CDC: Smoking rate among US adults reaches all-time low

This CDC report indicating that cigarette smoking among adults in the U.S. fell to a historic low of 14% in 2017 is great news. This translates to 3.5 million fewer smokers than in 2016, many of whom will avoid dying prematurely from tobacco-related cancer and many other diseases. But with more than 34 million adults in the U.S. still smoking cigarettes, and growing disparities when it comes to who is still smoking, the CDC report also highlights we have a significant challenge that requires a determined effort for the foreseeable future.

Here at the American Cancer Society, we know that there are several million Americans using e-cigarettes and a sizeable percentage of these people are using them in an attempt to quit using traditional, combustible tobacco products. We encourage primary care physicians to remind their patients that, to date, no e-cigarette has been approved by the FDA for use in smoking cessation. While the American Cancer Society does not recommend using e-cigarettes for smoking cessation, we do encourage primary care physicians to support those individuals who choose to use e-cigarettes in an attempt to quit smoking, especially if the patient is unwilling to use FDA-approved cessation options. That said, smokers who use e-cigarettes should be strongly discouraged from using e-cigarettes and combustible cigarettes concurrently, since such “dual use” largely eliminates the health benefits that come from switching completely to the e-cigarettes. It is understood that some smokers engage in a transition period during which they start using e-cigarettes while still smoking. In such cases, the smoker should be given positive support and encouraged to switch completely as soon as they can.

The most effective, proven approach to get patients to stop smoking and overcome nicotine addiction continues to be combining an FDA-approved nicotine replacement therapy with evidence-based behavioral counseling. Perhaps just as importantly, primary care physicians need to ask every patient about their tobacco use and offer them support to quit if they wish to. Time and again, research has shown that health care practitioner guidance is one of the most effective ways to get a patient to try and quit and ultimately succeed in doing so. 

I would be remiss if I didn’t recognize the role of the larger public health community played in bringing cigarette rates down to these record lows. But it is not time to become complacent. Though the CDC report has a lot of such positives, there are some negatives that concern me. The CDC report makes it abundantly clear there are geographical regions of the United States and population groups that still have an extraordinarily high number of smokers. We must continue pushing cessation efforts until everyone has quit smoking.

I know there are a lot of constraints on primary care physicians’ time. But they need to find time to discuss smoking cessation at each visit with their patients who are smokers and make an appointment that is exclusively dedicated to discussing the addiction. When that appointment comes, suggest medications, such as Chantix (varenicline, Pfizer), bupropion, and nicotine replacement therapy. If using nicotine replacement, use both short- and long-term nicotine replacement therapies combining patches with gums, sprays, inhalers, or lozenges. PCPs should also provide patients with behavioral counseling as studies show we can increase quit rates by up to 50% if we offer the counseling or some mechanism that addresses the psychological and behavioral components of addiction. Here at the American Lung Association we also have a program called ‘Freedom from Smoking’ accessible from our website (www.lung.org) available to anyone and may be used along with medications and nicotine replacement therapies.

Patients may say they want to try to quit combustible cigarettes by using e-cigarettes. This is not an FDA-approved smoking cessation method, even though it is sometimes advertised as such. We know that cigarettes are the deadliest product on the market, so saying something is safer than that is not really saying much. Patients may also try to tell you they want to quit ‘cold turkey.’ If they do, be sure to schedule them for a follow-up appointment rather quickly because the success rate of this method is well less than 10%.

The report from the CDC, FDA, and National Cancer Institute highlights the lowest ever recorded level of smoking in the United States. This news is very exciting as it represents the hard work and enormous effort over many years that has gone into helping patients with tobacco cessation and to ‘kick the habit’. Credit not only goes to health care teams and policy makers, but also to all the patients who have worked hard to either quit or avoid starting tobacco products altogether.

There is still much work to do as there are specific populations where further reduction in tobacco use is needed: such as racial minorities, low income, or disabled populations. For primary care physicians, or any health care provider, the most important care that can be delivered is to continue to ask patients about tobacco habits, encourage them to quit, and provide resources in a clinic or community setting. In a busy primary care practice there are many competing issues that need to be addressed with each patient, and when providers do not continue to ask about tobacco use, patients will think less about quitting. There are many approaches to tobacco cessation, which include medications, online interventions, and toll-free quit-lines. Getting just one patient to quit not only helps that patient, but also the friends, family, and co-workers of that patient as they are less likely to be exposed to second hand smoke.

This report highlights the encouraging, progressive improvement rate in smoking among adults. As cardiologists, we are always pleased when risk factors for cardiovascular disease can be reduced. However, with 14% of adults in the U.S. still smoking, there is still room for improvement.

To get patients to stop smoking, primary care physicians may want to present patients with data such as the study in Circulation that found  women who smoke a pack a day have a sixfold increased risk, and men who smoke the same amount have a threefold increased risk, for a heart attack compared with those who never smoke. Further, PCPs can also allude to a study in BMJ that found advise that even just one cigarette a day increases the risk for heart disease by as much as 50%, and for stroke by as much as 25%. Cardiovascular risk is reduced by smoking cessation, even in smokers with pre-existing cardiovascular disease.

For long-term smoking cessation, PCPs should prescribe FDA-approved medications such as varenicline and bupropion, or nicotine replacement therapies such as gums and patches and have the patient use them in conjunction with behavioral counseling. PCPs who do not have a substantial amount of time to discuss smoking cessation with their patients can refer patients to a smoking cessation clinic that does the prescribing and counseling for them. PCPs should also encourage the friends, family members and co-workers to support the smoker in his or her efforts to quit, as secondhand smoke has also been tied to cardiovascular disease, lung cancer, chronic sinusitis, pregnancy complications and adult onset asthma.

If first line smoking cessation strategies fail, are intolerant, or rejected by the patient, PCPs may support the use of e-cigarettes. However, researchers recently reported in Vascular Medicine and the Journal of Applied Physiology that markers for long-term cardiovascular health are impaired by e-cigarette exposure in humans and in mice. Additional research into the cardiovascular risk of using e-cigarettes is limited, evidenced by a review in Nature Reviews Cardiology that found dangers to e-cigarette smoking difficult to ascertain, given the wide variety of devices and ingredients used to make them.

Thus, e-cigarettes should only be used as a short-term therapy to smoking cessation. The authors of the Nature Reviews Cardiology review concluded, and I would agree, that “for cigarette smokers with known cardiovascular disease who quit smoking by using e-cigarettes, we recommend that they discontinue e-cigarette use when they are confident that they will not return to cigarette smoking.”

References:

Benowitz NL, Fraiman JB. Nat Rev Cardiol. 2017;doi:10.1038/nrcardio.

Franzen KF, et al. Vasc Med. 2018;doi:10.1177/1358863X18779694.

Hackshaw A, et al. BMJ. 2018;doi:10.1136/bmj.j5855.

Njølstad I, et al. Circulation. 1996. Feb 1;93(3):450-456.

Olfert IM, et al. J Appl Physiology. 2017;doi:10.1152/japplphysiol.00713.2017.