Former Surgeon General C. Everett Koop called cigarette smoking the "chief, single, avoidable cause of death in our society and the most important public health issue of our time."1

Tobacco use is responsible for approximately 440,000 national deaths each year.2 The World Health Organization (WHO)3 estimated that 4.9 million people die annually as a result of tobacco-related diseases. This translates to 1 in 10 adults worldwide. Furthermore, the WHO estimated that consumer tobacco use, as indicated by manufacturers, kills one-half of its regular users.3

Cigarette smoking harms nearly every organ of the human body. 4 The surgeon general's list of complications from cigarette smoking includes: cancers of the lung, larynx, bladder, mouth, esophagus, stomach, pancreas, kidney, cervix; acute myeloid leukemia; abdominal aortic aneurysm; cataracts; chronic bronchitis and other respiratory diseases; cardiovascular disease; stroke; maternal and fetal complications; periodontal disease; and other life-threatening, costly illnesses.5

In addition, secondhand smoke causes respiratory diseases and lung cancer in adults, as well as respiratory diseases, allergies, more severe asthma, ear infections, and sudden infant death syndrome.6 Nicotine dependence is a chronic disease with multiple relapses and retreatment before attainment of complete abstinence.7

Despite the serious health consequences of tobacco use, healthcare providers do not always advise and assist patients to quit. Arday8 reported that 13% of enrollees in Medicare were current smokers, and among those who visited a healthcare provider, only 71% reported receiving advice to quit. Data from a 2000 population-based cross-sectional survey in the United States revealed that of 14,089 smokers, 69% reported never being advised to quit by their healthcare provider. Hispanics (50%) and African-Americans (61%) reported receiving counseling less frequently compared to whites (72%).9 Results are similar in Canada where a national survey indicated that only one-half of persons who visited healthcare providers received smoking cessation advice.10

Prevalence

The WHO3 has described smoking as an epidemic with approximately 1.3 billion smokers worldwide. Of those smokers, 84% live in countries with developing and transitional economies.3 Even though the prevalence of cigarette smoking has decreased by one-half since the 1960's in the United States, median prevalence of current smoking in the 50 states and DC in 2001 was 23.4% (range: 13.3% to 30.9%).11 Of these adult smokers, the median prevalence of cigarette smoking was 25.5% among men (range: 14.6% to 31.7%) and 21.5% among women (range: 12.1% to 30.1%).11 The decline in smoking has been seen mostly in affluent groups and is unequal across socioeconomic and ethnic groups.11 Cigarette smoking rates are higher in lower socioeconomic groups and among those with a high school education or less.12

Cultural and ethnic differences exist in the use and the effects of tobacco. Minorities are disproportionately poor and comprise a disproportionate percentage of smokers.9 African-Americans tend to prefer high nicotine and mentholated cigarettes, tend to inhale more deeply, have higher serum cotinine levels per cigarette smoked, and have a slower rate of cotinine clearance than other ethnic groups.13-22 These differences may partially explain why African-Americans suffer increased morbidity and mortality from smoking-related diseases and report difficulties with cessation.22-25 American Indians have a higher prevalence of cigarette smoking and a greater level of cigarette consumption than whites.23 Nationally, African-American and Southeast Asian men have the highest prevalence of smoking, and Asian-American and Hispanic women have the lowest prevalence.23 Chinese-Americans metabolize nicotine more slowly and take in less nicotine per cigarette than whites.26,27

Smokeless tobacco is either chewing tobacco (loose leaf, pouches, plugs, or twists) or snuff (moist or dry). The overall prevalence of smokeless tobacco among Americans ages 12 years and older is 7.7 million, or 3.3%.4 The highest rates of smokeless tobacco use are found in American Indians and Alaska Natives, followed by white males between 18 and 35 years of age. Smokeless tobacco use is higher in rural areas than urban areas.4,28

Figure. No caption available.

Newest Trends in Tobacco Use

Some of the newest trends in tobacco use are either smoked or smokeless and can be just as dangerous to health as traditional cigarettes. The "hottest" products are bidis, kreteks, hookah pipes, and tobacco lozenges. Bidis (tobacco wrapped in Asian tendu plant leaves and often flavored like fruits or chocolate) are becoming popular with young people. Bidis are advertised as a safe alternative to commercially prepared cigarettes. However, research shows that the smoke contains the same carcinogens as conventional cigarettes, often in higher concentrations. Also, the incidence of cancer is higher with bidis, and bidis contain up to three times higher amounts of nicotine.29-31

Kreteks (a mixture of tobacco, cloves, and other additives), also known as clove cigarettes, deliver twice the amount of tar, carbon monoxide, and nicotine as moderate-tar cigarettes manufactured in the United States.29 In addition, kreteks contain the anesthetic compound eugenol, which suppresses the gag reflex, numbs the back of the throat, and can lead to aspiration pneumonia.32

Arguileh or hookah water pipes contain flavored tobacco and are often smoked in hookah bars or cafes. Research by Shihadeh33 suggested that a single standard hookah pipe session may produce as much tar as 20 low-tar cigarettes.

