Introduction
Since the publication of the first report of the Surgeon General’s Advisory Committee on Smoking and Health in 1964, more than 20 million deaths have occurred prematurely in the United States due to cigarette smoking.1 While efforts in the United States have led to a decline in cigarette smoking among adults from 42% in 1964 to 14% by 2019, more than 34 million adults still currently smoke.1,2 It is estimated that 50.6 million U.S. adults (20.8%) use some form of tobacco product.2
Cigarette smoking (including secondhand smoke exposure) is the leading cause of death and preventable disease in the United States, accounting for more than 480,000 deaths each year.1,2,3 If cigarette use continues at the current rate, 5.6 million U.S. children younger than 18 who are alive today will die prematurely as a result of smoking.3
Cigarette smoking has been causally linked to diseases of nearly all organs of the body, including an increased risk of heart disease, stroke, chronic obstructive pulmonary disease (COPD), diabetes mellitus, and lung cancer.1 Lung cancer caused by smoking is the leading cause of lung cancer deaths.1,4 It also causes complications in pregnancy, harms the fetus, and leads to diminished overall health status.1 People who smoke are estimated to lose more than 10 years of life expectancy, but the risk of all-cause mortality for smokers who quit also dramatically decreases the sooner they quit.1 Quitting smoking by 40 years of age can eliminate more than 90% of excess mortality caused by continuing to smoke.1
Inhaling secondhand smoke is also detrimental to health. It consists of a mixture of gases and fine particles that includes smoke from a burning tobacco product, as well as exhaled smoke.5 This smoke contains thousands of chemicals, hundreds which are toxic, including 70 that can cause cancer.4
Some cancers, along with respiratory and cardiovascular diseases, may result from exposure to secondhand smoke, and it can also cause serious adverse effects during pregnancy and in infants and children.4 A number of risks associated with secondhand smoke exposure during pregnancy affect unborn babies and infants; these include premature delivery, low birth weight, stillbirth, sudden infant death syndrome (SIDS), lower respiratory infection, asthma, and middle ear infection.4
Nicotine is a highly addictive, naturally occurring chemical found in tobacco.1 Cigarette companies intentionally modify tobacco products to “create and sustain addiction.”6
While cigarette smoking is the predominant form of tobacco use in the United States, other tobacco products are often used by and marketed to certain racial, ethnic, and lower socioeconomic populations, as well as children and young adults.7 These include bidis, tobacco smoked with a hookah/waterpipe, snus, dissolvables, cigars, cigarillos, electronic nicotine delivery systems (ENDS), and electronic cigarettes (also called e-cigarettes).7
E-cigarettes and ENDS are battery-powered devices that contain nicotine-filled cartridges or reservoirs for adding nicotine-containing liquid or “juice.” They produce a vapor that is inhaled as a mist that contains flavorings and various levels of nicotine and other toxic substances.8 Manufacturers and marketers tout e-cigarettes as cheaper and safer alternatives to traditional cigarettes.9 These claims are being made despite a number of studies linking e-cigarette use to several harmful effects likely caused by increases in blood nicotine level,10 multiple physical symptoms,11 and negative effects on indoor air quality.12 A significant concern is the increased focus by manufacturers, marketers, and retailers on e-cigarette use as a smoking cessation tool.9 The American Academy of Family Physicians (AAFP) does not endorse ENDS as cessation devices in any population due to insufficient evidence of their efficacy.13 The AAFP does support the seven U.S. Food and Drug Administration (FDA)-approved tobacco cessation options, acknowledging that pharmacotherapy and counseling substantially improve cessation outcomes.14
Call to Action
The AAFP urges all state, federal, and private sector institutions involved in tobacco prevention and cessation activities to increase and coordinate their efforts. Bold new initiatives are necessary to decrease the harm caused by tobacco and nicotine use. The AAFP supports the American Academy of Pediatrics, American Cancer Society Cancer Action Network, American Heart Association, American Lung Association, Americans for Nonsmokers’ Rights, Campaign for Tobacco-Free Kids, and Legacy® in their call for action by all levels of government to achieve the following three bold goals15:
Reduce smoking rates to less than 10% by 2024
Protect all Americans from secondhand smoke
Eliminate the death and disease caused by tobacco use
There are opportunities for family physicians to become active in advocating for tobacco and nicotine control measures at the community, state, and national levels. Family physicians are trusted members of their communities and can serve as effective agents in facilitating and advocating for policy change, especially at the local level. To reach these bold goals, the AAFP calls for advocacy in the areas listed below.
