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Tobacco use, particularly cigarette smoking, is widely recognized by the medical community and the general public as a major public health problem. Physicians and medical organizations share a public health duty to address this problem. Physicians and their professional organizations must contribute effectively to measures undertaken to deal with cigarette smoking. The issues involved are complex and affect medical practice in a number of ways. The following statement developed by six international organizations--the American College of Chest Physicians, American Thoracic Society, Asia Pacific Society of Respirology, Canadian Thoracic Society, European Respiratory Society, International Union Against Tuberculosis and Lung Disease--is intended to state the physician's responsibilities both to patients and to the community with regard to these general issues.
Smoking and Public Health
Smoking contributes to the onset of many diseases, and is thought to account for 87% of deaths in lung cancer, 82% in chronic obstructive pulmonary disease (COPD), 21% in coronary heart disease (CHD) and 18% in stroke cases 2. Therefore, once addicted to nicotine, the smoker faces an unacceptably increased risk of respiratory, neoplastic and cardiovascular disorders. Even without overt pulmonary symptoms, the smoker has a chronic inflammatory disease of the lower airways with an accelerated decline in lung function.
Smoking cessation has immediate and substantial health benefits, both symptomatically and pathophysiologically, and dramatically reduces the risk of most smoking-related diseases.2 One year after quitting, the risk of CHD decreases by 50%, and within 15 years the relative risk of dying from CHD for an ex-smokier approaches that of a lifetime non-smoker.5 The relative risks of developing lung cancer, COPD and stroke also decrease, but more slowly. Ten to 14 years after smoking cessation, the risk of mortality from cancer decreases to nearly that of people who have never smoked.6 Smoking cessation shows a beneficial effect on pulmonary function, particularly in younger subjects, and the rate of decline among former smokers returns to that of never-smokers.7 Recent evidence shows that ceasing before the age of 35 years is of greater benefit than ceasing at a later time.8
The nicotine in tobacco products is highly addictive.9,10 A greater percentage of casual users graduate to addictive patterns of use than occurs with cocaine, morphine or alcohol-containing substances.10,11 Regular use of tobacco products is commonly associated with difficulty in achieving and sustaining abstinence, even when advised strongly by health professionals. Nicotine is the addicting agent in tobacco products and is present in sufficient quantities in all commercially available tobacco products to cause and sustain addiction in children and adults.12 All tobacco products are addictive; however, cigarettes appear to maximize the addictive potential of nicotine by requiring the user to inhale the smoke into the lungs, thereby resulting in extrememly concentrated doses of nicotine being rapidly transmitted to the brain.10,13
Each physician is expected by the public, the medical profession and by each of his or her patients to prevent disease when possible, and to give the best available treatment once disease is present. This imposes upon all physicians the duty to ask each of their patients whether they smoke, and to provide proper information and counseling based on that history. Patients who are non-smokers should receive posititve reinforcement for decreasing their risk of smoking-related disease. A smoking patient requires a more detailed history of why and how much he or she smokes, whether there have been efforts to quit, any respiratory symptoms or deisease from smoking and a search for other risk factors which might increase the chance for that patient to develop cardiovascular disease, obstructive lung disease or lung cancer. Frank discussion of personal health risks, the benefits of smoking cessation and available methods to assist them in stopping smoking are mandatory elements of high-quality care for every patient.
Pediatricians, obstetricians and family practitioners have a special opportunity to influence the health of both young parents and children. Education of pregnant women regarding harmful effects of smoking on themselves and their fetuses, and the risk of lower respiratory tract illness and symptoms in children growing up with smoking parents may hel pmotivate the women to stop smoking before becoming severely addicted. Pediatricians and family practitioners should initiate counseling of children regarding harmful effects of smoking when the children are old enough to understand.
Physicians and Smoking Cessation:
Physicians should explain to every smoking patient the medical risks associated with smoking and the reduction in risk associated with smoking cessation. Physicians should encourage abstinence, and prescribe and follow-up on the use of specific smoking cessation programs and strategies such as self-help, behavioral or pharmacologic approaches. A variety of behavioral programs have been developed, and the physician should be able to utilize effectively locally available resources.
