Nicotine, Tobacco, Cessation, and Public Policy

Margaret Cox

Health Management & Public Policy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Will Power, Quit Victoria’s Tobacco Cessation Mascot

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nicotine, Tobacco, Cessation, and Public Policy

 

 

Tobacco’s Addictive Ingredient:

 

In examining smoking cessation, it is important to understand the chemical dependency brought on by the active ingredient in tobacco, nicotine.  Periodic use of nicotine often leads to a physical and mental addiction to the substance.  C10H14N2, or nicotine, is found in tobacco leaves as a naturally occurring, poisonous, yellow alkaloid.  Once nicotine enters the body, it is distributed through the bloodstream and can cross the blood-brain barrier in 6-7 seconds.[1],[2] Inside the brain’s structure, nicotine acts as an adrenaline stimulant for the body by increasing the activity of the acetylcholine receptors.  This causes a tobacco user to experience symptoms like a higher activity level, elevated heart rate and respiration, as well as blood vessel constriction, leading to an overall feeling of alertness and well being.  Nicotine also increases the activity of the dopamine receptors, causing tobacco users to feel both pleasure and a desire to maintain nicotine levels in the body.  In this respect, tobacco is somewhat similar to marijuana, cocaine and heroin, which also increase activity in the brain’s dopamine receptors. 

 

Types of American Tobacco:

There are three major types of tobacco produced in the United States: flue-cured (or bright) tobacco (55-57% of United States’ market), burley tobacco (37-39% of market), and Eastern burley/Southern Maryland (1-2% of market) tobacco.[3]  Flue-cured tobacco is primarily grown in North Carolina, the leaves are handpicked from the stalk, and it is hung and heated in humid conditions for 4-8 days until the plants turn yellow.  They are then rewet and dried further.  Burley tobacco leaves, mostly produced in Kentucky, remain on the stalk while they are slowly air dried while hanging from barn rafters.  In this variety, additives and artificial flavors are absorbed by the leaves more quickly and effectively.3  In America, burley tobacco is also used to make smokeless tobacco.  The Eastern Burley variety is used in tobacco blends, as it has a neutral flavor and odor.

 

Definition of Dependence:

Generally in tobacco literature, dependence and addiction can be used interchangeably and both terms are defined as being abnormally tolerant to and either psychologically and/or physically reliant on the habit-forming substance.  The behavior associated with using tobacco is both frequent, habitual, and feels uncontrollable.  According to the DSM-IV-TR, nicotine dependence falls under the heading of substance-related disorders, though not all daily smokers are nicotine dependent.  Nicotine dependence is characterized by three or more of the following characteristics over a twelve-month period: increased tolerance to the drug; withdrawal symptoms in the absence of the drug; taking larger amounts over a longer period than was intended (tolerance); a persistent desire or unsuccessful attempts to cut down or eliminate substance use; large amounts of time spent obtaining, using, or recovering from substance; giving up activities due to substance use; and continued use despite knowledge of having physical or psychological problems resulting from substance use.[4]  Due to the chemical dependence that often results from using nicotine, tobacco cessation can be extremely difficult.  The Center for Disease Control (CDC) reported that in 2002 approximately 45.8 million adults 18 and older were current smokers with an estimated 15.4% who had stopped smoking for more than one day in the past year in an attempt to quit.[5]  Yet, it is estimated that less than 3 percent of those who attempt to quit each year remain tobacco-free for a period of twelve months.[6]

 

Definition of Withdrawal:

Remaining tobacco-free is a problem for many individuals due to the highly addictive nature of tobacco’s active ingredient, nicotine.  As mentioned before the effect tobacco has on the acetylcholine receptors cases a person to feel alert and full of energy, while the effect tobacco has on the dopamine neurotransmitters cases a person to feel pleasure and a need to maintain nicotine in their system.  Over time with repeated exposure, a decreased responsiveness due to nicotine tolerance can cause a person to smoke more in order to get the same desired effect, making dependence and addiction even stronger and quitting even more difficult (as dose-response from either the number of cigarettes consumed in a day or total years of smoking increases, nicotine dependence increases, making cessation more difficult).  Tobacco cessation can cause a person to feel rundown, depressed, and fixated on the need for nicotine after initial termination, with withdrawal symptoms occurring within the first twenty-four hours after quitting.  Withdrawal symptoms also typically include feelings of irritability, restlessness, an inability to concentrate, and an increased incidence of weight gain (as stimulants function as an appetite suppressant, many people eat more after quitting).  When people quit using tobacco, they may also experience feelings of hostility; difficulty dealing with stress; and even decreased psychomotor and cognitive functioning.[7]  Though the physical and emotional withdrawal symptoms tend to peak after seventy-two hours, tobacco users may continue to experience withdrawal symptoms for months or even more than a year after cessation due to the psychological addiction associated with nicotine.  Withdrawal symptoms among cigarette smokers are particularly intense due to the fact that nicotine enters the body most quickly when smoked (as opposed to the dermal absorption of smokeless tobacco and/or nicotine replacement therapy aids), with the almost instant gratification leading to a greater physical dependency.  Further, studies have estimated that about 80% of all smokers want to quit, 35% try cessation annually, but less than 5% are successful, with the majority unable to maintain cessation for an week.  Without proper support, people are often unable to combat the withdrawal symptoms and often start using nicotine again within a matter of days.  This is evident when one examines the prevalent problem of nicotine in the United States and worldwide.[8] 

 

National and International Smoking and Production Prevalence Rates:

