It is time to recognise smoking for what it is – America’s longest-running and deadliest epidemic – and treat it with a commensurate sense of urgency, write the directors of three key health institutions involved in producing the 2020 United States Surgeon General’s report on smoking cessation, in the New England Journal of Medicine.
The 22 October 2020 Perspective article is by Robert R Redfield, Director of the Centers for Disease Control and Prevention, Stephen M Hahn, Commissioner of the Food the Drug Administration and Norman E Sharpless, Director of the National Cancer Institute.
The 2020 United States Surgeon General’s report on smoking cessation is the first such report to focus on this topic since 1990.
Its release came as the US Department of Health and Human Services was investigating an outbreak of deadly lung injuries linked to the use of e-cigarette, or vaping, products.
Although these products pose a new public health challenge, we cannot lose sight of the fact that the burden of death and disease associated with tobacco use in the United States is still overwhelmingly caused by combusted tobacco products, especially conventional cigarettes.
The rate of cigarette smoking among US adults is 13.7%, its lowest point since monitoring of smoking rates began in 1965, yet smoking remains the country’s leading preventable cause of death and disease, and it costs the United States more than $300 billion annually.
Increasing smoking-cessation rates among adults is the fastest way to reduce this health and economic burden. As leaders of three of the federal agencies responsible for reducing tobacco-product use, we are committed to intensifying our efforts to help Americans quit smoking.
Smokers want to quit
Most adult smokers want to quit. Less than 10% successfully quit each year, however, largely because cigarettes are designed to create and sustain nicotine addiction.
The population-wide cessation rate is driven by two factors: the number of quit attempts and their success rate. Each year, just over half of smokers attempt to quit, but most try to quit multiple times before succeeding. More needs to be done to increase the number of quit attempts and the likelihood of success of each attempt.
Tobacco dependence is a chronic, relapsing condition and should be treated accordingly. Clinicians should encourage patients to keep trying to quit and offer support and assistance until and even after they succeed.
Effective cessation treatments are available. Individual, group and telephone-based counselling increase success rates, as does each of the seven smoking-cessation medications approved by the Food and Drug Administration (FDA). Combining counselling and medication is the most effective approach.
Text messaging and the internet are additional channels for delivering evidence-based cessation interventions. Unfortunately, less than a third of smokers use cessation counselling or medication when trying to quit.
As the recent Surgeon General’s report notes, the role – if any – of new nicotine-delivery systems (eg, e-cigarettes) in helping adult smokers transition completely away from combustible products warrants further research. The report showed that “there is presently inadequate evidence to conclude that e-cigarettes, in general, increase smoking cessation.”
Many smokers face obstacles to obtaining care, are unaware of available resources, or have misconceptions about cessation treatments. Increasing cessation rates will require removing barriers to care and connecting smokers with evidence-based cessation treatments.
More broadly, proven population-based strategies, including smoke-free policies, increases in tobacco prices, and hard-hitting tobacco-education media campaigns are also important for motivating smokers to quit and helping them to succeed.
Helping smokers to quit
To accelerate progress in smoking cessation, a broad range of stakeholders must join forces. In this spirit, our agencies continue to advance and promote coordinated efforts to help smokers quit.
These efforts include the Cancer Center Cessation Initiative (C3I), the Million Hearts Tobacco Cessation Change Package, a national digital portal for cessation services, draft guidance for industry on developing nicotine-replacement therapy (NRT) products, and tobacco-education media campaigns.
Research shows that continuing to smoke after a cancer diagnosis impedes successful cancer treatment. C3I, launched in 2017 by the National Cancer Institute (NCI) as part of the Cancer Moonshot programme, leverages the opportunity “to capitalise on a highly feasible, readily available, and cost-effective strategy for increasing the success of cancer treatment and rates of recovery – smoking cessation”.
C3I has funded 42 NCI-designated cancer centers to implement smoking-cessation programmes that are designed to continue operating after the funding period ends. In early 2020, new supplemental funding was made available to enhance these programmes, expand C3I to previously unfunded cancer centers, and strengthen the consortium of participating centers.
Development and promotion of a digital tool kit and other resources will improve the reach, delivery, and effectiveness of cessation services at funded cancer centers and assist other cancer-treatment facilities in delivering cessation treatment.
The Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC), in partnership with the Million Hearts initiative, created the Million Hearts Tobacco Cessation Change Package to advance implementation of clinical cessation interventions using system-level quality-improvement strategies.
Released in 2019, the change package gives health systems and clinicians a menu of tools and resources to support integration of proven tobacco-cessation interventions into routine clinical care in outpatient, inpatient, and behavioural health settings. These tools and resources include practical guidance and sample protocols and policies for screening and treatment for tobacco use, referral to cessation services and follow-up.