Pharmacologic approaches to smoking cessation are currently based on nicotine replacement, and the physician should be cognizant of these approaches as well. Nicotine replacement during early abstinence helps to relieve symptoms of withdrawal and can increase quit rates.14 Nicotine delivered as a medication may also be addictive. However, the addiction potential of currently available medications appears related to their nicotine dosing characteristics. Thus, nicotine-delivering transdermal and polacrilex gum medications appear to be of minimal addiction potential. Other systems in development such as nasal sprays and vapor inhalers may be of greater addiction potential but would still be expected to be lower in addictiveness and toxicity than tobacco products, which appear to optimize the addictive effects of nicotine through their dosing and sensory characteristics.
Physician as Role Model:
Current and future physicians should be "exemplars" to their patients and communities. The physician should act as role model by not smoking and by creating a smoke-free environment in his or her office. Despite evidence on the negative health consequences, cigarette smoking is still hightly prevalent among physicians in some countries.15 While smoking rates among physicians often reflect general population smoking rates, in most countries doctors smoke much less than the general population. Reduction of physician smoking is important, as the tutors of the people in matters of health have a responsibility to present a proper image. No suggestion should ever be made, particularly by physician behavior, that smoking is not dangerous; therefore, physicians should not smoke in front of patients. Medical organizations should adopt active policies to establish physicians as role models in regard to smoking and health. Smoking prohibition in hospitals and all structures associated with health care should be mandatory, and such policies should be strongly supported by medical associations.
Students in medicine and other professionals (technicians, nurses, etc.) must be taught from the first years of study about the negative effects of smoking, the addictive properties of nicotine, and how to help their future patients avoid smoking if possible and to quit smoking if needed.
There is near universal agreement that those who start to smoke in the teenage years are the most likely candidates for eventual nicotine dependence. Disease prevention thus begins by educating the young person. Obviously, therefore, cigarette advertising should not be directed to these younger age groups.
Unfortunately (and despite their pious disclaimers) the tobacco industry persists in preparing shrewd strategies to "entrap" the young smoker. Cartoon characters vie for the youngster's interest along with alternate techniques of publishing pictures of young vigorous, handsome, athletic men and women who find a particular brand of cigarette the most refreshing. This insidious indoctrination is worldwide and should be opposed by individual physicians and by medical organizations.
Many communities have recognized the social implication of smoking and have, therefore, enacted public policy and legislation. The goals of these policies are: 1) to prevent the initiation of smoking and the development of nictoine addiction, 2) to encourage the cessation of tobacco use among those who already smoke cigarettes or use other tobacco products, and 3) to protect non-smokers. Such policy includes: 1) taxes on cigarettes, 2) restrictions on advertising, 3) restriction of cigarette sales to children and teenagers, 4) prohibition of smoking in specified public places, 5) assurances that smoke-free environments will be available in work places, 6) regulation of content and packaging of tobacco products, 7) public education, 8) promotion of smoking cessation services, 9) assistance for tobacco farmers, 10) restriction of international trade in tobacco, 11) health warnings on cigarette packages, and 12) abolition of "kiddie" packages of cigarettes. Such legislative issues are complex and involve balancing the rights and privileges of various heterogenous groups. Physicians have a special in these considerations. In addition to their role as citizens, physicians are leaders with regard to any issue affecting public health. Physicians should, therefore, be aware that public policy regarding smoking can be an effective instrument of public health and they have a responsibility to participate effectively in public debate, both as individuals and as members of medical organizations.
Most governments use the funds raised by tobacco excise taxes for general revenue. Governments should not fund routine services at the expense of public health. Alternative uses for such funds could include specific tobacco prevention and education programs, including mass media campaigns, smoking cessation efforts among the poor and helping tobacco farmers convert to other crops.
Such fiscal policies raise a number of important questions. A high price policy has also been criticized as an unfair penalty upon the poor. It is the physician's role to recognize and proselytize any perceived penalty in terms of health risks associated with cigarette smoking.
Tobacco use, particularly cigarette smoking, is a major cause of preventable disease and
premature death worldwide. Both smokers and non-smokers exposed to environmental
tobacco smoke are at risk. Cessation of smoking reduces risks. Although the addicting
properties of nicotine can make cessation difficult, both medical interventions aimed at
helping smokers quit and social policies aimed at control of cigarette smoking can have
significant benefits. Physicians should play an active role in control of smoking by
ensuring that counselling and pharmacologic therapy must be available for the individual
smoker. Physicians should also participate in the public debate regarding smoking both
individually and through medical organizations. As smoking represents a threat to the
public health, physicians must take a strong and active role seeking its control.
American College of Chest Physicians (ACCP)
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