Tobacco use is the primary source of preventable fatalities in the United States[9] and arguably throughout the world.  In the 20th century alone, an estimated 0.1 billion people worldwide died prematurely from tobacco use and the World Health Organization projects that number to be ten times as high for the 21st century.[10]  Yet, smoking continues to be a prevalent problem in the United States and internationally.  In 1999, the Department of Health and Human Services conducted the National Household Survey on Drug Abuse and found that among Americans age 12 and older, approximately 66.8 million (30.2% prevalence rate) were current tobacco users (having used tobacco at least once in the past month).[11]  This estimate includes approximately 3.6 million adolescents (ages 12-17).  In many nations, tobacco consumption and the burden of disease is highest among the lower socioeconomic status groups, while quitting remains the lowest among these same populations.[12]  Further, many of the 1.2 billion smokers worldwide live in low- and middle-earnings nations.[13]   Internationally, according to 1998 statistics, cigarette consumption remains high with the five highest consuming nations as follows: China (1,643 billion cigarettes consumed), United States (451 billion), Japan (328 billion), Russia (258 billion), and Indonesia (215 billion).[14]  The cost of tobacco is not judged merely in terms of mortality statistics, the government, the health care system, and the individual also feel the cost of tobacco.  Yet, tobacco production continues to be a highly profitable industry, especially in the United States.  The United States is leading exporter of man-made tobacco goods (sending approximately 24% of 500 billion manufactured cigarettes overseas in 2003 alone) and second only to Brazil in selling tobacco leaf to other countries.[15]

 

Costs Associated with Smoking:

Tobacco use is responsible for more deaths than AIDS, alcohol, motor vehicle accidents, homicide, drug abuse, and suicide combined.[16]  Tobacco use is linked to deaths due to stroke, lung and other cancers, coronary heart disease, chronic lung disease (Ex. emphysema), as well as other terminal conditions.  These chronic illnesses cause a drain on the individual and the healthcare system as expensive treatment may last for months and years before a patient dies.  According to the Center for Disease Control, tobacco use causes more than 440,000 deaths, more than 75 billion dollars in direct medical costs, and more than 5.6 million years of potential years of life lost each year in the United States.[17]  Though Philip Morris Companies, Inc. stated in 2001 that smokers contribute to the overall economy by increasing tax revenue, dying early, and not collecting on pensions as long[18] (and later apologized for making such statements), the reality of the situation is far different.  The economic costs of smoking are far-reaching, affecting everything from the number of days off (in 2001, smokers had an average of 6.16 sick days compared to 3.86 for non-smokers) to trash collection (20% of all trash collected in the United States in 1996 were cigarette butts).[19]    In addition to health care spending, work absences, and waste removal, national and international governments feel the burden of tobacco use from deforestation and cultivatable land loss due to tobacco farming, accidents and fire damage, higher insurance rates, and decreased productivity. 

 

Tobacco Production

According to the World Health Organization’s research, Brazil, China, India, Turkey, and the United States produce over two-thirds of all tobacco crops worldwide[20] with nearly half of the world’s tobacco growers living in China (approximately 15 million).[21]  In 2003, 12.75 billion pounds of tobacco were produced worldwide with 831 million pounds produced on the 416,000 acres in the sixteen tobacco-producing states of the United States (on less than 57,000 farms).[22]  The six major tobacco states are North Carolina, Kentucky, Tennessee, South Carolina, Virginia, and Georgia, which produce 90% of United States’ tobacco crop.[23]  On the subject of tobacco cessation, the tobacco industry often exploits the idea of the negative impact on tobacco farmers to play on the emotions of voters and sway politics in their favor, while many in the public believe that tobacco growers are given subsidies by the United States government.[24]  The government generally spends very little of the national economy on compensation for farmers, particularly for tobacco growers.  Further, if the federal government passed tobacco control legislation, tobacco farmers would be somewhat adversely affected economically by the change, though not nearly to the extent that the tobacco corporations would be affected if tobacco sales were reduced or eliminated.  At present, tobacco cultivation, while extremely profitable for the corporations, is not especially profitable for the farmers themselves.  For each dollar spent on a pack of cigarettes in the United States, tobacco farmers earn <$0.03, while tobacco companies earn >$0.63.[25]  This translates into many tobacco farmers seeking supplementary part-time or even full-time employment away from the home as 71% of all tobacco growers in the United States earn less than $20,000 annually.[26]  Additionally, from 1938 until this year, tobacco farmers in the United States were forced to work under the Federal tobacco program’s quota system that regulated the amount of tobacco crop each grower could produce annually in order to raise market prices nationally.  With declining tobacco use in the 1990s, tobacco quotas were lowered in 1997, further negatively impacting incomes for tobacco farmers in the United States.[27]  In October 2004, governments instituted the Fair and Equitable Tobacco Reform in order to lower market prices by 30-40 percent, allowing demand for tobacco to increase and keeping the tobacco market competitive both in the United States and abroad.[28]  The effect this reform will have on tobacco farmers and their economic situation has yet to be determined.  Though with the annual farming incomes averaging at about $20,000, an economic increase is predicted.

 

Tobacco farming is extremely labor-intensive and involves the use of costly products such as fertilizers and pesticides (often sold to growers by tobacco companies at the onset of the season).[29]  It is estimated that approximately 250 labor hours are required to bring each acre of harvested tobacco to consumers in developed countries (each acre yields approximately 2,000 lb. of tobacco at harvest) and 400-500 labor hours are needed in underdeveloped countries.[30]  Additionally, illness and injuries are quite common in farming, particularly in tobacco cultivation.  Aside from exposures to pesticides, another common chemical occupational hazard among growers and tobacco handlers is Green Tobacco Sickness (GTS).  People pick up this illness through the dermal absorption of nicotine caused by skin contact with wet tobacco leaves or tobacco plant contact with wet clothing, causing individuals to become stricken with symptoms such as nausea, feebleness, cramps, migraines, faintness, and variability in blood pressure and pulse.[31] 

 

