Cigarette smoking causes over 400,000 deaths annually in the United States. In 2012, 18.1% of adults smoked cigarettes.¹

Rates of smoking vary based on ethnicity, region, socioeconomic status, and education. Smoking rates are also higher among people with disabilities, substance use problems, mental health disorders, and HIV/AIDS and people on Medicaid.

Second- and third-hand smoke represent an underappreciated and definite risk to the household members of smokers and the general public.

Nicotine stimulates acetylcholine receptors in the brain and activates the sympathetic nervous system, leading to elevated circulating levels of norepinephrine, epinephrine, vasopressin, growth hormone, cortisol, and endorphins. Nicotine also stimulates specific dopaminergic reward centers in the brain leading, to its psychological addiction. These result in increases in heart rate, blood pressure, cardiac stroke volume, and coronary blood flow.

Other effects of nicotine use include arousal early in the day, relaxation during stressful situations, and an increased metabolic rate with reduced hunger leading to body weight reduction.

Most smoking cessation attempts fail. Nicotine is addictive, and people become physiologically (and psychologically) dependent on its effects. People who quit experience withdrawal symptoms with the peak varying from 24 hours to 4 weeks after quitting. Withdrawal symptoms include anxiety, impatience, restlessness, irritability, hostility, difficulty in concentrating, nicotine cravings, headaches, insomnia, depression, dysphoria, and hunger. Patients with a previous history of major depression, bipolar disorder, or alcohol and drug abuse may be especially susceptible to withdrawal and relapse.

Psychological addiction can continue for months to years following quitting. Daily activities related to smoking such as eating, drinking, sex, being around other smokers, and driving can act as triggers for nicotine cravings.

There are multiple known carcinogens in cigarette smoke, resulting in a high risk of lung, oral, esophageal, laryngeal, and urothelial cancers.

The risk of lung cancer increases in relation to the amount an individual smokes and the age at which he or she started smoking.

Cigarette smoking alters immunity in the lung as well as the structure and function of the airways. Smokers have a lower forced expiratory volume over 1 second (FEV₁) and an accelerated rate of FEV₁ decline when compared with nonsmokers. Cigarette smoking has resulted in a high prevalence of chronic obstructive pulmonary disease (COPD). It is also an important trigger for asthma attacks.

There is evidence that smoking contributes to vascular endothelial damage, coronary vasospasm, and increased platelet aggregation. Cigarette smoking is a known risk factor
for coronary artery disease, hypertension, and stroke. Smoking also alters the senses of taste and smell.

Smoking cessation mitigates some of these risks but does not drop the risk down to a lifelong nonsmoker.

The following steps, initially developed by the National Cancer Institute as the “Four A’s” program, can be used in most outpatient settings to identify smokers and aid quitting. The Four A’s have been expanded to the Five A’s by the Clinical Practice Guidelines for Treating Tobacco Use and Dependence.³

Ask: Systematically identify all tobacco users at every visit. Ask at every visit about smoking: Do you smoke? Have you considered quitting? Are you ready to quit? What can I do to help you quit? Consider expanding documentation of vital signs to include tobacco use.

Advise: Strongly urge all tobacco users to quit at every visit. The goal is to present compelling evidence about the importance of quitting and to educate the patient about methods for quitting and the help available. Clear, strong, and personalized advice based on both the patient’s health and his or her social situation works best. For example, tie tobacco use to current illness or if the patient lives with children, the adverse effects of smoking on children.

Assess: Determine willingness to make quit attempt by asking the patient to make a quit attempt at this time. If he or she is willing to try quitting, provide assistance and further information. Schedule a return visit to prepare a plan for smoking cessation. If the patient not ready to quit, continue to educate him or her about the risk of smoking and offer to schedule a follow-up visit to continue the discussion. However, even among smokers who report no plans to quit, pharmacotherapy use has been associated with increased quit attempts, fewer cigarettes smoked, and greater abstinence rates.⁴

Assist: Aid the patient in quitting with the development of a quit plan. Give consideration to drawing up a contract for the patient to sign in a similar fashion to a narcotics contract or asthma management plan. Discuss the patient’s motivation for quitting and the benefits and drawbacks of quitting. Identify roadblocks to quitting, and discuss strategies for overcoming these. Encourage the patient to discuss the plan with family and friends and enlist their support. Suggest the patient remove all tobacco-related products from the house as the quit date approaches.

Arrange: Arrange follow-up visits to confirm and maintain abstinence. The physician, a counselor, or even office staff can perform the follow-up. Focus on positive health benefits of cessation and congratulate the patient on quitting. Assess and treat withdrawal symptoms as needed. Educate patients about the numerous resources available to them to help them stay quit. If patients relapse, offer encouragement, discuss reasons for failure, and offer continued support.