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Smoking Prevention and Cessation

The publisher regrets that in the print and online versions of this book the Foreword and the Preface was omitted from the Frontmatter. Included on the following pages are the Foreword and the Preface.

Foreword

With 650,000 estimated deaths in Europe and 443,000 in the USA, smoking is by far the leading cause of death in the population of developed countries. Furthermore, the global burden of cancer is expected to grow due to dramatic increases in smoking habits in less developed countries (Oppeltz and Jatoi 2011), thereby producing large disparities in cancer-related mortality rates in different geographical areas (Kanavos 2006).

As extensively discussed in this volume, smoking is associated with a variety of chronic degenerative diseases, and the fraction of deaths attributable to smoking has been estimated to be around 30% for all cancers, 85–90% for lung cancer, 50–70% for aerodigestive tract cancers, in synergism with alcohol, 75–80% for chronic obstructive pulmonary diseases (COPD), such as emphysema and chronic bronchitis, and 30% for cardiovascular and cerebrovascular diseases, in synergy with other risk factors (De Flora and Bartsch 2012). In particular, according to the International Agency for Research on Cancer (IARC), there is evidence for a causal association of CS with cancers affecting (a) the respiratory system (nasal cavity and paranasal sinuses; nasopharynx, oropharynx, and hypopharynx; larynx and lung), (b) the urinary tract (kidney pelvis, ureter, and bladder), (c) the digestive system (oral cavity, oesophagus, stomach, colon-rectum, liver, and pancreas), (d) the reproductive tract (ovary and uterine cervix), and (e) the hematopoietic system (myeloid leukemia) (International Agency for Research on Cancer 2012).

Understanding the mechanisms of action of tobacco smoke is difficult because combustion of tobacco leaves generates more than 5,000 identified chemical compounds, 73 of which have been evaluated by IARC to be carcinogenic in humans and/or experimental animals (Hecht 2012). Accordingly, multiple mechanisms are expected to contribute to the carcinogenicity of this complex mixture. These mechanisms are nowadays investigated in depth, also by exploring molecular end-points at the level of DNA (genome), microRNA (miRNome), gene expression (transcriptome), and protein expression (proteome) (De Flora and Bartsch 2012; Izzotti et al. 2009).

The obvious approach to the prevention of smoking-related diseases is to refrain from smoking, to quit smoking, and to avoid passive exposures to environmental tobacco smoke. Epidemiological studies have demonstrated, on a large scale, that a decrease in the consumption of cigarettes is successful in attenuating the epidemic of lung cancer in the population of several countries (De Flora et al. 2005). Chemoprevention by means of dietary and/or pharmacological agents provides a complementary strategy, which finds specific targets in addicted current smokers who are unable to quit smoking and especially in ex-smokers and involuntary smokers.

The present volume is a compendium that embraces a number of issues related to smoking cessation and prevention of smoking-related diseases. It gives a global vision of smoking habits worldwide and analyzes the crucial problems of genetic determinants, smoking initiation, and nicotine dependence. The volume includes an accurate overview of the epidemiology of smoking-related diseases and deals with a detailed analysis of smoking prevention strategies by highlighting the basic principles of smoking cessation techniques at different levels and with various targets. Giuseppe La Torre, who is Associate Professor at the “La Sapienza” University of Rome, made a great job by working as an editor and coordinator of the volume. He coauthored all chapters together with other experts. The result is a comprehensive and detailed treatise providing the state of the art on the health effects and the prevention strategies towards the most widespread plague affecting human health in today’s world.

Silvio De Flora

Genoa, Italy

E-mail: sdf@unige.it

References

De Flora, S., & Bartsch, H. (2012). Genomic and post-genomic effects of cigarette smoke: Mechanisms and implications for risk assessment and prevention strategies. International Journal of Cancer, 131, 2721–2723.

De Flora, S., Quaglia, A., Bennicelli, C., & Vercelli, M. (2005). The epidemiological revolution of the 20th century. FASEB Journal, 19, 892–897.

Hecht, S. S. (2012). Lung carcinogenesis by tobacco smoke. International Journal of Cancer, 131

>International Agency for Research on Cancer. (2012). A review of human carcinogens: Personal habits and indoor combustions. IARC monographs on the evaluation of the carcinogenic risks to humans (Vol. 100, part E). Lyon: IARC.

Izzotti, A., Calin, G. A., Arrigo, P., Steele, V. E., Croce, C. M., & De Flora, S. (2009). Downregulation of microRNA expression in the lungs of rats exposed to cigarette smoke. FASEB Journal, 23, 806–812.

Kanavos, P. (2006). The raising burden of cancer in the develo** world. Annals of Oncology, 17, viii15–viii23.

Oppeltz, R. F., & Jatoi, I. (2011). Tobacco and the escalating global cancer burden. Journal of Oncology, 2011, 408104. doi:10.1155/2011/408104.

