How to Make the Case for Tobacco | American Lung Association

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How to Make the Case for Tobacco

According to a 2014 review of over 300 hospital CHNAs,1 tobacco is the 7th most frequently prioritized community health need, providing an obvious opportunity for public health agencies to work with hospitals that prioritize tobacco addiction. Although conditions such as substance abuse and diabetes are prioritized more frequently by hospitals, employers, and even public health, tobacco prevention and cessation can still be important interventions, even if tobacco use is not explicitly prioritized. Of the top 14 conditions prioritized (see graph below), almost all of them are directly impacted by tobacco use. 

This provides public health agencies with a tremendous opportunity to educate hospitals about the insidious impact of tobacco use in their priority efforts and to seek a place for tobacco cessation in the CHNA implementation plan.

Talking Points Linking Tobacco to Priority Community Health Needs

  • The bullet points address the contribution of tobacco to the condition.
  • The arrow is data regarding the positive impact of tobacco cessation on the primary condition.

What follows are high-level talking points on the role of tobacco use in each of the priority community health needs that are impacted by tobacco. The goal is not to convince hospitals to change their priorities to include tobacco use, but to provide public health agencies with the ability to articulate why efforts to address most priority conditions will be more successful if tobacco cessation is included as a component.

The priority community health needs (e.g., behavioral health, substance abuse) are listed based on the importance of the condition relative to the American Lung Association's work, taking into account the order in which hospitals prioritized them in the 2014 review. The hospitals in your community will not necessarily select the same priorities or in the same rank order.

Behavioral health (Ranked 2nd across CHNAs)

  • Approximately 50 percent of people with mental illness and addictions smoke compared to 23 percent of the general population.  While this group smokes half of all cigarettes produced, they are only half as likely as other smokers to quit.2
  • Psychiatric disorders are more common among smokers than in the general population. The prevalence of depression among current smokers was consistently twice as high as among former and never smokers.3
  • Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. 4
    • The effect size seems as large for those with psychiatric disorders as those without.
  • The effect of quitting tobacco is equal to or greater than anti-depressant treatment.5
  • Nicotine suppresses the impact of psychiatric medication so doses can generally be reduced when lesser amounts of nicotine are present.6

Substance abuse (Ranked 3rd across CHNAs)

  • Smoking-related diseases are a leading cause of death among individuals with substance abuse problems.7
  • Tobacco dependence treatment does not interfere with patients’ recovery from the abuse of other substances.8
  • Opioids
    • According to the National Institute on Drug Abuse, more than two-thirds of people who abuse drugs also smoke cigarettes, and among smokers, the craving for nicotine appears to increase the craving for illicit drugs.9
    • Cigarette smoking has also been determined to be a risk factor for prescription opioid abuse among chronic pain patients.10
    • Seventy-four to 97 percent of methadone-maintained individuals also smoke.11
  • Nicotine smoking may extend the duration of heroin reinforcement.12
  • Individuals who treat their addiction to tobacco and other substances at the same time are 25 percent more likely to sustain their recovery, compared to individuals who do not address tobacco while in recovery from other drugs.13
  • Participation in a smoking cessation intervention provided during substance abuse treatment was associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs.14 15
  • Smoking cessation and alcohol abstinence: What do the data tell us? (PDF Download Available).

Cancer16(Ranked 5th across CHNAs)

  • Smoking accounts for about 30 percent of all cancer deaths in the United States.17
  • Smoking accounts for about 80 percent of all lung cancer deaths.18
  • Smoking is a risk factor for at least a dozen other cancers, including stomach, pancreas, liver, colon, bladder, cervix, kidney, larynx, mouth, pharynx, esophagus, and myeloid leukemia.19
  • Patients with cancer who have recently quit smoking have an approximately two-fold increase in the five-year overall likelihood of survival from cancer.20
  • Researchers have found that treating cancer patients with comorbid smoking, depression, and/or alcohol use had higher cessation rates compared with usual care.21

Heart disease: Cardiovascular disease, hypertension, and stroke (Ranked 6th across CHNAs)

  • Smoking causes stroke and coronary heart disease22 , which are among the leading causes of death in the United States (heart #1, stroke #4).23
  • Even people who smoke fewer than five cigarettes a day can have early signs of cardiovascular disease.24
  • Smoking increases the risk for coronary heart disease AND stroke by two to four times.25
  • Increased blood pressure or hypertension is caused when smoking damages blood vessels and can make them thicken and grow narrower. This can also cause clots to form.26
  • Quitting smoking can lower your risk of heart disease as much as, or more than, common medicines used to lower heart disease risk, including aspirin, statins, beta blockers, and ACE inhibitors.27 .