Smokeless tobacco trends include chewing tobacco and snuff, and potential reduction exposure products (PREPs) such as Ariva (powdered tobacco lozenges), Accord (promoted as a "safer cigarette") and Revel (smokeless tobacco). These products have not been tested through toxicologic research or investigated for long-term use in humans.34

The surgeon general has reported that there is no such thing as a "safe cigarette."5 Ariva tobacco lozenges are particularly misleading because they are often placed next to nicotine replacement products in retail pharmacies and are advertised to stop nicotine cravings when smoking is not possible. Ariva should not be confused with Commit lozenges, which come in 2 milligrams and 4 milligrams doses and have been shown to be an effective smoking cessation method in a randomized clinical trial.35

Figure. No caption available.

Smokeless tobacco, including snuff and chewing tobacco, contains nicotine and toxins that cause pathologic changes in the mouth including cancer, leukoplakia, periodontal disease, inflammation, and ulceration.36 For a more complete discussion of PREP's, and a call to action for NPs to advocate regulation of tobacco products and nicotine delivery systems, see the article by Heath and colleagues.34

However, depending on the size and shape, cigars can be just as harmful as regular cigarettes. Compared to the standard cigarette in the United States, which contains between 7.2 and 13.4 milligrams per cigarette,37 the nicotine content in 10 commercially available cigars studied in 1996 ranged from 10 to 444 milligrams.38 Some premium cigars contain the tobacco equivalent of an entire pack of cigarettes.38 Like cigarettes, cigars can cause cancers of the oral cavity, larynx, esophagus, lungs, and pancreas, as well as heart and lung disease, depending on whether or not they are inhaled.39

Nicotine Dependence/Addiction

Substance dependence criteria outlined in the Diagnostic and Statistical Manual40 includes: withdrawal symptoms, increased use of the substance to obtain the same effects (tolerance), and inability to cut down or abstain from use despite knowledge of health hazards and the effects of substance use on ability to perform in daily life (productivity, cost, and so forth).

Nicotine is a highly addictive substance. When inhaled through a cigarette (a highly efficient drug delivery system), a "hit" of nicotine reaches the brain within 7 seconds. The neurobiology of nicotine addiction involves the release of dopamine stimulating the "pleasure pathway" in the brain.41

Nicotine, like cocaine, eventually replaces normal triggers of the pleasure pathway such as food, water, and sex, creating a physical as well as emotional dependence on the substance. Nicotine addiction is evident when the person engages in a compulsive behavior that is positively reinforcing (rewarding or pleasurable) and there is loss of control in limiting intake.40

People who are dependent on nicotine experience withdrawal symptoms (irritability, insomnia, moodiness, headache, difficulty concentrating) when they are unable to use tobacco, and have difficulty quitting. Nicotine dependence includes not only physiologic, but also emotional and psychological dependence.7

Recommendations for Treatment

Current evidence-based practice guidelines recommend that all healthcare providers perform the "5 A's"7 of tobacco treatment: Ask about tobacco use, Advise strongly that the tobacco user quit, Assess the patient's readiness to quit, Assist with quitting, and Arrange for follow-up. (see Table: "The 5 A's of Tobacco Treatment").7

Table. The 5 A's of Tobacco Treatment

Ask the patient if he/she has ever smoked or used any type of tobacco product. If the patient has smoked in the past and it has been less than 6 months since the last cigarette, the person is most likely in the "action" stage of behavioral change.42 The healthcare provider's role in this case is to assist during the quitting process and to help prevent relapse. If it has been more than 6 months since the patient quit using tobacco, he/she is in the "maintenance" stage of behavioral change.42 The healthcare provider's role in this case is to encourage continued abstinence and to help prevent relapse.