Preface

The idea behind this book has at least two roots, one in the past and the other more recent.

The oldest one is concerning the meeting I had to decide the title of my thesis to become a medical doctor. In 1989 Prof. Bruno Angelillo proposed to me to be involved in a research project, carried out by the Institute of Hygiene at the University of Naples, on the determination of urinary cotinine levels in children. The results of this research were astonishing: children of parents who were heavy smokers were comparable to light smokers, as concerning that of nicotine levels. The reason? They were passive smokers!

The more recent one is concerning my research activity on tobacco smoking that covers some important issues in this field, including smoking prevention among children and adolescents; smoking habits in particular settings (health professionals, medical students, general population, people with chronic diseases, patients with cancers); the association between smoking and gastric and pancreatic cancer, acne vulgaris, and erectile dysfunction; the impact of tobacco package health warnings with pictures on smoking cessation and prevention. But the main reason why I and my collaborators decided to start thinking about and writing this book is related to the fact that many health professionals paradoxically are smokers, despite the fact that they must play a key role in tobacco smoking prevention and control. At the international level there are very few examples of development of a curriculum at the undergraduate level on smoking prevention and cessation programs in biomedical faculties. In a workshop recently organized by the European Public Health Association (EUPHA), the situation at the School of Medicine level in four WHO European country regions (Finland, Italy, Portugal, and Turkey) was presented. It was shown that at the national level in Italy, there is no formal course concerning tobacco smoking prevention and control among the curriculum of Medical students. A focus group with some of them revealed that the following issues could be covered in such a course: (a) nicotine addiction; (b) epidemiology of tobacco smoking-related pathologies; (c) motivation for starting smoking; (d) economic aspects; and (e) skills for treating a smoker who wants to quit.

In Portugal (Lisbon), there is an Environmental Health optional module available for Medical students in the second and third years at the Lisbon Faculty of Medicine. Tobacco consumption is one of the most relevant topics included in the course, in which some field work is usually developed. Among the optional curriculum there is another course for the fourth-year students aiming to build capacity in hel** future patients to quit. Moreover, for students in the fourth and fifth years, a specific optional training activity is available, consisting of Research Community Projects that address the evaluation of tobacco consumption and related pathologies.

In Turkey (Ankara), Tobacco Control Classes have been developed since 2002, using a small-group discussion method. Medical students are distributed into up to 20 small groups, within which 10 hours of discussion are scheduled (five at the first class and five at the third class). The aim of the first year’s program is to increase the level of awareness of the newly enrolled medical students, through the discussion of basic concepts regarding tobacco and tobacco use and its effects on health in general, and its effects on the economy of the single person and of the country. During the third year, there are more detailed discussions regarding health hazards of tobacco use and ways of protecting people from tobacco use (also concerning secondhand smoking).

In Finland, an Internet-based tobacco cessation model course has been developed and is currently in use. This course can be tailored for use in both undergraduate and specialist training and as a tool in continuous professional education of all health professionals. It includes short multi-professional video clips as well as theoretical knowledge on smoking cessation counseling in different settings, offering a comprehensive and multi-professional national standard for smoking cessation training. The course can be adjusted to be completely Internet-based or to include a half day multi-professional seminar with group discussions, role-play exercises, case studies, and lectures.

So, this book tries to consider all the elements that can help the health professional and the biomedical student to understand the tobacco smoking world and to develop skills to face a smoker, whether a patient or not, in order to give the right advice, as well as a nonsmoker with the aim to sustain smoking prevention in the right setting.

Chapter 1 has the goal to introduce the reader to the world of tobacco smoking, the role of nicotine in inducing a nicotine addiction, as well as to be confident with some tools in measuring nicotine dependence and motivation to quit. The role of tobacco smoking as cause of many diseases is now well established, from the scientific point of view. It is well recognized that tobacco consumption is the leading cause of preventable deaths in the majority of high-income nations and increasingly in low- and middle-income nations and that it causes disability and productivity losses because of premature deaths. Nevertheless, it is a common experience to see smokers in different settings. Smokers smoke even if for most of them it is dangerous for their health. Why?

This book wants to give answers to this question and to give the best available evidence concerning smoking prevention and cessation strategies, first of all recognizing that tobacco smoking is a disease for many smokers (International Classification of Disease 10th revision: F17Nicotine dependence).

Chapter 2 underlines how cigarette smoking is the most common mode of tobacco consumption in many countries and the single most preventable cause of death in the world today. Tobacco use is responsible each year for nearly six million deaths, and exposure to tobacco smoke in the environment, defined as “passive smoking” or “secondhand smoking” (SHS), is an important cause of mortality and morbidity worldwide.