Respiratory (Ranked 11th across CHNAs)

  • Lung diseases caused by smoking include COPD, emphysema, and chronic bronchitis.28
  • COPD is the third leading cause of death in the United States.29
  • Smoking cessation is the only proven way of modifying the progression of COPD.31

Diabetes (Ranked 4th across CHNAs)

  • Smoking is a cause of Type 2 diabetes mellitus and can make it harder to control. The risk of developing diabetes is 30-40 percent higher for active smokers than nonsmokers.32
  • Smoking increases the risk of complications once diagnosed with diabetes, including heart and kidney disease, poor blood flow to legs and feet, blindness and nerve damage.33
  • For smokers with diabetes, quitting smoking will benefit health immediately. People with diabetes who quit have better control of their blood sugar levels.34

Maternal and Child Health: Reproductive, perinatal and infant35: (Ranked 8th and 10th across CHNAs)

  • Smoking can make it harder for a woman to become pregnant. It can also affect her baby’s health before and after birth. Smoking increases risks for36 :
    • Preterm (early) delivery
    • Low birth weight
    • Stillbirth (death of the baby before birth)
    • Ectopic pregnancy
    • Orofacial clefts in infants
    • Sudden Infant Death Syndrome (known as SIDS or crib death)
  • Smoking can also affect men’s sperm, which can reduce fertility and increase risks for birth defects and miscarriage.37
  • Tobacco dependence interventions for pregnant women are especially cost-effective because they result in fewer low birth weight babies and perinatal deaths, fewer physical, cognitive and behavioral problems during infancy and childhood and yield important health benefits for the mother.38
  • Interventions promoting breastfeeding to incentivize continued smoking abstinence may be effective prior to weaning.  Those promoting breastfeeding longer than six months and partner smoking cessation may increase rates of long-term smoking abstinence lasting longer than two years post-delivery.39

Oral health40 (Ranked 9th across CHNAs)

  • Tobacco users brush and floss much less frequently than non-users and report more oral health problems.41  
  • Current smokers (16%) were twice as likely as former smokers (8%) and four times as likely as never smokers (4%) to have poor oral health status.42
  • Smoking affects the health of your teeth and gums and can cause tooth loss.43

Obesity (Ranked 1st across CHNAs)

