Be Smoke Free in New Jersey, Quit 2 Win

The The Impact of Smoking and Impact of Smoking and HowHow to Succeed in Quitting to Succeed in Quitting CTCP White Paper 2007 CTCP White Paper 2007 Jon S. CorzineS. Corzine Jon GOVERNOR GOVERNOR Fred M. Jacobs, M.D., J.D.M.D., J.D. Fred M. Jacobs, COMMISSIONER COMMISSIONER New Jersey Quitline New Jersey Quitline 1-866-NJ-STOPS 1-866-NJ-STOPS www.NJQUIT2WIN.com www.NJQUIT2WIN.com New Jersey Quitnet® New Jersey Quitnet® www.NJ.QUITNET.com www.NJ.QUITNET.com INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 SMOKING HARMS NEARLY EVERY ORGAN IN THE BODY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 CANCERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 CARDIOVASCULAR DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 RESPIRATORY DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 REPRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 OTHER EFFECTS OF SMOKING ON HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 HOW MUCH DOES SMOKING REALLY COST? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 COST TO THE INDIVIDUAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 AGGREGATE MEDICAL COSTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 PRODUCTIVITY COSTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 TOTAL COSTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 SMOKERS REAP IMMEDIATE HEALTH BENEFITS BY QUITTING . . . . . . . . . . . . . . . . . . . . . . . . .28 WHY IS IT SO HARD FOR SMOKERS TO QUIT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 THE THREE FACES OF TOBACCO DEPENDENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 THE PHYSICAL ADDICTION TO NICOTINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 PSYCHOLOGICAL DEPENDENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 BEHAVIORAL DEPENDENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 SMOKING CESSATION COUNSELING AND PHARMACOTHERAPIES DO WORK . . . . . . . . . . . . . .31 AN EVIDENCE-BASED APPROACH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 PRACTICAL COUNSELING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 SOCIAL SUPPORT WITHIN THE TREATMENT PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 SOCIAL SUPPORT OUTSIDE OF THE TREATMENT PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 PHARMACOTHERAPIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 NEW JERSEY HELPS RESIDENTS QUIT 2 WIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 NEW JERSEY QUIT SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 NEW JERSEY QUITLINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 NEW JERSEY QUITNET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 NEW JERSEY QUITCENTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 QUIT 2 WIN CAMPAIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 SMOKE FREE NEW JERSEY: BREATH OF FRESH AIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 BE SMOKE FREE IN NEW JERSEY: QUIT 2 WIN CAMPAIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 INTRODUCTION Tobacco use is the single most preventable cause of death, disease and disability in the nation. It causes the deaths of more than 11,000 people each year in New Jersey alone — that is one in every five deaths that can be attributed to smoking. Yet more than 17 percent of adults in New Jersey continue to smoke. Although the State of New Jersey is making steady progress in reducing the number of people who smoke, we need to do more to reduce the terrible toll that smoking is taking on New Jerseyans’ health. That toll is far greater than people think. The 2004 Surgeon General’s report, The Health Consequences of Smoking, compiled all the evidence gathered since the original Surgeon General’s report on smoking 40 years earlier regarding the damage that smoking does to health. This report declared that cigarette smoking harms nearly every organ in the body. It significantly expands the list of diseases that smoking causes, and it confirms that smoking undermines smokers’ health in general. In June 2006 the Surgeon General issued a report on the health hazards of secondhand smoke, The Health Consequences of Involuntary Exposure to Tobacco Smoke. When he released the report, the Surgeon General said, “The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.” This report updates scientific conclusions about the scope of the health risk caused by secondhand smoke. To protect the State’s residents from this health risk, New Jersey enacted the Smoke-Free Air Act in 2006 to ensure that its residents are not subjected to these health risks in indoor public places. Smoking results in an enormous economic impact on New Jersey. The costs for direct medical care attributable to smoking are nearly $2.5 billion each year. In addition, lost productivity as a result of sick days, smoking breaks and disability costs New Jersey an additional $2.22 billion annually. On the positive side, clinical studies show that the health benefits that smokers gain by quitting are both immediate and long term, and there are effective tools to help smokers succeed in quitting. More than 70 percent of New Jersey’s 1.15 million smokers want to quit. However, only three percent succeed without help. New Jersey Quit Services provide the resources necessary to help smokers succeed in quitting. The New Jersey Department of Health and Senior Services (NJDHSS), through the Comprehensive Tobacco Control Program (CTCP), wants to make sure that all smokers get the help they need in order to succeed. The State has set a Healthy People 2010 goal to reduce smoking among 18- to 64year-olds from the current 17.4 to 15 percent, and among seniors 65 years of age and older, to 8 percent. To achieve this goal, NJDHSS is encouraging smokers to use its free and low-cost NJ Quit Services to help them succeed. These services were developed by experts in smoking cessation using scientifically based, proven approaches to help smokers quit for good. For example, 30 percent of smokers who register with New Jersey Quitline remain smoke-free 1 www.njquit2win.com six months after their quit date, well above the national average of 10 percent to 12 percent for structured cessation programs. Through the Be Smoke-Free in New Jersey: Quit 2 Win campaign, NJDHSS is mobilizing organizations, institutions and individuals across the State to encourage and support smokers in their decision to quit smoking by using NJ Quit Services. The purpose of this report is to document, for all who are in a position to help smokers quit, the full scope of what is at stake for smokers’ health and well-being and how NJ Quit Services are structured to achieve success in smoking cessation. 2 www.njquit2win.com EXECUTIVE SUMMARY Smoking Harms Nearly Every Organ in the Body Tobacco is the single most preventable cause of death, disease, impairment and disability in New Jersey. Tobacco-related diseases cause more than 11,000 deaths in the State each year. Since the first Surgeon General’s report on Smoking and Health, which conclusively identified smoking as a cause of lung cancer, more and more diseases and health conditions have been linked to smoking. In its report in 2004, The Health Consequences of Smoking, the Surgeon General’s office examined and compiled 40 years of research studies to identify information about all the health risks that smoking causes. The list has become lengthy. Cancers • Lung cancer • Laryngeal cancer • Esophageal cancer • Oral cancer • Bladder cancer • Cervical cancer • Kidney cancer • Pancreatic cancer • Stomach cancer • Acute myeloid leukemia Cardiovascular Disease • Coronary heart disease • Stroke • Abdominal aortic aneurism Lung Disease • COPD (emphysema, chronic bronchitis) • Pneumonia • More frequent viral and bacterial respiratory infections • Reduced lung function for newborns exposed in utero • Impaired lung development in youth/teens • Premature and accelerated decline in lung function in adults Other • Infertility among women • Complications in pregnancies of women who smoke (placenta previa, placenta abruption, premature rupture of membranes, premature birth) • Low birth weight in babies • Poor outcomes from surgery • Low bone density & hip fracture in women • Cataracts • Peptic ulcers • Periodontitis • Diminished health status On average, smoking shortens men’s lives by 13.2 years, women’s lives by 14.5 years, and at all ages, cigarette smokers are less healthy than nonsmokers. In fact, in 2004, the Surgeon General asserted that smoking harms nearly every organ in the body. The culprit is not nicotine. Instead, it is the 4,000 chemicals contained in cigarettes. At least 200 of these are known poisons, and 69 are known or probable carcinogens (cancer-causing agents). When smokers inhale, these toxins move from their lungs to the bloodstream and travel throughout the body, affecting every part of the body that they touch. In addition, nonsmokers who breathe cigarette smoke in smoke-filled indoor areas are also inhaling the same toxins and are at risk of many of the same diseases and health problems that affect smokers. In June 2006 the Surgeon General issued a definitive report 3 www.njquit2win.com that declared that secondhand smoke causes disease and premature death among nonsmoking adults and children, and that there is no safe level of exposure to secondhand smoke. How Much Does Smoking Really Cost? In addition to the health risks, smoking imposes economic burdens on smokers themselves and on New Jerseyans as a whole. First, smokers are paying more than ever for their cigarettes. New Jersey has put into place one of the highest cigarette taxes in the nation to discourage smoking, especially among young people. In New Jersey a pack of cigarettes costs approximately $6. A pack-a-day smoker spends more than $2,200 a year on cigarettes — money that smokers could put to better use. Smokers also incur more healthcare costs than nonsmokers. While the personal expenses of smoking are high, the public cost is staggering. An estimated $2.5 billion is spent in New Jersey each year in direct medical costs for treating tobacco-related illnesses — doctor visits, hospitalizations, diagnostic tests and medicines. These costs are born by individuals and employers through high insurance costs and by taxpayers who support Medicare and Medicaid and other federal and state healthcare programs. Finally, smoking costs an additional $2.2 billion annually because of lost productivity as a result of smokers who die prematurely, according to the CDC. The Surgeon General has documented that smokers have more frequent doctor visits and take more sick days than nonsmokers, incurring additional productivity costs to employers. Smokers Reap Immediate Health Benefits by Quitting Although the health risks of smoking are dire, smokers can reap health benefits almost immediately upon quitting, no matter how long they have been smoking. Much of the risk from smoking may be reversed. During the first day of quitting, smokers’ blood pressure and pulse rate drop, along with the carbon monoxide levels in their blood. At the same time, oxygen levels in the blood increase. Their risk of heart attack begins to decline. Within the first three months circulation improves and lung function increases, and by nine months the coughing, sinus congestion, fatigue and shortness of breath that smokers experience all decrease. By the end of one year, a former smoker’s heart attack risk is half that of a current smoker. Health risks continue to decline after that. Even smokers diagnosed with lung cancer and facing lung surgery can benefit from quitting. If they quit right before their surgery, their outcomes have been found to be more positive than those of current smokers. It is never too late to quit. 4 www.njquit2win.com Why It Is So Hard for Smokers to Quit Most smokers know they are putting their health