Community and State Advocacy for:
Evidence-based tobacco control policy changes, including increased tobacco excise taxes
Comprehensive, evidence-based tobacco control programs supported by tax revenue
Tobacco-free pharmacies and health care facilities, and elimination of all forms of tobacco sales in pharmacies
Comprehensive clean indoor air policies that include the use of e-cigarettes and ENDS
National Advocacy for:
Insurance coverage with no co-payments or cost sharing, including Medicaid coverage, for evidence-based cessation counseling, prescriptions, and over-the-counter tobacco cessation medications
Enhanced access to tobacco cessation services for all patients, regardless of health insurance
Aggressive and timely regulation of all products containing nicotine by the FDA’s Center for Tobacco Products (CTP)
Research on e-cigarettes to assess their safety, quality, and efficacy as a potential cessation device
Restriction of access and marketing of e-cigarettes to children and youth
Through these and other actions, the AAFP, its chapters, and its individual members can work in partnership to help eliminate the epidemic of tobacco-related death and disease.
Family Physicians’ Role
Family physicians can make a significant impact on the tobacco use behavior of Americans. Approximately 70% of individuals who use tobacco products see a physician each year.16 Recent evidence reinforces the positive impact that primary care physicians can have by encouraging smoking cessation with their patients.17
Patients want to quit smoking. Nearly 70% of adults who smoke say they want to quit, and more than half report having made a quit attempt in the past year.18 However, fewer than one-third try to quit using evidence-based cessation methods.18 Quitting smoking can be difficult without assistance. One study found that only 3%-5% of adults who attempted to quit without cessation assistance maintained their smoking abstinence for 6-12 months.19
While most individuals try to quit on their own without participating in smoking cessation programs,18 research shows that evidence-based cessation programs can double successful quitting rates.16 If physicians would advise 90% of people who smoke to quit and offer them medication or other assistance, 42,000 lives could be saved each year.20
There are many opportunities for family physicians to address tobacco use and nicotine dependence in the practice setting. The following actions may help physicians take advantage of those opportunities16,21:
Counsel all patients on the harms of nicotine and tobacco products
Promote medical education sessions for all care team staff that focus on effective cessation tools and ways to overcome barriers
Implement or enhance office-based prevention programs and policies, including those that target high-risk populations
Engage the health care team to provide tobacco cessation counseling and medical treatments
Provide a clearly defined process for practices and clinicians to assess patient interest in quitting, encourage quitting for those not currently interested, encourage counseling and use of cessation medications, and provide follow-up
Include a systematic way to provide patients with more information about and support for quitting, using appropriate members of the health care team besides physicians, when possible
List tobacco use as a cause of death when appropriate
Use tobacco use status as a vital sign
Create a flowsheet in the patient’s record so the clinician can see a summary of past smoking discussions and quit attempts
The AAFP encourages its members to use a variety of counseling techniques to address tobacco use and nicotine dependence, such as motivational interviewing, brief interventions, and group visits. Members should recognize and address barriers to successful intervention and treatment. Barriers exist at the patient and physician level, as well as at a systemic level.
Patient- and physician-level barriers include:
Lack of motivation to quit22
Nonadherence to medications and counseling23
Use of non-evidence-based treatments18
Limited time with patients24
Systemic-level barriers include:
Inconsistent follow-up to ensure that patients are adhering to cessation plans and appropriate referrals occurred25
Inadequate reimbursement and payment for cessation counseling and treatments26
Inconsistent follow-up with patients to remind them to utilize services20
Tobacco Cessation Tools for the Family Physician
Ask and Act
The U.S. Public Health Service (USPHS) encourages use of the five A’s (Ask, Advise, Assess, Assist, and Arrange) as a brief intervention for patients who smoke.16 The AAFP encourages its members and their practice teams to Ask all patients about tobacco use and then Act to help them quit. The AAFP’s Ask and Act tobacco cessation program uses an evidence-based strategy based on USPHS recommendations. This easy-to-remember approach provides the opportunity for every member of a practice team to intervene at every visit. The implementation of team-based care offers a significant opportunity to improve the rate of interventions for tobacco use and nicotine dependence. For more information about tobacco cessation tools and interventions, visit www.askandact.org.
