Smoking is the leading preventable cause of death. Each year it kills more than 5 million people around the world, 480,000 in the US alone. And for every person who dies, about 30 more have serious illnesses caused by smoking. On average, smokers die 10 years earlier than nonsmokers. Anyone who is concerned about preventive medicine must consider smoking cessation a priority. Fortunately, the Affordable Care Act (ACA) has taken a step in the right direction.
The ACA’s provisions
The Affordable Care Act requires health plans and health insurance to cover tobacco-use counseling and interventions without cost sharing or prior authorization. It requires screening of all patients for tobacco use and covering at least two attempts to quit each year. For each quit attempt, it authorizes four tobacco-cessation counseling sessions, each at least ten minutes long (including telephone, group, and individual counseling) and any FDA-approved tobacco-cessation medications (whether prescription or over-the-counter) for a 90-day treatment regimen when prescribed by a health care provider. In a separate provision, it requires that states not exclude FDA-approved cessation medications from existing Medicaid programs. These provisions should encourage providers and patients to increase their smoking cessation efforts.
It also allows some insurers to charge smokers premiums that are up to 50% higher than premiums for nonsmokers. That could be a double-edged sword: it could either encourage people to stop smoking to save money, or it could encourage them to lie about their tobacco use.
The harms of smoking
Tobacco was first used by shamans in the Americas to induce trances and later for ceremonial uses like the proverbial peace pipe. It developed a bad reputation as soon as it was introduced to Europe. King James I of England, who was born a scant 74 years after Columbus’ first voyage, wrote a treatise against it, saying that smoking was:
A custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black, stinking fume thereof, nearest resembling the horrible Stygian smoke of the pit that is bottomless.
The fact that tobacco is hazardous to health should not be news to anyone. But smokers might be surprised to learn just how long the list of hazards is. Smoking harms nearly every organ in the body. It is estimated to cause 87% of lung cancer deaths, 32% of coronary heart disease deaths, 79% of chronic obstructive pulmonary disease (COPD), and ⅓ of all cancer deaths, including cancers of the bladder, blood, cervix, colon, rectum, esophagus, kidney, ureter, larynx, liver, mouth, throat, pancreas, stomach, trachea and bronchus. Smokers have an increased risk of diabetes, rheumatoid arthritis, tuberculosis, peripheral vascular disease, cleft lip and palate, infertility, low sperm count, premature birth, ectopic pregnancy, low birth weight, miscarriage, macular degeneration, cataracts, sudden infant death syndrome (SIDS), osteoporosis, and rheumatoid arthritis. Smoking causes diminished overall health, increased susceptibility to infections, increased self-reported poor health, increased absenteeism, and increased health care utilization and cost.
A while ago there was a picture in the news of a woman who was complaining about air pollution from traffic as she smoked a cigarette. Anyone who is concerned about environmental toxins should be particularly concerned about tobacco smoke. Do all those advocates of “detox” realize that there are over 70 known carcinogens in tobacco smoke and that their detox regimens do nothing to reduce their risk? Do those who fear radiation from nuclear power and radon realize that smoking exposes the lungs directly to radioactive Polonium 210, which is 250,000 times more toxic than hydrogen cyanide? Second-hand smoke kills innocent bystanders and puts some of those it doesn’t kill in the hospital; for example, it is responsible for an estimated 7,500 to 15,000 hospitalizations for respiratory diseases every year for children under the age of 18 months.
Smoking has benefits, too
There are exceptions to everything. We are fond of pointing out that drugs that have effects are likely to have side effects too; conversely, things that are toxic are also likely to benefit some physiologic process in a human system that is so bewilderingly complex. There are reports that smoking benefits a few conditions to a small degree, including gum disease, Parkinson’s, Alzheimer’s, ulcerative colitis, and several others. This pro-smoking webpage claims that no studies have shown an increased risk of Alzheimer’s in smokers. That’s wrong: smoking is a recognized risk factor for Alzheimer’s and it was trivially easy to find a systematic review in PubMed that shows it increases risk.
The pro-smoking organization says:
The benefits of smoking tobacco have been common knowledge for centuries. From sharpening mental acuity to maintaining optimal weight, the relatively small risks of smoking have always been outweighed by the substantial improvement to mental and physical health.
In my opinion, and in the consensus of mainstream scientists, they got that exactly backwards. Any benefits pale in comparison to the documented harms.
Smoking cessation interventions
It’s hard to compare the success rate of different interventions in different studies because of different definitions of what constitutes success. Remember what Mark Twain said:
Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.
Whether they found it easy or difficult, lots of people have succeeded in stopping, either on their own or with assistance. Former smokers now outnumber current smokers. Behavioral support and medication can approximately quadruple the chances that a quit attempt will be successful.