at risk by smoking. In fact, 76 percent of New Jersey smokers want to quit. Yet 1.15 million smokers in the State are still smoking. The fact is that quitting smoking is one of the greatest challenges that most smokers will ever have to face. Only three percent of smokers are able to succeed in quitting if they do it on their own. On average, smokers try to quit eight to 11 times before they succeed. Nicotine dependence is a powerful addiction, and quitting is not just a matter of simple will power. First, nicotine is a highly addictive substance. Breaking that physical addiction is difficult, but it is not the only aspect of the dependence on smoking. In addition to the physical addiction, smoking creates a powerful psychological and behavioral dependence. Smokers turn to their cigarettes to help them face stress and difficulties in their lives. They also develop powerful habits surrounding the physical act of smoking. These forms of dependence must also be broken to quit successfully. Smokers who focus on only one of the three aspects of tobacco dependence are likely to fail and often become further discouraged. Smoking Cessation and Pharmacotherapies Do Work In 2000 the U.S. Public Health Service published Clinical Practice Guidelines for Treating Tobacco Use and Dependence, which recommends the most effective approach to successful smoking cessation. To prepare the guidelines, a panel of experts reviewed more than 6,000 studies on smoking cessation published between 1975 and 2000. The guidelines recommend that tobacco dependence be treated as a chronic condition that involves relapse and often requires repeated intervention. They also conclude that smoking cessation services can produce long-term and even permanent results if they encompass the following elements: • Provision of practical counseling, which gives smokers problem-solving skills needed to identify what triggers them to smoke and to replace smoking with other behaviors. • Provision of social support within the context of the counseling services as part of the treatment program. • Help in securing social support outside of the counseling setting from family, friends or informal groups. In addition, the guidelines recommend that all smokers use one or more pharmacotherapies to combat their physical addiction. These include all forms of nicotine replacement therapy (NRT) products, and the antidepressant pharmaceutical product bupropion SR (Sustained Release) (ZybanTM, WelbutrinTM). In addition, another therapy option is becoming available in the new anti-smoking pill that reduces withdrawal symptoms, varenicline (ChantixTM), which will be available in summer 2006. 5 www.njquit2win.com New Jersey Helps Residents Quit 2 Win The State of New Jersey is committed to helping smokers succeed if they want to quit. The State, through the CTCP, provides a unique package of three free or low-cost smoking cessation services to help its smokers quit: via telephone at New Jersey Quitline (1-866-NJ-STOPS), on the Internet at New Jersey QuitNet® (www.nj.quitnet.com) and at clinics through a network of New Jersey Quitcenters across the State. This enables smokers to select the method that meets their individual preferences and gives them the best chance for success. All three services work with smokers to assess their level of addiction, plan and prepare for a quit date and develop a quitting plan that meets their needs. NJ Quitline provides trained counselors in 26 different languages from 8 a.m. to 8 p.m., Monday through Friday and from 11 a.m. to 5 p.m. on Saturday. Of the registered users at NJ Quitline, 30 percent are found to be smoke-free six months after their quit dates, the benchmark for long-term success. NJ QuitNet offers free services 24 hours a day, seven days a week. Registered users have access to trained counselors and peer support groups. There are currently eight NJ Quitcenters around the State in Camden, New Brunswick, Newark/ Union City, Somerville, Long Branch/Toms River, Jersey City, Somers Point and Trenton. The State’s Healthy People 2010 target on tobacco use seeks to reduce adult smoking rates to 15 percent by that year. In the last five years progress has been made toward that goal, and New Jersey’s smoking rates, now at 17.4 percent, are among the lowest in the nation. However, more needs to be done to help the 1.15 million current smokers who want to quit. With a tight budget that leaves little money for advertising in a region that is dominated by two of the most expensive media markets in the nation — New York and Philadelphia, New Jersey is “deputizing” its citizens to help carry the word about its effective Quit Services. The Quit 2 Win campaign calls on organizations, institutions and individuals to encourage smokers to quit and to inform them about New Jersey’s Quit Services. To arm its deputies, the CTCP has created a Quit 2 Win Web page with a wealth of downloadable materials. These include: • Poster/print ad • Newsletter articles of varying lengths • PowerPoint presentations on why smok;ers should quit and how they can succeed • Digital video featuring two people who quit smoking using NJ QuitNet and NJ Quitline • Digital video of college students who quit by using NJ QuitNet • Fact sheets on NJ Quit Services and the Quit 2 Win campaign • E-cards for encouraging smokers to quit In January 2006 Governor Richard J. Codey signed into law a broad-based ban on smoking in indoor public places and workplaces, including restaurants and bars. The Smoke-Free Air Act ensures that workers have a safe workplace and that all nonsmokers, including children and senior citizens, can breathe smoke-free air. The NJDHSS joined with the Robert Wood Johnson Foundation in a public information campaign to raise awareness of the new law among residents and employers. The Smoke-Free New Jersey – A Breath of Fresh 6 www.njquit2win.com Air campaign, funded with an initial $380,000 from the foundation, provides information via ads and direct mail. NJDHSS also established a new Web page www.smokefree.nj.gov as a resource center for downloading information about the law. In addition, NJDHSS extended a radio advertising campaign to help smokers who want to quit by increasing awareness of NJ Quitline in anticipation of a significant increase in the demand for smoking cessation services. NJDHSS also joined with the American Cancer Society Eastern Division, the American Lung Association of New Jersey and the American Heart Association of New Jersey – Heritage Affiliate to mount a statewide campaign, Be Smoke Free in New Jersey: Quit 2 Win, to coincide with the implementation of the Smoke-Free Air Act. The campaign informs smokers about the services and tools available to help them succeed in quitting and focuses on reaching smokers through the workplace and doctors’ offices. This campaign is calling on employers and union leaders to use the resources at www.NJQuit2Win.com, to inform employees and union members about how to quit and how NJ Quit Services and the other partners’ resources can help them succeed. The campaign is also calling on physicians, nurse practitioners and physician assistants to intervene with patients who smoke by adopting a 2A’s + R process (Ask, Advise and Refer) to Ask patients if they smoke, Advise them to quit and Refer them to the NJ Quit Services. Downloadable materials are available online, at NJQuit2Win.com, to facilitate this process. Conclusion By working together NJDHSS, health professionals and New Jerseyans can help more smokers Quit 2 Win back their health and drastically reduce the human and economic toll that tobacco is taking on the State of New Jersey. 7 www.njquit2win.com SMOKING HARMS NEARLY EVERY ORGAN IN THE BODY Most people are aware that lung cancer and heart disease are caused by smoking. However, few people realize the full scope of tobacco-related diseases that can plague smokers. The list of diseases caused by smoking has continued to increase significantly HOW MUCH DOES SMOKING over the past 40 years. Even the well-known diseases that are linked to smoking are often considered to be long-term consequences of smoking, and many young smokers believe REALLY COST? that there is plenty of time to quit before something happens to them. Smokers are not aware of how the chronic conditions caused by smoking can adversely affect their quality of life apart from the life-threatening illnesses. These conditions, such as bronchitis, loss of bone mass, cataract and gum disease, can significantly hinder simple, routine activities, such as HEALTH BENEFITS SMOKERS REAP IMMEDIATEwalking, talking, breathing and seeing clearly. Cigarette smoke contains 4,000 chemicals that pose health risks to smokers, including 200 known poisons BY QUITTING and 69 known and probable cancer-causing substances.1 These substances, not the nicotine, are what produce the health risks. In May 2004 the Surgeon General’s report, The Health Consequences of Smoking, definitively documented a comprehensive and lengthy list of the health risks related to smoking. Getting the full story about the risks of WHY IS IT SO HARD FOR SMOKERS smoking may prompt more smokers to try to quit. Following is an overview of the conclusions reached in the Surgeon General’s report, along TO QUIT? with descriptions of each disease or health condition and how it affects quality of life. Cancers SMOKING CESSATION COUNSELING AND PHARMACOTHERAPIES Most people are well aware that smoking causes lung cancer. However, many are not aware that smoking causes nine additional cancers throughout the body. How does this occur? DO WORK Cigarette smoke damages DNA inside a cell. The cell then becomes abnormal and overactive, growing and dividing in a disorderly fashion to create new, out-of-control cells. Contrary to what most people think, nicotine is not the culprit. Nicotine is the addictive substance in cigarettes. However, it is the other 3,999 chemicals in cigarettes, including at least 200 poisonsHELPS known or probable carcinogens (cancer-causing substances) that NEW JERSEY and 69 RESIDENTS cause illness. These toxins travel throughout the body, harming every organ they reach. QUIT 2 WIN From the lungs, these chemicals enter the bloodstream, are filtered by the kidneys and collect in the urine. Some of the chemicals have been found even in breast milk. As these chemicals travel throughout the body, they cause cancers. In addition to the obvious places with which tobacco smoke initially comes into contact, such as the mouth and lungs, it also causes cancer of the larynx (voice box), pharynx, esophagus, bladder, kidneys, stomach, pancreas and cervix. It also causes acute myeloid leukemia, a cancer of the white blood cells. 