Electronic Health Records
Electronic health records (EHRs) allow for integration of evidence-based recommendations into the practice workflow. The AAFP encourages the use of EHRs that include the following:
A template that prompts clinicians or their practice teams to collect information about tobacco and nicotine use, secondhand smoke exposure, current cessation interest, and past quit attempts
Clinical decision support that assists clinicians and/or staff in screening for use, encouraging quitting, connecting patients and families to appropriate cessation resources, and advising them about the benefits of smoke-free environments
The AAFP encourages all members to track and assess tobacco and nicotine use at every visit or opportunity. Tobacco use assessments can be beneficial in meeting requirements of a variety of quality reporting programs.
Tobacco Cessation and Telehealth
In addition to office-based tobacco cessation interventions, telehealth services can be an effective way to expand access and improve adherence to chronic care management, such as treating tobacco dependence, and provide physicians enhanced methods of delivering evidence-based treatment.27
Telehealth utilizes phone- or video-based clinical services through a patient’s primary care team and can be used to supplement services provided by state-led tobacco quitlines. Research shows that telehealth smoking cessation programs can be an effective tool in tobacco cessation treatment; for example, compared with in-person counseling, they result in similar abstinence rates from weeks 9 to 12, and lead to greater patient satisfaction and better adherence to pharmacotherapy treatment than quitline-style telephone counseling.28,29
Payment and Covered Benefits
Repeated clinical tobacco cessation counseling is “one of the three most important and cost-effective preventive services that can be provided in a medical practice.”21 The AAFP strongly advocates for health plan coverage and appropriate payment for evidence-based physician services for screening and treatment of tobacco use consistent with the U.S. Preventive Services Task Force (USPSTF) recommendations.30
The AAFP recommends that all people who use tobacco in the United States be aware of the existence of and have access to all evidence-based, FDA-approved therapies and counseling. The Centers for Medicare & Medicaid Services (CMS) pays for physician services related to smoking cessation counseling provided to Medicare beneficiaries.31 The Patient Protection and Affordable Care Act (ACA) requires insurance plans to cover many clinical preventive services, including tobacco use screening and counseling.32 A guide to coding for tobacco cessation and screening is available on the AAFP’s website.
High-risk Populations
Despite the overall decline in tobacco use, certain populations maintain high rates. Higher rates of tobacco and nicotine use in these populations increase their risk of harmful health effects. Populations more likely to use tobacco include the following:
Individuals in some racial and ethnic minority groups33
Lesbian, gay, bisexual, and transgender (LGBT) individuals34
Individuals with lower education levels and lower socioeconomic status34,35
Individuals living in rural areas36
Individuals with mental illness37
Individuals with substance abuse disorders38,39
Individuals with mental illness smoke at rates that are twice as high as the general population.37 Nearly half the cigarettes sold in the United States are smoked by individuals with mental illness.39 Smoking prevalence is particularly high among individuals diagnosed with schizophrenia, bipolar disorder, depression, post-traumatic stress disorder (PTSD), and alcohol/illicit drug use disorders.39 In addition, smoking prevalence increases as the number of mental disorders increases, with 61% smoking rates for individuals diagnosed with three or more mental disorders.39
Other populations with increased health threats from tobacco use include people who are pregnant; people with human immunodeficiency virus (HIV); and people with comorbid conditions such as diabetes, cancer, cardiovascular disease, COPD, diabetes, and asthma.