A 2008 systematic review of reviews found evidence for the effectiveness of these approaches:
- Group therapy (odds ratio 2.17)
- Bupropion (OR 2.06)
- Intensive physician advice (OR 2.04)
- Nicotine replacement therapy (OR 1.77)
- Individual counseling (OR 1.56)
- Telephone counseling (OR1.56)
- Nursing interventions (OR 1.47)
- Tailored self-help interventions (OR 1.42)
These findings are robust: the confidence intervals ranged from a low of 1.26 to a high of 3.45. They found that an increase in price increased cessation rates by 3-5%, and comprehensive clean indoor laws increased quit rates by 12-38%. They did not include data on varenicline, which had just recently come on the market.
The FDA has approved five nicotine replacement products and two prescription drugs (bupropion and varenicline) and has approved the combination use of nicotine patches and bupropion. Varenicline appears to be more successful than bupropion, but not more successful than nicotine replacement. Both drugs have troublesome side effects, including reports of suicide with varenicline. They are expensive and are meant for short-term use only.
It’s hard to know just how effective these drugs are; results vary considerably from study to study. In one study where subjects were treated for 24 weeks, the abstinence rate at 24 weeks was 70.5% for varenicline, but it was 50% for placebo. In other words, it was about half again as effective as a sugar pill. And the abstinence rate after one year was 44% for varenicline versus 37% for placebo. Varenicline is only FDA-approved for up to 12 weeks. In another study where subjects were treated for just 12 weeks, the abstinence rate at one year was 23% for varenicline and 10% for placebo. Reports of placebo group responses of 10% and 50% are worrisome; the response of placebo groups in clinical studies is typically around 1/3. Markedly higher or lower percentages suggest something else may be going on, like one or more unrecognized confounding factors that may have influenced results.
A number of other prescription drugs have been tried off-label, with varying results. Alternative treatments have not been proven effective. Cochrane reviews of acupuncture and hypnosis were not favorable. Acupuncture:
Although pooled estimates suggest possible short-term effects there is no consistent, bias-free evidence that acupuncture, acupressure, or laser therapy have a sustained benefit on smoking cessation for six months or more.
We have not shown that hypnotherapy has a greater effect on six-month quit rates than other interventions or no treatment. There is not enough evidence to show whether hypnotherapy could be as effective as counseling treatment. The effects of hypnotherapy on smoking cessation claimed by uncontrolled studies were not confirmed by analysis of randomized controlled trials.
“Doctors don’t do prevention” is a lie
This is a common complaint we hear from alternative medicine advocates, especially from naturopaths. It is so wrong it hardly deserves an answer. Doctors are the ones who invented prevention, who have always known it’s better to prevent disease than to treat it, who actually have evidence-based ways to prevent disease.
Some chiropractors claim they can prevent disease by keeping the spine in alignment with maintenance adjustments; some acupuncturists claim they can prevent disease by eliminating blockages in the flow of qi; some naturopaths claim they know more than doctors about what causes disease and how to prevent it. But there’s not a shred of evidence that any of these claims are true. In fact, there is evidence that alternative providers are worse at prevention: their patients are less likely to be vaccinated than patients of MDs.
It’s instructive to google “naturopathy” and “smoking cessation” and see what the naturopaths are up to. They do a lot of the same things doctors do: counseling, behavioral modification, identifying triggers and ways to avoid temptation. But instead of evidence-based treatments, they rely on things like homeopathy (the homeopathic remedy Tabacum is said to be very effective), traditional acupuncture, ear acupuncture, laser stimulation of acupoints, herbal remedies (including lobelia, hyssop, ginseng, valerian, skullcap, and lung yin tonic to prevent dryness), diet advice, detoxification, guided imagery, drinking large amounts of filtered water with lemon, etc. I could not find any evidence that naturopaths are any more effective than other health care providers in helping smokers stop smoking, or in keeping people from starting to smoke in the first place. They pride themselves on their imagined expertise at prevention, but they haven’t even been able to demonstrate that their methods are effective against the major preventable cause of disease.
You might blame doctors for not doing enough to discourage smoking, but you can’t deny that doctors are trying. Every time I go to an appointment I am asked if I smoke, even though my medical record documents that I have never smoked. Instead of criticizing doctors, perhaps it would make more sense to criticize the patients who don’t follow their doctors’ advice. Thanks to the ACA, it should be easier for patients to follow that advice.
We can anticipate that the provisions of the ACA will have an impact on smoking cessation rates. The size of that impact remains to be seen. I am cautiously optimistic. The effort is certainly worthwhile. If we had to choose a single preventive intervention to improve the health of an individual patient or of society as a whole, there could be no better choice than smoking cessation.