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2
Factors Perpetuating the Tobacco Problem

Over the past 40 years, much progress has been made in reducing the number of individuals who initiate tobacco use and in increasing the percentage of tobacco users who have quit. Current trends, however, indicate that reductions in the initiation of tobacco use have slowed and that the annual rate of cessation among smokers remains fairly low. This chapter provides an overview of the factors that impede additional progress and suggests that substantial and sustained efforts will be required to further reduce the prevalence of tobacco use and thereby reduce tobacco-related morbidity and mortality summarized in the introduction of this report and in numerous Surgeon General reports (see Box 2-1). First and foremost, tobacco products are highly addictive because they contain nicotine, one of the most addictive substances used by humans. Nicotine’s addictive power thus poses significant challenges to smoking cessation efforts at both the individual and the population levels. Second, factors such as distorted risk and harm perceptions, which are associated with the initiation and maintenance of tobacco use among young smokers, pose a continuing obstacle for prevention and control strategies. Finally, the apparent concentration of heavy smoking among populations with particular vulnerabilities and a possible emerging trend toward the later onset of less frequent smoking suggest that new approaches and strategies may be needed to reduce the prevalence of tobacco use on a permanent basis.

NATURE OF NICOTINE ADDICTION

Nicotine is considered a highly addictive substance (DHHS 1988; Royal College of Physicians 2000; WHO 2003). The science base supporting this



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Ending the Tobacco Problem: A Blueprint for the Nation 2 Factors Perpetuating the Tobacco Problem Over the past 40 years, much progress has been made in reducing the number of individuals who initiate tobacco use and in increasing the percentage of tobacco users who have quit. Current trends, however, indicate that reductions in the initiation of tobacco use have slowed and that the annual rate of cessation among smokers remains fairly low. This chapter provides an overview of the factors that impede additional progress and suggests that substantial and sustained efforts will be required to further reduce the prevalence of tobacco use and thereby reduce tobacco-related morbidity and mortality summarized in the introduction of this report and in numerous Surgeon General reports (see Box 2-1). First and foremost, tobacco products are highly addictive because they contain nicotine, one of the most addictive substances used by humans. Nicotine’s addictive power thus poses significant challenges to smoking cessation efforts at both the individual and the population levels. Second, factors such as distorted risk and harm perceptions, which are associated with the initiation and maintenance of tobacco use among young smokers, pose a continuing obstacle for prevention and control strategies. Finally, the apparent concentration of heavy smoking among populations with particular vulnerabilities and a possible emerging trend toward the later onset of less frequent smoking suggest that new approaches and strategies may be needed to reduce the prevalence of tobacco use on a permanent basis. NATURE OF NICOTINE ADDICTION Nicotine is considered a highly addictive substance (DHHS 1988; Royal College of Physicians 2000; WHO 2003). The science base supporting this

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Ending the Tobacco Problem: A Blueprint for the Nation BOX 2-1 Surgeon General’s Reports on Tobacco Use 1964–2006 1964 Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service 1967 The Health Consequences of Smoking: A Public Health Service Review 1968 The Health Consequences of Smoking: 1968 Supplement to the 1967 Public Health Service Review 1969 The Health Consequences of Smoking: 1969 Supplement to the 1967 Public Health Service Review 1971 The Health Consequences of Smoking: A Report of the Surgeon General 1972 The Health Consequences of Smoking: A Report of the Surgeon General 1973 The Health Consequences of Smoking 1974 The Health Consequences of Smoking 1975 The Health Consequences of Smoking 1976 The Health Consequences of Smoking: Selected Chapters from 1971 through 1975 1978 The Health Consequences of Smoking, 1977–1978 1979 Smoking and Health: A Report of the Surgeon General 1980 The Health Consequences of Smoking for Women: A Report of the Surgeon General 1981 The Health Consequences of Smoking—The Changing Cigarette: A Report of the Surgeon General 1982 The Health Consequences of Smoking—Cancer: A Report of the Surgeon General 1983 The Health Consequences of Smoking—Cardiovascular Disease: A Report of the Surgeon General 1984 The Health Consequences of Smoking—Chronic Obstructive Lung Disease: A Report of the Surgeon General 1985 The Health Consequences of Smoking—Cancer and Chronic Lung Disease in the Workplace: A Report of the Surgeon General 1986 The Health Consequences of Involuntary Smoking: A Report of the Surgeon General 1988 The Health Consequences of Smoking—Nicotine Addiction: A Report of the Surgeon General 1989 Reducing the Health Consequences of Smoking—25 Years of Progress: A Report of the Surgeon General 1990 The Health Benefits of Smoking Cessation: A Report of the Surgeon General 1992 Smoking and Health in the Americas: A Report of the Surgeon General 1994 Preventing Tobacco Use Among Young People: A Report of the Surgeon General 1998 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 2000 Reducing Tobacco Use: A Report of the Surgeon General 2001 Women and Smoking: A Report of the Surgeon General 2004 The Health Consequences of Smoking: A Report of the Surgeon General 2006 The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General SOURCE: (CDC 2006).

