Should Women Quit Smoking Now or Wait?
Should Women Quit Smoking Now or Wait?
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Assistant Professor, Dept. of Internal Medicine, Meharry Medical College Nashville, Assistant Clinical Professor, Div. Of General Internal Medicine and Public Health, Vanderbilt University Medical School, Nashville. Dr. Gupta reports no financial relationship to this field of study.
Synopsis: Early age at initiation of smoking is associated with an increased mortality risk in women. Quitting reduces the excess mortality risk for all major causes of smoking related deaths.
Source: Kenfield SA, et al. JAMA. 2008;299:2037-2047.
According to the most recent Surgeon General's Report on the issue, tobacco smoking remains the leading preventable cause of disease and death in the United States, causing approximately 440,000 deaths each year and costing approximately $157 billion in annual health-related economic losses.1 Although there has been a decline in the smoking rates, an estimated 46.2 million adults in the United States still smoked cigarettes in 2001.2
In their study, Kenfield et al utilize data from the Nurses' Health Study to assess the relationship between cigarette smoking and smoking cessation on total and cause-specific mortality in women. The authors designed a prospective observational study of 104,519 female participants from the Nurses' Health Study Group with follow-up from 1980 to 2004. The main outcome measure studied was hazard ratios (HRs) for total mortality, as well as for mortality categorized into vascular and respiratory diseases, lung cancer, other cancers, and other causes.
Interestingly, rather than present the data as pack-years (as this combines cigarettes smoked per day and the duration), the authors elected to further sub-classify current smokers into various categories of cigarettes smoked per day (1 to 14, 15 to 24, 25 to 34, and 35 or more), categories of age at initiation of smoking (17 years or younger, 18 to 21 years, 22 to 25 years, and 26 years or older) and for past smokers, into categories of time since quitting (< 5 years, 5 to 10 years, 10 to 15 years, 15 to 20 years, and > 20 years).
The authors found that compared with never smokers, current smokers had an increased risk of dying from any major cause during the follow-up period. Among the heavy smokers (>35 cigarettes/day), the strongest association was for mortality from COPD and non-specified respiratory disease as well as lung cancer. In the category of other cancers (smoking non-related), current smokers had an increased risk of death from colorectal cancer. The increased risk for death from ovarian cancer also occurred but this was not statistically significant. The study concluded that overall, approximately 64% of all deaths among current smokers were attributable to cigarette smoking; specifically, 69% of vascular deaths, 90% of respiratory deaths, 95% of lung cancer deaths, and 86% of lung and other smoking-related cancer deaths were attributable to current cigarette smoking. Additionally, those women who started smoking at age 17 years or younger had 22% higher likelihood of dying than those who initiated smoking at or after 26 years.
Among former smokers, there was a significant 13% reduction in the risk of all-cause mortality within the first 5 years of quitting smoking and the excess risk decreased to the level of a never smoker 20 years after quitting. The quickest decline in risk after quitting was for vascular mortality (CAD and CVA). Approximately 28% of all deaths among past smokers were attributable to cigarette smoking; specifically, 24% of vascular deaths, 75% of respiratory deaths, 81% of lung cancer deaths, and 57% of lung and other smoking-related cancer deaths were attributable to former cigarette smoking.
Commentary
Although today in the United States, former smokers outnumber current smokers, this study emphasizes the impact of smoking on all cause mortality and its burden as a result. There are considerable benefits of smoking cessation as well as developing and implementing effective school tobacco prevention programs, in addition to enforcing youth access laws so that smokers initiate later in life.
Current data reveals that there has been some success at the rate at which clinicians recommend smoking cessation.3, 4 As a result, smoking prevalence among adults in the United States has declined from about 25 percent in 1996 to about 21 percent by 2006.5
However, the current study clearly delineates the burden of tobacco smoke as a chronic preventable disease and thus much more can be done to promote smoking cessation.
I will take this opportunity to briefly discuss the 2008 update to the Treating Tobacco Use and Dependence, a U.S. Public Health Service-sponsored Clinical Practice Guideline that was recently released.6 This guideline contains strategies and recommendations that may be used by clinicians as well as other healthcare stakeholders to significantly reduce tobacco use prevalence by delivering an evidence-based treatment intervention to patients who smoke.
The key finding of the 2008 guideline update recommends that clinicians perform a brief intervention for every potential smoker at a clinic visit by following the "5A's" (Ask, Advise, Assess, Assist, Arrange). The clinicians should intervene at every visit in a brief, cost effective manner. Currently, there is strong evidence that counseling is a critical part of tobacco cessation and therefore such should be offered to each smoker. Telephone counseling is now available nationwide through 1-800-QUIT-NOW program. Finally, there are seven different smoking cessation medications approved by the US Food and Drug Administration for treating tobacco use and dependence: 5 nicotine substitutesgum, patch, lozenges, nasal spray and inhaler; and 2 non-nicotine medicationsbupropion and varenicline. In addition to being individually effective, evidence suggests that the combination of varenicline (2 mg) and long-term nicotine patch with as needed use of nicotine gum or nasal spray produces significantly higher long term abstinence rates than the nicotine patch alone.
In summary, the significant healthcare and economic burden of smoking-related illnesses can be successfully prevented by adhering to recommendations as outlined by the recent guideline update as well as ensuring the involvement of all stakeholders including the patient, clinician, insurers and policy makers.
References
1. US Dept of Health and Human Services. 2004 Surgeon General's ReportThe Health Consequences of Smoking. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm#lights. Accessed May 16, 2008.
2. Centers for Disease Control and Prevention. Cigarette smoking among adultsUnited States, 2001. Morbidity and Mortality Weekly Report. 2003a;52(40):953-56.
3. Denny CH, et al. Physician advice about smoking and drinking: are U.S. adults being informed? Am J Prev Med. 2003;24:71-74.
4. Quinn VP, et al. Tobacco-cessation services and patient satisfaction in nine nonprofit HMOs. Am J Prev Med. 2005;29:77-84.
5. Centers for Disease Control and Prevention. State-specific prevalence of cigarette smoking among adults and quitting among persons aged 18-35 years-United States, 2006. MMWR. 2007;56:993-996.
6. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: US Dept of Health and Human Services; May 2008. http://www.ahrq.gov/path/tobacco.htm#Clinic. Accessed May 16, 2008.
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