Tobacco, Public Health and Primary Care

1998 promises to be one of the most important years in the fight for tobacco control and prevention, as high-profile, tobacco-related issues take center stage in the U.S. Congress and elsewhere. At the top of this list is sweeping national tobacco control legislation. This anticipated policy is a result of the agreement reached by 40+ State Attorneys General and the tobacco industry in 1997, whereby the tobacco industry would pay more than $365 billion over 25 years to settle numerous state lawsuits against the tobacco industry, help states recover Medicaid costs of treating tobacco-caused illness, and to reduce the access and appeal of tobacco products by minors and adults alike. This multilayered measure must be approved by the U.S. Congress and signed by President Clinton in order to take affect.

The use of tobacco products is the leading cause of premature mortality in the United States. More than 400,000 people each year die from tobacco use1, more than the total combined deaths caused by motor vehicle accidents, suicides, homicides, AIDS, and alcohol and illicit drug abuse. Smoking is the primary contributor to 87% of lung cancer deaths, 21% of deaths from heart disease, 82% of deaths from pulmonary disease, and 30% of all cancer deaths.2 On average, each smoker who died in 1990 as a result of his or her smoking would have lived 15 additional years if he or she had been a nonsmoker.3 The social cost of smoking in 1990 was estimated at $68 billion-$20.8 billion in direct medical costs and $47 billion in lost productivity due to smoking-related premature death and disability.3

Primary care physicians have a compelling interest to reduce the use of deadly tobacco products. This reduction can be accomplished in two ways: preventing people from starting to use tobacco and getting users to quit. The premise of this Project-in-a-Box is that a multifaceted approach to tobacco use prevention is the most powerful way to curb the epidemic. Tobacco cessation efforts for those already addicted to tobacco products are also essential. The primary care physician can play a crucial role in both prevention and cessation, for individual patients and for the community at large. All it takes is a basic knowledge, a core set of skills in tobacco prevention/cessation, and a willingness to make a difference in the leading public health challenge of the modern era.

STUDENT ORGANIZERS GUIDE
This Project-in-a-Box contains a brief historical look at tobacco use, a discussion of the science of nicotine addiction, an analysis of tobacco advertising and promotion, and information about various tobacco prevention and cessation efforts. It also provides useful references and action-oriented resources for further activity and study on the issues surrounding tobacco use. It is designed to serve as a resource document with a complete list of organizational contacts.

Activity Suggestions

• Organize a brown bag lunch or afternoon discussion group to talk about the information contained in this module. This could also be done after class or over dinner.
• Invite a speaker. Possibilities include a generalist physician who is active in tobacco prevention/cessation, a representative from a local tobacco control group, or an official from the city or state health department. Topics for speakers may include: tobacco prevention success stories; how primary care physicians integrate tobacco prevention/cessation into their clinical practice; or community organizations involved in tobacco control.
• Discuss the issues and create a plan for action. Develop a community project addressing tobacco as a public heath problem or perhaps your school could begin a seminar series on tobacco.

A Historical View of Tobacco Use
The art of smoking was carried back to Europe by early explorers of North America, where tobacco was used by indigenous peoples for recreational as well as religious purposes. In Europe, the practice was initially met with skepticism, and, in some cases, frank hostility. In Germany, for example, smoking tobacco was once punishable by death. In Russia, castration was the punishment of choice, and smokers in Turkey were executed as infidels.

Despite this strong initial response against smoking tobacco, the practice soon became not only acceptable, but also a mark of sophistication. Chewing tobacco was also popularized, and the ever-present spit-filled cuspidor is thought to have contributed to the spread of tuberculosis and other infectious diseases. Smoking tobacco became the dominant form of use during the industrial age, when new manufacturing techniques allowed mass production of relatively inexpensive cigarettes.

