Scratch almost any long-time tobacco user over the age of 30 and beneath the surface will be found more often than not a person desperate to kick the habit. Do the same with a tobacco user under the age of 30 and chances are the reverse will hold true.

The reason is simple. Smokers in their teens and twenties imagine themselves to be invulnerable and immortal, while those approaching middle age (or already well into the autumn of life) perceive themselves at increasingly greater medical risk the longer they continue lighting up, according to Bill Blatt, MPH, director of tobacco programs for the American Lung Association at its national headquarters in Washington, DC. “Unless a serious medical issue is involved, most younger adults don’t think of quitting as something urgent,” he says.

But perhaps they should. Blatt’s American Lung Association colleague, Erika Sward, offers this sobering reminder: “Tobacco use remains the leading cause of preventable deaths in the United States. Approximately 443,000 people die every year of smoking and smoking-related illness. Annually, health care expenditures and lost productivity from smoking and smoking-related illness total more than $193 billion.”

Varied Motivations

That figure of 443,000, which includes death not just from lung cancer but also from heart disease and other maladies attributable to smoking, is alarming, without question. But more so is the fact that this toll remains stubbornly unchanged from year to year despite aggressive efforts by government and private-sector health advocates to discourage tobacco use. “The truth is that we are making progress even though the number of tobacco-related deaths stays constant,” insists Sward, who serves as the association’s director of national advocacy. “For example, we’ve recently seen the rate of adult smoking dip below 20% as a percentage of the population for the first time in a number of years.”

Tobacco users who decide to quit do so for any number and combination of reasons. For some, the motivator is the increasingly exorbitant purchase price of tobacco products—a price driven sky-high mainly through imposition of heavy taxes. For others, the choice to give up smoking is born out of a desire to escape societal disapproval. Then there are those who seek to quit because of the shrinking number of places where they can legally use tobacco products. And, of course, still others worry about the impact smoking will have on their health today and years from now.

Unfortunately, the addictive nature of nicotine—the chemical compound that gives tobacco its pleasurable effects—makes it almost impossible for users to quit cold turkey. Best results typically are obtained by breaking the habit in stages and with the help of a smoking-cessation program that features medications and social support, Blatt contends. “Programs are essential because only 5% of people who attempt to quit cold turkey succeed,” he says.

Quit plans come in different sizes and shapes. Most include a listing of toll-free “quit lines” that habit-kicking hopefuls can dial whenever the urge to light up threatens to overwhelm. “A big obstacle to quitting is discouragement,” Blatt explains. “Many smokers who try to quit but can’t then feel there’s no point in making any further quit attempts. Quit lines exist to offer support along with information so that people making quit attempts don’t defeat themselves.” Blatt says quit line workers often invite callers to “look back and examine the way they have been trying to quit—we use the terminology ‘practice quits’ to describe these earlier unsuccessful attempts because it’s a more positive framing. As the smoker contemplates those past efforts, this provides a foundation to build on for next time and hopefully increase the likelihood of quitting.”

The American Lung Association operates (800) LUNGUSA, staffed by respiratory therapists and nurses. “We work with the caller, figure out what resources are available in their area, and help create a quit plan,” Blatt says. “We’ll even go so far as to set up a schedule to call that person back as often as they would like in order to provide support and encouragement throughout the entire quit attempt.”

Pushing for Change

Beyond working directly with tobacco users on quitting, the American Lung Association also lobbies for laws and regulations intended to discourage smokers from ever taking up the habit in the first place and to give those already hooked added reasons to swear off. “We’ve long understood that legislative advocacy is a very effective way to bring about positive change that helps millions of Americans,” says Sward.

Convincing lawmakers to dramatically raise taxes on tobacco products is one such strategy. Earlier this year, for example, tobacco-control advocates helped win passage of federal legislation hiking the national tax on cigarettes $0.62 per pack. This sum is in addition to whatever taxes the states themselves levy, and those too can be significant. Emblematic is Wisconsin, which, in September, boosted its tobacco tax to $0.75 per pack.

Tobacco tax increases are often an easy sell (except in states where tobacco growing and cigarette manufacturing are important industries) because smoking is generally unpopular and because of promises to use the anticipated extra tax revenue to pay for popular programs, such as those targeting kids and teenagers with the message that tobacco use is uncool. Critics of higher taxes on tobacco complain, however, that low-wage adults—the very ones who smoke the most and are least willing to quit—bear an unfair burden because making cigarettes more expensive consumes a larger proportionate share of their household income than is the case for people with more disposable income.

Another legislative strategy to promote an end to tobacco use involves what are known as comprehensive smoke-free laws. These are measures that seek to restrict the places where cigarettes, cigars, and pipes may be puffed. Sward says 25 states and the District of Columbia have thus far passed comprehensive smoke-free laws—South Dakota, Wisconsin, and Nebraska being the three most recent to hop aboard the bandwagon.