Assessing readiness to quit involves an assessment of the patient's thinking about quitting within the next 6 months. If the patient says "yes", then assess if the patient is thinking about quitting within the next 30 days. If the patient says "yes", he/she is in the "preparation" stage of change and needs help starting a plan to quit.42 If the patient is not thinking of quitting within the next 6 months, he/she is in the "precontemplation" stage, and the clinician's role is to continue to ask and offer assistance at every visit. If the patient is thinking of quitting within 6 months, but not 30 days, he/she is in the "contemplation" stage and the clinician's role is the same as the precontemplation stage.42

One biological risk factor is nicotine dependence. A quick and easy assessment of nicotine dependence is to ask the patient how soon after waking does he/she smoke in minutes (time to first cigarette [TTFC]). TTFC has a positive correlation with the Fagerstrom Test for Nicotine Dependence (FTND). The FTND is a short, easy-to-administer, reliable questionnaire with six questions used to measure nicotine dependence (see Figure: "Example of FTND").43 Higher scores indicate higher level of dependence, for example, a total score of 5 or higher indicates a high degree of nicotine dependence. The FTND has internal consistency ranges from 0.61 to 0.87 and acceptable construct validity.43

Figure. Example of FTND

A psychological risk factor is readiness to quit. A quick and easy assessment tool to determine readiness to quit is the Readiness to Quit Ladder.44 This 1-item, 11-point Likert scale has been shown to be reliable and valid,45 and is easily understood by people of various cognitive abilities, educational levels, and cultures.46 The higher the person scores on the Readiness to Quit Ladder, the more likely he/she is to quit47 (see Figure: "Readiness to Quit Ladder").

Figure. Readiness to Quit Ladder

There are several levels of smoking abstinence. Two measures commonly used are point prevalence abstinence and continuous abstinence. Seven-day point prevalence is the self-reported status of smoking at least 7 days prior to the time measured.48 Prolonged abstinence is sustained abstinence after an initial grace period in which smoking is not counted as a failure between two follow-ups.48 Smoking status can be validated with the use of a carbon monoxide monitor (breath) or cotinine level (saliva, blood, hair). Validation of smoking cessation can be positive reinforcement for people who are tapering off or who have quit tobacco use, and it can also substantiate practice or research outcomes.

Treatment

The most effective treatment for nicotine dependence includes treating the physiological, emotional, and behavioral components of the disease. Treatment should be tailored to the individual. However, the "cold turkey" approach is not recommended. Fiore et al.49 reported that when smokers try to quit on their own, their long-term success rate is only about 5%, compared with 15% to 25% when using the interventions recommended in the evidence-based practice guidelines. Evidence-based guidelines recommend that patients who are ready to quit be referred for intensive counseling, treated with appropriate medications to reduce the intensity of withdrawal symptoms, and encouraged to obtain social support (group or individual).7 The purpose of tobacco treatment is to help individuals quit using tobacco products for good if they are ready, and to help them progress to the next level in their readiness to quit.

Reviews of behavior change interventions suggest that more intensive smoking cessation programs have the strongest outcomes.46 Evidence supports that increased counseling intensity (in terms of total contact time, session length, and the number of sessions) improves quit rates for treatment of tobacco dependence. The Public Health Service's Treating Tobacco Dependence Guideline7 recommendations for intensive smoking cessation interventions include: 1) four to seven sessions 20 to 30 minutes in length over a minimum of 2 weeks; 2) individual and/or group counseling with problem-solving and skill training; 3) social support; 4) relapse prevention; and 5) pharmacotherapeutics (nicotine replacement therapy [NRT], bupropion [Zyban]). The National Cancer Institute recommends that cessation programs should: 1) target high-risk populations; 2) target specific stages of cessation; and, 3) tailor education for the targeted audience.50,51

First-line pharmacotherapy for tobacco cessation includes NRTs and bupropion. Medications may be used as monotherapy or in combination therapy for the most effective individual treatment. Some NRTs such as the patch, gum, or lozenge may be purchased over-the-counter (OTC). Oral inhalers or nasal spray and bupropion must be ordered by prescription (see Tables: "OTC Pharmacotherapy for Tobacco Cessation" and "Prescription Pharmacotherapy for Tobacco Cessation").

Table. OTC Pharmacotherapy for Tobacco Cessation

Table. Prescription Pharmacotherapy for Tobacco Cessation

All of the NRTs are pregnancy Category D and should not be given with recent history of myocardial infarction (less than 2 weeks), unstable angina, or serious underlying dysrhythmias.7 Most nicotine-dependent patients require at least 3 months of NRT to remain abstinent. Evidence-based practice guidelines7 state that it may be appropriate to continue pharmacotherapeutic treatment (bupropion or NRT) for longer than usually recommended.7 Nicotine (Nicoderm CQ, Habitrol, or generic) patches are available in 7, 14, and 21 mg doses and are prescribed based on the number of cigarettes (or amount of tobacco) used per day. The patient should be instructed to follow directions for application printed on the package, such as apply to hairless, clean, dry area (usually between the neck and waist) once per day; assure adherence to the skin; remove at bedtime if it disturbs sleep; and do not smoke or use tobacco with the patch. If the patch causes skin irritation, treat with an OTC corticosteroid cream upon removal and rotate site.