Tobacco Use in Adolescents
In 2017, approximately 3.6 million middle and high school students were current tobacco users.40 Among high school students, 7.6% reported smoking in the past 30 days, with one in five reporting use of some form of tobacco.41 In addition to the well-known, long-term health effects of smoking, children may experience immediate effects on the brain, as well as the respiratory, cardiovascular, gastrointestinal, immune, and metabolic systems.42
While cigarette smoking by youth has been on the decline, the FDA reported a 77% increase in ENDS use among high school students within a 12-month timeframe in 2018.43 The Surgeon General’s Advisory on E-cigarette Use Among Youth, released in 2018, classified ENDS use among youth as an epidemic.44 The surgeon general called for immediate action to mitigate the rapid increase of ENDS use among youth, which subsequently leads to nicotine addiction. Nicotine exposure in adolescence can impact brain development, which affects learning, memory, and attention. Evidence also suggests ENDS use during adolescence may lead to traditional cigarette smoking later in life.44
There is clear evidence of a causal relationship between tobacco advertising and the influence, initiation, and progression of tobacco use among youth.7 Tobacco companies extensively market to youth, adolescents, and young adults.7 In a 1984 R.J. Reynolds report, the company expressed how essential those smokers are when they stated, “Younger adult smokers are the only source of replacement smokers If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle.”45 The tobacco industry has worked hard and spent aggressively to keep these customers. In 2016, cigarette and smokeless tobacco companies spent a combined $9.5 billion on advertising and promotional expenses in the United States.46,47
Tobacco prevention programs are increasingly important to curb youth tobacco use initiation, particularly as the landscape of tobacco and nicotine products changes and adapts to appeal to new generations. Nearly all adults who smoke every day initiated smoking at 26 years or younger, with the majority (88%) beginning by 18 years of age.7 Despite some recent promising declines in overall youth ENDS use, middle and high school students continue to use ENDS at alarmingly high rates.48
Tar Wars
The AAFP encourages its members to talk to children and adolescents about the risks of using tobacco and nicotine products, and to participate in community awareness and prevention activities. Tar Wars, the AAFP’s tobacco prevention program, helps keep youth from using tobacco and nicotine products. This program was developed by a family physician and health educator in 1988. It teaches children about the effects of tobacco use, the cost of using tobacco products, and advertising techniques used by the tobacco industry to market their products to children.
Research and Development
The budgets in the public and private sectors for development of new technologies and approaches to tobacco use screening and treatment are not commensurate with the size and scope of the tobacco and nicotine use epidemic. The AAFP encourages increased funding for the pursuit of innovative approaches to identifying those at risk for tobacco and nicotine use and helping people quit. This includes providing medications, counseling, policy change, and improvements in primary care clinic systems.
Medical Education
The AAFP strongly advocates for in-depth, effective education in the prevention and cessation of tobacco use in medical schools and residency programs. The AAFP also encourages family physicians to participate in continuing medical education (CME) activities and programs related to prevention and cessation of tobacco use, and strongly encourages organizations involved in the creation of CME to integrate tobacco and nicotine use screening, prevention, and treatment into their curricula. Organizations involved in the ongoing credentialing of primary care physicians, such as the American Board of Family Medicine (ABFM), should include questions about tobacco dependence treatment in examinations and test preparation materials.
Taxation and Subsidies
The AAFP believes that increasing taxes on tobacco products provides a major disincentive to potential buyers. The AAFP encourages the development of health education and other tobacco control programs funded by the taxes collected on tobacco products. The AAFP supports its chapters’ efforts to ensure that funds from the Master Settlement Agreement (MSA) or excise taxes on tobacco products be used primarily for tobacco use prevention, cessation, education, and other elements of comprehensive tobacco control.
Secondhand Smoke
The AAFP strongly supports prohibiting the use of all tobacco and nicotine products that emit smoke, vapor, or any form of inhalable substance in all public places. All tobacco or nicotine product smoke or inhalable vapor in indoor spaces must be eliminated to fully protect those who do not use such products. Mitigation efforts such as separating people who smoke or use any device containing nicotine that emits a vapor from those who do not within the same air space, cleaning the air, opening windows, or ventilating buildings do not effectively eliminate secondhand smoke exposure. Family physicians should advise their patients, especially those with children and those with cardiovascular diseases or other chronic conditions, to avoid establishments that permit smoking and to request that family members not smoke in their home or vehicle. To reduce children’s exposure to secondhand smoke, family physicians should encourage all household members who use tobacco to quit and to create a smoke-free home. The AAFP urges all employers to provide smoke-free work environments and incentives for employees who participate in cessation programs. Family physicians and AAFP chapters are encouraged to work with local governments and agencies to advocate for comprehensive clean indoor air ordinances and regulations.