In the United States, cigarettes grew in popularity after World War I and reached their pinnacle in the mid-1960s, at which point 52% of adult males and 32% of adult females were cigarette smokers. A landmark Surgeon General's report, published in 1964, was among the first documents to chronicle the hazardous effects of smoking tobacco. Since that time, the prevalence of smoking has declined substantially--from 40.4% of the total adult population in 1965 to 25.7% in 1991. Since 1991, however, the prevalence rate has remained essentially unchanged. The smoking prevalence rate among youths and adolescents has actually shown an increase in the 1990s.4 The data, reported from the 1997 Youth Risk Behavior Survey, found that past-month smoking rates among high school students are on the rise-increasing by nearly a third from 27.5% in 1991 to 36.4% in 1997. Nearly half (48.2%) of male students and more than a third (36%) of female students reported using some form of tobacco-cigarette, cigar or smokeless tobacco-in the past month. Among African American students, whose low smoking rates over the past decade have been a public health success story, past-month cigarette smoking rates increased by an estimated 80% between 1991 and 1997. Teen use of smokeless tobacco, considered rare before 1970, increased nearly tenfold between 1970 and 1985, and has remained almost constant.

Physicians can affect tobacco advertising
Continued attention must be paid to the effects of tobacco advertising and promotions on youth, particularly due to the recent finding that youth are more likely than adults to smoke the most advertised cigarette brands.14 As community health advocates, primary care doctors can become involved in media-based tobacco control efforts. For more information, contact:

Media Campaign Resource Center for Tobacco Control

phone: (301) 231-7537

fax: (301) 984-8527

e-mail: cdt7@oddc1.em.cdc.gov

The Nature of Tobacco Addiction
Tobacco-delivered nicotine is highly addictive. Of the approximately 20 million people who try to quit smoking annually, only about 3% have traditionally had long-term success.5 Even among addicted smokers who lose a lung or have major heart surgery because of their habit, only about 50% maintain long-term smoking abstinence.6 One of the hallmarks of any addiction is continued use of the substance despite adverse consequences, and tobacco use fits this criterion. Indeed, there is evidence suggesting nicotine to be as addictive as heroin and cocaine.7 And because tobacco use involves daily and repeated doses of nicotine, the overall prevalence of addiction exceeds those of many other commonly abused substances.

The pathophysiology of nicotine dependence is beyond the purview of this module, and has been described elsewhere.8 In brief, the conditioning effect of nicotine is thought to be produced through activation of nicotinic receptors in the brain, modulation of neurohormones such as epinephrine and cortisol, and by affecting the mesolimbic dopaminergic reward system. In a typical day, a smoker experiences hundreds of such pairings by puffing on cigarettes and the resultant intense neural activation.

Most nicotine addicts begin using tobacco during childhood and adolescence. For adults who smoke daily, approximately 90% began regular use of cigarettes by age 18.9 If a person reaches the age of 18 without becoming a user of tobacco products, he or she has little chance of becoming a user as an adult. On the other hand, most teenagers who initiate regular use of tobacco products will become addicted, and their habit will remain active for years. Thus, the most effective way to achieve a broad-based reduction in tobacco-related disease will have as its core a strong, youth-centered focus on prevention. Cessation efforts and adult-based prevention efforts will remain important adjunctive approaches, but cannot hope to achieve the same level of impact as youth and adolescent prevention efforts.

• Americans spend an estimated $50 billion annually on direct medical care for smoking-related illnesses. Lost productivity and forfeited earnings due to smoking-related disability account for another $47 billion per year.
• The average cost per smoker for effective cessation treatment is $165.61.
• Smoking cessation interventions are less costly than other routine medical interventions such as treatment of mild to moderate high blood pressure or high cholesterol and preventive medical practices such as periodic mammography.
• Smoking cessation interventions can save costs by reducing health risks and complications for infants and young children.
  

