The public health impact of smoking is enormous. Of the over 40,000 premature deaths attributable in Canada to tobacco, approximately 16,000 result from lung cancer and 8,000 from chronic obstructive pulmonary disease (COPD). Minimally, half of tobacco related death is lung related. For many years cigarette smoking has been identified as the most important preventable cause of illness and death in our country.
The elimination of tobacco smoke would yield substantial benefits for public health and the population in general. But what about the individual user? Today the evidence demonstrates that quitting tobacco use has major and immediate health benefits for persons of all ages. Quitters, quite simply, live longer than those who continue to smoke. Persons quitting before the age of 50 have one-half the risk of dying in the next 15 years compared with continuing smokers. The lung cancer risk, for example, drops to about half of the risk of continuing users but the drop is much greater for those quitting before the age of 30. Stopping also results in a decrease in the decline in lung function with quitters reverting to the natural decline of non smokers.
Cigarette smoking is the major cause of COPD in Saskatchewan and is the fifth leading cause of death in Canada. COPD is not an illness one can get rid of but there are ways to slow its progression. The foremost initiative to stabilize the disease is to stop smoking. Minimally there are 25,000 persons in Saskatchewan diagnosed with this problem and 90% of these individuals are suffering because of their tobacco use.
Absorption of cigarette smoke from the lung is rapid and complete, producing with each inhalation a high concentration arterial bolus of nicotine that reaches the brain within seconds, faster than by intravenous injection. Nicotine has a terminal half-life in blood of two hours. Smokers therefore experience a pattern of repetitive and transient high blood nicotine concentrations from each cigarette with regular consumption required to maintain raised concentrations. Overnight blood levels drop considerably to close to those of non smokers. As so well put by a tobacco researcher in the mid 1970's. "If it were not for the nicotine in tobacco smoke, people would be little more inclined to smoke than they are to blow bubbles."
Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce abstinence. Persons willing to try to quit using tobacco should be provided with treatments that are most likely to be successful. Persons not yet at this stage should receive interventions designed to motivate them to quit.
There is no one method that has been proven effective for all persons. A variety of interventions including counselling, telephone quit lines, self help materials and group programs can be utilized. First line pharmacotherapies have a good track record for improving quit rates. In Saskatchewan these are limited to three products; buproprion (prescription requirement), nicotine gum and the nicotine patch. The Lung Association of Saskatchewan does not encourage the placement of these products on the formulary. However, clinicians should be allowed reimbursement for providing tobacco dependence treatment as they are for treating other chronic conditions.
Effective tobacco interventions need to be seen as an integral part of health care delivery. Clinicians need training and support and this must be expanded beyond the office of the MD. All health care providers from those providing eye care to oral health practitioners should be comfortable with cessation information. Unfortunately this is still not standard practice. It is disappointing that many smokers present at primary care settings and are not offered effective assistance in quitting.
In general terms, quitting success is in direct proportion to the number and intensity of interventions. This success is also cost effective as suggested by the huge array of tobacco related illnesses and compromises made to our health including the immune system. Although a minority of tobacco users achieves permanent abstinence in an initial quit attempt, many typically cycle through multiple periods of relapse and remission. It is suggested that nearly half of smokers try to quit each year. This suggests that a very large number of tobacco users do want to quit but either need additional motivation or require a greater variety of quitting methods.
It has become obvious that there is not one treatment that will be effective for all smokers. Also we may need to redefine our measure of success and conclude that success should not be defined only on the basis of permanent abstinence. The chronic disease model places more emphasis on longer term counselling and follow-up. We must recognize that relapse is common and may reflect the chronic aspect of the problem and not just the personal failure of the individual.
We must also begin to address who is using tobacco if we are to successfully treat this chemical dependency. The general prevalence of smoking has declined for the past 30 years but this may be stabilizing in the low 20% range. But an emerging phenomenon has been the increasing association of continued smoking with markers of social disadvantage. This also includes persons with mental health difficulties. It is evident that future progress in aiding tobacco users to quit is increasingly going to have to tackle the problems posed by poverty.
Effective prevention of cigarette smoking and help for tobacco users to quit can yield health benefits for populations and individuals. Preventing young people from starting smoking would have a more delayed but ultimately huge impact on morbidity and mortality but it remains important to also address those individuals who would receive immediate benefits by stopping all tobacco use. Promoting and supporting quitting of tobacco use should be an important health policy.