The global prevalence of smoking any form of tobacco, in 2006, was higher for men (41.1%) than for women (8.9%) and males accounted for 80% of all smokers. Women’s smoking prevalence rates are projected to rise, especially in many low- and- middle-income countries. Smoking behavior is usually established during adolescence, and adolescent smokers vastly underestimate the addictive potential of nicotine.

Chapter 3 concerns smoking-related diseases epidemiology. World Health Organization (WHO) ranks smoking consumption as the first leading cause of the global burden of disease in industrialized countries, and it continues to kill more than 600,000 nonsmokers who die from passive exposure to tobacco smoke. Tobacco-attributable mortality is projected to increase from three million deaths in 1990 to 8.4 million deaths by 2020: longevity has been improving rapidly for nonsmokers, but not for men who continue smoking cigarettes.

Cigarette smoke contains about 4,000 chemical agents that are known to be poisonous and toxic to the human body. This chapter describes the epidemiology of cigarette smoking-related diseases focusing on cardiovascular diseases, main smoking-related cancers, and other diseases less frequent but still related to cigarette smoking such as acne, Sudden Infant Death Syndrome (SIDS), maculopathy, smoking-related allergy, and early menopause. For each disease the epidemiology and the scientific evidence will be presented and discussed.

In Chapter 5 classic determinants of smoking initiation are considered: family, peer, society, and personal characteristics. In the family smoking is involved in both parental and sibling relations, through genetic and psychological pathway or indirectly by preventing friendship formation with smoking peers. Peer influence has been indicated as one of the most important determinant on smoking initiation. Selection and socialization are two main concepts used to explain peer role. At societal level, gender and socioeconomic status have been found associated with smoking initiation. Finally, personal characteristics are considered: the personality differences between smokers and nonsmokers are usually small, but they are important if one considers the large number of people who smoke: neuroticism, poor control, anger, and the levels of extraversion are involved.

Smoking prevention is the main theme of Chapter 6. Youth is a crucial moment for tobacco-related behaviors. The earlier a kid first tries smoking, the higher his or her chances of ultimately becoming a regular smoker, of experiencing a range of risk factors and health problems in adulthood, and of progressing to addiction to other harmful substances. Mass media campaigns intended to reduce tobacco initiation use brief, recurring messages to inform and motivate individuals to remain tobacco free. Other interventions such as school-based programs, laws, or parents’ education can be also useful in reaching such a goal. The aim of this chapter is to help the reader get familiar with the main community interventions for preventing smoking in young. The first part of this chapter covers school-based smoking prevention interventions; the second and the third parts involve the workplace and the law in smoking prevention interventions, whereas the final part is concerned with the role of health communication in preventing smoking habits in youth.

How to tackle smoking at the population level is the general context of Chapter 8. Given the tobacco epidemic as a global challenge demanding concerted global and national action, the answer was the World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC), adopted in 2003. Regarding legislation on tobacco, in Europe it is based on two fundamental laws: one is the Directive on Tobacco Controls, dated 2001, which concerns the manufacture, presentation, and sale of tobacco products, in particular the use of warnings on packets and the prohibition of descriptions such as “mild” or “light,” and the other is the Directive on Tobacco Advertising, published in 2003, that bans tobacco advertising in the print media, on radio, and over the Internet and at international sports events in Europe. Currently, 29 countries and jurisdictions have implemented policies on warnings of tobacco packages, and several studies were performed to evaluate the impact before and after the introduction.

The big issue of smoking among health professionals is the leading theme of Chapter 9. Tobacco smoking can be considered an old and a new challenge for public health and is both a matter of personal health and a public health concern for healthcare providers.

Healthcare professionals have an important role to play both as advisers—influencing smoking cessation—and as role models. Studies have shown that patients are often responsive to counseling received from healthcare professionals.

Healthcare workers and staff attitudes towards smoking have been shown to be important in determining the effectiveness of workplace smoking policies and nurses who smoke should set an example by quitting smoking both for themselves and their patients

Healthcare professionals, nurses, and medical doctor who smoke downplay their role in patient education and tend to show a more negative attitude towards patients. Moreover, it has been proposed that before nurses can serve as role models for positive health behaviors, they must incorporate these behaviors into their own personal lifestyles.

Among health professionals the prevalence of tobacco smoke is extremely high, more than other professional categories, and this could be partly attributed to a low weight that tobacco smoking has in the medical curriculum of future physicians, which will contribute in a determinant way to healthy choices of their patients. In order to realize that, medical students need to be adequately trained with the aim of acquiring competencies and skills that help patients to prevent tobacco smoking and to increase smoking cessation, through a program oriented to specific issues related to the potential harm of tobacco products.

The aim of Chapter 10 is to give an overview on the basic smoking cessation techniques, including counseling and use of first-line medications as recommended by the Clinical Practice guidelines.