• Ask every patient at every visit if he or she smokes
• Write a patient's smoking status in the medical chart under vital signs

  Blood Pressure:________________________________

  Pulse:________________ Weight:_________________

  Temperature:__________________________________

  Respiratory Rate:_______________________________

  Tobacco Use: (circle one)      Current      Former      Never

• Ask patients about their desire to quit, reinforcing their intentions
• Motivate patients who are reluctant to quit
• Help motivated smokers set a quit date
• Prescribe nicotine replacement therapy, such as nicotine gum and nicotine patch
• Help patients resolve problems that result from quitting. Counseling may be helpful to some patients to increase the likelihood of success
• Encourage relapsed smokers to try quitting again

Thoughts on the AHCPR Guideline
"The guideline is a call to action to clinicians to approach smoking as a chronic condition that is very difficult, but not impossible, to treat." --Douglas B. Kamerow, M.D., M.P.H., AHCPR's director of clinical practice guideline development.

"This guideline not only challenges the way we practice medicine but also can tremendously improve the services we are able to provide smokers who want to quit. While there is no perfect way to quit, clinicians are in a unique position to tailor proven treatments to the particular needs of those patients who want to overcome their nicotine addiction." --Michael C. Fiore, M.D., M.P.H., chair of the guideline panel and director of the University of Wisconsin's Center for Tobacco Research and Intervention.

Tobacco Advertising and Promotion
The tobacco industry loses nearly 5,000 customers a day-3,500 stop smoking and nearly 1,500 die. To maintain the consumer base, these companies must recruit 5,000 new smokers a day, a task that requires an aggressive marketing effort.

The Federal Trade Commission (FTC) issues an annual report to Congress on cigarette sales and advertising. According to a recent FTC report, the cigarette industry spent $4.9 billion on advertising and promotional expenditures in 1995-which amounts to more than $13 million a day. The largest category of advertising and promotional expenditures was promotional allowances, which accounted for 38% of all expenditures. Cigarette companies spent $1.87 billion in 1995 on promotional allowances, which include payments to retailers for shelf space, cooperative advertising with retailers and trade promotions to wholesalers. A moderately sized retailer may receive incentive payments as high as $8,000 per year to stock a variety of different brands of cigarettes.10

Spending on discount coupons, multiple-pack promotions ("buy one, get one free"), and retail value-added offers (non-cigarette items, such as key chains or lighters given away with the purchase of cigarettes) totaled $1.35 billion in 1995; and expenditures for distribution of branded specialty items through the mail, at promotional events, or by any means other than at the point of sale with the purchase of cigarettes was $665.2 million in 1995. Promotional items may have special appeal to youths, as they typically have less disposable income and are more price sensitive than adults.

Money spent by giving cigarette samples to the public nearly doubled from 1994 to 1995 (increasing from $7 million to $13.8 million), although these expenditures remained well below their pre-1994 levels.

Continuing a long-term trend, the industry's expenditures on advertising in newspapers declined 20%, from $24.1 million in 1994 to $19.1 million in 1995. Although newspaper spending accounted for 23.1% of total expenditures in 1981, it accounted for only 0.4% of total industry spending in 1995.

Spending on magazine advertising totaled $248.8 million in 1995, according to the FTC report, while outdoor advertising expenditures were $273.3 million. The tobacco industry heavily advertises in magazines that appeal to youthful readerships, such as Spin, Rolling Stone, Sports Illustrated, Cycle World, Mademoiselle and Glamour.11 Many nonadvertisement scenes in such magazines also depict a glamorous model smoking.12

As in every year since 1989, the industry reported that no money or other form of compensation had been paid to have any cigarette brand names or tobacco products appear in any motion pictures or television shows.

Nearly $126 million was spent on advertising and promotion for smokeless tobacco products in 1994-an increase of $6.7 million from 1993-and more than $127 million was spent in 1995, according to another FTC report to Congress. Advertising and promotion expenditures have increased every year since 1987, when slightly less than $68 million was spent. The report notes increases in spending for magazine advertising and public entertainment among other things.

