What are the health effects of smoking and how can they be mitigated?

Evil Effects of Smoking and Mitigation Strategies

Smoking is the single largest preventable cause of disease and premature death, responsible for approximately 440,000 American deaths annually, with 30% of all cancer deaths and 20% of cardiovascular deaths directly attributable to tobacco use. 1

Mortality and Morbidity Impact

Cardiovascular Disease

• Nearly 20% of all cardiovascular deaths are caused by tobacco use, including more than 148,000 deaths from active smoking and an additional 35,000 deaths from secondhand smoke exposure 1
• Smoking increases risk for coronary heart disease, stroke, and peripheral vascular disease 2, 3
• Quitting smoking reduces coronary heart disease death risk by 50% after just 1 year of abstinence 1
• The economic cost of lost productivity from smoking-attributable cardiovascular disease was $35.6 billion in 2000 1

Cancer Risk

• Approximately 30% of all cancer deaths in the United States are attributable to active smoking 1
• Tobacco smoking is causally related to at least 16 types of cancer: lung, colon and rectum, oral cavity, nasal cavities and sinuses, pharynx, larynx, esophagus (both squamous cell carcinoma and adenocarcinoma), stomach, pancreas, liver, urinary bladder, kidney (adenocarcinoma and transitional cell carcinoma), uterine cervix, and myeloid leukemia 1
• Cigarette smoking causes 85-90% of lung cancer deaths, with environmental tobacco smoke responsible for an additional 3,000 lung cancer deaths among nonsmokers 1
• The risk of lung cancer is 20-40 times higher in lifelong smokers compared to non-smokers 4
• Oral cavity cancer shows convincing evidence of large increased risk (relative risk ≥2.0) from smoking 5
• Up to 75% of oral cancer cases may be attributable to tobacco and alcohol use combined 5
• Cancer risk follows a clear dose-response relationship, increasing with number of cigarettes smoked per day, depth of inhalation, and duration of smoking 1, 5

Diabetes Risk

• Smoking is an independent and modifiable risk factor for type 2 diabetes 1
• Men and women who smoked 2 packs per day had 45% and 74% higher diabetes incidence rates respectively compared to never-smokers 1
• Women smoking 15+ cigarettes daily had 30-40% higher diabetes risk compared to never-smokers 1
• Quitting smoking reduced diabetes incidence to that of nonsmokers after 5 years in women and 10 years in men 1
• Tobacco use may exacerbate diabetes complications 1

Other Health Effects

• Smoking causes respiratory diseases including COPD and tuberculosis 1, 2
• Increased risk for impaired immune function, autoimmune diseases (rheumatoid arthritis), eye disease (age-related macular degeneration), and erectile dysfunction 1
• Smoking during pregnancy causes ectopic pregnancy, orofacial clefts, fetal growth restriction, preterm delivery, and sudden infant death syndrome 1
• Smoking contributed to 23.2-33.6% of sudden infant death syndrome cases in 2002 1

Economic Burden

• Total economic losses from tobacco use: $157.7 billion annually (1995-1999 data), including both direct medical expenses and lost productivity 1

Mitigation Strategies

Clinical Intervention Framework

Physicians must advise all smokers to quit and provide comprehensive cessation support combining behavioral counseling with pharmacotherapy. 1

Behavioral Counseling Approaches

• Even brief counseling (as little as 3 minutes) produces long-term quit rates, but longer programs are more effective 1
• Three particularly effective counseling types: practical counseling with problem-solving and skills training, social support as part of treatment, and facilitation of social support outside treatment 1
• Hospitalization for ischemic heart disease or smoking-related morbidity creates a "teachable moment" for intervention 1
• Special populations (African Americans, Native Americans, pregnant women) benefit from tailored interventions 1

Pharmacotherapy Options

First-line FDA-approved agents for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion. 1, 6, 7, 8

Varenicline

• Studies show varenicline is superior to bupropion or nicotine patch for smoking cessation 1
• Common adverse effect: nausea in almost 30% of patients 1
• FDA warning: monitor for neuropsychiatric symptoms including changes in mood, depression, mania, psychosis, suicidal thoughts, aggression, and hostility 6
• Patients should stop varenicline and contact healthcare provider immediately if neuropsychiatric symptoms occur 6
• Three dosing approaches available: standard 12-week course starting 1 week before quit date, flexible quit date between days 8-35, or gradual reduction approach over 24 weeks 6

Nicotine Replacement Therapy (NRT)

• Available as gum, inhaler, lozenge, nasal spray, and transdermal patch 1, 7
• Fewer adverse effects than varenicline or bupropion 1
• Contraindications: recent heart attack, irregular heartbeat, uncontrolled high blood pressure 7
• Used patches contain enough nicotine to poison children and pets—proper disposal is critical 7

Bupropion

• FDA Black Box Warning: increased risk of suicidal thinking and behavior, particularly in children, adolescents, and young adults 8
• Contraindications: seizure disorder, current or prior bulimia/anorexia nervosa, abrupt discontinuation of alcohol/benzodiazepines/barbiturates/antiepileptics 8
• Cannot be used within 14 days of MAOI therapy 8
• Dose-related seizure risk—maximum daily dose 450 mg with gradual titration 8
• Can cause false-positive urine tests for amphetamines 8

Critical Pitfalls to Avoid

• Do not combine varenicline with nicotine patch without warning patients about increased nausea, vomiting, headache, dizziness, and fatigue 6
• Counseling and pharmacological interventions are currently underutilized—clinicians must actively offer these treatments 1
• Patients with mental health conditions require closer monitoring during smoking cessation, as symptoms may worsen 6
• Pregnant women should be advised that smoking cessation without medication is preferred, but NRT is believed safer than continued smoking 7
• Breastfeeding women using varenicline must monitor infants for seizures and excessive vomiting 6

Benefits of Cessation in Cancer Patients

• Continued smoking after cancer diagnosis critically compromises treatment efficacy, increases recurrence risk, and reduces overall survival 2
• Stopping smoking may prolong survival in cancer patients and decreases risk of recurrent pulmonary carcinoma 4, 2
• Oncologists and dental professionals should encourage smoking cessation, especially in patients with cancer 1, 5

Population-Level Interventions

• Comprehensive tobacco-control programs include: advertising restrictions, increased excise taxes, reduced minor access, education and counter-advertising, clean air laws, and readily available cessation treatment 1
• States with strong tobacco-control programs (California, Massachusetts) have seen accelerated declines in smoking prevalence, cardiovascular mortality, and lung cancer incidence at younger ages 1
• Combining higher tobacco taxes with comprehensive media and public education campaigns produces lower smoking rates than either strategy alone 1

Screening Recommendations

• Any oral abnormality lasting more than 2 weeks should be reevaluated and considered for biopsy 5
• Dental professionals should routinely screen for oral cancer, particularly in patients with smoking history 5