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Ending the Tobacco Problem: A Blueprint for the Nation claim has been reviewed in-depth by the Institute of Medicine (IOM) in its 2001 report, Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction (IOM 2001), and by the U.S. Department of Health and Human Services in the 1988 Surgeon General’s report, The Health Consequences of Smoking: Nicotine Addiction (DHHS 1988). These reports highlight the research literature showing that nicotine, through a complex set of mechanisms and actions that affect the neurochemistry of the brain, establishes and maintains dependence on tobacco use. The evidence derives from animal and human studies, from molecular biology and neurochemistry to behavioral studies. The evidence, in fact, is overwhelming. One of the main implications of addiction is the loss of control of drug (nicotine) use. This means that when a person would like to stop or reduce the level of consumption of an addictive drug, like nicotine, it is difficult to do so. Physical dependence on nicotine is associated with psychoactive as well as positive and negative reinforcing effects, the development of tolerance, and the experience of withdrawal symptoms. Dependence is associated with direct and indirect effects of nicotine on brain neurotransmitters, which are directly related to the behaviors associated with addiction and withdrawal. In addition, behavioral factors, including conditioning, play an important role along with the neurochemical effects. Finally, there are some physiological effects of cigarette smoke independent of the nicotine that might contribute to the overall pleasure and addictive properties of nicotine. Nicotine from cigarette smoke is rapidly absorbed in the lungs, from which it is quickly passed into the brain. Nicotine exerts its actions by binding to nicotinic cholinergic receptors (nAChRs) in the brain (Dani and De Biasi 2001). Composed of five subunits, the main receptor mediating nicotine dependence is believed to be the α4β2 nicotinic cholinergic receptor. Mice lacking the β2 subunit gene do not self-administer nicotine, nor do they exhibit other behavioral effects associated with nicotine exposure. The α4 subunit is associated with nicotine sensitivity. Mutations of that subunit lead to increased sensitivity to nicotine-induced reward behaviors as well as to effects on tolerance and sensitization (Tapper et al. 2004). Nicotine affects many neurotransmitter systems: dopamine, norepinephrine, acetylcholine, serotonin, γ-aminobutyric acid, glutamate, and endorphins. The major effect of nicotine is to stimulate release of these transmitters. The result of dopamine release is critical to the reinforcing effects of nicotine and occur in the mesolimbic area, the corpus striatum, and the frontal cortex. A pathway of particular importance to drug-induced reward involves the dopaminergic neurons in the ventral tegmental area of the midbrain and the release of dopamine in the shell of the nucleus accumbens. Dopamine release signals a pleasurable experience. For example, the threshold for intracranial self-stimulation in rats, a model for brain reward, is lowered acutely with nicotine exposure, indicating greater reward.