While the mass media has been used to encourage tobacco consumption, it has also been used to discourage tobacco use. In his review of 56 evaluated mass media programs to influence tobacco use, Flay identified three principal ways in which the mass media has been used to discourage the use of tobacco:13 1) to inform the public of the health consequences of cigarette smoking; 2) to promote specific smoking cessation actions like calling a telephone helpline for assistance in stopping smoking; and 3) to provide smoking cessation clinics to those smokers who desire to stop smoking. Flay concludes that while it is difficult to draw clear inferences about program effects from any single evaluation study, on the whole, the evidence strongly supports the view that mass media programming can produce meaningful, though sometimes small, effects in the smoking habits of the population.

Youth Access to Tobacco
Although it is illegal in all states to sell cigarettes to persons under the age of 18, children and adolescents have easy access to tobacco products. Minors succeed in buying cigarettes over the counter (in two out of three attempts) and through vending machines 90-100% of the time. Minors consume more than 500 million packs of cigarettes per year and at least half of those are illegally sold to minors.15 As previously discussed, nearly all chronic tobacco use begins before high school graduation, so curbing youth access to tobacco is a powerful tool against adult tobacco addiction.

Tobacco Prevention, Cessation and the Primary Care Provider
Primary care physicians are often leaders in their communities and can mobilize schools and communities to develop tobacco use prevention and policy change strategies. Physicians who have examined their roles in this larger context should encourage their colleagues to act as advocates for such programs and participate in their development and implementation.16

Clinicians should aggressively help their smoking patients quit, according to a recent clinical practice guideline sponsored by the Health and Human Services' (HHS) Agency for Health Care Policy and Research.17 The guideline represents the first time the total body of information on smoking cessation has been analyzed systematically. In developing the guideline, the panel reviewed more than 3,000 scientific articles that addressed the assessment and treatment of tobacco dependence, nicotine addiction, and clinical practice.

The guideline challenges every clinician to find out if their patients smoke, repeatedly encourage them to quit, and recommend proven treatments. The panel's recommendations include using the nicotine patch or gum-which double the chances of successfully quitting-combined with a clinician's encouragement, support and practical advice to smokers on how to cope with situations and behavior that make them want to smoke.

Other recommendations to health care administrators, purchasers and insurers include changing the health care delivery system to make it a standard practice to identify and treat smokers and other tobacco users. Primary care providers should stress that the most successful smoking cessation programs are supported by institutional policies. They incorporate reimbursement practices, clinical and systems procedures, incentives for providers, and clinician education. Interventions by many kinds of health care providers are also powerful components of successful programs. Supporting institution-wide smoking cessation programs can yield both short- and long-term cost savings for patients. Working to make institutional change impacts not only the health of patients but also the quality and costs of care.