To illustrate the injuries and medical costs associated with tobacco workers and growers, Struttman et al. (2002) conducted an eight-year evaluation of Kentucky farmers where tobacco, particularly burley tobacco, is the leading cash crop for the state.[32]  Burley tobacco farms tend to possess fewer acres, as the growing process for burley tobacco is less mechanized than other types of tobacco or other types of agricultural harvesting and the geography of the localities producing burley tobacco restrict farm acreage as they are amidst hilly terrain.[33]  Burley tobacco harvesting comprises multiple stages, including tasks such as tobacco spearing and hanging tobacco plants from barn tiers for drying.  The investigators excluded incidences of Green Tobacco Sickness in their research, but included all other types of injuries in their analysis in order to obtain a final count of 674 injuries and an estimated total hospital cost of $273,387 (not including medical providers’ costs, rehabilitation fees, etc.).   Individually, the average cost per laborer was $403 with more than one quarter of all injured individuals lacking insurance coverage on any kind and 17% of individuals covered by Medicare and Medicaid.  The cost analysis also omits the expenditures associated with lost work time and wages paid to substitute laborers.   Further, the researchers even alluded to the idea that 674 might be a conservative number of injuries, as underreporting by hospital staff appeared to have occurred during some years of the study.  But, among injuries reported, the most common injuries involved falls, piercing/cuttings, overexertion, and agricultural machinery.  These types of injury are not as common in traditional agriculture, as tobacco farming tend to employ less mechanization and more manual labor. 

 

With all of the agricultural expenditures, illness, injury, and minimal profits, tobacco farming, though more profitable than other agricultural endeavors, is not as lucrative as the tobacco companies make it seem.  Further, though the tobacco companies speak of the economic hurt tobacco farmers would incur if tobacco control legislation were passed, among the tobacco-producing counties in the United States, approximately half of these regions gain 1% or less of their net income from tobacco farming.[34]

 

Research examining farming alternatives has been conducted in the flue-cured tobacco farming industry.  Flue-cured tobacco farming is more mechanized, has higher acreage, and generates more revenue than burley tobacco farming.[35]  In an effort to examine alternative agricultural opportunities for flue-cured tobacco growers, Purcell et al. (2003) conducted a case study in Pittsylvania County, Virginia using 1997 data (a time period before the tobacco quotas were lowered among farmers nationwide due to reduced tobacco consumption).[36]  The investigators utilized Geographic Information Systems (GIS) and Linear Programming (LP) in order to analyze approximately 7,900 acres in the region for crop and livestock alternatives.  Researchers assessed the baseline net revenue for various scenarios of farming options and found that with a 50 percent cut in tobacco quota, Pittsylvania tobacco farmers were subject to a minimum 16.9% baseline net revenue loss.  So, though tobacco farming is not extremely profitable, it generates more revenue than traditional agriculture growing and livestock alternatives.  Therefore, in evaluating tobacco control legislation, the economic effect on tobacco growers should be considered.

 

In an economic analysis of tobacco farming, Altman et al. estimated that the total number of jobs lost in the South would be approximately 36,500 should tobacco use be eliminated in the United States.[37]  However, Altman went on to mention that economic safeguards could be implemented to control for the adverse economic impact in the South.  He proposed that state and/or federal governments could raise tobacco excise taxes and allocate increased revenue for tobacco-reliant regions, particularly for tobacco harvesters.  The allotted funds could be used to help farmers diversify their land or to aid conversion into alternative ventures altogether.  This would safeguard harvesters from job loss while encouraging them to become less dependent on tobacco profits.  It would also protect growers from the financial risk associated from attempting ventures into new enterprises and offset the financial burden of start-up costs.  Additionally, Altman points out that some governments in tobacco-producing states (particularly Virginia and Kentucky) tender low-interest loans for small businesses (such as tobacco farms) interested in diversifying. 

 

Tobacco Corporations and Marketing Campaigns

As mentioned previously, tobacco companies in the United States earn more than sixty cents for each pack of cigarettes sold, a higher profit margin than farmers, government taxes, and retailers combined.  Philip Morris, a United States tobacco corporation noted for the Marlboro brand name, is the world’s leading tobacco company, holding 16.4% of the global market and with net earnings of 47 billion US dollars in 1999 alone.[38]  Other leading tobacco corporations selling tobacco in the transnational market include: the United Kingdom’s British American Tobacco (BAT) with 15.4% of the global market, Japan Tobacco International (JTI) with 7.2% of the market, Germany’s Reemsta with 2.6% of the market, and Spain’s Altadis with 1.9% of the market.[39]  In order to maintain high net earnings, tobacco companies utilize massive advertising campaigns in an effort to attract new consumers, particularly younger consumers.

 

In the United States in 1970, tobacco companies spent 361 million dollars on advertising, while in 1993 tobacco companies spent six billion dollars.[40]  Though the United States government banned televised marketing in 1994, tobacco advertising expenditures remain high.  Tobacco companies continue to advertise using promotional allowances, special offers/gifts, coupons, in-store advertising, entertainment, magazines/newspapers, specialty item distribution, sporting events, direct mail, free samples, outdoor marketing (e.g. outside convenience stores), public transport, and the internet for a total marketing campaign cost of approximately 9,660,950,000 dollars (about $200 per smoker or $0.46 per pack of cigarettes) in the year 2000 alone.[41]  In fact, as the number of smokers and total cigarette consumption has been declining, the tobacco industry continues to spend more money each year on advertising.[42] 

 

As mentioned previously, tobacco companies also benefit from their marketing campaign as it attracts potential consumers, particularly adolescents.  In a study of 2,518 California adolescents in 1999, Pierce et al. (2002) found two primary social persuasions that were significant forecasters of adolescent smoking were peer pressure and receptiveness to tobacco corporate marketing campaigns.[43] Though adolescents with more-authoritative parents tended to smoke less than adolescents with less-authoritative parents, having friends who smoke and interest in advertising were still the chief determinants of adolescent experimentation with tobacco.  Tobacco consumption among adolescents is also influenced by the cost of cigarettes (the cheaper it is, the more teens will try/continue smoking) and tobacco company promotions (i.e. clothing and other paraphernalia), another type of marketing often employed by the tobacco industry.[44]