This chapter, then, addresses three basic principles of smoking cessation: (a) TransTheoretical approach Model (TTM) of behavior change, (b) counseling, and (c) pharmacotherapy. The TTM identifies that the smoker can progress through five stages of change (Precontemplation, Contemplation, Preparation, Action, Maintenance) an individual passes through with the aim of changing an established behavior. The stage of change is a variable that involves past behavior and behavioral intention to characterize an individual’s readiness to change. Counseling (individual and group counseling) and pharmacotherapies (nicotine replacement therapy, bupropion, varenicline) are explained and discussed extensively. Furthermore, since Advice and Assistance by physicians have an important role in hel** smokers to quit, the so-called “minimal intervention” is described. The minimal intervention aims to create or strengthen motivation to stop smoking. It is rapid and effective and is based on the model of the five “As”: Ask, Advice, Assess, Assist, Arrange.

Chapter 11 deals with smoking cessation among different settings. This chapter aims to address the role and the efficacy of smoking cessation interventions among different settings and concerning health professionals as well as workplace. By reading it the reader will be able to understand how smoking cessation interventions work in different settings, understand how smoking cessation interventions among healthcare personnel can play a fundamental role in supporting similar policies addressed to the general public, and learn what strategies have been adopted in real healthcare settings to promote smoking cessation.

Media and smoking cessation is the subject of Chapter 12. Quitting tobacco is not easy as tobacco dependence is a cluster of behavioral, cognitive, and physiological phenomena. The Easy way method, in fact, is based on the contrary on psychological mechanisms of smoking desire and also on the use of techniques borrowed from cognitive psychology. But the method described in the books “The Easy Way to Stop Smoking” written by Allen Carr was never tested in controlled trials. Through an examination of the conceptual bases of persuasion, the World Wide Web has many of the characteristics necessary for persuasive communication. The Internet, in fact, has opened up new possibilities in public health. The web is a promising channel to reach a large number of smokers. Substantial numbers of smokers from numerous countries seek Web-based smoking cessation resources and add to the growing support for Web-assisted tobacco interventions as an additional tool to address the need for global smoking cessation efforts.

A review of the ethical aspects of tobacco smoking is the content of Chapter 13. Philosophically, smoking has long been regarded as a paradigmatically private-regarding vice, best treated as such. Folk wisdom has long held tobacco smoking to be unhealthy and it actually is axiomatic that tobacco smoking is hazardous to health and that it is a merely private-regarding vice, harming only smokers themselves, is challenged by evidence of the harmful effects of “passive smoking.”

Smokers and nonsmokers all have rights. Nonsmokers and employers are becoming less tolerant of smokers. Nonsmokers are speaking up their rights and demanding protection from smoke hazard. As the Surgeon General stated in the 1986 report: “the right of smokers to smoke ends where their behaviour affects the health and well-being of others.” Three subtypes of individual rights can be distinguished: the right to life, liberty, and use of private property, and all three aspects of individual rights are central to efforts to control environmental tobacco smoke (ETS).

There are four main principles of bioethics that apply to tobacco control: autonomy, beneficence, non-maleficence, and justice. Persons are deemed to have autonomy on the basis of their nature as rational and moral beings. Preservation of individual autonomy requires both information about a health risk behavior and voluntary choice (that is, without nicotine addiction).

Beneficence is the obligation for national governments to promote public well-being, and non-maleficence refers to the obligation of governments to avoid harm (embodied, for example, in the “Precautionary principle,” by which a government may preclude population exposure to a likely hazard even without absolute proof of the hazard). The principle of justice requires the fair and equitable distribution of social goods and, accordingly, the fair and equitable distribution of social and biological burdens.

Therefore, the central question is: Should political intervention in a private affair as basic as tobacco smoking in enclosed public spaces be justified in the name of public health protection?

Thus, without doubt, public health protection (primarily concerned with the health of the entire population, rather than the health of individuals) is the critical mass of the general governmental tobacco smoking discouragement policy or the burgeoning global wave of tobacco smoking proscription in enclosed public spaces, which is arguably buoyed by the 2005 World Health Organizations’ Framework Convention on Tobacco Control.

Finally, Chapter 14 deals with the economic issues related to tobacco smoking. It causes disability and productivity losses because of premature deaths. Economic damages caused by smoking—based on both direct and indirect costs—account for $200 billion. The largest number of publications available about smoking-related illnesses economic costs dates back to the 1980s–1990s. They show that smoking places tremendous financial and health burdens upon both society and individuals.

Treatment for smoking-related diseases is expensive and preventing these diseases could provide immediate short-term financial returns. Additionally, tobacco treatment programs could produce substantial savings in the long term, along with health and quality of life benefits.

Ho** these ways of considering smoking cessation and prevention issues will be helpful for the reader, I wish you a good reading.

November 2012

Giuseppe La Torre