A third strategy centers around tightening the rules by which tobacco products are made and sold. Adoption of the federal Family Smoking Prevention and Tobacco Control Act of 2009 (signed into law by President Barack Obama on June 22) now gives the Food and Drug Administration authority to regulate tobacco in a manner similar to pharmaceuticals. Henceforth, tobacco manufacturers run the risk of having their products yanked from the market in the event the FDA finds their ingredients or additives to be harmful. Moreover, the FDA now can compel disclosure of a tobacco product’s contents and force the tobacco industry to conduct research showing the effect its wares have on health. On top of that, the FDA can order modifications to tobacco marketing campaigns if it finds they are deceptive. “This legislation will make sure the tobacco companies cannot market or advertise their products in a manner that appeal to youth,” says Sward. “We think this is important, since eight out of 10 adult smokers started the habit before the age of 18, a fact that we believe qualifies smoking as, incidentally, a pediatric disease. So, from now on, any claims the tobacco companies want to make about their wares must be scientifically proven.”

The legislation will not prohibit the motion-picture industry from continuing to showcase tobacco use in movies, however. That means cigarette smoking can continue to be depicted on the big screen as glamorous, exciting, admirable. In consolation, Sward notes that “the tobacco industry has been prevented for the last 10 years from buying product placements in movies” and this will remain the case. “The goal is to ‘de-normalize’ smoking, and I believe the new law goes a long way toward helping us achieve this.”

Not About Prohibition

Foes of comprehensive smoke-free laws and of the Family Smoking Prevention and Tobacco Control Act argue that such measures place the nation on a slippery slope that could lead to a 21st-century version of Prohibition, replete with the problems of bootlegging, smuggling, and black marketeering similar to those resulting from the Roaring Twenties ban on liquor. Indeed, critics warn that antismoking zealotry is already pushing the United States in dangerous directions: The recent experience of Eau Claire, Wis, is an example of that trend (earlier this year, a local homeowners’ association in that city adopted rules outlawing smoking within privately owned homes). Other observers wonder whether unintended consequences might emerge from efforts to curb smoking, in essence making tobacco seem like forbidden fruit and transforming it into the ultimate symbol of rebellion against societal norms.

Sward disputes those notions. “The American Lung Association and its partners are not in favor of prohibition,” she demurs. “We recognize that Prohibition did not work the first time around; and with a product as addictive as tobacco—45 million people in America are considered addicts to smoking—prohibiting it is not ultimately going to get us to where we want to be. I don’t know that we will ever eliminate smoking in the United States. Our goal is simply to reduce consumption and make sure that the tobacco industry does not continue to have the type of power they previously had with regard to getting people addicted to the product.

“People are quitting smoking, but new smokers are being added to the population as other people pick up the habit. Hopefully, we’ll one day reach the point where we have more people quitting than starting. If these things happen and we all continue to work together toward reducing tobacco use, we should eventually see tobacco knocked off the list as the leading cause of preventable death in the [United States].”

Rich Smith is a contributing writer for RT. For further information, contact [email protected].

The American Lung Association for quite some time has sought to convince respiratory therapists, nurses, pulmonologists, and other clinicians that spending more time talking to tobacco-using patients about the importance of quitting can be productive.

“One thing we’ve learned over the years is that it’s not enough to advise patients against smoking; you also must point them toward—or, better still, provide—the resources that can help them kick the habit,” says Erika Sward, director of national advocacy for the American Lung Association.

For many providers, time is scarce. “They don’t feel that they have much of it to spend with the patient on smoking cessation,” Sward says.

To make things a bit more time-efficient for those providers and for every clinician who wants to help patients snuff out further use of tobacco, the American Lung Association has developed a multistep intervention protocol.

  • Ask. Make it a point to ask every patient at every visit whether they use tobacco, says the American Lung Association’s Bill Blatt, MPH, director of tobacco programs. “Clinicians should think of this question as like taking an additional vital sign,” Blatt believes.
  • Advise. For those patients who do use tobacco, a clear message about the virtues of quitting should be offered. “Tell the patient that the best thing they can do to improve their own health is to give up smoking,” says Blatt. “This may seem obvious, but it’s been shown that, if a doctor, nurse, respiratory therapist, or other clinician offers this advice in a straightforward way, it actually increases the likelihood that the patient will make an effort to quit. It also increases the likelihood of success once the quit attempt is made.”
  • Assess. This involves determining the patient’s readiness to make a quit attempt. Usually, readiness means that they are willing to give it a serious try, says Blatt.
  • Assist. If the patient shows readiness to quit, then help should be offered to create a quit plan. “A quit plan can be prepared in 5 minutes or less,” says Blatt. “Always give the patient a target quit date that’s a few weeks ahead so that there will be time to mentally prepare. And, unless medically contraindicated, every quit plan should specify use of a prescription cessation medication to help the patient cope with the urge to smoke.”
  • Arrange. Once the patient commits to quitting, follow-up help must be promptly lined up so they can receive the necessary support and encouragement to persevere, says Blatt.

It is important that patients never be badgered or otherwise pressured into a quit attempt, he warns: “It has to be voluntary in order for the smoker to have the best chance of kicking the habit. Quitting is not an easy task, so the person who is going to quit has to want to quit.”

—RS