Framework Convention on Tobacco Control Public Health Treaty
The AAFP fully supports the World Health Organization’s (WHO’s) Framework Convention on Tobacco Control (FCTC) and urges its full ratification by the United States. The FCTC is the world’s first global public health treaty that requires nations to adopt a comprehensive range of measures designed to reduce the devastating health and economic impact of tobacco use. The FCTC calls for provisions that include price and tax measures to reduce the demand for tobacco products.49
The non-price measures to reduce the demand for tobacco products stated in the FCTC address the following50:
Protection from exposure to tobacco smoke
Regulation of the contents of tobacco products
Regulation of tobacco product disclosures
Packaging and labeling of tobacco products
Education, communication, training, and public awareness
Tobacco advertising, promotion, and sponsorship
Demand reduction measures concerning tobacco dependence and cessation
The core supply reduction provisions stated in the FCTC address the following50:
Illicit trade in tobacco products
Sales to and by minors
Provision of support for economically viable alternative activities to tobacco farming and production
The United States signed the treaty in 2004, but it has yet to be sent to the Senate for ratification.50 The AAFP supports the FCTC and urges the Senate to ratify the treaty.
Electronic Nicotine Delivery Systems (ENDS)
Electronic nicotine delivery systems (also called electronic cigarettes, e-cigarettes, vaping devices, or vape pens) are battery-powered devices used to smoke or “vape” a flavored solution that usually contains nicotine.8 The AAFP recognizes the alarmingly high rates of ENDS use, especially among youth and young adults, as well as their use by those attempting to quit smoking tobacco.51,52
The AAFP calls for further research to assess ENDS’ safety, quality, and efficacy as potential cessation devices. The AAFP also recommends that the marketing and advertising of ENDS to children and youth cease immediately. The AAFP encourages members to screen for ENDS use starting with school-age children, to discuss the potential harms of ENDS, and to recommend cessation interventions to e-cigarette users. The AAFP encourages members to inform patients who use ENDS, especially children, that the majority of these products contain nicotine and are addictive.
Tobacco Advertising and Labeling
The AAFP opposes all forms of advertisement of tobacco products, including all forms of ENDS, and direct or indirect marketing of tobacco products to children. The AAFP will endeavor to place advertising material in and develop relationships with publications that do not accept tobacco advertising. If placing advertising material in a publication that accepts tobacco advertising is unavoidable, the adjoining pages will not promote tobacco or alcohol. The AAFP urges removal of corporate tax deductions for the advertising of tobacco products. The AAFP supports state and community efforts to reduce or eliminate point-of-sale advertising.
The AAFP strongly supports prominently displayed labeling that warns potential users of health hazards of all tobacco products, including all forms of ENDS. The AAFP supports “plain pack” tobacco product packaging, removal of logos and colors associated with individual brands, and implementation of depictions of tobacco-related disease on packaging.
Federal Tobacco 21, Distribution, and Sales
In December 2019, after years of state-level advocacy, the federal minimum age for sale of tobacco products was raised from 18 to 21 years of age for all retail establishments and individuals, with no exemptions.53 Although this federal Tobacco 21 legislation is a significant achievement for tobacco control advocates and public health, substantial deficiencies remain in the areas of implementation and enforcement.
Since the new federal law raises the minimum age for sale to 21, states are expected to enforce underage access laws to reduce the illegal sale of tobacco products to individuals under the age of 21.54 However, no federal support has been provided to states to help make this transition. Federal guidance gives states up to three years to be in compliance with the new age-at-sale requirements, even though the legislation itself requires states to be in compliance sooner.53,54 Additionally, the new law cuts the allowable penalty for states that are out of compliance from up to 40% of a state’s federal block grant funds to only up to 10% with no escalating penalty.54 This change significantly limits the federal government’s ability to incentivize states that are consistently out of compliance.
The AAFP supports active enforcement of minimum legal age-of-sale verification at the time of sale with a burden of verification on tobacco retailers. The AAFP opposes state and local laws designed to penalize minors for possession, use, and purchase of tobacco products. The AAFP supports requiring that all tobacco products be placed behind sales counters in retail stores. The AAFP supports legislation to ban the sale of tobacco products via the internet and from vending machines and ban the promotional distribution of free tobacco products. The AAFP supports tobacco retailer licensing programs and zoning requirements reducing the density, type, and location of tobacco retailers.