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Clinical guidelines

Supporting smoking cessationA guide for health professionals

Tobacco smoking: the scope of the problem

Tobacco smoking is a worldwide threat to human life. The World Health Organization (WHO) estimates that around 5.4 million people died prematurely in 2008 from tobacco-related diseases and, on current trends, this number will increase to 8 million deaths each year before 2030. Eighty per cent of these deaths will occur among people in the developing world.15 Fortunately, in Australia the prevalence of tobacco smoking has decreased. The proportion of people aged 14 years and over smoking tobacco daily in 2010 was 15.1%, down from 16.6% three years previously.1

Australia is a signatory to the WHO Framework Convention on Tobacco Control, a worldwide effort to control the effects of tobacco smoking on human health.16 The framework is the world’s first public health treaty and commits governments to enacting a minimum set of policies which are proved to curb tobacco use. These include bans on tobacco advertising, promotion and sponsorship; clear warning labels; smoke free policies; higher prices and taxes on tobacco products; and access to, and availability of, smoking cessation services. It also encourages international cooperation in dealing with cigarette smuggling and cross-border advertising. Australia is leading the world in the introduction of plain packaging of tobacco products.

As a result of changes in public policy and changing community attitudes to tobacco, the status of tobacco smoking is gradually shifting from a socially acceptable behaviour to an antisocial one.17 With the advent of national tobacco control policies and programs, the prevalence of smoking in Australia is among the lowest of any nation.18 While Australia’s level of smoking continues to fall and is the third lowest for OECD (Organisation for Economic Cooperation and Development) countries,19 Indigenous Australians are still more than twice as likely as non-Indigenous Australians to be current daily smokers.2 However, there has been a progressive decrease in daily smoking rates for Aboriginal and Torres Strait Islander people, declining from 49% in 2002 to 45% in 2008, and then to 41% in 2012–13.3

The importance of smoking cessation was reinforced in the report of the National Preventative Health Taskforce, which stated that the evidence for interventions to reduce smoking is strong and has accumulated over many years. The report made several key recommendations on improving advice from health professionals, including ensuring all smokers in contact with health services are routinely asked about their smoking status and supported to quit.20

National Preventative Health Taskforce Key action area 6: Tobacco control20

Ensure all smokers in contact with health services are encouraged and supported to quit, with particular efforts to reach pregnant women and those with chronic health problems.

Ensure all state or territory funded healthcare services (general, maternity and psychiatric) are smoke free and protect staff, patients and visitors from exposure to secondhand smoke, both indoors and on facility grounds.

Nevertheless, smoking still causes a higher burden of disease than any other behavioural risk factor, representing 9.6% of the total burden in men and 5.8% in women.21 Tobacco smoking is responsible for the deaths of about 15 500 Australians each year (Table 1) and smoking-related disease contributes as a comorbidity to many others.20

Table 1. Deaths attributable to tobacco by specific cause, Australia, 2003 (burden of disease calculations)21
Specific cause
Number of deaths
Percentage of all tobacco caused deaths (rounded)*

Lung cancer

6 309

41

COPD

4 175

27

CHD

1 962

13

Stroke

577

4

Oesophageal cancer

572

4

Other

1 916

12

Total

15 511

 

* Column does not add up to 100% due to rounding Note: COPD = Chronic Obstructive Pulmonary disease; CHD = Covonary heart disease

Reprinted with permission: Scollo MM, Winstanley MH, editors. Tobacco in Australia: facts and issues. 3rd edn. Melbourne: Cancer Council Victoria, 2008. Available from www.tobaccoinaustralia.org.au

Interventions to assist cessation are in the context of a changing environment: the low community tolerance for tobacco smoking is one sign of a continuing ‘denormalisation’ of tobacco use in Australia.23

Tobacco smoking harms almost every organ of the body, causing a wide range of diseases and harming the health of smokers (Table 2).24