 

Tobacco advertisements are also found in discreet fashion in films and on television, both through brand appearance and tobacco consumption.  It could be argued that children and are a major target of this type of advertising as one review of 50 G-rated animated films found 76 characters using tobacco products for a total duration of 45 minutes.[45] Another study has found that 90 percent of films reviewed for various age groups have incidences of cigarette consumption.[46]  Researchers have also found that children and adolescents observing cigarette smoking and brand exposure in movies is a potential risk factor for introduction to tobacco use (the findings were statistically significant, even when controlling for peer pressure, personality traits, and parental influence).[47]  One study has also noted that the fictitious cigarette smoking represented in film does not mimic reality of smoking.  In movies, smokers are depicted as influential, wealthy, romantic, and cool, with the addictive nature of nicotine seldom symbolized, while the reality that the majority of smokers have a lower socioeconomic status is hidden.[48] 

 

 

Tobacco Cessation and Healthy People 2010 (www.healthypeople.gov)

Healthy People 2010 is a Center for Disease Control program that establishes a holistic set of national health objectives in an effort to measure health improvement over the decade.  Healthy People was established in 1979 with “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention”.  The goal of the Healthy People program is to remove disparities from the health care system while improving quality and years of healthy life among Americans.  Healthy People have identified 28 health focuses, 467 specific objectives, and ten leading health indicators (major national health issues) for the current decade.  Tobacco use is classified as a one of the public health issues and there are 27 objectives related to tobacco exposure in non-smokers, current tobacco use, smoking cessation, advertising, tobacco use in the workplace, and governmental tobacco control legislation.  Healthy People 2010 includes the following specific objectives: to decrease cigarette consumption among adults to 12 percent, to decrease current cigarette use among adolescents to 16 percent, to increase the average age adolescents try smoking from 12 years to 14 years, and to increase smoking cessation attempts among adults (to 75 percent) and adolescents (to 84 percent).  Though federal tax still collects $0.11 per tobacco dollar[49] and though tobacco companies continue to spend millions of dollars on campaign contributions for the United States government and on lobbying in Congress,[50] the federal government is starting to take a more active role on the issue of tobacco cessation through the implementation of programs like Healthy People 2010. 

 

 

Transtheoretical Model of Change

Prochaska, DiClemente, and Norcross[51] (1992) originally proposed the Transtheoretical Model of Change to describe an individual’s attempt to quit smoking (the theory has now been applied to a variety of problematic behaviors).  Stage one is the Precontemplation stage when the individual is not sincerely considering the idea of suspending tobacco use at any point in the future.  This is the least active stage and individuals are frequently either unaware or “underaware” of their nicotine addiction or the harm it is causing them at this point.  Stage two is Contemplation when the individual realizes they have a problem and is now considering an attempt to terminate their smoking habit.  Though they are thinking about quitting, they have not yet committed themselves or resolved to try at this point.  Stage three is Preparation when the individual intends to try to quit in the next month and has attempted to quit in the past year, though unsuccessfully.  At this time, a person may modify their behavior by reducing cigarette consumption, though smoking is not entirely eliminated at this point.  Stage four is Action when the individual has made behavioral changes, has committed him/herself to attempting cessation, and abstains from smoking for a period of one day to six months.  Stage five is Maintenance when an individual continues to abstain from smoking and is making an effort to avoid relapse from the time period of six months or longer.  At this point, an individual is continuing in their prior efforts and expanding behavioral changes.  Additionally, individuals may or may not experience or advance through all of the stages.  Some people skip stages when attempting tobacco cessation. 

 

Research has demonstrated that the leading predictor of a successful cessation attempt for individuals using the Transtheoretical Model is a person’s readiness to change.[52]  Though a person may have intentions of quitting, they may not be prepared for the behavioral modifications necessary for tobacco cessation.  Prochaska et al. (1992) reason that while 50-60 percent of smokers are in the Precontemplation stage, 30-40 percent of smokers are in the Contemplation stage, and only 10-15 percent of smokers have advanced to the Action stage.[53]

 

Primary Health Care Professionals and Cognitive/Behavioral Interventions

Russell et al. (1979) conducted an early study of smoking cessation and medical intervention in the United Kingdom with more than 2,000 current smokers participating in the research project.[54]  Subjects visiting their general practitioner for regular consultation were randomized to one of three intervention groups or a nonintervention control group.  The three intervention groups were: participants given a smoking questionnaire given prior to their appointment, participants given a one to two minute smoking cessation guidance, and participants given both a one to two minute smoking cessation guidance and leaflet containing instructions on how to quit.  Smoking cessation was evaluated after one year had elapsed.  While 0.3% in the control group had quit, 1.6% in the questionnaire group had quit, 3.3% in the guidance group had quit, and five percent of individuals given instruction and the leaflet were no longer smoking.  These findings demonstrate that medical intervention, no matter how brief, may have a statistically significant effect on prompting individuals to make a successful attempt at smoking cessation.