REFERENCES

1. Centers for Disease Control and Prevention. Cigarette Smoking: Attributable Mortality and Years of Potential Life Lost-United States 1990. Morbidity and Mortality Weekly Report. 27 August 1993;42:33:645-649
2. Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Pub. No. (CDC)89-8411. Washington. DC: U.S. Department of Health and Human Services, 1989.
3. Herdman R, Hewitt M, Laschober M. Smoking Related Deaths and Financial Costs:Office of Technology Assessment Estimates for 1990. Testimony before the Senate Special Committee on Aging. 6 May 1993:2-4.
4. Centers for Disease Control and Prevention. Tobacco use among high school students. MMWR. 1998, United States, April 3, 1998.
5. 5. Pierce JP, Fiore M, Novotny T, Hatziandreu E, Davis R. Trends in cigarette smoking in the United States: projections to the year 2000. JAMA. 1989;261:61-65.
6. West R, Evans D. Lifestyle changes in long-term survivors of acute myocardial infarction. Journal of Epidemiology and Community Health. 1986;40:103-109.
7. Henningfield J, Cohen C, Slade J. Is nicotine more addictive than cocaine? British Journal of Addiction. 1991;86:565-569.
8. Benowitz N. Cigarette smoking and nicotine addiction. Medical Clinics of North America. 1992;76:415-437.
9. Centers for Disease Control and Prevention. Preventing tobacco use among young people: A Report of the Surgeon General. Washington DC: US Department of Health and Human Services, 1994:65.
10. Comerford A, Slade J. Selling cigarettes: a salesman's perspective. Paper commissioned by the Committee on Preventing Nicotine Addiction in Children and Youth, 1994.
11. Basil M, Schooler C, Altman D, Slater M, Albright C, and Maccoby N. How cigarettes are advertised in magazines: special messages for special markets. Health Communication. 1991;(3)2:75-91.
12. Amos A. Youth and style magazines: hooked on smoking? Health Visitor. 1993;(66)3:91-93.
13. Flay BR. Selling the Smokeless Society: 56 Evaluated Mass Media Programs and Campaigns Worldwide. Washington, DC: American Public Health Association, 1987; also see: Flay, BR. Mass media and smoking cessation: a critical review. Am J Public Health 1987;77:153-160.
14. Changes in the cigarette brand preferences of adolescent smokers-United States, 1989­1993. MMWR. 1994;43:577­581.
15. Altman D, Foster V, Rasenick-Douss L, et al. Reducing the illegal sale of cigarettes to minors. JAMA. 1989;261:80-83.
16. Blum A. Role of the health professional in ending the toboacco pandemic: clinic, classroom and the community. National Cancer Institute. ICCR International Conference on Smoking Prevention: facts, maybes and rumors. Journal of the National Cancer Institute Monopgraph No. 12. Bethesda, MD; NIH Publication No. 91-3227,1992:37-43.
17. Smoking Cessation Clinical Guideline Number 18, AHCPR Publication No. 96-0692: April 1996.

RESOURCES

The Advocacy Institute (AI)

Works on efforts to counter the influence of the tobacco industry and provides strategic consulting and advocacy support on policy issues related to tobacco control.

The Advocacy Institute

1707 L Street, N.W., Suite 400

Washington, DC 20036-4505

(202) 659-8475

http://www.scarcnet.org/

 

Agency for Health Care Policy and Research (AHCPR)

Provides materials on smoking cessation for health professionals and consumers.

AHCPR Publications Clearinghouse

P.O. Box 8547

Silver Spring, MD 20907-8547

(800) 358-9295

http://www.ahcpr.gov/

 

American Cancer Society (ACS)

Provides smoking education, prevention and cessation programs and distributes pamphlets, posters, and exhibits on smoking. Refer to your phone book for the ACS chapter in your area or contact the national office below for further information.

American Cancer Society

1599 Clifton Road, N.E.

Atlanta, GA 30329

(800) ACS-2345

http://www.cancer.org/

 

American Council on Science and Health (ACSH)

Provides scientific evaluations on tobacco-related topics.

American Council on Science and Health

1995 Broadway, 2nd Floor

New York, NY 10023-5860

(212) 362-7044

http://www.acsh.org/

 

American Heart Association (AHA)

Promotes smoking intervention programs at schools, workplaces and health care sites. Refer to your phone book for the AHA chapter in your area or contact the national office below for further information.

American Heart Association

National Center

7272 Greenville Avenue

Dallas, TX 75231

(800) AHA-USA1

http://www.americanheart.org/

 

American Lung Association (ALA)

Conducts programs addressing smoking cessation, prevention and the protection of nonsmokers' health. Provides a variety of educational materials for health professionals and the public. Use the phone book to find the ALA chapter in your area or contact the national office below for more information.

American Lung Association

1740 Broadway

New York, NY 10019-4274

(800) LUNG-USA

http://www.lungusa.org/

 

Bureau of Alcohol, Tobacco and Firearms (BATF)

Provides general information about current tax rates and tax revenues pertaining to tobacco.

