Maryland's Tobacco Resource Center - Linking Professionals to Best Practices

Chronic Health Conditions

"Smoking plays a causal role in several long-term health conditions and worsens their outcomes."  ...  Professor Kamran Siddiqi, University of York 

Smoking cessation for those with a chronic health condition

Smoking is known to cause and/or contribute to a number of chronic health conditions, including diabetes, pulmonary disease, and heart disease .1 Smoking with a chronic health condition is known to accelerate the disease(s) progression, worsen health outcomes, and is associated with poor treatment compliance.1 It’s been estimated that more than 16 million Americans live with a smoking related health condition.1 Thus this population represents a vulnerable group who are in need of smoking cessation efforts. 

There is strong evidence in support of the effectiveness of cessation interventions in achieving smoking abstinence among those with chronic health conditions.1 However, four out of every nine smokers report never having a discussion about smoking cessation with their healthcare provider.1 Additionally, more than 2/3 of smokers have reported never trying evidence-based treatments in past year quit attempts.1 

                                                               

                      

 

             There is hope! 

             Interventions work...  

 

 

 

Key Facts

  • Cigarette smoking causes more than 480,000 deaths each year in the U.S., or about 1 in 5.1 
  • Smoking increases risk of death from all causes in men and women.
  • The top 3 causes of death related to smoking are cardiovascular disease, pulmonary disease, and cancer.1 
  • Life expectancy is on average 10 years lower for smokers compared to non-smokers.1    
  • All smokers regardless of the intensity and duration of smoking, can benefit from quitting.1 No one is too old to not see the benefits of quitting. 

We summarize how smoking is related to the top 3 causes of death:  

Cardiovascular Disease (CVD):

  • Smoking causes stroke and coronary heart disease which are among the leading causes of death nationwide.
  • A recent study found that former heavy smokers can reduce their risk of CVD by as much as 39% after 5 years of cessation.2 
  • However, smoking cessation for people diagnosed with CVD can be quite challenging.  
    • One study examining health outcomes on hospitalized patients who experienced acute coronary syndromes (ex. myocardial infarction), received a smoking intervention, and were abstinent during hospital admission, found that nearly 2/3 (62.8%) resumed smoking after discharge.
  • Patients who are hospitalized for CVD issues are an important “touch point” to promote cessation that is making a difference within this group. 
    • A 2015 Cochrane review found that smoking cessation interventions, performed during and after hospitalization for cardiovascular issues, was an effective way to achieve abstinence over a 1-year timeframe.4   

​​Pulmonary Disease

  • Smoking is an established cause of many lung diseases; including COPD (Chronic Obstructive Pulmonary Disease), lung cancer, and worsens the prognosis of asthmatic conditions.
  • Lung Disease contributes to premature death, and according to a 2019 study utilizing mortality/morbidity projections from the World Health Organization, is expected to become the third leading cause of death by 2060.
  • Abstinence from smoking is known to slow the progression of COPD; but abstinence rarely happens suddenly. 
    • People with COPD who smoke say they know the consequences of smoking, but only want help and support after they have made the choice to quit.
    • Loved ones are encouraged to offer support without instilling guilt and while respecting one’s autonomy to make the decision to quit.6 
    • The presence of more severe COPD symptoms has been shown to increase the likelihood of patients being motivated to quit.
    • Providers are encouraged to offer brief interventions, utilizing motivational interviewing techniques, on tobacco cessation with their COPD patients who are unmotivated to quit. This is an evidence-based interview method that can help patients realize the risk of smoking, benefit of cessation, and thus instill motivation to quit.
  • Despite the challenges, people with COPD can and do quit smoking     
    • Results from a longitudinal study examining quit rates at 1 and 5 year follow ups amongst COPD outpatients determined that 19% of smokers with COPD are likely to quit at the 1-year mark and 45% are likely to quit at the 5-year mark. 
    • It is important to address both physical dependence with medications such as nicotine replacement therapy or nicotinic agonists (ex. varenicline)1,9 and behavioral habits with interventions such as motivational interviewing.
    • Clinical trials for smoking cessation have shown success in treating people who have COPD with FDA approved smoking-cessation medications such as Chantix:9 

Cancer

  • Cigarette smoking can cause or contribute to cancers almost anywhere in the body.1 
  • Smokers have approximately 15-30 times the risk of being diagnosed with lung cancer compared to non-smokers.10 
  • Cancer diagnosis can affect quit rates, by motivating smokers to quit. In one study, 39% of patients with lung cancer smoked at time of diagnosis, while only 14% smoked 5 months after diagnosis.11  
    • Quitting smoking at any time reduces the risk of all cancers.
    • The risk of mouth, throat, and voice box cancers drops by half after 5-10 years of cessation.
    • The risk of bladder, esophagus, or kidney cancer is reduced after 10 years of cessation. 
    • The risk of lung cancer is reduced by half after 10-15 years of cessation.1 
    • Predictors of relapse, or continuation of smoking after diagnosis, include12 
      • low household income. 
      • other smokers in home. 
      • symptoms of depression. 