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Ending the Tobacco Problem: A Blueprint for the Nation As would be expected with substances associated with tolerance and addictive properties, neuroadaptation occurs with chronic nicotine exposure. A suspected biological correlate of this is an increase in nAChRs in the brain. This increase is thought to reflect nicotine-mediated desenstitization, meaning that more nicotine is required to deliver the same neurochemical effect. For example, nicotine withdrawal in rodent models is associated with increased threshold for intracranial self-stimulation, indicating reduced reward due to inadequate dopamine release. Independent of nicotine effects, cigarette smoking is associated with decreased activity of monoamine oxidase enzymes in the brain, which are associated with the degradation of dopamine. Inhibition of monoamine oxidase activity would augment nicotine effects of increasing dopamine levels and contribute to positive reinforcement, tolerance, and addiction. As most smokers report, stopping smoking is acutely associated with withdrawal symptoms of irritability, restlessness, anxiety, problems getting along with friends and family, difficulties concentrating, increased hunger and eating, and cravings for tobacco. Another symptom is the lack of pleasure or enjoyment, known as anhedonia. These symptoms are believed to be due to the relative deficiency in dopamine release, related to nicotine-mediated changes in receptor function and structure. Nicotine addiction is thus sustained by a combination of positive effects of nicotine on neurotransmitter levels related to pleasure and arousal, the dampening effect of those pleasure or reward mechanisms over time, and the need for continued nicotine exposure to avoid the negative affects related to the decreased neurotransmitter levels, particularly that of dopamine, that would occur without nicotine. However, in addition to the pharmacological mechanisms of nicotine, conditioning is also thought to play an important role in tobacco addiction. With regular drug use, specific moods or other environmental factors, known as “cues,” become associated with the pleasurable or rewarding effects of the drug. This association between the cues and the anticipated pleasure associated with the drug, known as conditioning, is a powerful contributor to addiction (O’Brien 2001). Smoking is maintained in part by conditioning. For example, smoking becomes associated with specific behaviors, such as drinking a cup of coffee or alcohol. Repetition of these coexisting behaviors over time leads to the behavior becoming a cue the person to want to smoke. Behaviors can be conditioned to either the positive or negative reinforcing effects of nicotine. For example, because smoking becomes associated with relieving the negative affects of nicotine withdrawal, the smoker can associate smoking with relieving other negative feelings, such as stress. Managing conditioned behaviors is often an important factor in the success of nicotine cessation.

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Ending the Tobacco Problem: A Blueprint for the Nation Smoking also facilitates nicotine dependence through sensorimotor factors associated with the act of smoking. Several studies have found that sensorimotor factors play an important role in maintaining smoking behavior in some smokers (Brauer et al. 2001; Naqvi and Bechara 2005; Rose 2006; Rose et al. 2000, 2003). A number of researchers, including Rose and colleagues, have used nicotinized and denicotinized cigarettes to study the separate roles of pharmacological actions of nicotine and the sensory/behavioral aspects of cigarette smoking on smoking withdrawal and smoking behavior (Rose et al. 2000). The results of those studies indicate that smoking denicotinized cigarettes can produce satisfaction as well as psychological rewards and can reduce the craving sensations. This finding is consistent with reports from smokers who described positive feelings as they inhale cigarette smoke but who do not experience these feelings when these sensory effects are blocked (Rose 1988; Rose et al. 1999). It has been suggested that the stimulation of nicotinic receptors on vagal nerve endings in the respiratory tract plays a role in mediating the immediate subjective effects of cigarette smoking (Rose et al. 1999). The findings from this body of work thus suggest that airway sensory replacement may be an important aspect to be considered when determining the smoking cessation strategies to be used for some smokers (Rose et al. 1999; Westman et al. 1995). In recent years, a body of research literature on the genetics of tobacco use has emerged. Over the past decade, researchers have cast some light on the role of genetic factors in tobacco use and dependence (Hall et al. 2002; Kendler et al. 1999; Lerman and Berrettini 2003; Li 2003, 2006; Madden et al. 1999; Sullivan and Kendler 1999). A review of a number of studies with twins suggests a significant genetic component in the initiation and maintenance of tobacco use (Kendler et al. 1999; Sullivan and Kendler 1999). On the basis of findings from studies of families, adopted children, and twins, Sullivan and Kendler estimate that a genetic influence may contribute approximately 60 percent to the possibility of smoking initiation, with environmental and personal influences contributing the remainder (Sullivan and Kendler 1999). Genetic influences are also estimated to contribute significantly (about 70 percent) to nicotine dependence. Tyndale (2003), meanwhile, has reported on differences in the estimates of genetic influences on smoking initiation by gender, with rates ranging from 32 to 70 percent among females and 31 to 61 percent among males (Tyndale 2003). Estimates of the genetic influence on smoking persistence range from 4 to 49 percent among females and from 50 to 71 percent among males. Additional studies indicate that the age of smoking onset, the amount smoked, and smoking persistence are also influenced by genetics (Heath et al. 1999; Koopmans et al. 1999; Madden et al. 1999).