United States Department of Treasury

Bureau of Alcohol, Tobacco and Firearms

Regualtions Branch

650 Massachusetts Avenue, N.W.

Room 5000

Washington, DC 20226

(202) 927-8210

http://www.atf.treas.gov/

 

Centers for Disease Control and Prevention (CDC),

National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP),

Office on Smoking and Health (OSH)

Directs the U.S. government's tobacco and health activities. Collects and distributes smoking and health information in a variety of forms, including pamphlets, posters, scientific research reports, national campaigns and public service announcements. Maintains a bibliographic database of smoking and health-related information that spans 30 years and contains more than 56,000 records. The database is searchable through the OSH Web site. It is also available on a CD-ROM (CDP file) that is available for use at Federal Deposit libraries. Copies may be purchased from the Government Printing Office (GPO) by calling (202) 512-1800.

Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion

Office on Smoking and Health

Mail Stop# K-50

4770 Buford Highway, N.E.

Atlanta, GA 30341-3724

(770) 488-5705 (general information/publication requests)

(800) CDC-1311 (media campaign response line/fax service)

http://www.cdc.gov/tobacco/

 

Doctors Ought to Care (DOC)

Provides school curricula, smoking intervention information and tobacco counteradvertisements for use in clinics, classrooms and communities.

Doctors Ought to Care

5615 Kirby Drive

Suite 440

Houston, TX 77005

(713) 528-1487

http://www.bcm.tmc.edu/doc/

 

Environmental Protection Agency (EPA)

Serves as the U.S. government's lead agency on environmental issues. The EPA offers publications and information on the adverse effects of environmental tobacco smoke and indoor air pollution.

Environmental Protection Agency

Indoor Air Quality Information Clearinghouse

P.O. Box 37133

Washington, DC 20013-7133

(800) 438-4318

http://www.epa.gov/iaq/

 

Federal Trade Commission (FTC)

Serves as the U.S. government's main authority on trade issues. The FTC provides publications and information related to trade policies and tobacco advertising, including health warning labels, and produces a report that contains data on the tar, nicotine and carbon monoxide of domestic cigarettes.

Federal Trade Commission

Public Reference Branch

600 Pennsylvania Avenue, N.W.

Washington, DC 20580

(202) 326-2222 (publications)

(202) 326-3090 (tobacco-related questions)

http://www.ftc.gov/

 

Food and Drug Administration (FDA)

Responds to consumer requests for information and publications and provides information regarding the regulations restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and adolescents; Final Rule.

Food and Drug Administration

Office of Consumer Affairs

5600 Fishers Lane, HFE-50

Rockville, MD 20857

(301) 827-4420

http://www.fda.gov/

 

National Cancer Institute (NCI)

Develops and implements smoking intervention programs and produces publications on smoking. NCI also provides telephone counseling services for smoking cessation. Programs and materials are available to health professionals and the public.

National Cancer Institute

Office of Cancer Communications

31 Center Drive, MSC-2580

Building 31, Room 10A24

Bethesda, MD 20892-2580

(800) 4-CANCER

http://www.nci.nih.gov/

 

National Health Information Center (NHIC)

Helps the public and health professionals locate information on tobacco and other topics through identification of resources, an information and referral system, and publications. Uses a database containing descriptions of health-related organizations to refer inquirers to the most appropriate resources. Prepares and distributes publications and directories on health promotion and disease prevention topics.

National Health Information Center

P.O. Box 1133

Washington, DC 20013-1133

1-800-336-4797

(301) 565-4167

http://nhic-nt.health.org/

 

Stop Teenage Addication to Tobacco (STAT)

Provides information and programs for health professionals and the public concerning tobacco use and the need to stop tobacco marketing to youth.

Stop Teenage Addiction to Tobacco

Community Intervention of Minneapolis

1-800-328-0417

http://www.youthtobacco.org/

 

Agency for Health Care Policy and Research

Smoking Cessation Consumer Tools Kit: Two Questions, Three Minutes, A Lifetime of Difference for Your Patients.

Smoking Cessation Two-Three Minute Inititative, January 1998. Agency for Health Care Policy and Research, Rockville, Maryland.

http://www.ahcpr.gov/clinic/toolskit.htm