Nicotine gum (Nicorette) or lozenge (Commit) may be preferred monotherapy for patients who smoke or use smokeless tobacco, or may be used as adjunct therapy for breakthrough craving in patients already taking other tobacco treatment medications. Nicotine gum may be difficult to use if the patient has dentures or temporomandibular joint (TMJ) syndrome. Nicotine gum and lozenges come in 2 milligram and 4 milligram dosages. If the tobacco user smokes 25 or more cigarettes per day, the 4 milligram dose gum is recommended; if less than 25 cigarettes per day, the 2 milligram dose gum is recommended.52 If the patient desires a cigarette more than 30 minutes after awakening, the 2 milligram lozenge is recommended; for the patient who desires to smoke less than 30 minutes after awakening, the 4 milligram lozenge is recommended. The gum should be chewed slowly until the peppery or minty taste or tingling sensation appears, then "parked" between the cheek and gum, similar to "parking" chewing tobacco.7 Dosing for the gum is one piece every 1 to 2 hours for 6 weeks, then every 2 to 4 hours for 2 weeks, then every 4 to 8 hours for 2 weeks.52 The lozenge should be dissolved slowly while rotating the lozenge to different areas of the mouth.

Nicotine oral inhaler or nasal spray is contraindicated if the patient has severe reactive airway disease. In addition, nasal spray should be avoided with patients who have underlying chronic nasal disorders such as rhinitis, nasal polyps, and sinusitis.7 The metered nasal spray (Nicotrol) contains 0.5 milligram of nicotine in 50 microliter aqueous nicotine solution; each bottle contains approximately 100 doses or 1 week's supply. Dose is one spray (0.5 milligram nicotine) in each nostril, one to two times/hour. The nicotine oral inhaler is a 10 milligram cartridge that delivers 4 milligram of inhaled nicotine vapor. Patients should be instructed to puff the cartridge as if they are lighting a cigar or pipe. Dosing is 6 to 16 cartridges/day.52

Bupropion is a dopamine reuptake inhibitor used for treatment of depression (Wellbutrin) or smoking cessation (Zyban only). For smoking cessation, dosing is 150 milligram/day for 3 days, then 150 milligram b.i.d.7 Patients should take bupropion for at least 2 weeks prior to quitting tobacco use. Bupropion may be used safely with NRT and is usually taken for at least 6 months.7 Contraindications include a history of seizures, bulimia, or anorexia nervosa, or monoamine oxidase inhibitors within the previous 14 days.7

Varenicline (Chantix) is the latest drug for smoking cessation to be approved by the Food and Drug Administration. Varenicline is an alpha-4 beta-2 nicotinic receptor partial agonist.53 This dual action at the nicotine receptor site is believed to result in a lesser amount of dopamine release as well as prevention of nicotine binding. Data from three published trials suggest the use of varenicline significantly increases long-term abstinence rates compared to placebo and bupropion.54-56 Varenicline is a pregnancy Category C.53 Dosing begins 1 week prior to the quit date with 0.5 milligram/day for days 1 through 3, then 0.5 milligram b.i.d. for days 4 through 7. On the quit date, patients begin 1 milligram b.i.d.. Patients should take varenicline for 3 to 6 months. It does not interact with other medications, and the most common side effect is nausea.53

A pocket guide containing information on the 5 A's algorithm, a pharmacologic guide, the 5 R's of motivational techniques, and the Fagerstrom test for nicotine dependence can be found in A Healthcare Provider's Guide to Successful Tobacco Cessation Interventions (2007) on the Nurses for Tobacco Control Coalition (NTCC) Web site: http://www.nurses4tobaccocontrol.org .58 There is also a national quit line for referral for tobacco treatment available at 1-800-QUIT NOW.

Conclusions

NPs are ideally suited for tobacco treatment because of nursing's focus on health promotion, disease prevention, and a holistic, humanistic, patient/family-centered approach. Furthermore, tobacco prevention, control, and treatment are essential to nursing research and scholarship. More nursing outcomes research is needed to provide evidence-based knowledge for all nurses who work with tobacco-users. Nursing practice, research, education, and scholarship are instrumental in achieving the Healthy People 2010 goal to reduce illness, disability, and death related to tobacco use and exposure to secondhand smoke.57

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