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Ending the Tobacco Problem: A Blueprint for the Nation The number of studies that have assessed the role of specific genes in smoking behavior continues to grow. The work of Malaiyandi and colleagues (2005), for example, suggests that cytochrome P450 (CYP) 2A6, the liver enzyme which mediates the conversion of nicotine to cotinine, may play an important role in smoking (Malaiyandi et al. 2005). In a review of recent genetic studies of nicotine dependence, Li (2006) presents evidence that several genes may be implicated in nicotine dependence (Li 2006). Some of these genes include gamma-aminobutyric acid 2, which modulates neuronal excitability; nicotinic acetylcholine receptor alpha4, (CHRNA4), which modulates tolerance to nicotine; decarboxylase and brain-derived neurotropic factor, which influence dopamine and serotonin, which play important roles in the reward system of addiction; and the catechol-O-methyltransferase gene, which plays a role in the dopaminergic circuits central to the reward system. These and future studies of the role of genetic influences on smoking have the potential to further the understanding of nicotine addiction and its treatment. The role of genetics in identifying the best treatment strategies for subgroups of smokers is another important emerging area of research. Pharmacogenetics researchers have examined a variety of polymorphisms and gene variances in smokers and their response to a number of current and widely used cessation pharmacotherapies for nicotine dependence. The results of these studies suggest that specific subgroups of smokers have a significantly higher probability of abstinence when they use nicotine patches, nicotine nasal spray, and bupropion treatment (Lerman et al. 2002, 2004; Swan et al. 2005). However, these studies generally involve small numbers of subjects and the genetic associations need to be replicated. It is expected that continuing research in this area will provide results that can better guide clinicians in selecting the best treatment options for individuals who want to quit smoking and will aid the in development of new drug targets that will help in cessation (Lee and Tyndale 2006). SMOKING CESSATION Once the grip of nicotine addiction has taken hold, quitting is hard. Epidemiological data from the 2004 National Health Interview Survey (NHIS) suggest that of the 44.5 million U.S. adults who were current smokers, about 40.5 percent (or 14.6 million) of smokers reported that they had stopped smoking for at least 1 day in the preceding 12 months in an effort to quit (CDC 2005b). Although the number of smokers who attempt to quit is significant, actual quit rates are about 5 percent, and in studies that include biochemical verification of abstention, the actual quit rate is about 3 percent (Shiffman 2004). Some researchers suggest that each year only about 2 percent of smokers will quit permanently (Hughes 2003;

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Ending the Tobacco Problem: A Blueprint for the Nation Shiffman 2004). Eventually, however, 50 percent of individuals who have ever smoked will quit (CDC 2005a). Many smokers regret having engaged in smoking behavior. One major study of smokers in four countries (the United States, Canada, the United Kingdom, and Australia) found an overwhelming high level of regret among adult smokers (about 90 percent). This finding was consistent across the four countries (Fong et al. 2004). Regret was defined as responses of strong agreement and agreement with the statement “If you had to do it over again, you would not have started smoking.” Although the overall level of regret was high, it was more likely to be experienced by older smokers, women, and those who had tried to quit more often. With such high levels of regret, it is not surprising that 70 percent of smokers report an interest in quitting (Fiore et al. 2000; Hughes 1999; Hymowitz et al. 1997). Interest in quitting, however, does not translate into immediate plans or actions to quit (Larabie 2005). When smokers interested in quitting are queried about their specific plans to quit, only 10 to 20 percent report a plan to quit in the next month (Etter et al. 1997). Eventually, however, about 70 percent of smokers will make at least one quit attempt (Fiore et al. 2000). Individuals who contemplate taking steps to quit often engage in a process of weighing the pros and cons of smoking (Velicer et al. 1999). In a comprehensive review of the literature spanning five decades, McCaul and colleagues found that the primary factor motivating smokers to quit is a health concern (McCaul et al. 2006). This finding was robust across retrospective studies of former smokers, cross-sectional studies of current smokers, and prospective studies of smokers in cessation studies. Health concerns were also reported as a primary motivating factor among smokers in the Community Intervention Trial for Smoking Cessation (COMMIT) cohort study of smokers monitored for 13 years. Smokers who had made one serious attempt to quit in the period from 1993 to 2001 reported the most common reasons for quitting were concerns for current and future health (92 percent), expense (59 percent), concern for effects on others (56 percent), and setting a good example for children (52 percent) (Hyland et al. 2004). These results are similar to those found in an early COMMIT survey (1988 to 1993) (Hymowitz et al. 1997). Physicians are in a unique position to encourage smoking cessation by their patients (Fiore et al. 2000; Russell et al. 1979; Schroeder 2005). Physician counseling and intervention are estimated to double the likelihood of quitting (Goldstein et al. 1997). Many physicians, however, miss clinical opportunities to counsel patients. Schroeder (2005) notes that only a minority of physicians are aware of and implement the 5 A’s (ask, advise, assess, assist, and arrange) of cessation treatment. A number of factors may contribute to physicians’ limited participation