8 www.njquit2win.com According to American Cancer Society (ACS) data released in 2005, cancer — not heart disease — is now the leading cause of death in the U.S. for people under 85 years old.2 The ACS also estimates that in 2006, 170,000 people in the U.S. will die of tobacco-related cancers.3 Many of the cancers caused by smoking are fast-spreading and difficult to diagnose in the early stages. As a result, many of these cancers are not able to be treated successfully. Even when treatment is possible, the treatment itself can pose tremendous emotional and physical burdens. Surgery is painful and recovery is slow. Radiation and chemotherapy, used in combination or individually, commonly cause hair loss, skin rashes, diarrhea, mouth sores, infection, tiredness, shortness of breath and bleeding after minor injuries. Furthermore, these side effects are more severe for those who continue to smoke. Following is a closer look at the types of cancer caused by smoking and their impact on people’s lives. Lung Cancer The Surgeon General issued the first Report on Smoking and Health in 1964. It conclusively linked lung cancer to smoking and began the decades-long effort to identify other diseases and health conditions caused by smoking. Today, lung cancer is the leading cancer killer of both women and men. Many women will be surprised to learn that lung cancer, not breast cancer, is the leading cause of cancer-related death among women. By 2001, the Surgeon General had reported that approximately 90 percent of all lung cancer deaths are caused by smoking and, therefore, could have been prevented. Smokers of all ages and backgrounds are susceptible to lung cancer, as 87 percent of all lung cancers are caused by smoking. The American Cancer Society estimated that 174,470 Americans would be diagnosed with lung cancer in 2006, and 162,460 would likely die from it.4 In New Jersey, an estimated 4,960 new cases of lung cancer were projected, and approximately 4,620 residents were expected to die from it.5 While incidence and mortality rates are declining among men, rates are still rising among women as a result of increased numbers of women who began to smoke over the past several decades. Since 1987, more women have been dying of lung cancer than breast cancer each year.6 Survival rates for lung cancer are not good. About 60 percent of those diagnosed with it die within a year, and the death rate increases to between 70 percent and 80 percent two years after diagnosis.7 The survival rate is better with early diagnosis. However, only 16 percent of lung cancers are identified at an early stage. This is due to the fact that they are difficult to detect through X-rays and often develop for some time without causing recognizable symptoms. CT scans are sometimes prescribed as a means of early detection. If lung cancer is diagnosed early, the cancerous sections of the lungs or an entire lung can be surgically removed and the prognosis is improved. Many of these patients can resume their normal lives and activities, while others experience shortness of breath and restrictions to physical activity. Other treatment options for lung cancer include radiation and chemotherapy or a combination of the two. 9 www.njquit2win.com Laryngeal Cancer Smoking causes cancer of the larynx (the voice box), which contains the vocal cords. When air touches the vocal cords, located in the neck just below the throat, they vibrate to produce the human voice. As early as 1964 the Surgeon General indicated that smoking might be the leading cause of laryngeal cancer. Extensive evidence and subsequent reports in the 1980s reinforced the conclusion that smoking causes this disease. New cases of laryngeal cancer were expected to reach 9,510 in 2006. An estimated 3,740 people in the U.S. were expected to die from the disease in the same year,8 and 100 of those were projected to be New Jerseyans.9 Throat and ear pain can signal developing laryngeal cancer, which most often begins in the flat squamous cells that line the larynx. Over time, smoking can trigger a change in the cells that then become precancerous. If smokers quit, these abnormal cells can go away and never develop into cancer. Laryngeal cancer curtails patients’ ability to eat, breathe and speak. Treatment options include radiation, chemotherapy or surgery on the vocal cords. Surgery may remove all or parts of the voice box. If this cancer spreads to the spinal cord, the thyroid or the lymph nodes, surgery may also be performed on these sites, if medically indicated.10 Patients who lose their voice box have their windpipe surgically routed to the skin surface in the front of the neck, forcing them to breathe through a hole in the neck, rather than through the nose and mouth, where air is normally filtered and warmed. The hole, called a stoma, is susceptible to post-surgical bleeding and infection. Pneumonia becomes a threat if food or liquid enters the hole. Speech for a patient after the larynx has been removed (a laryngectomy) is comparable to a controlled belch, which can be more difficult to understand than a normal voice. Devices like the electronic larynx can produce an artificial vibration that becomes the patient’s voice. Esophageal Cancer The esophagus is the tube that carries food from the mouth to the stomach. Cancer of the esophagus caused by smoking usually occurs in the flat squamous cells that line the esophagus. By 1979 studies pointed to a link between smoking and esophageal cancer with increased risk associated with greater numbers of cigarettes smoked. In 1982 the Surgeon General concluded that smoking was the major cause of esophageal cancer. By 1989 the Surgeon General estimated that tobacco use causes 78 percent of esophageal cancer deaths in men and 75 percent in women. An estimated 14,550 new cases of this cancer were projected to occur in the U.S. for 2006, and approximately 13,770 people were expected to die of the disease,11 including an estimated 270 in New Jersey.12 10 www.njquit2win.com Esophageal cancer has a grim prognosis. It is usually detected late, and most patients die within five years of diagnosis. Surgery, radiation, chemotherapy or combinations of these treatments are typical treatment options. Surgery often involves the removal of part of the esophagus, the lymph nodes and parts of the stomach.13 Patients who lose the ability to swallow after having parts of their esophagus removed often cannot get enough food by eating on their own. These people may need feeding tubes inserted through the skin and muscle to deliver food directly into the stomach. Bladder Cancer The bladder is a hollow organ that stores urine before it passes out of the body through the urethra. As early as 1964 the Surgeon General pointed to a possible link between smoking and bladder cancer. The 1972 Surgeon General’s report reinforced that link and suggested that the risk of bladder cancer may increase with the number of cigarettes smoked. By 1990 the Surgeon General had concluded that smoking does cause bladder cancer and that smokers are twice as likely to get bladder cancer as nonsmokers. Nationwide, the American Cancer Society estimated that 61,420 people would contract bladder cancer in 2006. In New Jersey, an estimated 1,690 new cases would be diagnosed14 during 2006, and approximately 162 residents would die of bladder cancer.15 Bladder cancer most often begins in the lining of the bladder and grows inward, which makes it difficult to treat. Treatment can include surgery, radiation therapy, immunotherapy and chemotherapy. When surgery is indicated, patients may have part or all of their bladders removed. Men can lose the prostate, and women can lose the uterus, ovaries, fallopian tubes or part of the vagina. Risk of bleeding, infection, bladder leakage or blockage may follow. Some patients undergo urostomy, in which the bladder is replaced by a bag worn outside the body. Bladder cancer also carries risk of sexual repercussions, including infertility, nerve damage and impotence in men.16 Kidney Cancer The kidneys, two bean-shaped organs affixed to the back of the abdominal wall, clean the blood and expel waste products from the body. As carcinogenic substances from cigarettes pass through the kidneys to the bladder, people may develop cancers of one or both organs. Cancer can also form in the lining of the kidneys and the tubes connecting the kidneys to the bladder, which are called ureters. In 1982 the Surgeon General identified smoking as a contributory factor in the development of kidney cancer. In 1989 the Surgeon General determined that there was a definitive link between cigarette smoking and kidney cancer and concluded that risk increases proportionally with the number of cigarettes smoked and the duration of smoking. 11 www.njquit2win.com An estimated 38,890 new cases of kidney cancer were projected for 2006 in this country. About 12,840 people would die of this disease during this same year,17 including approximately 102 New Jersey residents.18 Smoking increases the risk of getting kidney cancer by about 40 percent.19 Kidney cancer is often found at a late stage, because it can become quite large without causing any pain. Since the kidneys are deep inside the body, there is no way to see or feel small tumors during a physical exam. And there are no simple tests to diagnose this cancer early.20 Surgery is the primary treatment. The chances of surviving kidney cancer without having surgery are poor. People with heart or lung problems may not be considered eligible for surgery. Therefore, many smokers may not qualify. Surgery can include removal of the affected kidney, ureters and part of the bladder. While people can live with only a portion of one kidney or no kidneys, many will have to undergo dialysis treatment, which involves cleansing the blood regularly through a machine. A combination of radiation and chemotherapy may accompany surgery. Cervical Cancer The cervix connects the uterus to the vagina. As with many other cancers, cervical cancer begins in the cells of the lining. Since 1982, the Surgeon General has pointed to a possible causal relationship between cervical cancer and smoking. The 1989 and 1990 reports presented further evidence indicating higher risk among smokers than nonsmokers and former smokers. Finally, in the 2001 report, Women and Smoking, the Surgeon General concluded that smoking does cause cervical cancer and noted that nicotine is present in the cervical mucous of women who smoke. However, in 2004 the Surgeon General indicated that the presence of the human papilloma virus (HPV), a sexually transmitted organism that causes warts, is also a contributing factor to the relationship between smoking and cervical cancer. Once one of the most common causes of cancer deaths among women, cervical cancer deaths have declined substantially in the U.S. as a result of the widespread use of the Pap test to detect cervical cancer early. An estimated 9,710 new cases were projected for this country in 2006, including 340 new cases in New Jersey. Approximately 3,700 women would die of the disease this year nationwide,21 including 40 in New Jersey22. Cervical cancer typically strikes women between the ages of 35 and 55. However, the American Cancer Society recommends that women continue to get an annual Pap test until they are 70 years old. Hispanic women are more than twice as likely, and African-American women are 50 percent more likely than non-Hispanic white women to get cervical cancer.23 In addition to radiation and chemotherapy, treatment for cervical cancer may include laser treatments and, depending on the extent of the cancer, may require surgical extraction of tumors, including removal of part or all of the uterus, the cervix and lymph 12 www.njquit2win.com nodes, and in some cases, the bladder, vagina, rectum and part of the colon. Surgery can result in loss of the nerves that help a woman feel arousal and loss of the ability to have children.24 Pancreatic Cancer The pancreas is an organ behind the stomach that helps digest food and control blood sugar levels. It consists of two types of tissue, the exocrine and endocrine tissue. Cancerous tumors are most frequently found in the exocrine tissue. Since 1972 the Surgeon General’s reports have examined the effect of smoking on pancreatic cells. In 1990, the Surgeon General indicated that smoking cessation reduces the risk of pancreatic cancer, but it was not until 2004 that the Surgeon General conclusively linked pancreatic cancer to smoking. The American Cancer Society predicts an estimated 33,730 people in the U.S. will be diagnosed with pancreatic cancer in 2006. Nearly as many people — 32,300 — were predicted to die of this cancer during the same year, including 1,050 New Jerseyans.25 This cancer is difficult to detect until the tumor has become quite large and spread to other organs. Only one of four patients with pancreatic cancer lives at least one year after diagnosis.26 In addition to radiation and chemotherapy, surgery