Table 2. Health effects of smoking

Eyes

Macular degeneration, cataracts

Stomach

Cancer, ulcer

Hair

Hair loss

Pancreas

Cancer

Skin

Ageing, wrinkles, wound infection

Bladder and kidney

Cancer

Brain

Stroke

Women

Cervical cancer, early menopause, irregular and painful periods

Mouth and pharynx

Cancer, gum disease

Men

Erectile dysfunction

Lungs

Cancer, COPD, pneumonia

Arteries

Peripheral vascular disease

Heart

Coronary heart disease

Bones

Osteoporosis

Smoking is strongly related to many chronic diseases including coronary heart disease, stroke, chronic obstructive pulmonary disease (COPD), asthma, rheumatoid arthritis and osteoporosis,19 and is responsible for 20% of all cancer deaths in Australia.25 Smoking also has adverse effects in pregnancy, both for the mother and the developing fetus, and exposure to secondhand tobacco smoke has been shown to damage the health of children and adults. The only proven strategy for reducing the risk of tobacco-related diseases and death is to avoid taking up smoking and, failing that, to quit as early as possible in adult life.24 Quitting smoking has immediate, as well as long-term benefits, reducing the risks for diseases caused by smoking and improving health in general.

Readers of this guide who want to know more about tobacco use and tobacco control measures, including summaries of what is known about smoking cessation, can access the excellent resource Tobacco in Australia at www.tobaccoinaustralia.org.au

Key findings from the 2010 National Drug Strategy Household Survey report1

  • Fifteen per cent of people in Australia aged 14 years or older were daily smokers. This declined from 16.6% in 2007, and from 24.3% in 1991.
  • One-quarter of the population were ex-smokers and more than half had never smoked.
  • Tobacco smoking (smoked in the previous 12 months) remains higher among certain populations, such as those with the lowest socioeconomic status (24.6%) and those living in remote areas (28.9%).
  • Indigenous Australians were 2.2 times as likely as non-Indigenous Australians to smoke tobacco.
  • Compared with non-smokers (ex-smokers and those who never smoked), smokers were more likely to rate their health as being fair or poor, were more likely to have asthma, were twice as likely to have been diagnosed or treated for a mental illness and were more likely to report high or very high levels of psychological distress in the preceding 4 week period.
  • A higher proportion of smokers reported being diagnosed with or treated for a mental illness in 2010 (from 17.2% in 2007 to 19.4%).
  • Almost 40% of smokers had reduced the amount they smoked in a day, and 29% had tried unsuccessfully to give up smoking.
  • The proportion of people nominating cost as a factor for wanting to quit smoking increased significantly from 35.8% in 2007 to 44.1% in 2010.

Effectiveness of treating tobacco dependence

The benefits of quitting smoking are well established. Successfully quitting smoking can result in an increase in life expectancy of up to 10 years, if it occurs early enough.26 There is also substantial evidence that advice from health professionals including doctors, nurses, pharmacists, psychologists, dentists, social workers and smoking cessation specialists helps smokers to quit.27–30 While spending more time (longer than 10 minutes) advising smokers to quit yields higher abstinence rates than minimal advice,11 offering brief advice (as little as 3 minutes) has been shown to have clear benefits.27,31,32 Providing brief advice to most smokers is more effective and efficient than spending a longer time with a few patients.31,33

Smoking cessation is both cost- and clinically effective compared with other medical- and disease-preventive measures, such as the treatment of hypertension and hypercholesterolaemia.34–37 Research shows that the cost per life year saved by smoking cessation interventions makes it one of the most cost-effective healthcare interventions.38,39 Along with childhood immunisation and aspirin use with high-risk adults, overall efforts to reduce tobacco smoking are among the most beneficial preventive interventions for human health.38,40,41

Advice-based help and pharmacotherapy can both increase the rate of success of quit attempts, and when they are used the benefits are cumulative.11 Smokers should be offered cessation treatment, either counselling (individual or group) or medication, or both, which is individualised and customised to their own personal situation and experience.