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Ending the Tobacco Problem: A Blueprint for the Nation in encouraging patients to stop smoking. External factors such as time constraints, lack of financial incentives, or reimbursement for cessation services can be a hindrance (Schroeder 2005), as can the lack of smoking cessation educational resources in the practice setting or in the community (Tremblay M et al. 2001). Physicians’ lack of knowledge, expertise, or skill in smoking cessation, as well as their negative beliefs and perceptions regarding their role in getting patients to quit have also been noted (Schroeder 2005; Tremblay et al. 2001). Physicians, for example, may believe that patients can’t quit or do not fully understand that patients may try and fail a number of times before they are successful at quitting. Physicians may also fear a negative response from a patient if quitting smoking is addressed in the clinical visit (Schroeder 2005). Strategies to support physicians in engaging patients to quit smoking need to be identified and tested. Schroeder (2005), for example suggests a shortcut option encouraging physicians to ask, advise, and refer. Such strategies, however, will require enhanced support for community resources available for referral, such as quitlines. Stages of Change The desire or intention to quit smoking, along with an eventual attempt to quit smoking, has been viewed by many researchers as a series of transitional change stages by proponents of the transtheoretical model of change. The stages of change include precontemplation, contemplation, preparation, action, and maintenance (Prochaska and DiClemente 1983). Early studies that used the model found that cessation activity differed substantially by stage of change and that stages of change were, in turn, predictive of quit attempts and the success of quitting at 1 and 6 months (DiClemente et al. 1991). Wewers and colleagues (using data from Current Populations Surveys conducted in 1992–1993, 1995–1996, and 1998–1999) used the Stages-of-Change Model to study movement in the readiness to quit among Americans in the 1990s (Wewers et al. 2003). The percentage of individuals in each stage of change over the three survey periods ranged from 63.7 to 59.1 in the precontemplation stage (not seriously thinking of stopping within the next 6 months), 33.2 to 28.7 percent in the contemplation stage (planning on quitting in the next 6 months but not in the next 30 days or planning on quitting in the next 30 days but making no quitting attempts in the past 12 months), and 9.3 to 7.7 percent in the preparation stage (planning on quitting in the next 30 days and making a quit attempt of at least 24 hours duration in the past 12 months). Overall, the study results indicated very little movement in the stages of readiness to change among the U.S. population in the 1990s. Some surveys examining the stages of change and quitting have de-

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Ending the Tobacco Problem: A Blueprint for the Nation scribed mixed results. Etter (2004) reported an association between smoking prevalence and stages of change: a higher prevalence of smoking was associated with a lower motivation to quit, as were fewer quit attempts and higher levels of cigarette consumption (Etter 2004). These findings were reported on the basis of data from all 50 U.S. states; these results were seen in the 1996 and 1999 Behavioral Risk Factor Surveillance System surveys but not in the 1993 survey. Although the Stages-of-Change Model has been useful in moving cessation research from a focus on smoking and not smoking end points to the process of change from smoking to nonsmoking, questions have been raised about the need to elucidate more clearly other variables that may be implicit in the stages of change (intention to change, past quit attempts, current behavior, and the duration of the current behavior) but that are not explicitly assessed in research studies of stages of change and quitting (Etter and Sutton 2002). Recently, West (2005) has questioned the stages of change paradigm as a description of the cessation process. He found that the majority of smokers stop smoking impulsively, without going through stages of precontemplation and contemplation. Of course, this does not mean that concerns about health and the other harmful effects of smoking have not played an important role in the attempt to quit. Quitting Attempts Understanding which smokers will eventually take steps to quit, who will be successful at quitting, and how long smoking abstinence will endure can be difficult to discern from the literature. Difficulties arise because periods of cessation vary, as do definitions of “abstinence.” Definitions of smoking cessation in the literature typically range from a 24-hour point-prevalence abstinence rate to a 6-month prolonged period of abstinence (Velicer and Prochaska 2004). Some researchers account for whether the smoker has had smoking lapses or was totally abstinent during the period of cessation reviewed (Hughes et al. 2004). Cessation outcomes can also vary depending on whether quitting was unaided or assisted with behavioral or pharmacological therapies. What is clear is that smoking careers can be long in duration. Birth cohort data from NHIS indicate that half of 15- to 17-year-olds who reported smoking at least 100 cigarettes in their lifetime will likely continue to smoke for 16 to 20 years (Pierce and Gilpin 1996). The literature also reinforces the view that nicotine addiction and tobacco dependence show some similarities with chronic diseases that are characterized by periods of relapse and remission (Fiore et al. 2000); thus the path to smoking cessation will include cycles of abstinence, lapses, relapse, and abstinence. Smokers who move from contemplating quitting to action typically