can sometimes remove the cancer or alleviate symptoms of this cancer, which is rarely curable. Surgery requires removal of part of the pancreas, stomach and gallbladder, as well as parts of the small intestine and bile duct. Pancreatic cancer can cause pain and digestive problems if the bile duct is blocked.27 Stomach Cancer The stomach is a sack-like organ that secretes gastric juice to begin digesting food before it passes to the small intestine. The stomach has five tissue layers, and the innermost layer, or mucosa, is where most cancers originate.28 Although data compiled by the Surgeon General in 1964, along with subsequent studies, reported consistently higher death rates from stomach cancer among current smokers than among lifetime nonsmokers, the Surgeon General did not conclusively link smoking with stomach cancer until 2004. Smokers have twice the risk of stomach cancer compared with nonsmokers.29 There were expected to be 22,280 new cases of stomach cancer diagnosed in the U.S. in 2006, and 11,430 people were expected to die of the disease.30 The five-year survival rate after initial diagnosis is only 22 percent. This cancer is also difficult to diagnose, as it often does not produce symptoms. By the time it is detected, it has typically spread to other parts of the body.31 13 www.njquit2win.com Because precancerous changes may not produce symptoms, cancer may develop slowly over a long period before being detected. The primary treatment for stomach cancer is surgery. Post-surgical side effects can include heartburn, abdominal pain, especially after eating, and vitamin shortages, which may require regular injections of vitamin supplements. In addition, most people will need to change their diets, eating smaller and more frequent meals.32 Acute Myeloid Leukemia (AML) There are six types of leukemia classified as acute or chronic, lymphoid or myeloid, depending on the type of abnormal cell that results. Acute myeloid leukemia (AML) starts in the bone marrow and produces abnormal white blood cells. In 1990 the Surgeon General stated that smoking was implicated in leukemia but that the studies did not yield consistent results. However, by 2004, the evidence became strong enough to determine that acute myeloid leukemia is, indeed, caused by smoking. The risk of this cancer also increases with the number of cigarettes smoked and the duration of smoking. Exposure to chemicals such as benzene in cigarettes is a key factor in causing leukemia. Benzene is classified as a human carcinogen, and cigarette smoking causes 90 percent of smokers’ benzene exposure. Acute myeloid leukemia (AML) affects adults almost exclusively. The American Cancer Society predicted that 11,930 new cases of AML would occur in the U.S. in 2006, and an estimated 9,040 of these patients would die of this leukemia the same year.33 This would include 219 New Jerseyans.34 With advancing age at diagnosis, there is a reduced cure rate. The five-year survival rate in adults under 65 is about 33 percent, but in people over 65, it is only four percent. The average age at the time of diagnosis is 65. Chemotherapy is the primary form of treatment.35 Side effects of AML include tiredness and shortness of breath as the cancerous white blood cells overpower the red blood cells that provide oxygen to the body. The abnormal cells also overpower the platelets, which promote blood clotting in injuries. This results in bruising, nosebleeds and bleeding gums. Leukemia can also cause swelling of the spleen and liver, as well as bone and joint pain if it spreads to the surface of the bone. Because white blood cells play a critical role in battling infection, leukemia patients become increasingly vulnerable to serious illness as abnormal white blood cells crowd out the healthy ones.36 Cardiovascular Diseases Coronary Heart Disease Studies pointed to the link between smoking and heart disease as early as the first Surgeon General’s report in 1964, which noted that male smokers had higher death rates from coronary heart disease (CHD) than nonsmokers. By 1979, the Surgeon General 14 www.njquit2win.com concluded decisively that smoking was one of the main risk factors of the disease. Subsequent reports also linked smoking to atherosclerosis (the hardening and thickening of the arteries) and strokes. By 1983 the Surgeon General said that smoking “should be considered the most important of the known modifiable risk factors for coronary heart disease.” In 2004 the Surgeon General examined the substantial evidence that smoking causes coronary heart disease (CHD), particularly in younger smokers. He also associated smoking with sudden death in heart attacks and asserted that smoking may increase the risk of developing congestive heart failure after a heart attack. In addition, this report for the first time documented the biological basis for smokingrelated CHD. Smoking promotes the development of atherosclerosis. As toxins in cigarette smoke travel through the blood, they cause the deposit of fatty plaques and scar tissue and the development of blood clots, which thicken the artery wall and lead to inflammation. All of these factors clog the arteries and obstruct blood flow, which impedes the flow of oxygen. When atherosclerosis occurs in coronary arteries — those carrying blood to the heart — it diminishes the heart’s ability to function and causes heart attacks. CHD is the leading cause of death in the U.S. In 2003 an estimated 1.2 million Americans had a heart attack, and 479,305 Americans died of heart attacks that year.37 More than 134,000 of those deaths are linked to smoking.38 Smokers have two to four times the risk of coronary heart disease as nonsmokers, and smokers have about twice the risk of sudden death from a heart attack. In fact, a smoker who has a heart attack is more likely than a nonsmoker to die within an hour of the event.39 Stroke Strokes are caused when arteries leading to the brain either burst or become blocked by atherosclerosis or a blood clot. This causes part of the brain to be deprived of oxygen, which destroys nerve cells. As a result, the parts of the body that these cells control cannot work. The body reacts to stroke differently depending on where it strikes and how much brain tissue is involved. Strokes can cause paralysis, vision and speech problems, loss of memory and changes in behavior.40 Smoking dramatically increases the risk of developing a stroke. In 1989 the Surgeon General found a causal relationship between smoking and strokes and in 1990 concluded that smokers have a two to four times greater risk of having a stroke, compared with nonsmokers. Stroke is the third leading cause of death in the U.S. Approximately 700,000 cases of stroke occurred in 2003, and 157,800 people died from strokes.41 Smoking-related strokes kill more than 23,000 Americans each year, and around 30 percent of stroke victims are dead within a year after their strokes.42 Together, stroke and CHD are responsible for one death every 33 seconds in the U.S., according to the 2004 Surgeon General’s report. 15 www.njquit2win.com Abdominal Aortic Aneurysm (AAA) The abdominal aorta is the largest vessel that leads blood away from the heart. Smoking causes atherosclerosis, or clogging of the blood vessels, which in turn causes most cases of AAA. An aneurysm is a balloon-shaped bulge in the vessel wall, which can burst and cause sudden death, particularly when it occurs in the abdominal aorta. In 1983 the Surgeon General indicated that AAA is more common in smokers than nonsmokers, and by 2004 the Surgeon General was able to confirm this link based on the results of multiple studies. The Surgeon General’s 2004 report notes that in 2003, AAA caused 15,000 deaths in the U.S. Studies have shown smokers to be four or five times more likely to die of AAA than nonsmokers. Abdominal aortic aneurysm does not always produce symptoms, but doctors can diagnose it through scans, X-rays or other imaging techniques, such as CT scans. Unfortunately, because AAA does not always produce symptoms, timely diagnosis can be hard to achieve. As a result, AAA is often a sudden killer. If the ruptured aneurysm is not fatal, surgery to replace portions of the aorta with a patch or artificial piece of blood vessel is the common treatment, but some patients have their aorta propped open with devices called stents. Frequent ultrasounds may be required to monitor the aorta’s condition, as changes can be rapid and deadly.43 Respiratory Diseases Smoking decreases a smoker’s lung function. This impairs the lung’s ability to exchange oxygen and carbon dioxide. It also impairs the ability to expel dangerous bacteria and viruses from the lungs. As a result, smokers are more vulnerable to acute and chronic respiratory infections than nonsmokers. Chronic Obstructive Pulmonary Disease (COPD) COPD is an umbrella term for a large group of lung diseases in which airflow is hampered and breathing becomes difficult. Emphysema and chronic bronchitis are the most serious conditions under the COPD umbrella. The Surgeon General characterizes COPD as a slow death by asphyxiation. In 1964 the Surgeon General determined that smoking causes chronic bronchitis. However, it was not until 1984 that the Surgeon General established a conclusive link between smoking and the full range of COPD, then referred to as chronic obstructive lung disease (COLD). In 2003, 10.7 million adults in the U.S. were estimated to have COPD. However, an estimated 24 million Americans have evidence of reduced lung function, which signals an 16 www.njquit2win.com under-diagnosis of these conditions. COPD is the fourth leading cause of death, claiming the lives of 120,000 Americans in 2002. Smoking is responsible for 80 percent to 90 percent of the deaths. Female smokers are nearly 13 times as likely to die of COPD as women who have never smoked. Male smokers are nearly 12 times as likely to die of COPD as men who have never smoked.44 The effects of all forms of COPD on lung function are irreversible. There are no curative treatments for it. Existing medications are intended to reduce symptoms or complications of the disease.45 However, smoking cessation will often decrease the main symptoms of chronic bronchitis, namely cough and sputum production. Emphysema This disease aggressively destroys a person’s ability to breathe. Emphysema destroys the walls between the air sacs in the lungs and diminishes their flexibility. This impairs the exchange of oxygen and carbon dioxide and diminishes patients’ lung surface area until they cannot get enough oxygen in their blood. Emphysema is a particularly debilitating condition, as many patients use supplemental oxygen through nasal tubes and must carry oxygen bottles with them wherever they go. Patients describe advanced emphysema as a constant feeling of drowning.46 Patients living with severely compromised lung function often must restrict their activities and plan their lives around their illness, giving up travel and hobbies and modifying even simple routine tasks, like dressing and bathing. Some people find it necessary to quit their jobs and cannot even leave their homes if their condition is aggravated by pollution or changes in weather.47 Chronic Bronchitis Chronic bronchitis is an inflammation of the lining of the bronchial tubes. A heavy mucus, or phlegm, develops in the airways that restrict the airflow to and from the lungs. This produces the chronic cough that is common among smokers.48 The inflammation eventually leads to scarring of the lining of the bronchial tubes, which become an ideal breeding place for infections. In 2002 alone, an estimated 9.1 million Americans were diagnosed with chronic bronchitis. Women are more than twice as likely to be diagnosed with chronic bronchitis as men. In 2002, 2.9 million males were diagnosed with chronic bronchitis