In 2005 some 40 percent of the 45 million adult smokers in the United States tried to quit. But most of them failed to stay off cigarettes for more than a few weeks. A closer look at why smokers have such a hard time overcoming their nicotine addiction reveals that many do not follow proven smoking cessation treatment strategies, such as those widely recommended by the United States Public Health Service (USPHS).
For example, the USPHS recommends that anyone trying to stop smoking should receive behavioral counseling and have access to anti-smoking medications that have been approved by the United States Food and Drug Administration (FDA). Research has shown that smokers who pursue a cessation program that includes brief counseling and medication are more likely to give up cigarettes and remain smoke-free than smokers who try to quit without assistance.
The problem is that most smokers who attempt to quit do so without getting any assistance and typically return to smoking within a few days or weeks. And among those who do get help, many pursue unproven stop smoking methods, such as hypnosis, acupuncture, cutting back on the amount smoked daily or switching to cigarettes that promise lower tar or nicotine content. Moreover, unsuccessful efforts to stop smoking can discourage future attempts.
Over the past ten years, SAPRP has funded several studies to examine particular policies and programs that might lead more smokers to pursue proven tobacco cessation treatments.
Tobacco use patterns have changed dramatically in the United States since the Surgeon General first issued his report on smoking and health in 1964. Today, there are more ex-smokers in the population than current smokers. Recent declines in cancer mortality have been attributed to reductions in cigarette smoking. Unfortunately, too many smokers delay quitting until it is too late to gain a real health benefit. Nearly half of all lung cancers diagnosed today are found in former smokers and most are detected in a late stage where prognosis is poor. Thus, one of the critical challenges facing tobacco control today is the need to persuade smokers, especially younger smokers, to quit sooner rather than later.
Most smoking cessation strategies involve efforts to convince smokers to at least attempt quitting and to use treatments that will increase their odds of staying smoke-free. Effective treatments for tobacco dependence are available, and new approaches to treatment are in the research pipeline.
However, if they are to make a significant contribution to reducing the public health problems caused by cigarette smoking, being effective is not enough. Treatment programs also have to be available and used by the people who need them. Highly effective interventions that reach only a tiny fraction of smokers will not have much impact on overall tobacco use. Thus, interventions that have the greatest chance of
reducing tobacco use in the population are those that are both accessible and effective.
Figure 1 provides a listing of tobacco control policies that research suggests are successful in building demand for and use of proven cessation treatments. Some of the policies listed affect cessation indirectly while others are specifically intended to improve the delivery of cessation treatments. However, in all cases, the effort to develop effective tobacco control policies is guided by two fundamental questions:
1. What can be done to persuade more smokers to attempt to quit?
2. Among those who do make a quit attempt how can we encourage them to make use of treatments that will increase their odds of staying smoke-free?
Research shows that concern about their health is the number one reason smokers try to quit. However, many smokers, especially younger smokers, perceive the health consequences of smoking as remote and irrelevant. This is why policies that reduce the appeal of tobacco products--such as higher taxes on cigarettes, comprehensive advertising bans, hard hitting anti-tobacco education campaigns, and smoke-free policies--represent the best initial hope for encouraging smokers to try to quit and thus can indirectly influence the demand for proven cessation methods.
It is also important to make the health consequences of smoking more relevant to individual smokers by getting healthcare professionals to deliver personalized cessation messages and quitting advice during routine patient visits and making better use of communications tools such as the Internet that allow for the delivery of personalize health messaging.
Once an individual smoker is persuaded of the need to quit, the second challenge is to them to use proven smoking cessation treatments that best suit their needs. Research shows that policies that make the treatments more accessible and affordable work the best.
For example, the recent Institute of Medicine (IOM) report on ending the tobacco epidemic observed that increased demand for and use of proven interventions--and hence, higher cessation rates--could be achieved by:
1) Reaching more smokers with cessation messages;
2) Providing incentives that encourage more smokers to attempt to quit;
3) Educating smokers about the benefits of using proven treatments when they do try to quit; and
4) Providing continuity of care and tailored interventions.
In the mid-1980s, over 90 percent of former smokers reported that they stopped smoking without using medications or receiving formal assistance or help from anyone. However, this statistic has changed over the past two decades with the introduction and wide-scale availability of medications to treat nicotine dependence.
Treatment guidelines from the USPHS recommend that all smokers making an attempt to quit should receive behavioral counseling and be offered FDA approved medications that can help people stop smoking. USPHS clinical practice guidelines recommend that health care workers screen all their patients for tobacco use and provide advice and quitting assistance to all tobacco users.
But despite these guidelines, population based surveys reveal that only about one in four smokers have ever tried an approved "stop smoking" medication or received counseling support to quit. Incentives in which providers are paid based on their performance are now being used to motivate health care professionals to improve the delivery of tobacco cessation treatments to their tobacco using patients.