  • The most compelling reason to include tobacco cessation in efforts to address obesity is that smoking is conducive to greater accumulation of visceral fat and greater insulin resistance. As noted above, smoking increases the risk of metabolic syndrome and type 2 diabetes.44
  • Sources
    1. Health Research & Educational Trust: Hospital-based Strategies for Creating a Culture of Health, October 2014. North American Quitline Consortium (2016). A Promising Practices Report. Quitlines and Priority Populations: An Update on Our Progress to Reach and Serve Those Most Impacted by Tobacco’s Harm, 2016. (Thomas-Haase, T and Rudie M). Phoenix, Arizona.
    2. Goodwin RD, et al. Depression among current, former, and never smokers from 2005 to 2013: The hidden role of disparities in depression in the ongoing tobacco epidemic. Drug Alcohol Depend, 2017; 173:191-9.
    3. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: Systematic review and meta-analysis. BMJ, 2014; 348:g1151.
    4. Goodwin RD, et al. Depression among current, former, and never smokers from 2005 to 2013: The hidden role of disparities in depression in the ongoing tobacco epidemic. Drug Alcohol Depend, 2017; 173:191-9.
    5. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. 7, Specific Populations and Other Topics
    6. Hurt RD, Offord KP, Croghan IT, et al. Mortality Following Inpatient Addiction Treatment: Role of Tobacco Use in a Community-based Cohort. JAMA, 1996; 275:1097-103.
    7. Lemon SC, Friedman PD, Stein MD. The impact of smoking cessation on drug abuse treatment outcome. Addictive Behaviors, 2003; 28(7):1323-31.
    8. National Institute on Drug Abuse. Nicotine Craving and Heavy Smoking May Contribute to Increased Use of Cocaine and Heroin. NIDA Notes: Nicotine Research, October 2000; 15(5). 
    9. Liebschutz JM, et al. Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain. J Pain, 2010; 11:1047-55.
    10. Zirakzadeh A, Shuman C, Stauter E, Hays JT, Ebbert JO. Cigarette smoking in methadone-maintained patients: an up-to-date review. Curr Drug Abuse Rev, 2013; 6:77-84.
    11. Li L, Liu Y, Zhang Y, Beveridge TJ, Zhou W. Temporal changes of smoking status and motivation among Chinese heroin-dependent, methadone-maintained smokers. Addict Behav, 2010; 35:861-5.
    12. Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 2004; 72(6):1144-56.
    13. KOHN, C.S.; TSOH, J.Y.; AND WEISNER, C.M. Changes in smoking status among substance abusers: Baseline characteristics and abstinence from alcohol and drugs at 12-month follow-up. Drug and Alcohol Dependence 69:61–71, 2003. PMID: 12536067.
    14. Smoking cessation and alcohol abstinence: What do the data tell us? Available from: 
    15. American Cancer Society. Health Risks of Smoking Tobacco. November 12, 2015.
    16. Lortet-Tieulent J, et al. State-level cancer mortality attributable to cigarette smoking in the United States. JAMA Internal Medicine, December 2016; 176(12):1792-8.
    17. The Health Consequences of Smoking: A Report of the U.S. Surgeon General, 2004.
    18. Centers for Disease Control and Prevention. What is Cancer? January 23, 2017.
    19. Karam-Hage M, Cinciripini PM, Gritz ER. Tobacco use and cessation for cancer survivors: An overview for clinicians. CA: A Cancer Journal for Clinicians, 2014; 64:272-90.
    20. Cooley ME, Lundin R, Murray L. Smoking Cessation Interventions in Cancer Care: Opportunities for Oncology Nurses and Nurse Scientists. Annual Review of Nursing Research, 2009; 27:243-72.
    21. U.S. Department of Health and Human Services.The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    22. Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics Report. Deaths: Final Data for 2014. June 30, 2016; 65(04).
    23. U.S. Department of Health and Human Services.The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    24. U.S. Department of Health and Human Services.The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    25. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    26. National Heart, Lung, and Blood Institute. What are the Benefits of Quitting Smoking? https://www.nhlbi.nih.gov/health/health-topics/topics/smo/benefits
    27. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    28. Centers for Disease Control and Prevention. National Center for Health Statistics. National Vital Statistics Report. Deaths: Final Data for 2014. June 30, 2016; 65(04).
    29. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 
    30. Wu J, Sin D. Improved patient outcome with smoking cessation: when is it too late? International Journal of Chronic Obstructive Pulmonary Disease, 2011; 6:259-267.
    31. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
    32. American Lung Association. State of Tobacco Control 2017. 10 of the Worst Diseases Smoking Causes.
    33. Centers for Disease Control and Prevention. Smoking and Diabetes. January 23, 2017.
    34. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
    35. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    36. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    37. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May.
    38. Logan CA, Rothenbacher D, Genuneit J. Postpartum Smoking Relapse and Breast Feeding: Defining the Window of Opportunity for Intervention. Nicotine & Tobacco Research, March 2017; 19(3):367-72.
    39. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
    40. Andrews,J, Severson H, et. al. Relationship Between Tobacco Use and Self-Reported Oral Hygiene. Journal of the American Dental Association, Volume 129, Issue 3, March 1998
    41. NCHS Data Brief No. 85: Smoking and Oral Health in Dentate Adults Aged 18-64. February 2012
    42. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
    43. Chiolero A, Faeh D, Paccaud F, Cornuz J. Consequences of smoking for body weight, body fat distribution, and insulin resistance. The American Journal of Clinical Nutrition, April 2008; 87(4):801-9.
    Resources
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