compared with 6.2 million women.49 17 www.njquit2win.com Acute Respiratory Illnesses Smokers who are otherwise healthy suffer an increased risk of viral and bacterial infections of the upper and lower respiratory tract, including influenza, infectious bronchitis and pneumonia. The chemicals in cigarette smoke impair the physical defenses in the respiratory tract. According to the Surgeon General, smokers not only have more respiratory infections but also more severe illnesses and are more likely than nonsmokers to die of acute respiratory illnesses. Respiratory Effects In Utero Women who smoke during their pregnancies subject their infants to greater risk of developing difficulty breathing and an increased number of lower respiratory illnesses. Smoking causes low birth weight in infants, and their lung function is generally reduced as a result of the underdevelopment of the lungs at birth. These problems may extend into adulthood, raising these infants’ risk of developing chronic respiratory diseases later.50 In Childhood and Adolescence Youth and teens who smoke impede their lung development and make themselves vulnerable to a wide variety of respiratory problems, including more coughing and wheezing than nonsmokers. They experience a decrease in physical stamina and are generally less physically fit than nonsmoking youths. Teens who smoke experience reduced lung growth and a premature decline in lung function as they age. In Adulthood Adult smokers damage their lungs and experience a premature and accelerated decline in their lung function as they age. The Surgeon General’s 2004 report cited some studies indicating that smokers’ lung function begins to decline in their mid-30s rather than late 30s, which is the accepted wisdom. Reproduction Infertility Among Women While evidence has been mounting about the toll that smoking while pregnant takes on the developing fetus, the Surgeon General also concluded in 2004 that smoking can actually prevent women from becoming pregnant. As early as 1980, the Surgeon General warned both women and men that smoking may increase their risk of infertility. In 2001, 18 www.njquit2win.com the Surgeon General determined that women who smoke have a greater risk of delayed conception or an inability to conceive. Finally, the studies examined in 2004 revealed a consistent pattern of reduced fertility among women who smoke, and the Surgeon General concluded that smoking, indeed, causes infertility among women. Reduced fertility is measured by the length of time women try to conceive and fail, usually either a one- or two-year period. The delay or reduction in a woman’s ability to conceive a child is related to the amount of cigarettes she smokes and the length of time she has been a smoker. The studies included women trying to conceive for the first time and those who were trying for subsequent pregnancies. Women who want to become pregnant and are current smokers should make every effort to quit smoking in order to increase their chances for conception. Effects on Pregnancy Pregnant women and mothers who smoke endanger the health of their children at every stage of their development, before and after they are born. The Surgeon General warns that smoking during pregnancy increases the risk of miscarriage, stillbirth, infant death and sudden infant death syndrome (SIDS). Nicotine absorbed through cigarette smoking can be found in every part of the body, even in breast milk. Because mothers share their bodies with their developing babies, they share the toxic elements in cigarette smoke. Up to one in 10 infant deaths are caused by the mother’s smoking.51 The Surgeon General cited estimates from several studies that between 13 percent and 17 percent of pregnant women smoke. However, as 18 percent to 25 percent of pregnant women quit some time after they learn they are pregnant, the actual percentage of pregnant women who have smoked at any time during pregnancy is likely to be greater. Another factor that raises the real proportion of pregnant women who smoke is the fact that many women do not report their smoking status accurately because it is considered to be an unacceptable behavior. Pregnant smokers either under-report the number of cigarettes smoked or claim to be nonsmokers when they actually do smoke. Pregnancy Complications The Surgeon General’s 2001 report Women and Smoking52 stated that smoking during pregnancy causes greater risks for placenta previa, placenta abruption, premature rupture of membranes, shortened gestation and preterm delivery. Pregnant women who smoke are approximately twice as likely to experience these complications. Placenta Previa: When the placenta, the organ that nourishes the baby, is too close to the opening of the uterus, it can bleed. The blood loss interferes with the flow of nutrients to the fetus, potentially causing growth retardation and congenital problems. The mother must stay in bed and sometimes is hospitalized. If bleeding cannot be controlled, a caesarian section is required, and the baby is delivered preterm. 19 www.njquit2win.com Placenta Abruption: Smoking can cause the placenta to separate too soon from the uterus, producing hemorrhaging, shock and blood clotting in the mother. This can require premature delivery either through induced labor or caesarian section. This condition increases the risk of preterm delivery, stillbirth and infant death. Infants who survive may have breathing and feeding problems and even brain damage. Smokers are 1.4 to 2.4 times more likely to have placental abruption than nonsmokers. Preterm Premature Rupture of Membranes: The amniotic sac, which holds the fetus in the uterus and protects it from infection, can burst before the fetus is mature. This condition results in preterm delivery, and the baby suffers the health consequences of a premature birth. Premature Birth: Smoking while pregnant can cause premature delivery. In many cases, this is the result of one of the pregnancy complications identified above. However, there is sufficient evidence that smoking can cause premature delivery even without the presence of these pregnancy complications. Smoking causes up to 14 percent of all preterm deliveries.53 Low Birth Weight (LBW) The 2001 Surgeon General’s report warned that smoking during pregnancy results in lower-than-average birth weight even in full-term infants. Smoking accounts for 20 percent to 30 percent of all low birth weight babies.54 Every year, 300,000 newborns in the U.S. die from low birth weight, making it the leading cause of infant mortality. Smoking is a major factor in producing low birth weight babies, who often weigh only 5.5 pounds. Nicotine inhaled by the mother, along with carbon monoxide and other toxic chemicals, passes from her bloodstream into that of her unborn baby. Nicotine narrows the blood vessels and restricts the flow of oxygen to the unborn baby and limits the fetus’s growth. In addition, many of the complications of pregnancy that are also caused by smoking can result in premature delivery and low birth weight. Infants born to smoking mothers weigh about 5 ounces less than babies of nonsmoking mothers. However, quitting smoking in the early stages of pregnancy has immediate benefits to the infant. Babies born to these mothers weigh the same as babies born to mothers who did not smoke during pregnancy. Even quitting by the third trimester has a significant impact in reducing much of the risk of low birth weight. Stillbirths and Sudden Infant Death Syndrome (SIDS) The 2001 Surgeon General’s report documented an increased incidence of stillbirths and SIDS after birth among infants of women who smoke. With regard to SIDS, however, the evidence is not clear whether exposing the fetus to smoke during pregnancy can cause SIDS or whether the fetus must also be exposed to smoke after birth. But the effect of smoking both before and after birth clearly points to a causal relationship between smoking and SIDS. 20 www.njquit2win.com Other Effects of Smoking on Health Poor Outcomes From Surgery Since 1990, the Surgeon General has reported that smokers are at greater risk of postoperative respiratory complications from all types of surgeries than are nonsmokers. Smokers’ respiratory problems, already discussed in this report, put patients at greater risk of postoperative pneumonia. Patients who have reduced lung function and COPD are at risk of respiratory failure during surgery. In addition, the chronic diseases caused by smoking can all result in poor postoperative outcomes. For example, the greater prevalence of coronary heart disease among smokers increases their risk of serious heart problems during and after surgery. Finally, apart from these risks, the Surgeon General has reported that smoking causes poor wound healing. This delayed healing leads to infections and increased scarring. In fact, studies have revealed that smokers have lower survival rates after surgery than do nonsmokers. Low Bone Density and Hip Fractures Among Women In the 2001 report, Women and Smoking, the Surgeon General determined that smoking causes both low bone density and hip fractures in postmenopausal women. Low bone density can lead to osteoporosis, a condition in which the bones become fragile and fracture easily. Although 60 percent to 80 percent of low bone density is caused by genetics, the remaining 20 percent to 40 percent is caused by other factors, including smoking. People build and store bone until age 30. Subsequently, the bones begin to break down faster than new bone can be formed, as part of the natural aging process. In women, bone loss accelerates after menopause, when their bodies stop producing estrogen, which protects against bone loss. Female smokers lose bone density after menopause at a faster rate than nonsmokers, and female smokers go through menopause at an earlier age than nonsmokers. Women are four times more likely than men to develop osteoporosis.55 According to the Surgeon General, low bone density causes 300,000 hip fractures each year. These fractures are particularly dangerous, as they frequently lead to significant impairment, disability and death. One-fourth of those able to walk and take care of themselves before fracturing a hip, require long-term care afterward. Six months after a hip fracture, only 15 percent of patients can walk across a room unaided. In addition, 24 percent of patients with hip fractures aged 50 and over die in the year following their fracture.56 21 www.njquit2win.com Cataract Cataract is a clouding of the lens of the eye, which commonly happens as people get older. This condition can make it difficult for people to read, drive or see expressions on other people’s faces. Cataract is the leading cause of blindness worldwide. Although cataract rarely causes blindness in the U.S., it is a leading cause of vision loss. Data about the association of smoking and cataract development have grown enormously since its first mention in the 2001 Surgeon General’s report. The 2004 report concluded that large epidemiological studies provide substantial proof that smoking causes nuclear cataract — damage to the center of the lens. This part of the lens has very little ability to repair itself when damaged. Other parts of the lens are the cortical and posterior subcapsular areas. Nuclear is the most common form of cataract among whites (32 percent). Nuclear cataract comprises 20 percent of African-American cases of cataract, second to cortical cataract, which represents 42 percent of African-American cataract. About half of all Americans aged 65 have some degree of clouding of the lens, and the number sharply rises as people age. At age 75, an estimated 70 percent of people have cataract that significantly impairs their vision. Smoking is one of the few known risk factors for cataract other than aging. By quitting smoking, smokers