References

     
  1. Australian Institute of Health and Welfare. 2010  National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW, 2011. Available at http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421314 [accessed 12 August 2011].
  2. Australian Institute of Health and Welfare. Substance use among Aboriginal and Torres Strait Islander people. Cat. no. IHW 40. Canberra: AIHW, 2011. Available at www.aihw.gov.au/publication-detail/?id=10737418268[accessed 19 August 2011].
  3. Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey: first results, Australia, 2012−13.  Cat. no. 4727.0.55.001. Canberra: ABS, 2013.
  4. Fiore MC, Jaén CR, Baker TB, Bailey WC, et al. for the Guideline Panel. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, May 2008. Available at http://www.ncbi.nlm.nih.gov/books/NBK63952/ [accessed 20 March 2011].
  5. World Health Organization. WHO report on the global tobacco epidemic: The MPOWER Package. Geneva: World Health Organization, 2008. Available at http://whqlibdoc.who.int/publications/2008/9789241596282_eng.pdf [accessed 23 March 2010].
  6. World Health Organization. WHO Framework Convention on Tobacco Control, adopted 16 June 2003 (entered into force 27 February 2005). Geneva: WHO, 2005. Available at www.who.int/tobacco/framework/en/ [accessed 25 March 2011].
  7. Scollo MM, Winstanley MH, editors. Tobacco in Australia: facts and issues. A comprehensive online resource. 3rd edn. Melbourne: Cancer Council Victoria, 2008. Available from www.tobaccoinaustralia.org.au [accessed 25 March 2011].
  8. Shafey O, Dolwick S, Guindon GE, editors. Tobacco Control Country Profiles 2003. 2nd edn. Atlanta, GA: American Cancer Society, 2003. Available at www.who.int/tobacco/global_data/country_profiles/en/index.html [accessed 27 March 2011].
  9. Australian Institute of Health and Welfare. Australia’s health 2010. Cat. no. AUS 122. Canberra: AIHW, 2010.
  10. Australian Government. National Preventative Health Taskforce. Australia: The Healthiest Country by 2020. National Preventative Health Strategy – the roadmap for action. Canberra, Commonwealth of Australia, 2010. Available at www.preventativehealth.org.au/internet/ preventativehealth/publishing.nsf/Content/ nphs-roadmap/$File/nphs-roadmap.pdf [accessed 30 August 2011].
  11. Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The burden of disease and injury in Australia 2003. PHE 82. Canberra: Australian Institute for Health and Welfare, 2007. Available at www.aihw.gov.au/publications/index.cfm/title/10317 [accessed 25 March 2011].
  12. Chapman S, Freeman B. Markers of the denormalisation of smoking and the tobacco industry. Tob Control 2008;17:25–31. Available at http://tobaccocontrol.bmj.com/cgi/reprint/17/1/25.pdf [accessed 28 March 2011].
  13. US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.
  14. Australian Bureau of Statistics. 4831.0.55.001. Tobacco smoking in Australia: a snapshot 2004–05. September 2006. Available at www.abs.gov.au/ausstats/abs@.nsf/ mf/4831.0.55.001 [accessed 28 March 2011].
  15. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004;328:1519.Epub.
  16. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008, Issue 2. Art. no. CD000165.
  17. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst Rev 2004, Issue 1. Art. no. CD003698.
  18. Carr A, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database Syst Rev 2006, Issue 1. Art. no. CD005084.
  19. Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev 2008, Issue 1. Art. no. CD001188.
  20. Litt J, Ling M-Y, McAvoy B. How to help your patients quit: practice based strategies for smoking cessation. Asia Pac Fam Med 2003;2:175–9.
  21. Richmond R, Mendelsohn C, Kehoe L. General practitioners’ utilization of a brief smoking cessation program following reinforcement contact after training: a randomised trial. Prevent Med 1998;27:77–83.
  22. Van Schayck O, Pinnock H, Ostrem O, et al. Tackling the smoking epidemic: practical guidance for primary care. Primary Care Resp J 2008;17:185–93.
  23. Parrott S, Godfrey C. Economics of smoking cessation. Br Med J 2004;328:947–9.
  24. Shearer J, Shanahan M. Cost effectiveness analysis of smoking cessation interventions. Aust NZ J Public Health 2006;30:428–34.
  25. Cornuz J, Gilbert A, Pinget C, et al. Cost- effectiveness of pharmacotherapies for nicotine dependence in primary care settings: a multinational comparison. Tob Control 2006;15:152–9.
  26. Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. J Am Med Assoc 1997;278:1759–66.
  27. Krumholz HM, Weintraub WS, Bradford WD, et al. Task force #2—the cost of prevention: can we afford it? Can we afford not to do it? 33rd Bethesda Conference. J Am Coll Cardiol 2002;40:603–15.
  28. Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med 2008;358:661–3.
  29. Maciosek MV, Coffield AB, Edwards NM, et al. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 2006;31(1):52–61.
  30. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2009: Implementing smoke-free environments. The MPOWER Package. Geneva, World Health Organization, 2009.
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