 

Presently, tobacco cessation programs tend to vary in length of program (ranging from one day to ongoing treatment unspecified in duration) and in type of program (whether it utilizes multiple types of support, contains multiple steps, or are single-faceted interventions).  In a United States Public Health Report reviewing more than 6,000 research articles and abstracts from the Journal of the American Medical Association (2000), various smoking cessation treatment methods relating to clinical practices were evaluated.[55]  The issue of the dose-response relationship between level of nicotine dependence and length of cessation counseling was mentioned as cigarette consumption varies among tobacco users and has a potential effect on successful cessation.  However, the authors noted that in some cases a brief intervention may be successful.  Practical counseling and social support offered during and/or outside of treatment were reported to be particularly valuable methods for increasing smoking cessation success rates among individuals.  Further, the importance of the availability of cost-effective treatment and health insurance coverage for such programs was highlighted, as many smokers are of a lower socioeconomic status.  Of particular mention was the “5 As” strategy, a program to aid individuals seeking smoking cessation.  This strategy recommends that patients are systematically ASKed whether they use tobacco in order to identify smokers; that identified smokers be ADVISEd to quit; that health care professionals ASSESS whether identified smokers wants to quit; that a health care professionals ASSIST identified smokers who want to quit; and that health care workers ARRANGE follow-up sessions for identified smokers who want to quit.[56]  

 

Nicotine Replacement Therapy and Pharmacological Cessation Treatments

Due to the addictive nature of nicotine, smoking cessation is extremely difficult and relapse is common among individuals who attempt to quit.  As withdrawal symptoms can be difficult to endure among nicotine-dependent individuals, nicotine replacement methods and pharmacological aids are often employed to support individuals attempting to quit smoking.  However, it is recommended that individuals should first attempt cessation independent of any nicotine replacement therapy method or pharmacological aid.[57]  Nicotine replacement methods deliver lower nicotine levels to the body than derived from smoking without the carcinogenic effects of tobacco.  NRT methods are neither toxic nor addictive or habit-forming[58] and are often available over the counter.  As previously mentioned, cigarette smoking delivers nicotine to the body in 6-7 seconds, while nicotine replacement therapy is not absorbed as quickly.  Nicotine replacement products are intended to be and most effective when used as an adjunct to treatment rather than a replacement for other cessation programs or counseling.[59]  

 

Nicotine replacement methods include: Nicotine gum, the Nicotine transdermal patch, the Nicotine nasal spray, the Nicotine inhaler, and the Nicotine sublingual tablet.  In a meta-analysis of 53 nicotine replacement therapy (NRT) studies (17,703 participants) findings suggested that NRT 6-12 month cessation rates are twice as high (15-25%) with an odds ratio of 1.71 (95% CI=1.56-1.87) than when compared to control study participants who are attempting cessation independent of any nicotine replacement method. [60]  The current NRT products have demonstrated similar efficacy in use, although little research has been conducted to compare the different nicotine replacement methods to each other.  This is particularly important considering that the various nicotine replacement methods have different effects on the body.  While nicotine gum, nicotine nasal spray, and nicotine inhalers are administered through self-dosing when the individual is “craving” nicotine and absorbed by the body within minutes, the nicotine transdermal patch is adhered to the body in the morning and functions by administering an extended release of nicotine to the individual over the course of a day.  These products are offered in varying doses and can be dispensed to individuals based upon the degree of nicotine dependence.  Though intended for short-term use and to be weaned steadily as the degree of nicotine dependence diminishes, some individuals do employ nicotine replacement methods for extended periods of time.  Nicotine replacement methods are sometimes combined to combat withdrawal symptoms for an individual attempting cessation (i.e. nicotine gum used in conjunction with the nicotine transdermal patch).[61]

 

For some individuals, pharmacological treatment is employed, as some prescription medications have been found to be effective in the off-label use of aiding smoking cessation.  These medications are sometimes prescribed in addition to NRT methods, although they can be administered independent of NRT methods.  Commonly used as antidepressants, Buproprion (Wellbutrin), Doxepin, Desipramine, and Nortriptyline, exhibit evidence that they may increase smoking abstinence in moderate to heavy smoking individuals.[62]  Clonidine, an Alpha2-adregenergic agonist (often used to manage hypertension), is sometimes prescribed to curb withdrawal symptoms in individuals unable to tolerate other pharmacological aids and nicotine replacement methods.  Although, Clonidine is administered as a final option due to side effects like dry mouth, sedation, and dizziness.[63]  Other pharmacological treatment methods have been evaluated as aids to tobacco cessation and yielded inconclusive results, including medications such as appetite suppressants, benzodiazepines, beta-blockers, buspirone, caffeine/ephedrine, cimetidine, dextrose tablets, lobeline, moclobemide, and SSRIs.[64] 

 

Successful Tobacco Cessation Studies and Program Implementation

While some tobacco cessation programs exist relatively independently, other programs are part of a holistic public health initiative.  The North Karelia Project is an example of a region’s all-encompassing health initiative.[65],[66]  The North Karelia project began in 1972 as an effort to reduce the high rates of cardiovascular diseases in the community.  Local representatives, national experts, and World Health Organization officials implemented a campaign to urge citizens modify their diet and quit smoking in order to avoid cardiovascular diseases.  This region was one of the first localities to ban smoking in public places and even popularized smoking cessation using national broadcasts and “quit and win” competitions.  Cholesterol-lowering promotions were also popular and government assistance prompted many dairy farmers to convert their farms to berry production.  Though the project was originally intended to last for five years, it went on until 1997, twenty years after it’s original stop date.

A similar initiative has been developed in Victoria, Australia.  VicHealth has identified a number of priority health issues in the region, mainly: healthy eating, built environment, inequalities, mental health and well-being, physical activity, substance misuse, sun protection, and tobacco control.[67]  This organization has been instrumental in developing programs like: “the walking school bus”, an “out of school hours sports program”, “arts for health program”, and many other pro-health safety behavior programs.  The VicHealth Centre for Tobacco Control is an extension of VicHealth and works in conjunction with Quit Victoria in an effort to reduce tobacco rates among the 19.2% of Australian adults who currently smoke in Victoria.[68]  Together, the VicHealth Centre for Tobacco Control and Quit Victoria are working to educate Victorians about the adverse effects of smoking, the negative impact of marketing campaigns, the benefits of committing to a smoking cessation program, the positive impact of promoting tobacco control legislation removing smoking from sporting venues, dining areas, and other public places, and efforts to keep youth from attempting to smoke.  Their website promotes smoking cessation with a mascot (Will Power), a song, a quit calendar, and smoking cessation research and literature.