can reduce their risk of cataract. They can delay the onset of cataract as they age and the severity of the condition as it develops. In the early stages cataract is treated by using strong lighting and prescribing glasses. In later stages, when vision is substantially impaired, surgery to remove the cataract is safe and effective. Peptic Ulcers Peptic ulcers occur when stomach acid penetrates the stomach or duodenum (the connection between the stomach and the small intestine) and causes sores or erosions that can bleed. In the 1980s researchers identified a gastric bacterium, H. pylori, which infects the gastrointestinal tract and causes the majority of ulcers, including 100 percent of duodenal ulcers and 70 percent to 90 percent of gastric ulcers. In 2004 the Surgeon General’s report cited conclusive evidence that smoking causes peptic ulcers in the duodenum and in the stomach among people who are infected with H. pylori bacteria. There are 350,000 to 500,000 new cases of peptic ulcers each year, and more than 1 million ulcer-related hospitalizations each year. The most common symptom of an ulcer is a burning pain in the stomach, between the breastbone and the navel, especially when the stomach is empty. This pain can be severe enough to awaken a patient in the middle of the night and can last anywhere from a few minutes to several hours. Other symptoms include nausea, vomiting, blood in the stool or loss of appetite. Bleeding may be the first and only symptom of an ulcer. When an ulcer bleeds and continues to bleed without treatment, it can lead to anemia and severe weakness.57 22 www.njquit2win.com Periodontitis The teeth and gums are the first parts of the body to make contact with cigarette smoke and are also the first parts of the body to display the damage caused by smoking. Periodontal disease is a chronic bacterial infection of the gums that affects the bone supporting the teeth. Periodontitis inflames the soft tissue surrounding the teeth and can lead to serious infection. As periodontal disease progresses, it alters and destroys the healthy bone and tissue that anchor the teeth. Over time, the gums recede, the pockets between the teeth and gums deepen and the teeth loosen. Tooth loss results. It was not until the last 15 years that a substantial amount of research has been done on smoking and oral health. The 2000 Surgeon General’s report, Oral Health in America, first brought widespread attention to the issue, but the 2004 Surgeon General’s report conclusively stated that smoking causes periodontal disease. In addition, the Surgeon General observed that the severity of the disease is related to the number of cigarettes smoked and the duration of smoking history. Smokers are seven times more likely to suffer from gum disease than nonsmokers.58 While only 21.6 percent of the adult population in the U.S. smokes59, at least half of all cases of periodontal disease occurs among smokers. Practicing good oral hygiene is insufficient to prevent this condition. Studies cited in the 2004 Surgeon General’s report have found that even when smokers practice good oral hygiene, they have more gums with pockets, deeper pockets and more gum attachment loss than nonsmokers. Diminished Health Status In 2004 for the first time, the Surgeon General concluded that there is “abundant evidence” that smokers of all ages have, overall, poorer health than nonsmokers and as a result, experience a diminished quality of life. The Surgeon General based this conclusion on measuring the use of health care services and expenditures among smokers, their absenteeism and self-reported health status. As noted earlier, cigarette smoke and the toxins contained in it reach every organ in the body. The carbon monoxide in cigarette smoke binds with hemoglobin in red blood cells and restricts the amount of oxygen available for the body’s cells to function properly.60 According to the Surgeon General’s 2004 report, cigarette smoke increases smokers’ exposure to oxidants, which promote aging and many of the chronic diseases associated with aging. Smoking also decreases micronutrients that act as antioxidants in the blood, such as vitamin C and beta-carotene. Smokers are found to have elevated levels of white blood cells and C-reactive protein, which indicate the presence of chronic inflammation. Several studies cited in the Surgeon General’s 2004 report have shown that smokers consistently had higher rates of absenteeism from work than nonsmokers, and their absences tend to be longer. Some studies revealed a correlation between the number of cigarettes smoked per day and the number of absences from work. In one study absences by smokers were 43 percent higher than absences by nonsmokers for those smoking less 23 www.njquit2win.com than one pack of cigarettes a day; by 57 percent for those smoking a pack a day; and by 100 percent for those smoking more than one pack a day. Finally, other studies cited in this report find that former smokers also have somewhat more frequent absences than nonsmokers. Former smokers who are recent quitters have higher absentee rates than those who are long-term quitters. Absentee rates for former smokers declined gradually over time after they quit smoking. Smokers tend to incur more medical costs, to visit a doctor more often and to be admitted to the hospital more frequently than nonsmokers. This pattern can be seen even among adolescents and young adults when compared with nonsmokers in the same age group. Six of the seven studies conducted on smokers’ medical costs showed that their costs were at least 15 percent higher than nonsmokers’ costs, and one study showed a 25 percent differential. Also, in several studies smokers were found to be at least 15 percent more likely than nonsmokers to visit doctors or clinics and 10 percent more likely to be hospitalized than nonsmokers. The length of time that smokers spend in the hospital for each hospital stay is also greater than that for nonsmokers. The Surgeon General’s 2004 report also cited subjective surveys regarding how people view their health status as another indicator of a diminished level of health for smokers. Although these surveys asked a variety of questions using a variety of survey designs, they consistently demonstrated that smokers rate their general health status lower than nonsmokers. One study showed a decline in rating one’s health as “good” in direct proportion to the number of cigarettes smoked per day. Smokers also report feeling tired or fatigued more frequently than nonsmokers. Smokers in one study were 71 percent more likely to feel tired. In another study, smokers were 60 percent more likely to report fatigue. Overall, smokers reported more symptoms of illness, more bouts of illness and more fatigue, and smokers rate their physical health lower than nonsmokers. SECONDHAND SMOKE The U.S. Environmental Protection Agency (EPA) has classified secondhand smoke as a cause of cancer in humans (a Class A carcinogen). Secondhand smoke contains the same 4,000 chemicals that pose health risks to smokers, including 200 known poisons and 69 known and probable cancer-causing substances.61 The EPA has estimated that secondhand smoke causes 62,000 deaths each year in the U.S. among nonsmoking adults, including 3,000 lung cancer deaths and more than 35,000 coronary heart disease deaths. In June 2006, the Surgeon General’s report conclusively documented the health risks of secondhand smoke. The Health Consequences of Involuntary Exposure to Tobacco Smoke, reported the results of a comprehensive review of decades of scientific research on secondhand smoke and its effects on the health of nonsmokers. Surgeon General Richard H. Carmona declared, “The scientific evidence is now indisputable: Secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.” The report found that nonsmokers exposed to secondhand smoke at home or at work increase their risk of heart disease by 25 to 30 percent and lung cancer by 20 to 30 percent. 24 www.njquit2win.com NJDHSS estimates that 90 to 121 of the more than 4,600 lung cancer deaths in the State each year are related to secondhand smoke.62 In addition, the Department estimates that 1,050 to 1,860 of the 27,500 deaths from heart disease and stroke annually in the State are caused by secondhand smoke.63 The Surgeon General also refuted the notion that ventilation can eliminate the threat of secondhand smoke to nonsmokers. The report cites the conclusion of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), the preeminent authority on ventilation issues, that ventilation technology cannot be relied upon to control health risks from exposure to secondhand smoke. The Surgeon General declares that there is no safe level of exposure to secondhand smoke and concludes that even short exposure can damage the blood vessels and increase the risk of a heart attack. Conclusion The public now has clear evidence of the wide-ranging impact that smoking has on health and how it harms smokers and nonsmokers alike. Based on a 2005 New Jersey survey that indicated the number of residents who allow smoking in their homes, an estimated 727,650 children under 18 years old were exposed to secondhand smoke.64 Now New Jersey’s smokers have additional reasons to quit, but they need more information about the real health risks associated with smoking and about the programs and services available to help them succeed in quitting smoking. 25 www.njquit2win.com SMOKING HARMS NEARLY EVERY ORGAN IN THE BODY HOW MUCH DOES SMOKING REALLY COST? The costs of smoking go beyond the health risks. Smoking imposes economic burdens on New Jersey’s healthcare industry and New Jersey smokers as well as all taxpayers in the State. SMOKERS REAP IMMEDIATE HEALTH BENEFITS BY QUITTING Cost to the Individual Smoker Cigarettes cost about $6 a pack in New Jersey, and taxes make up a substantial part of the cost. New Jersey is one of a growing number of states that has raised cigarette taxes regularly. Raising the cost of a pack of cigarettes has been found to be an effective way to WHY IS IT SO HARD FOR SMOKERS has implemented two separte tax increases on reduce smoking. Since 2004, New Jersey cigarettes, raising the total tax to $2.57 1QUIT? TO /2 per pack, the highest in the nation.65 Today, a pack-a-day smoker in New Jersey spends more than $2,200 a year on cigarettes. This is a substantial amount of money that smokers could use for other purposes. However, the economic cost to smokers is not just the price of the cigarettes. Smokers need to add to the equation the higher healthcare expenses that they incur. As noted in SMOKING CESSATION COUNSELING have more health problems than nonsmokers even if the last section, smokers generally AND PHARMACOTHERAPIES they do not have a major tobacco-related disease. As the Surgeon General reported, DO WORK smokers get sick more often and have more doctor visits than nonsmokers, on average. Even for smokers with a good insurance plan, the co-payments add up. Smokers also have more sick days, and for those who work for hourly wages and do not get paid sick days, this means lost income. For smokers with tobacco-related chronic health conditions, these costs multiply. HELPS RESIDENTS NEW JERSEY QUIT 2 WIN Aggregate Medical Costs While the cost of smoking is high for the individual smoker, the aggregate costs nationally and locally for healthcare are in the billions of dollars. According to the CDC estimates for 2002, $2.48 billion is spent annually in New Jersey alone for the direct medical costs of treating tobacco-related illnesses, including outpatient care, hospital care, prescription and nonprescription drugs, home health care, and other products related to health care.66 The real healthcare costs are likely to be much higher because the 2002 estimate does not include the new conditions that the Surgeon