Health Care Response to Chronic Health Conditions and Smoking

  • People with a chronic health condition reported that a health professional spoke to them about their smoking most of the time, with figures ranging from 68% (CVD) to 77% (Cancer), which is higher than people without a chronic health condition (about 50%).13 
  • As people with chronic health conditions are more likely to visit the doctor and/or be hospitalized than the general population, cessation interventions from healthcare providers is of paramount importance. Even brief advice from a provider is known to improve quit rates.1  
  • For patients not yet ready to quit, providers are still advised to utilize these methods on subsequent visits, but focus on providing future interventions, such as educational materials or utilizing therapy techniques such as motivational interviewing to help promote cessation and resolve patient ambivalence regarding quitting.1 
  • For patients who are ready to quit, providers should offer patients evidence-based treatments such as NRT, cessation medications (varenicline, bupropion), referrals to cessation resources such as quit lines, counselors, and/or peer coaches in an individually tailored manner that also addresses potentially co-occurring mental health issues.1 

Conclusions:  ​

  • Achieving and maintaining smoking abstinence is a challenge for any smoker. 
  • The health risks associated with continued smoking in people with chronic health conditions are substantial and warrant active, systematic efforts to encourage smoking cessation in this group.1  
  • Health Care Providers can take advantage of "teachable moments" to assess their patients’ readiness to quit and promote cessation. These may include times when patients are hospitalized or at their subsequent follow-up appointment.
  • Current evidence suggests the combination of behavioral interventions, like motivational interviewing, and pharmacotherapy, like Chantix or Bupropion, are most effective for smoking cessation.1 
  • Pharmacotherapy is an effective tool to quit smoking. Consider the graph below which shows the results of a study assessing the use of varenicline (aka Chantix) in achieving smoking abstinence among people recently hospitalized with acute CVD symptoms.  This graph illustrates the efficacy of interventions and the ability of people with chronic health conditions to abstain from smoking.4 

References: 
  1. U.S. Department of Health and Human Services. (2020) Smoking cessation: 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. From https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/i...

  1. Duncan, M. S., Freiberg, M. S., Greevy, R. A., Kundu Jr, S., Vasan, R. S., & Tindle, H. A. (2019). Association of smoking cessation with subsequent risk of cardiovascular disease. JAMA, 322(7), 642–650. https://doi.org/10.1001/jama.2019.10298 

  1. Colivicchi, F., Mocini, D., Tubaro, M., Aiello, A., Clavario, P., & Santini, M. (2011). Effect of smoking relapse on outcome after acute coronary syndromes. The American Journal of Cardiology, 108(6), 804–808. https://doi.org/10.1016/j.amjcard.2011.04.033 

  1. Barth, J., Jacob, T., Daha, I., & Critchley, J. A. (2015). Psychosocial interventions for smoking cessation in patients with coronary heart disease. The Cochrane Database of Systematic Reviews, (7), CD006886. https://doi.org/10.1002/14651858.CD006886.pub2 

  1. Sleeman, K. E., de Brito, M., Etkind, S., Nkhoma, K., Guo, P., Higginson, I. J., Gomes, B., & Harding, R. (2019). The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. The Lancet. Global health, 7(7), e883–e892. https://doi.org/10.1016/S2214-109X(19)30172-X 

  1. Eklund, B. M., Nilsson, S., Hedman, L., & Lindberg, I. (2012). Why do smokers diagnosed with COPD not quit smoking? A qualitative study. Tobacco Induced Diseases, 10(1), 17. https://doi.org/10.1186/1617-9625-10-17  

  1. Melzer, A. C., Feemster, L. C., Crothers, K., Carson, S. S., Gillespie, S. E., Henderson, A. G., Krishnan, J. A., Lindenauer, P. K., McBurnie, M. A., Mularski, R. A., Naureckas, E. T., Pickard, A. S., Au, D. H., & COPD Outcomes-based Network for Clinical Effectiveness and Research Translation Consortium (2016). Respiratory and bronchitic symptoms predict intention to quit smoking among current smokers with, and at risk for, chronic obstructive pulmonary disease. Annals of the American Thoracic Society, 13(9), 1490–1496. https://doi.org/10.1513/AnnalsATS.201601-075OC 

  1. Tøttenborg, S. S., Thomsen, R. W., Johnsen, S. P., Nielsen, H., & Lange, P. (2016). Determinants of smoking cessation in patients with COPD treated in the outpatient setting. Chest, 150(3), 554–562. https://doi.org/10.1016/j.chest.2016.05.020 

  1. Tashkin, D. P., Rennard, S., Hays, J. T., Ma, W., Lawrence, D., & Lee, T. C. (2011). Effects of varenicline on smoking cessation in patients with mild to moderate COPD: A randomized controlled trial. Chest, 139(3), 591–599. https://doi.org/10.1378/chest.10-0865 

  1. What are the risk factors for lung cancer? (2020). Centers for Disease Control and Prevention. Retrieved 27 October 2020, from https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm 

  1. Park, E. R., Japuntich, S. J., Rigotti, N. A., Traeger, L., He, Y., Wallace, R. B., Malin, J. L., Zallen, J. P., & Keating, N. L. (2012). A snapshot of smokers after lung and colorectal cancer diagnosis. Cancer, 118(12), 3153-3164. https://doi.org/10.1002/cncr.26545 

  1. Hopenhayn, C., Christian, W. J., Christian, A., Studts, J., & Mullet, T. (2013). Factors associated with smoking abstinence after diagnosis of early stage lung cancer. Lung Cancer, 80(1), 55-61. https://doi.org/10.1016/j.lungcan.2012.12.013 

  1. Nugent, C. N., Schoenborn, C. A., & Vahratian, A. (2014). Discussions between health care providers and their patients who smoke cigarettes. Women, 18(24), 25-44. PMID: 25483845 

  1. Windle, S. B., Dehghani, P., Roy, N., Old, W., Grondin, F. R., Bata, I., Iskander, A., Lauzon, C., Srivastava, N., Clarke, A., Cassavar, D., Dion, D., Haught, H., Mehta, S. R., Baril, J. F., Lambert, C., Madan, M., Abramson, B. L., & Eisenberg, M. J. (2018). Smoking abstinence 1 year after acute coronary syndrome: follow-up from a randomized controlled trial of varenicline in patients admitted to hospital. Canadian Medical Association Journal, 190(12), E347-E354. https://doi.org/10.1503/cmaj.170377