 

 

In a 1993 to 1996 smoking cessation program implemented in 20 primary care clinics in Pennsylvania, primary care nurses recruited 1,695 patients.[69]  The study was sponsored by a health maintenance organization (HMO).  Patients with an HMO (that supported nicotine replacement therapy) were compared to those without an HMO.  After a one-year enrollment period that included scheduled smoking cessation counseling visits, patients with an HMO self-reported quitting at a rate of 30.5 percent compared to those without an HMO who reported cessation at a 20.9 percent quit.  Those without an HMO were less likely to maintain smoking cessation counseling visits.  This study supports the theory that smoking cessation rates increase with a cost-effective therapy and that quitting is more successful when cessation attempts combine counseling and nicotine replacement therapy.

 

There are special interest groups that need to be considered on the subject of smoking cessation.  Smoking tends to be higher among mental health patients, as dual diagnosis common within this population.  Yet, although this theory has been repeatedly reinforced, little research has been conducted on the subject smoking cessation programs within mental health populations.

 

Tobacco Control Legislation

Legislation has historically had a direct and indirect effect on tobacco cessation.  As it was previously mentioned, federal excise taxes could serve as a potential funding source for tobacco growers.  However the implementation of additional taxes, smoking bans, and advertising tobacco control legislation could all have an indirect effect on cigarette consumption as well.

 

The effects of second-hand smoke (or environmental tobacco smoke) and the move towards indoor smoking bans (or clean air indoor policy) are a strong initiative currently being debated in many cities and states nationwide.  While California, Florida, Massachusetts, New York, and Vermont have all adopted anti-smoking legislation within bars and restaurants in an effort to make more workplaces smoke-free, cities in thirty states have followed suit[70] with most clean indoor air policies being implemented through self-enforcement.[71]  While the arguments in favor of smoking restrictions in public places and workplaces lie in the harmful effects of environmental tobacco smoke, smoking restrictions also tend to have an indirect effect on smoking prevalence and daily cigarette consumption.[72]  This may be particularly true for current smokers who are in the contemplation stage, as it may influence them to move into the preparation and/or the action stage.[73]  An additional benefit to more public smoking restrictions is the removal of further social influences for onset in adolescents.[74]  So, while Clean Air Indoor Policies may limit the amount environmental tobacco smoke in public, it may also influence smoking prevalence, cigarette consumption, and onset within the general population. 

 

Further research has indicated that other tobacco control factors tend to decrease smoking prevalence rates in adolescents.  It has been suggested that a tobacco price or tax increase of ten percent could potentially reduce tobacco consumption anywhere from three to six percent within the general population, especially among adolescents who where higher tobacco prices have led to dramatically decreased tobacco sales in the past.[75]  Additionally, though laws exist restricting the sale of cigarettes to minors, enforcement of these laws has been weak.[76]  By restricting access, adolescent onset and prevalence rates could decrease.  As previously mentioned, research has demonstrated that children and adolescents are influenced (if not, targeted) by the marketing campaigns of the tobacco industry.  So, obviously by further restricting the ability of tobacco companies to market to the general public, onset rates in adolescents could be reduced.[77]

 

Tobacco Information and Cessation Resources

1.      About Smoking: http://www.quitsmoking.about.com/

2.      Agency for Healthcare Research and Quality: http://www.ahrq.gov/consumer/index.html#smoking

3.      American Cancer Society: http://www.cancer.org/docroot/PED/ped_10.asp

4.      American Legacy Foundation: http://www.americanlegacy.org/

5.      American Lung Association: http://www.lungusa.org/

6.      Center for Disease Control and Prevention (TIPS): http://www.cdc.gov/tobacco/

7.      Center for Tobacco Cessation: http://www.ctcinfo.org/

8.      Circle of Friends (for women): http://www.join-the-circle.org/

9.      Clean Break Online: http://www.cleanbreak.com/

10.  Great Start (for pregnant women): http://www.americanlegacy.org/greatstart/

11.  Healthy Living-TLC (The Last Cigarette): http://www.bcbsmo.com/healt_links/healthyliving/TLC.shtml

12.  National Cancer Institute Smokefree Site: http://smokefree.gov/

13.  National Institute of Drug Abuse: http://www.nida.nih.gov/

14.  North American Quitline Consortium: http://www.naquitline.org/

15.  QuitNet: http://www.quitnet.com/

16.  Stand Ohio (for adolescents): http://www.standohio.org/index.asp

17.  Treatobacco.net: http://www.treatobacco.net/home/home.cfm

18.  World Health Initiative, Tobacco Free Initiative: http://www.who.int/tobacco/en/



[1] The Columbia Electronic Encyclopedia, 6th Edition.  New York, New York: Columbia University Press; 2003.

[2] “Nicotine”.  March 13, 2005.  Wikipedia. http://en.wikipedia.org/wiki/Nicotine

[3] The Tobacco Epidemic.  New York, New York: Karger, 1997.

[4] Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).  Washington, D.C.: American Psychiatric Association, 2000.

[5] “Cigarette Smoking Among Adults – United States, 2002”.  Morbidity and Mortality Weekly Report (MMWR).  May 28, 2004; 53(20): 427-431.

[6] Fiore, M.C.  “Trends in Cigarette Smoking in the United States: The Epidemiology of Tobacco Use”.  Medical Clinics of North America.  2002; 76: 289-303.

