Tobacco Control 

• A better understanding of the true cost of smoking will help people quit the unhealthy behavior. Smoking reduces life expectancy for men by seven years and by almost five years for women. When factoring in the price of premature death, the cost of a pack of cigarettes increases substantially. A study published in the Journal of Health Economics found a mortality cost as high as $222 per pack for men (in 2006 dollars) compared to $4-7 retail cost using Value of a Statistical Life (VSL).

• Worldwide nearly one quarter of all teenage smokers smoked their first cigarette before they were 10 years old. If children take up smoking and do not stop then half of them will die from a smoking-related disease. 

• In low and middle income countries, a 10 percent increase in the price of tobacco products reduces the number of smokers by 37.6 million (9.3 million deaths averted) as compared to 18.6 million (4.4 million deaths averted) with other tobacco control measures.¹

• By contrast, in high income countries, a similar intervention will reduce the number of smokers by 4.1 million (1 million deaths averted) as compared with 4.0 million (900,000 deaths averted) by non-price measures. Therefore, active health policy measures are likely to have a larger impact in developing countries such as India.¹

• California traditionally has been cited for its success in tobacco control because of its long-running comprehensive tobacco control programs. California’s adult smoking prevalence declined approximately 40% during 1998 -2006, and consequently lung cancer incidence in California has been declining four times faster than in the rest of the nation.

• Similarly, Maine, New York, and Washington have seen 45% -60% reductions in youth smoking with sustained comprehensive statewide programs.

• Simple counseling by physicians in the management of smoking cessation is often effective, particularly when the message is repeated by a nonsmoking physician at every visit.  This is all but impossible, or counter productive if the physician is a smoker. Smoking rates among  US physicians have come down from 60% to 2% but remains high in China, where 41% of male physicians are smokers, compared to a national male average of 57%.²  Furthermore 37% of the Chinese physicians have smoked in front of their patients. Although 64% advise smokers to quit, only 48% ask about smoking status of the patients. This may be equally applicable to Indian physicians.

• Assessment of smoking should be completed at each medical visit, and a physician should advise against smoking and offer both behavioral and other methods including pharmacologic intervention to those who smoke.

• Although 80% of smokers are aware of adverse health effects, they often underestimate the risk. A clear understanding of the various benefits motivates smokers to quit. These benefits of quitting tobacco include: Improving the taste of the food; improving exercise tolerance; decrease and disappearance of smokers cough, decreased risk of CVD, diabetes, chronic obstructive lung disease and lung cancer.

• Moderately increasing exercise can largely minimize the approximately 2 kg weight gain that occurs with smoking cessation. Thus, the public health effects of smoking exercise and obesity are inextricably intertwined.³  Organized smoking cessation programs may be necessary for more heavy smokers

• Patients concerned about the health consequences of smoking and the willingness to stop the tobacco are important considerations for success.   Predictors of the outcome of smoking cessation efforts are: Motivation to quit; intention to quit; confidence in quitting; and degree of nicotine addiction.  Physician counseling guidelines for smoking cessation include:

• Ask about smoking every visit
• Advise and encourage smokers to quit
• Assist the patient by agreeing upon a quit date
• Provide self help materials
• Arrange follow-up visit to assess smoking status and encourage continued abstinence
• Encourage subjects to increase physical activity to minimize weight gain
• Emphasize the financial savings
• Help patients identify and avoid triggers (such as after alcohol) and facing them if the triggers    cannot be avoided (such as after meals)
• Prescribe nicotine replacement,  bupropion or varenicline therapy

• Where necessary, nicotine replacement or bupropion therapy should be considered since they appear to facilitate smoking cessation. Varenicline is a novel selective nicotine acetylcholine receptor partial agonist developed specifically for smoking cessation, with documented short- and long-term efficacy versus placebo. Most smokers who quit may relapse, and this should not be considered as a failure. Most smokers attempt to quit 3-4 times before they maintain abstinence.⁴ 

Sources

1. Ajay VS, Prabhakaran D. Coronary heart disease in Indians: implications of the INTERHEART study. Indian J Med Res. Nov 2010;132(5):561-566.

2. Jiang Y, Ong MK, Tong EK, et al. Chinese physicians and their smoking knowledge, attitudes, and practices. Am J Prev Med. Jul 2007;33(1):15-22.

3. Kawachi I, Troisi RJ, Rotnitzky AG, Coakley EH, Colditz GA. Can physical activity minimize weight gain in women after smoking cessation? Am J Public Health. Jul 1996;86(7):999-1004.

4. Enas EA. Management of coronary risk factors: Role of lifestyle modification. Cardiology Today. 1998;2:17-29.