In the United States, the number of adults who smoke cigarettes is continuing to fall, resulting in lower rates of mortality due to smoking-related cancer, particularly lung cancer.
However, the story of cigarette smoking in the United States very much remains a good news/bad news scenario, according to Ahmed Jamal, MBBS, and colleagues from the Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC), in Atlanta, Georgia.
Analysis of 2016 data from the National Health Interview Survey shows that the number of people smoking cigarettes has dropped by more than 5% since 2005, the study authors say in a report published online January 19 in Mortality and Morbidity Weekly Report. Similarly, the number of adult ever-smokers who quit rose from 50.8% in 2005 to 59.0% in 2016. Most of these quitters were aged between 25 and 44 years.
However, the bad news is that there are still 37.8 million (15.5%) people smoking in the United States — down from 45.1 million (20.9%) in 2005 — and striking sociodemographic disparities in cigarette smoking persist, Dr Jamal and colleagues point out.
Notably, the prevalence of cigarette smoking didn’t change significantly between 2015 and 2016, and the number of people smoking fewer than 10 cigarettes a day actually increased from 16.4% in 2005 to 25% in 2016.
“We Have a Long Way to Go”
When asked to comment, Maher Karam-Hage, MD, associate medical director of the Tobacco Treatment Program at the University of Texas MD Anderson Cancer Center in Houston, said, “We have a long way to go.”
More needs to be done to remove the financial barriers that prevent smokers from getting treatment, Dr Karam-Hage told Medscape Medical News. “Any patient interested in quitting needs to be provided with any treatment they need, without any limits in sessions or amount of medication they may need.”
More clinicians also need to treat using the standard of care, said Dr Karam-Hage, noting that at present, only 5% of identified smokers receive both medication and counseling.
The CDC reports that in 2016, cigarette smoking continued to be disproportionately high among males, those aged 25 to 64 years, people with less education, and those living below the poverty line. A high prevalence of smoking was also seen among First Nations Americans; those with disabilities; people without medical insurance or those on Medicaid; those with a lesbian, gay, or bisexual sexual orientation; and those living in Southern or Midwestern states.
“Proven population-based interventions, including tobacco price increases, comprehensive smoke-free laws, high-impact anti-tobacco media campaigns, and barrier-free access to tobacco cessation counseling and medications, are critical to reducing cigarette smoking and smoking-related disease and death among U.S. adults, particularly among subpopulations with the highest smoking prevalence,” the authors write.
This echoes the comments made recently after publication of the Cancer Statistics 2018 report from the American Cancer Society (ACS), as reported by Medscape Medical News. It credits reductions in smoking as well as advances in early cancer detection and treatment for the 26% decline in mortality rates from all cancers between 1991 and 2015. During these two decades, the 45% drop in lung cancer deaths in men represents the largest decrease in cancer mortality, the authors noted.
At the time, Otis W. Brawley, MD, chief medical officer of the ACS, said that the statistics “reiterate where cancer control efforts have worked, particularly the impact of tobacco control.” Despite this, he added, “tobacco remains by far the leading cause of cancer deaths today, responsible for nearly 3 in 10 cancer deaths.”
Declines in Adult Smoking
The new report from the CDC was undertaken to assess progress toward the government’s Healthy People 2020 program aimed at reducing the number of cigarette smokers to 12% or less.
The latest figures show that the average number of cigarettes smoked each day declined from an average of 17 in 2005 to 14 in 2016. The proportion of people who smoked 20 to 29 cigarettes per day dropped from 34.9% in 2005 to 28.4% in 2016.
“The good news is that these data are consistent with the declines in adult cigarette smoking that we’ve seen for several decades,” said Corinne Graffunder, DrPH, director of the Office on Smoking and Health at the CDC, in a statement. “These findings also show that more people are quitting, and those who continue to smoke are smoking less.”
“The bad news is that cigarette smoking is not declining at the same rate among all population groups,” added coauthor Brian King, PhD, deputy director for research translation, Office on Smoking and Health. “Addressing these disparities with evidence-based interventions is critical to continue the progress we’ve made in reducing the overall smoking rate.”
Not All Smokers Receive Help
Although identification of smokers has improved — 80% of tobacco users can be identified through electronic health records and automatic screening — only 60% are advised to quit and only 30% receive counseling or medications to quit, Dr Karam-Hage said.
Once barriers to tobacco treatment are removed, “proactive programs that reach out to all smokers or tobacco users who can be identified in any setting” need to be established, he suggested.
More tobacco treatment specialists from all backgrounds need to be trained to deliver the best evidence-based treatments, he added, noting that a national certification process now exists to train tobacco treatment specialists.
MD Anderson has 1 of 16 certified training programs, and for patients, the 10- to 12-week Tobacco Cessation Program helps about 50% quit smoking.
We do not leave any stone unturned.
“We do not leave any stone unturned,” said Dr Karam-Hage. “We do intensive counseling, proactive medication management, and adjustment during treatment. We treat common psychiatric comorbidities, such as depression, anxiety, or insomnia.”
For smoking cessation, a combination of medications, such as buproprion and varenicline, or “a patch plus a lozenge” are more effective than single agents, Dr Karam-Hage emphasized. This is particularly true in patients who are heavy smokers or who have a high index of addiction to nicotine, he said.
For patients who have managed to reduce smoking by 50% but still can’t quit, clinical research at MD Anderson shows that a small increase in the dose of varenicline after the first few weeks — from the approved dose of 2 mg/day to 3 mg/day — “helps them to get to quit,” said Dr Karam-Hage.
Patients are followed with a phone call every 3 months for the following year, and those who relapse are re-enrolled.
Dr Karam-Hage called the US Food and Drug Administration’s new dual strategy for reducing nicotine in cigarettes while promoting newer nicotine delivery devices that don’t contain combustible tobacco “promising.” He predicted that “if implemented carefully, it will have a major impact on reducing combustible tobacco use and cigarette smoking.”
MMWR Morb Mortal Wkly Rep. January 19, 2018; 67:53-59. Full text
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