[7] “NIDA Infofacts: Cigarettes and Other Nicotine Products”.  March 2005.  National Institute on Drug Abuse.  http://www.nida.nih.gov/Infofax/tobacco.html

[8] Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).  Washington, D.C.: American Psychiatric Association, 2000.

[9] “The Burden of Tobacco Use among Adults”.  Dublin, Ohio: Tobacco-Free Ohio, 2001.

[10] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[11] Kopstein, A.  “Tobacco Use in America: Findings from the National Household Survey on Drug Abuse”.  January 2, 2002.  Department of Health and Human Services: Substance Abuse and Ment Health Services Administration.  http://media.shs.net/Prevline/pdfs/tobacco.pdf

[12] “Tobacco Increases the Poverty of Individuals and Families”.  2004.  World Health Organization.   http://www.paho.org/English/AD/SDE/RA/TOB_FactSheet1.pdf

[13] Petersen, P.  “Tobacco and Oral Health: the Role of the World Health Organization”.  Oral Health and Preventative Dentistry.  2003, 1(4): 309-315.

[14] “The Burden of Tobacco Use among Adults”.  Dublin, Ohio: Tobacco-Free Ohio, 2001.

[15] Womach, J.  “Tobacco Price Support: An Overview of the Program”.  June 10, 2004.  Library of Congress: Congressional Research Service. http://www.ncseonline.org/NLE/CRSreports/04Jun/95-129.pdf

[16] “Demographics and Health Effects”.  January 2005.  Database and Educational Resource for the Treatment of Tobacco Dependence.  http://www.treatobacco.net

[17] “Tobacco Information and Prevention Source (TIPS)”.  January 26, 2005.  Center for Disease Control-National Center for Chronic Disease Prevention and Health Promotion.  http://www.cdc.gov/tobacco/issue.htm

[18] Kmietowicz, Z.  “Tobacco Company Claims that Smokers Help the Economy”.  British Medical Journal.  July 21, 2001; 323: 126.

[19] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[20] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[21] Warner, K.  “The Economies of Tobacco:Myths and Realities”.  Tobacco Control.  2000, 9:78-89

[22] Womach, J.  “Tobacco Price Support: An Overview of the Program”.  June 10, 2004.  Library of Congress: Congressional Research Service. http://www.ncseonline.org/NLE/CRSreports/04Jun/95-129.pdf

[23] Capehart, T.  “Trends in U.S. Tobacco Farming”.  November 2004.  Economic Research Service, US Department of Agriculture.  http://www.ers.usda.gov/publications/tbs/nov04/tbs25702/

[24] Altman, D., Levine, D., Howard, G, and Hamilton, H.  “Tobacco Farming and Public Health: Attitudes of the General Public and Farmers”.  Journal of Social Issues.  1997, 53(1): 113-128.

[25] Altman, D., Levine, D., Howard, G, and Hamilton, H.  “Tobacco Farming and Public Health: Attitudes of the General Public and Farmers”.  Journal of Social Issues.  1997, 53(1): 113-128.

[26] “Tobacco Increases the Poverty of Individuals and Families”.  2004.  World Health Organization.   http://www.paho.org/English/AD/SDE/RA/TOB_FactSheet1.pdf

[27] Capehart, T.  “Trends in U.S. Tobacco Farming”.  November 2004.  Economic Research Service, US Department of Agriculture.  http://www.ers.usda.gov/publications/tbs/nov04/tbs25702/

[28] Capehart, T.  “Long-Lived Tobacco Program to End”.  February 2005.  Amber Waves: Economic Research Service, U.S. Department of Agriculture.  http://wwwers.usda.gov/AmberWaves/February05/Findings/LongLivedTobacco.htm

[29] “Tobacco Increases the Poverty of Individuals and Families”.  2004.  World Health Organization.   http://www.paho.org/English/AD/SDE/RA/TOB_FactSheet1.pdf

[30] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.

[31] “Tobacco Increases the Poverty of Individuals and Families”.  2004.  World Health Organization.   http://www.paho.org/English/AD/SDE/RA/TOB_FactSheet1.pdf

[32] Struttmann, T. and Reed, D.  “Injuries to Tobacco Farmers in Kentucky”.  Southern Medical Journal.  August 2002, 95(8): 850-856.

[33] Capehart, T.  “Trends in U.S. Tobacco Farming”.  November 2004.  Economic Research Service, US Department of Agriculture.  http://www.ers.usda.gov/publications/tbs/nov04/tbs25702/

[34] Warner, K.  “The Economies of Tobacco:Myths and Realities”.  Tobacco Control.  2000, 9:78-89

[35] Capehart, T.  “Trends in U.S. Tobacco Farming”.  November 2004.  Economic Research Service, US Department of Agriculture.  http://www.ers.usda.gov/publications/tbs/nov04/tbs25702/

[36] Purcell, W., Taylor, D., and Halili, R.  “Evaluating Alternative Agricultural Enterprises in a Flue-Cured Tobacco-Producing Region of Virginia: A Case Study”.  August 2003.  Virginia Tech.  http://www.reap.vt.edu/publications/reports/r58rev.pdf

[37] Altman, D., Levine, D., Howard, G, and Hamilton, H.  “Tobacco Farming and Public Health: Attitudes of the General Public and Farmers”.  Journal of Social Issues.  1997, 53(1): 113-128.

[38] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[39] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[40] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.

[41] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[42] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[43] Pierce, J., Distefan, J., Jackson, C., White, M., Gilpin, E.  “Does Tobacco Marketing Undermine the Influence of Recommended Parenting in Discouraging Adolescents from Smoking?”.  American Journal of Preventative Medicine.  2002, 23(2):73-81.

[44] Sargent, J. and DiFranza, J.  “Tobacco Control for Clinicians Who Treat Adolescents”.  CA A Cancer Journal for Clinicians.  March/April 2003, 53(2): 102-123.