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Ending the Tobacco Problem: A Blueprint for the Nation fail. A study of self-quitters (Garvey et al. 1992) found that the majority of relapses occurred in the first few days and weeks post-cessation. Although most self-quitters (87.2 percent) relapsed within 1 year of their quit date, the majority of relapses occurred in the first few days and weeks after stopping: 13 percent relapsed by 1 day after quitting, 32 percent by 3 days, 49 percent by 1 week, and 62 percent by 2 weeks. The results of another study of motivated self-quitters support the findings of an early relapse to smoking (Hughes et al. 1992). That study reported smoking cessation results by the use of two measures: one measure that reflected complete abstinence and another measure that reflected some smoking (smoking an average of one cigarette per day or less since the last follow-up and observer verification of no smoking of more than 10 cigarettes on any 2 days). The study findings, which used biochemical verification, indicated that 33 percent of self-quitters were abstinent at 2 days, 24 percent at 7 days, 22 percent at 14 days, 19 percent at 1 month, 11 percent at 3 months, 8 percent at 6 months, and 3 percent at 6 months. By using the more relaxed criteria, 47 percent were abstinent at 2 days, 38 percent at 7 days, 32 percent at 14 days, 27 percent at 1 month, 20 percent at 3 months, and 11 percent at 6 months. Under a worst case scenario of unsuccessful quitting attempts, Piasecki and colleagues described cessation attempt “fatigue,” or a decrease in motivation and ability to stay abstinent (Piasecki et al. 2002). Cessation attempt fatigue is noted to be associated with lower expectations for cessation success, a reduced ability to cope or to believe in having the capacity to quit or stay abstinent, and fewer resources to exert control over behaviors or actions related to tobacco use. Smoking lapses and relapses to smoking, however, do not necessarily represent total quit failures but, rather, represent learning experiences along the pathway to cessation. Early on in a cessation attempt, smokers may face a number of circumstances that encourage a smoking lapse, including symptoms associated with nicotine addiction (withdrawal, negative affect, urges, and cravings), the presence of social environmental factors such as smokers in the environment, or easy access to tobacco products (Brauer et al. 1996; Piasecki 2006). Although any smoking behavior after quitting has been identified as a very strong predictor of an eventual relapse (Kenford et al. 1994; Shiffman et al. 2006; Westman et al. 1997), it may not necessarily be a final outcome. Hyland and colleagues (2006) found that quit attempts in the previous year and a longer duration of past quit attempts were important predictors of new quit attempts, suggesting that some smokers will continue to attempt to abstain from smoking, despite past lapses or relapses (Hyland et al. 2006). Other researchers note that smokers with failed quit attempts may reduce the intensity of smoking and the level of addiction for several months