The CDC is partnering with the National Association of Community Health Centers on a pilot programme implementing the change package in six community health centers in two states.
The NCI and CDC are also developing a national digital portal for cessation services that will connect tobacco users to text-messaging cessation services. Such services may be especially appealing to young adults.
The portal, which is expected to launch in 2021, is an extension of the 1-800-QUIT-NOW telephone portal that the two agencies established in 2004, which routes callers to their state’s quitline. Similarly, the new portal will route smokers to text-messaging cessation services available in their state or, for people living in states without such services, to the NCI’s national SmokefreeTXT text-messaging service. This will enable nationwide promotion of text-messaging cessation services.
In 2019, the FDA Center for Drug Evaluation and Research issued draft guidance on developing NRT products. It addresses drug development and trial design issues, including study end points, to assist sponsors in bringing innovative NRT products to the market.
The agency is considering the policy issues raised in the comments it received about this draft guidance and plans to issue final guidance in the future. The FDA is committed to increasing access to and use of smoking-cessation treatments, including NRT products with new indications and treatment regimens.
Finally, the FDA and the CDC are conducting tobacco education media campaigns. Over the past two years, the FDA has aired the “Every Try Counts” public education campaign to encourage adult cigarette smokers to “keep trying” to quit and to “practice the quit”. Since the campaign’s launch, more than 900,000 people have visited its website and more than 8,500 have signed up for text-messaging programmes designed to help smokers quit.
This campaign complements the CDC’s “Tips From Former Smokers” media campaign. The Tips campaign, now in its 9th year, profiles people who are living with serious, long-term health effects from smoking and second-hand smoke exposure.
The 2020 campaign also includes ads featuring people who have cared for a loved one with a smoking-related disease. Between 2012 and 2018, an estimated 1 million adults successfully quit smoking because of the Tips campaign.
Because the smoking rate among adults has fallen in recent years, and because smoking can be overshadowed by other emerging public health issues, it’s possible to overlook the continuing toll of smoking on people in the United States.
But this toll is staggering. About 34 million US adults still smoke, and half of them will die prematurely if they continue smoking. Smoking kills nearly half a million Americans each year, accounting for nearly one in five US deaths. Sixteen million Americans are living with a serious disease caused by smoking.
This epidemic is entirely preventable. Despite the tenacious grip of nicotine addiction, three in five US adults who ever smoked have quit.
The initiatives described above are examples of the range of actions required for helping all smokers quit. It’s time we recognise smoking for what it is – our country’s longest-running and deadliest epidemic – and treat it with a commensurate sense of urgency.
Smoking Cessation: A Report of the Surgeon General
Washington DC: US Department of Health and Human Services 2020.
From the Centers for Disease Control and Prevention, the Food and Drug Administration and the National Cancer Institute.
Tobacco smoking is the leading cause of preventable disease, disability and death in the United States. Smoking harms nearly every organ in the body and costs the United States billions of dollars in direct medical costs each year.
Although considerable progress has been made in reducing cigarette smoking since the first US Surgeon General’s report was released in 1964, in 2018, 13.7% of US adults (34.2 million people) were still current cigarette smokers.
One of the main reasons smokers keep smoking is nicotine. Nicotine, a drug found naturally in the tobacco plant, is highly addictive, as with such drugs as cocaine and heroin; activates the brain’s reward circuits; and reinforces repeated nicotine.
The majority of cigarette smokers (68%) want to quit smoking completely. The 1990 Surgeon General’s report, The Health Benefits of Smoking Cessation, was the last Surgeon General’s report to focus on current research on smoking cessation and to predominantly review the health benefits of quitting smoking.
Because of limited data at that time, the 1990 report did not review the determinants, processes or outcomes of attempts at smoking cessation. Pharmacotherapy for smoking cessation was not introduced until the 1980s.
Additionally, behavioural and other counselling approaches were slow to develop and not widely available at the time of the 1990 report because few were covered under health insurance, and programmes such as group counselling sessions were hard for smokers to access, even by those who were motivated to quit.
The purpose of this report is to update and expand on the 1990 Surgeon General’s report based on new scientific evidence on smoking cessation. Since 1990, the scientific literature has expanded greatly on the determinants and processes of smoking cessation, informing the development of interventions that promote cessation and help smokers quit.
This knowledge and other major developments have transformed the landscape of smoking cessation in the United States. This report summarises this enhanced knowledge and specifically reviews patterns and trends of smoking cessation; biologic mechanisms; various health benefits; overall morbidity, mortality, and economic benefits; interventions; and policies that promote smoking cessation.
Redoubling efforts to help Americans quit smoking – Federal initiatives to Tackle the Country’s Longest-Running Epidemic
Smoking Cessation: A Report of the Surgeon General[Internet]