General added to the list of tobacco-related illnesses in 2004. Some of these costs are borne by individuals as out-of-pocket expenses for medical care or drugs. Other costs are paid by insurers, which raise insurance 26 www.njquit2win.com premiums for all New Jerseyans. In addition, other costs are born by New Jersey taxpayers. The CDC estimates that treating smoking-related illnesses represents 14 percent of all costs of the Medicaid program, which is supported with state and federal funds. The CDC estimates that each adult smoker costs his or her employer $1,623 in excess medical expenditures.67 Studies cited in the 2004 Surgeon General’s report found that smokers are 15 percent more likely than nonsmokers to visit doctors or clinics and 10 percent more likely to be hospitalized.68 In addition, female smokers incur an additional $17,500 more in lifetime medical expenses than female nonsmokers, and male smokers incur an additional $15,800 in such expenses compared with male nonsmokers.69 Productivity Costs The CDC estimates that New Jersey loses another $2.2 billion in costs associated with lost productivity as the result of the premature death of smokers.70 This estimate is low, as it does not include the impact of the newly identified smoking-related diseases. In addition, this estimate does not include the cost of lost work because of sick days, doctor visits and disability. This results in lost revenue for employers. The 2004 Surgeon General’s report cited a number of studies demonstrating that smokers have higher rates of absenteeism than nonsmokers. One study cited in a CDC brief found that, on average, female smokers are absent two more days a year than female nonsmokers, and male smokers are absent four more days a year than their nonsmoking counterparts.71 Total Costs Employers can estimate the additional costs and lost revenue generated by their employees who smoke through a cost model. The CDC estimates the total cost to employers for each smoking employee for both lost productivity and medical expenses is $3,856 a year.72 Approximately 17 percent of New Jersey adults smoke. Therefore, employers can multiply the number of their employees by 17 percent and multiply that product by $3,856 to find out the costs they bear because of employees who smoke. Using this model, if employers have 1,000 employees, the employers are incurring approximately $655,520 annually in additional costs, which can make a substantial impact on the company’s bottom line. As a result, it is in the best interest of the business bottom line for employers to encourage their employees to quit smoking. 27 www.njquit2win.com HOW MUCH DOES SMOKING REALLY COST? SMOKERS REAP IMMEDIATE HEALTH BENEFITS BY QUITTING Although smokers are aware that they risk serious health consequences by smoking, some believe that the damage has already been done and that they can do nothing about it. The good news is that they are wrong. What many smokers do not know is that quitting will give them major health benefits no matter WHY IS IT SO HARD FOR SMOKERS how long they have been smoking. Quitting after years of smoking not only prevents further damage but also actually may reverse TO QUIT? some of the effects smoking has already caused. These benefits begin to happen within minutes after smoking the last cigarette, and the improvement continues for years. • Within 20 minutes after quitting, blood pressure and pulse rate decrease. • After eight hours, carbon monoxide levels in the blood drop while oxygen levels rise. • After 24 hours, the chance of a heart attack decreases. • CESSATION COUNSELING start regenerating, and the ability SMOKING After 48 hours, nerve endingsAND PHARMACOTHERAPIES to smell and taste is enhanced.73 DO WORK Additional potential health benefits are achieved in a matter of months. • After three months, circulation improves, walking becomes easier and lung function increases. • After nine months, coughing, sinus congestion, fatigue and shortness of breath NEW JERSEY HELPS RESIDENTS decrease.74 QUIT 2 WIN However, the greatest potential health gains are made after one year or more of being smoke-free. While it takes longer to accrue these health benefits, they offer the most substantial advantages. • After one year, the added risk of coronary heart disease is decreased to half that of a current smoker. • After five years, risk of cancers of the mouth, throat and esophagus is reduced by 50 percent. • After 10 years, the risk of lung cancer drops to half that of smokers. • After 15 years, the added risk of coronary heart disease is the same as nonsmokers.75 Even smokers who already have been diagnosed with lung cancer and are facing lung surgery can benefit from quitting. A recent study found that some lung cancer patients who quit for at least one year before their diagnosis, and even some smokers who quit only after diagnosis, had lower mortality rates and recurrence rates than smokers who continued to smoke after diagnosis.76 Within minutes of quitting, smokers can, once again, take control of their lives and experience improvements in their breathing, feeling less shortness of breath and less fatigue and having more stamina. 28 www.njquit2win.com SMOKERS REAP IMMEDIATE HEALTH BENEFITS BY QUITTING WHY IS IT SO HARD FOR SMOKERS TO QUIT? The Three Faces of Tobacco Dependence Given the enormous impact that tobacco use has on a person’s health and finances, why do so many people continue to smoke? For those who have never struggled with a tobacco SMOKING CESSATION COUNSELINGaAND PHARMACOTHERAPIES choice. However, just addiction, quitting may seem like simple matter of will power and DO WORK as researchers have learned a great deal during the last several decades about the health impacts of tobacco use, they have also gained a greater understanding of the highly addictive nature of smoking. Smoking triggers a three-pronged dependence: physical, psychological and behavioral. NEW JERSEY HELPS RESIDENTS Smoking is not simply a bad habit that can be dropped. On average, smokers try to quit eight to 11 times before they succeed,77 and most smokers who try to quit relapse within QUIT 2 WIN the first week.78 Without addressing all three aspects of this addiction, most smokers fail to quit for good. The Physical Addiction to Nicotine Nicotine is one of the most addictive drugs available. Furthermore, when cigarette smoke is inhaled, nicotine reaches the brain within 10 seconds — much faster than when a drug is injected intravenously.79 As soon as nicotine reaches the brain, it causes a release of epinephrine (adrenaline) and glucose, which raise the heart rate, respiration and blood pressure. In addition, nicotine causes the body to release dopamine in the part of the brain that controls feelings of pleasure and motivation — the “reward center.” This is the “hit” that the body starts to expect and crave, and it is similar to the physical reaction that occurs in abuse of drugs, such as cocaine or heroin. When bloodstream nicotine levels are at their peak, the brain is highly stimulated.80 The more people smoke, the more tolerance they develop to the effects of nicotine, and thus, the more nicotine they need to get the same pleasurable sensation. Nicotine is metabolized quickly in the body, causing smokers to continue smoking throughout the day to seek these pleasurable feelings and avoid withdrawal symptoms. Withdrawal from nicotine can make smokers feel irritable, jittery, tired or depressed.81, 82 In addition, smokers can experience severe cravings, sleep disturbances, cognitive difficulties and attention deficits.83 Withdrawal symptoms can begin within a few hours of smoking the last cigarette, peak within the first few days and typically last a few weeks.84 The struggle to get through those initial weeks may be one of the greatest challenges many smokers ever face. 29 www.njquit2win.com However, many smokers report that their intense cravings for a cigarette continue beyond those first few weeks. These cravings are not caused by nicotine, but by the other two elements of addiction to smoking — psychological and behavioral dependence. Psychological Dependence Because of the pleasurable sensations derived from nicotine, smokers develop cravings for the things they associate with smoking, such as the feel of the cigarette in their hand and those things that become a part of their smoking ritual. Taking the cigarette out of the pack, lighting up and exhaling the smoke all become a part of the pleasure that the smoker receives from smoking. Each of these things becomes part of the dependence. Smokers also depend on smoking to combat feelings of stress, loneliness, anger, depression, frustration or anxiety. Cigarettes may become a source of comfort. Many former smokers speak of quitting smoking as “losing their best friend.” They are psychologically dependent on cigarettes. Behavioral Dependence Quitting smoking is not just about giving up cigarettes. When smokers quit, they have to overcome the habits that they have developed which surround their addiction and trigger their urge to smoke. For example, many smokers must have a cigarette in the morning to begin their day. That cigarette can be as important, or more important, than their morning coffee. It is an integral part of their morning routine, much like brushing their teeth or reading the morning paper might be for others. Altering that routine can make an individual feel uncomfortable and unprepared to start the day. There are many daily routines that smokers associate with smoking: walking the dog, talking on the phone, driving to work, taking their afternoon break, drinking coffee or cooking dinner, to name a few. For smokers trying to quit, activities associated with smoking can produce cravings seemingly beyond their control. While nicotine gum and patches may alleviate the physical aspects of withdrawal, cravings often persist because the activities that trigger smoking are so closely tied to a smoker’s daily routines. Activities become associated with cigarettes and can create the urge to smoke. To succeed in quitting, smokers need to overcome the habit of lighting a cigarette whenever they undertake those activities. Identifying and learning how to deal with personal triggers are among the most important steps in quitting. 30 www.njquit2win.com WHY IS IT SO HARD FOR SMOKERS TO QUIT? SMOKING CESSATION COUNSELING AND PHARMACOTHERAPIES DO WORK An Evidenced-Based Approach The U.S. Public Health Service issued the first set of guidelines for treating tobacco NEW JERSEY HELPS RESIDENTS dependence in 1996, Smoking Cessation Clinical Practice Guideline No. 18, to advise health care providers and tobacco treatment specialists on the most effective treatment QUIT 2 WIN approaches. The report’s conclusions were grounded in 3,000 research studies on cessation published in the 19 years between 1975 and 1994. At that time there were few smoking-cessation programs and they had not existed long enough to provide sufficient data regarding their efficacy and effectiveness in long-term cessation. However, in the next six years both tobacco dependence programs and the research on them exploded. Funds from the Master Settlement Agreement provided to the states by the tobacco industry and other sources became available to develop scientifically based cessation programs. These developments made it possible to conduct rigorous studies to determine the best methods and guidelines for treatment of tobacco dependence. By 2000, an additional 3,000 studies of cessation programs were published and the Public Health Service had gathered sufficient data to develop a more definitive set of guidelines for treatment programs, backed by substantial research findings. Treating Tobacco Use and Dependence was sponsored by a consortium of federal government and nonprofit agencies, including the CDC, the National Cancer Institute, the National Institute on Drug Abuse, the National Heart, Lung and Blood Institute, the Agency for Health Care Research and Quality, the Robert Wood Johnson Foundation and the University of Wisconsin Medical School’s Center for Tobacco Research and Intervention. The CDC now asserts that “The science base (about how to prevent and control tobacco use) has been established over several decades of clinical, behavioral, and epidemiologic research and has been proved through rigorous evaluation of comprehensive programs at the national, state and local levels.”85 The new guidelines were based on extensive systematic reviews of scientific literature and research about which methods, pharmacotherapies and counseling curricula would be most effective in helping State programs, clinics, health care professionals and other social programs that target tobacco dependence. The report concludes that the following three types of counseling and behavior therapies are particularly effective and should be used with all patients attempting tobacco cessation. • Provision of practical counseling (problem-solving skills/skills training). (See Chart A); • Provision of social support as part of treatment (intratreatment social support); • Help in securing social support outside of treatment (extratreatment social support). 