[45] Goldstein, A., Sobel, R., Newman, G.  “Tobacco and Alcohol Use in G-Rated Children’s Animated Films”.  Journal of the American Medical Association.  March 24/31, 1999: 281(12): 1131-1136.

[46] Dalton, M., Tickle, J, Beach, M., et al.  “The Incidence and Context of Tobacco Use in Popular Movies from 1988-1997”.  Preventative Medicine.  2002, 34:516-523.

[47] Sargent, J., Beach, M., Dalton, M., et al.  “Effect of Seeing Tobacco Use in Films on Trying Smoking Among Adolescents: Cross-Sectional Study”.  British Medical Journal.  2001, 323: 1394-1397.

[48] Sargent, J. and DiFranza, J.  “Tobacco Control for Clinicians Who Treat Adolescents”.  CA A Cancer Journal for Clinicians.  March/April 2003, 53(2): 102-123.

[49] Mackay, J. and Eriksen, M.  The Tobacco Atlas.  Geneva, Switzerland: World Health Organization, 2002.

[50] Lindblom, E. and McMahon, K.  “Toll of Tobacco in the United States of America”.  February 14, 2005.  Campaign for Tobacco-Free Kids.  http://tobaccofreekids.org/research/factsheets/pdf/0072.pdf

[51] Prochaska, J., DiClemente, C., and Norcross, J.  “In Search of How People Change: Applications to Addictive Behaviors”.  American Psychologist.  1992, 47: 1102-1114.

[52] Ward, K., Klesges, R., and Halpern, M.  “Predictors of Smoking Cessation and State-of-the-Art Smoking Interventions”.  Journal of Social Issues.  1997, 53(1): 129-145.

[53] Prochaska, J., DiClemente, C., and Norcross, J.  “In Search of How People Change: Applications to Addictive Behaviors”.  American Psychologist.  1992, 47: 1102-1114.

[54] Russell, M., Wilson, C., Taylor, C., Baker, C.  “Effect of General Practitioner Advice against Smoking”.  British Medical Journal.  July 28, 1979, 2(6814): 231-235.

[55] “A Clinical Practice Guideline for Treating Tobacco Use and Dependence”.  Journal of the American Medical Association.  June 28, 2000, 283(24): 3244-3253.

[56] Anderson, J., Jorenby, D., Scott, W., Fiore, M.  “Treating Tobacco Use and Dependence”.  Chest.  March 2002, 121(3): 932-941.

[57] Fiore, M., Bailey, W., Cohen, S. et al.  “Treating Tobacco Use and Dependence”.  Rockville, Maryland: U.S. Department of Health and Human Services, National Institute of Health (NIH Pub. No. 01-4342), August 2001.

[58] Henningfield, J. and Keenan, R.  “Nicotine Delivery Kinetics and Abuse Liability”.  Journal of Consulting and Clinical Psychology.  1993, 61: 1-8.

[59] Ward, K., Klesges, R., and Halpern, M.  “Predictors of Smoking Cessation and State-of-the-Art Smoking Interventions”.  Journal of Social Issues.  1997, 53(1): 129-145.

[60] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.

[61] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.

[62] Fuller, M. and Sajatovic, M.  Drug Information Handbook for Psychiatry: A Comprehensive Reference of Psychtropic, Non-Psychotropic, and Herbal Agents, 3rd Edition.  Hudson, Ohio: Lexi-Comp, Inc., 2002.

[63] Fuller, M. and Sajatovic, M.  Drug Information Handbook for Psychiatry: A Comprehensive Reference of Psychtropic, Non-Psychotropic, and Herbal Agents, 3rd Edition.  Hudson, Ohio: Lexi-Comp, Inc., 2002.

[64] Fiore, M., Bailey, W., Cohen, S. et al.  “Treating Tobacco Use and Dependence”.  Rockville, Maryland: U.S. Department of Health and Human Services, National Institute of Health (NIH Pub. No. 01-4342), August 2001.

[65] “The North Karelia Project”.  Cardiovascular Health Practitioners’ Institute.  http://www.cvhpinstitute.org/links/northk.htm

[66] Nissinen, J.  “The North Karelia Project”.  February, 25, 2000.  Cardiovascular Health Practitioners’ Institute.  http://www.cvhpinstitute.org/nissinen/an2.htm

[67] “VicHealth”.  VicHealth.  http://www.vichealth.vic.gov.au/default.asp

[68] “VicHealth Centre for Tobacco Control.”  June 9, 2004.  VicHealth Centre for Tobacco Control.  http://www.vctc.org.au/index.html

[69] Sidorov, J., Christianson, M., Girolami, S., and Wydra, C.  “A Successful Tobacco Cessation Program Led by Primary Care Nurses in a Managed Care Setting”.  American Journal of Manageable Care.  February 1997, 3(2): 207-214.

[70] Nissimov, R. “Council Bans Smoking in Indoor Dining Areas”.  March 10, 2005.  Houston Chronicle. 

[71] Jacobson, P., Wasserman, J., and Anderson, J.  “Historical Overview of Tobacco Legislation and Regulation”.  Journal of Social Issues.  1997, 53(1): 75-95.

[72] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.

[73] Prochaska, J., Velicer, W., DiClementi, C., Farrer, J.  “Measuring Processes of Change: Applications to the Cessation of Smoking”.  Journal of Consulting and Clinical Psychology.  1980, 56:520-528.

[74] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.

[75] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.

[76] Jacobson, P., Wasserman, J., and Anderson, J.  “Historical Overview of Tobacco Legislation and Regulation”.  Journal of Social Issues.  1997, 53(1): 75-95.

[77] Bolliger, C. and Fagerstrom, K.  The Tobacco Epidemic.  New York, New York: Karger, 1997.