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Ending the Tobacco Problem: A Blueprint for the Nation after a relapse (Knoke et al. 2006). The ability to reduce smoking levels may prime relapsed smokers to be more successful in latter quit attempts. Results from the Community Intervention Trial for Smoking Cessation (surveys from 1988, 1993, and 2001) found a significant increase in quitting among participants who were able to reduce their daily cigarette consumption by 50 percent. Those who reduced their cigarette consumption by more than 50 percent were 1.7 times more likely to quit smoking by 2001 than those who did not reduce their cigarette consumption (Hyland et al. 2005). Smokers who attempt to quit smoking with the use of some assistance tend to fare better than self-quitters; however, many smokers may not be informed about effective cessation methods (Hammond et al. 2004). Although it is not the intention of the committee to provide an exhaustive review of cessation therapies, it is important to highlight current guidelines for assisting smokers with quitting. The U.S. Department of Health and Human Services’ Clinical Practice Guideline for Treating Tobacco Use and Dependence identifies three counseling and behavioral therapies that are effective in helping smokers quit. These include providing smokers with practical counseling that focuses on (1) problem-solving skills and skills training for relapse prevention and stress management, (2) providing social support as part of treatment, and (3) helping smokers obtain social support outside of treatment. Current guidelines also recommend eight effective pharmacotherapies that can assist smokers in their attempts to quit. Five therapies are nicotine-based (nicotine gums, patches, nasal sprays, inhalers, lozenges/tablets), two are antidepression medications (bupropion and nortriptyline), and one is a medication (clonidine) that is used for the treatment of hypertension (Fiore et al. 2000; Foulds 2006; Henningfield et al. 2005). Recently, varenicline, a nicotinic cholinergic receptor partial agonist, has been marketed for smoking cessation. Bupropion, nicotine inhalers, nasal sprays, and nicotine patches are considered first-line medication treatments that double long-term abstinence rates compared with those achieved with placebo. Nicotine gum, also a first-line treatment, improves the long-term abstinence rate by about 30 to 80 percent. There is emerging evidence from a few studies that selected use of combinations of nicotine replacement therapies (a nicotine patch with either a nicotine gum or a nicotine nasal spray) may have greater efficacy than a single form of nicotine replacement, but this has not been proven (Fiore et al. 2000). Summary The previous sections can be summarized succinctly: nicotine in cigarettes and other forms of tobacco is highly addictive. Once addiction takes

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Ending the Tobacco Problem: A Blueprint for the Nation sons with a lifetime history of some type of psychiatric morbidity, but this needs additional confirmation (Breslau 1995; Breslau et al. 1991, 1993, 1994; Grant et al. 2004; Hughes et al. 1986; Lasser et al. 2000). Children with psychiatric and behavioral comorbidities and adverse experiences are at risk for smoking initiation. Children with attention-deficit/ hyperactivity disorder (ADHD) were found to have a higher risk of cigarette use initiation and smoking maintenance, as well as abuse of other substances, than those in non-ADHD comparison groups (Daley 2004; Lambert and Hartsough 1998; Wilens et al. 1997). Wallace also notes that a body of literature has associated a host of adverse experiences—including direct physical or sexual abuse, the presence of depressive effect, suicide attempts, sexually transmitted diseases, and an impoverished, dysfunctional household environment—with substantially increased risks of smoking initiation (De Von Figueroa-Moseley et al. 2004; Dube et al. 2003; Mcnutt et al. 2002; Nichols and Harlow 2004). Furthermore, Wallace notes that, although the research literature is not extensive, higher rates of smoking have been documented among incarcerated individuals, homeless individuals, and other populations. Among these populations, the highest rates of smoking have been reported among inmates. Hughes and Boland (1992) and Lightfoot and Hodgins (1988) reported a 77 percent smoking rate in the past 6 months among inmates in a penitentiary for men. High rates (71 percent) of current smoking have also been reported among women arrested in New York City (Durrah and Rosenberg 2004). The higher rates of smoking among prisoners may be influenced by the intersection of a number of other factors associated with higher rates of smoking, such as substance abuse, lower socioeconomic status, and high rates of psychiatric comorbidities among incarcerated individuals (Andersen 2004). The literature describes a group of “hardcore” smokers who have never attempted to quit smoking. This subgroup of smokers is often described as a small but intractable public health problem. Using data from the 1998-99 Tobacco Use Supplement of the Current Population Survey, Augustson and Marcus (2004) defined “hardcore” smokers as established daily smokers (smoking for at least 5 years) who smoke more than 15 cigarettes per day with no reported history of quit attempts and who are over 25 years of age (Emery et al. 2000). They found that “hardcore” smokers represent 24.7 percent of heavy chronic smokers, 17.6 percent of all established smokers, and 13.7 percent of all current smokers. They are also more likely to be male, unmarried, not working, and to have lower education levels. Warner and Burns (2003) suggest that “hardcore” smokers represent members of a group of smokers whose behavior may be especially resistant to change (Warner and Burns 2003). Genetic vulnerability may be one reason some “hardcore” smokers

