The just-released Surgeon General’s Report on Smoking Cessation is a typically massive (700 pages) and evidence-based document with multiple authors and reviewers (including Catherine Saucedo and me from the SCLC). The first such report since 1990, it is a valuable compendium of the history, current status, controversies and challenges of smoking cessation. Much of the literature review that drives the Report stopped at 2017, with the exception of the rapidly evolving field of electronic nicotine delivery devices.
For those working in this arena, there are few surprises. Nevertheless, the Report details important history, presents current trends, and gives an impartial and evidence-based summary about what is known and what needs to be discovered. As such, it will serve as a valuable source for those working in tobacco control and public health. Media reports have mainly focused on the lamentable fact that clinicians still underperform in helping smokers try to quit. Some have seized on the fact that there is not yet firm evidence that e-cigarettes help smokers quit. For those who do not have the time to read the entire report, here are my takeaway messages:
Who are the people who smoke?
- As of 2018, adult smoking prevalence was at a modern low of 13.8%. For young adults (age 18-24), cigarette smoking prevalence is even lower–10.4% —which bodes well for future smoking trends. But there are still 34.2 million people who smoke, 68% of whom would like to quit. Those who continued to smoke consumed fewer cigarettes.From 2005 to 2015, the percentage of current smokers who smoked daily declined from 80.8% to 75.7%.
- More than 60% of U.S. adults who have ever smoked cigarettes have quit. Although a majority of cigarette smokers make a quit attempt each year, less than one-third use cessation medications or counseling to support those attempts.
- Some progress has occurred. Past-year quit attempts and recent and longer term cessation have increased modestly over the past two decades. Advice from health professionals to quit smoking has increased since 2000; however, 4 out of every 9 adult smokers who saw a health professional during the past year did not receive advice to quit. Similarly, use of evidence-based cessation counseling and/or medications increased among adult smokers since 2000, yet more than two thirds who tried to quit did not use evidence-based treatment.
- Smoking prevalence is increasingly concentrated in populations that may face barriers to quitting. These include persons with behavioral health conditions (mental health illnesses or substance use disorders); persons of low socioeconomic status; persons who are LGBTQ; American Indians/Alaska Natives; recent immigrants from countries with a high smoking prevalence; residents of the South and Midwest; and persons with disabilities. These populations also exhibit lower rates of cessation, partly due to less health insurance coverage.
- There is increasing dual use of tobacco and marijuana.
Smoking cessation improves health
- The health benefits from stopping smoking are huge. Smoking causes multiple cardiovascular and cerebrovascular diseases, chronic obstructive pulmonary disease, and multiple reproductive disorders.
- The estimated annual cost of treating tobacco-associated health problems is $170 billion.
Policies to improve smoking cessation
- Multiple strategies can increase smoking cessation efforts: raising the price of cigarettes; adopting comprehensive smoke-free policies; implementing mass media campaigns; requiring pictorial health warnings on tobacco packages (note: this is a new evidence-based strategy); maintaining comprehensive statewide tobacco control programs; and providing comprehensive, barrier-free evidence-based insurance coverage.
- Not yet sufficient evidence demonstrating that plain cigarette packaging, limited retail access, or limiting flavored products will increase smoking cessation.
Smoking cessation strategies for individuals who smoke
- In addition to counseling and the 7 FDA approved medications, there is sufficient evidence to support quitlines, text messaging, and web or internet-based interventions.
- The evidence is suggestive but not sufficient to infer that cytisine—a medication available in other countries but not yet in the U.S., increases smoking cessation.
- There is no evidence that medications increase smoking cessation among light smokers.
- “The evidence is inadequate to infer that e-cigarettes, in general, increase smoking cessation. However, the evidence is suggestive but not sufficient to infer that the use of e-cigarettes containing nicotine is associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine, and the evidence is suggestive but not sufficient to infer that more frequent use of e-cigarettes is associated with increased smoking cessation compared with less frequent use of e-cigarettes.” (Note: I have inserted quotes here to indicate the precise language used, because this subject has been so controversial. The SG Report mentions in many places the need to protect youth from e-cigarette exposure as well as the need to understand better the potential of these devices to help smokers quit.)
- The evidence is inadequate to infer that smartphone apps for smoking cessation are independently effective.
- The evidence is suggestive but not sufficient to infer that vaccines generating adequate levels of nicotine-specific antibodies can block the addictive effects of nicotine and aid smoking cessation. (Note: I had given up on nicotine vaccines, but the report notes that next-generation vaccines hold promise for producing higher antibody levels and may—with periodic booster shots—serve to help smokers quit.)
System-level approaches to smoking cessation
- The evidence is sufficient to infer that strategies that link smoking cessation-quality measures with payments to clinicians, clinics, or health systems increase the rate of delivery of smoking cessation treatments.
- Effective October 1, 2016, CMS required inpatient psychiatric facilities to begin reporting on the first two tobacco cessation performance measures (document tobacco use and deliver cessation treatment when indicated) from the Joint Commission. CMS extended this requirement to the third Joint Commission cessation measure (arrange for treatment post discharge) effective October 1, 2017, and then discontinued the first measure for fiscal year 2019. These changes led to a 10-fold increase in the number of smokers who received inpatient tobacco treatment.
For us at the Smoking Cessation Leadership Center, it was gratifying to see our establishment in 2003 as a tobacco cessation milestones called out in Table 8-1 of the Report. But the year 2000 quote from then Surgeon General David Satcher is still pertinent two decades later:
“Our lack of greater progress in tobacco control is more the result of failure to implement proven strategies than it is the lack of knowledge about what to do.”
This Surgeon General’s Report reminds us that we have made substantial progress, but spurs us to do even better.