness, or frustration. Quitting smoking represents the loss of a valuable coping tool for many smokers.

Over half of the living Americans who have ever smoked have now quit smoking. According to surveys, 70% of the remaining smokers would like to stop smoking and half of them tried to do so in the past year. However, most quit attempts fail, in part because only one in three smokers trying to quit use any assistance when quitting, despite the existence of effective treatments that improve the success rate of a quit attempt.

Approximately 25% of smokers who use state-of-the-art treatment are not smoking 1 year after their quit attempt, though many more smokers quit for a short time and then relapse. Most relapse occurs in the first week of a quit attempt. In contrast, only 6% of smokers who try to quit without assistance succeed for 1 year. Behavioral scientists regard smoking cessation to be a learning process rather than an action requiring a discrete episode of will power. Smokers learn from mistakes made during a prior attempt at quitting, thereby increasing the likelihood that the next attempt will succeed. Psychologists have identified a series of cognitive stages through which smokers pass as they move toward nonsmoking: (1) initial disinterest in quitting; (2) thinking about health risks and contemplating quitting; (3) preparing to quit in the near future; (4) currently taking action to stop smoking; and (5) maintained nonsmoking (see Chapter 19).

Surveys of former smokers reveal how and why they stop smoking. Fear of illness is the reason most often cited. However, awareness of health risks alone is not sufficient to motivate smoking cessation. Over 90% of current smokers know that smoking is harmful to their health, yet they continue to smoke. Many smokers rationalize that they are immune to the health risks of smoking until these risks become personally salient. Current symptoms (e.g., cough, breathlessness, and chest pain), even if they represent minor illness rather than the onset of a smoking-related disease, stimulate change in smoking behavior more powerfully than does fear of future disease. Illness in a family member may also motivate smoking cessation. The price of cigarettes and the social unacceptability of smoking are other frequently cited reasons.

Evidence-based clinical guidelines for smoking cessation were released by the US Public Health Service in 2000 and updated in 2008 (http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf). These guidelines identify two methods, psychosocial counseling and pharmacotherapy, as having strong evidence of efficacy. Each is effective individually, but combining the two produces higher cessation rates. There is no strong evidence to support the efficacy of hypnosis or acupuncture for smoking cessation.

Psychosocial Support

Effective psychosocial support provides smokers with both practical behavior change strategies and also support and encouragement as part of treatment. Cognitive behavioral treatment methods address the barriers to quitting smoking that are rooted in habit. These methods are effective in aiding smoking cessation. In a typical program, smokers monitor their cigarette intake to identify the things that trigger the smoking, change their habits to break the link between the trigger and smoking, and learn to anticipate and handle the urges to smoke when they occur. The counselor also provides social support to bolster the smoker’s confidence in the ability to stop smoking.

Psychosocial support was originally developed for delivery in individual or group settings. To broaden the reach of behavioral treatment, in-person methods were adapted for delivery by telephone and found to be effective. Cognitive behavioral treatment techniques can also be packaged into booklets or videotapes for use at home. These techniques have also been adapted for delivery using newer communication tools, including websites, text messaging, mobile phone applications, and social media. Most of these programs are new and their effectiveness is not yet demonstrated.

Pharmacological Treatment

Seven products have been approved by the US Food and Drug Administration (FDA) as smoking cessation aids and rated as first-line drugs by the US Public Health Service tobacco treatment guidelines (Table 21-1). These include five nicotine replacement products, bupropion (an atypical antidepressant), and varenicline, a nicotine receptor partial agonist. Nortriptyline and clonidine have also shown efficacy for smoking cessation in clinical trials but have not been submitted for approval by the FDA for this indication and are considered second-line drugs by the US Public Health Service guideline panel.