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Ending the Tobacco Problem: A Blueprint for the Nation find it difficult to stop smoking. Emerging genetic and pharmacogenetic studies have identified a potential role for gene variances in frustrated cessation attempts. One study, for example, found that smokers with a variant CYP2B6 gene have increased cravings for cigarettes following cessation and are about one and one half times more likely to relapse during treatment (Lerman et al. 2002). Information on genetic variants related to dopamine, serotonin, and nicotine metabolism, as well as other mechanisms that play important roles in nicotine addiction and maintenance, will be important to understand and better assist “hardcore” smokers and other smokers who have difficulty quitting. There seems to be little doubt that a subset of the population of long-term smokers is more heavily addicted and less amenable to cessation inteventions. It is likely that these smokers are particularly vulnerable to nicotine addiction on the basis of predisposing personal characteristics and environmental stresses. These observations have two important implications: first, it is clear that specialized cessation interventions will be needed to assist them with quitting. Second, a realistic assessment of the prospects of achieving a substantial reduction in the prevalence of tobacco use must take the size of the “hardcore” target populations into account. CONCLUSION Smoking prevalence reflects the combined effects in any given period of the changes in the number of new smokers and in the number of smokers who have quit (Niaura and Abrams 2002). This chapter has provided an abridged overview of an extensive body of literature on the factors that affect the trends in smoking prevalence, with particular attention given to how the unique nature of nicotine addiction poses significant challenges to the success of tobacco control efforts. At the center of the story emerging from this literature is the fact that nicotine addiction stimulates and sustains long-term tobacco use, with all of its serious health hazards and social costs. The literature also indicates that, although an overwhelming majority of smokers (90 percent) regret having begun to smoke, overcoming the grip of addiction and the associated withdrawal symptoms is difficult; most smokers must try quitting several times before they are successful. Progress in helping smokers who want to quit and achieve successful and permanent cessation requires that a variety of cessation technologies, both clinical and population-based, be readily available to the smoking population, that they be used, and that they be effective. This task is discussed further in Chapter 5 of this report. While tackling the difficult challenge of helping addicted smokers quit, the fact that thousands of individuals begin smoking each day must also

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Ending the Tobacco Problem: A Blueprint for the Nation be addressed. Most of these new smokers are youth and adolescents who, in part because of their developmental stage, do not clearly understand the full range of risks and consequences of smoking or who discount these long-term health risks because of a belief that they do not apply to them personally. These distortions of judgment include a failure of youth and adolescents to appreciate the risk and grip of addiction when they begin smoking. Tolerance and dependence to nicotine can occur early on after initiation (Bottorff et al. 2004; DHHS 1994; DiFranza et al. 2000; IOM 1994), and the early initiation of smoking is related to the number of years that a person will smoke and the quantity of cigarettes smoked per day in childhood. Less is known about initiation and subsequent intensity after adolescence (Escobedo et al. 1993; Taioli and Wynder 1991). Unfortunately, many youths view themselves as invulnerable to addiction and its associated harm. They are also sensitive to the social factors and norms that promote smoking, such as the influences exerted by peers, family members, and the exposure to smoking in the media. These influences tend to override the information about the risks of smoking. Therefore, to substantially reduce the rate of smoking initiation, it will be necessary to do a better job of counteracting the perceived benefits of smoking and to develop new tools that make the personal risks of starting to smoke more salient. All new smokers are not young, however. Some initiate smoking during their college years, which helps to explain why some new smokers have characteristics that differ from those of usual smokers: they tend to have higher levels of education and income than other smokers. It is also noteworthy that some new smokers smoke at lower levels, and some never reach a level of dependence. It will be important for tobacco control experts to pay close attention to these emerging trends and to design appropriate interventions to respond to them. On the other side of the ledger are smokers who have a more difficult time quitting. “Hardcore” smokers with a long career of smoking and individuals with psychiatric comorbidities or special circumstances, including incarceration and homelessness, have not been the primary targets of traditional cessation treatments or research studies. Achieving success in substantially reducing tobacco use will require taking stock of the progress made with current tobacco prevention and control strategies, identifying where they fall short in responding to emerging smoking trends, and identifying the characteristics and behaviors of subpopulations of smokers. Success will also require the rigorous implementation of known, effective strategies and pushing the envelope to develop new and innovative approaches that can build on the existing tools and strategies used to help people quit smoking.

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