31 www.njquit2win.com The guidelines also stress the effectiveness of using pharmacotherapies such as nicotine replacement therapies (NRTs) and other drugs such as bupropion. In addition, the guidelines recommend that these pharmacotherapies be used for all patients attempting to quit smoking, unless there is a previously existing medical condition that precludes their use. Smoking cessation counseling programs are structured to help smokers combat not only the physical addiction but also the psychological and behavioral stumbling blocks to quitting. Programs can also assist in identifying the most effective NRTs to help overcome the physical addiction. Practical Counseling Treating Tobacco Use and Dependence compiled and analyzed studies conducted throughout the nation to identify the methods of counseling that are the most effective in treating tobacco dependence. It concluded that practical counseling — training in problemsolving skills — is an effective method of treatment. As discussed in the previous section, breaking dependence on tobacco is not just a matter of will power. Practical counseling provides smokers with tools to help them combat all three forms of dependence: physical addiction, and emotional and behavioral dependence. First, the counselor provides basic information about the effects of nicotine addiction and withdrawal, explaining what withdrawal feels like, what to expect and how long it can last. The counselor also explains how even one cigarette can undo weeks of diligent resistance. This coaching helps smokers make more informed and better choices as they go through the quitting process. Another technique is to teach smokers how to anticipate the triggers that make them want to pick up a cigarette and to avoid these triggers by changing their behaviors or activities. (See Chart A). This empowers ex-smokers to take control of the situation by showing them what they can do to ward off these triggers and stay in control. Smokers can avoid these situations and replace them with other activities. For example, some smokers are used to going outside to smoke with friends during their work breaks. The counselor may encourage them to take a walk instead. Other smokers may feel the urge to smoke when they are under pressure to meet deadlines at work. Obviously, one cannot eliminate this trigger. However, the counselor can help smokers anticipate this type of trigger and together develop substitutes for smoking when it occurs. 32 www.njquit2win.com Chart A: Practical Counseling Therapies86 Practical Counseling (ProblemSolving Skills Training) Recognize Danger Examples • • • • • Negative effects on health, appearance and budget Being around other smokers Drinking alcohol Experiencing urges Being under time pressure Develop Coping Skills • Learn to anticipate and avoid temptation • Learn cognitive strategies that will reduce negative moods • Accomplish lifestyle changes that reduce stress, improve quality of life or produce pleasure • Learn cognitive and behavioral activities to cope with smoking urges (e.g., distracting attention) • The fact that any smoking (even a single puff) increases the likelihood of a full relapse • Withdrawal typically peaks within one to three weeks after quitting • Withdrawal symptoms include negative mood, urges to smoke and difficulty concentrating Provide Basic Information Social Support Within the Treatment Program Counseling alone may not be sufficient for some smokers. Structured group support can make the difference in helping these smokers achieve their quitting goals. Group sessions provide a sense of community among smokers as they begin the quitting process. Participants connect with others by discussing concerns and fears about quitting and sharing quitting techniques that work. Members can empathize and offer suggestions to newcomers. New members may be more willing to accept advice from others who have succeeded in quitting and who have more experience with the quitting process. Members encourage and motivate each other to keep trying when quitting seems most difficult. Likewise, those who have been in the program longer and are offering advice and suggestions often feel obligated to try harder as they become role models to others. This social support helps the newer quitters through some of the difficult periods of early withdrawal and helps the more seasoned members of the group to work through their own recurring setbacks and urges. As bonds form, members of the group start to feel connected and begin to want to succeed not only for their own benefit but also because of an obligation to contribute to the success of the group. They do not want to disappoint those who are cheering for them. The result is a stronger determination by all group members to succeed. 33 www.njquit2win.com Social Support Outside of the Treatment Program While having a support network within the counseling setting is an important key to successful quitting, smokers can gain an extra boost toward success if they also receive support from their friends and families. Since smoking cessation requires behavioral, physical and emotional adjustments, the support from friends, family members and co-workers is essential. They need to recognize their important role in the process. Research shows that this social support increases smokers’ chances of successful quitting by 50 percent. By offering encouragement and help in avoiding the smoking triggers, rewarding progress and expressing confidence in the smoker’s ability to succeed, friends and family members can make the difference between success and failure in the quitting process. Pharmacotherapies Nicotine Replacement Therapy (NRT) NRTs and other pharmacotherapies are effective in combating the physical symptoms of nicotine withdrawal. Five first-line pharmacotherapies are found to increase reliably longterm smoking abstinence rates. These include various forms of nicotine replacement, including the gum, inhaler, nasal spray, and patch, as well as antidepressants. Nicotine gum is an over-the-counter product found to increase smoking cessation success rates by 30 percent to 80 percent. The nicotine inhaler, a prescription product, has been found to more than double long-term abstinence rates. The nicotine nasal spray, another prescription medication, also more than doubles long-term cessation success. The nicotine patch, available by prescription and over-the-counter, doubles long-term success rates. Another NRT option that was not referenced in the treatment guidelines is a nicotine lozenge, which has been on the market since late 2002— two years after the guidelines had been published. The treatment guidelines also recommend using a combination of NRTs to increase success rates for smoking cessation. The guidelines state that using the patch to maintain a continuing dose of NRT in conjunction with another form of self-administered NRT, such as gum or nasal spray to stave off an acute craving, is more effective than using a single source of NRT. While there are similarities in the way smokers experience nicotine withdrawal, varying levels of addiction among smokers affect the withdrawal symptoms. The NRTs now available make it possible for a counselor to work with smokers to identify the appropriate therapy and dosage for each smoker. NRTs like any other treatment, may not work as expected for some smokers. It is important to note that nicotine replacements must be used correctly or they will not be effective. For example, someone using the nicotine patch should use the recommended 34 www.njquit2win.com dose and not cut the patch in half or quarters in an attempt to save money. In addition, for the gum to be effective, it must be chewed as directed in the instructions in the package. If the instructions are not followed, it will not have the desired effect, and the medications can fail, which can make smokers feel as if they have tried every method available and are unable to succeed. A counselor can explain the proper use of the NRTs and how modifications in their use can sabotage smokers’ efforts. Other Medications Bupropion SR (Sustained Release) is an antidepressant that is recommended to alleviate the symptoms of nicotine withdrawal. Known as ZybanTM or WelbutrinTM, bupropion SR is the first non-nicotine medication approved by the Food and Drug Administration (FDA) for smoking cessation. Both medications are antidepressants. Studies have shown that the use of these products doubles long-term cessation rates when compared with a placebo. In May 2006 the Food and Drug Administration approved a new therapy for smoking cessation, varenicline, which works to block nicotine’s effect in the brain. The drug targets the addiction center of the brain and reduces the severity of withdrawal symptoms. In addition, if smokers, who are trying to quit using varenicline smoke a cigarette, the drug can reduce the pleasure usually derived from smoking. Studies have shown that 20 percent of smokers using this therapy remained smoke-free one year after quitting. The drug became available by prescription in the summer of 2006 under the name Chantix™. Two second-line pharmacotherapies, clonidine and nortriptyline, are also available. These are sometimes prescribed if the first-line therapies are not effective. Both of these are prescription drugs for use under a doctor’s guidance. They are considered second-line treatments because the FDA has not approved their use for smoking cessation and because there are more concerns about side effects with these drugs. Clonidine is an antihypertensive drug that alleviates such symptoms of nicotine withdrawal as nervousness, agitation, headache and tremor accompanied by a rapid rise in blood pressure. Nortriptyline is another antidepressant. Chart B describes each type of therapy available, how it is used, and the pros and cons of its use. 35 www.njquit2win.com Chart B: Parmacotherapies87 Therapy Use Pros • Easy to use • Few side effects • Steady dose of nicotine • Convenient • Flexible dosing • Faster release of nicotine compared with patches Cons • Possible skin irritation. • Slow release of nicotine. • Cannot eat or drink acidic foods while chewing the gum • Must be used frequently to obtain adequate nicotine level • May not be suitable for people with dental problems • Eye and nose irritation is common but decreases within one week • Must be used frequently to obtain adequate nicotine level • Must be used frequently to obtain adequate nicotine level • May cause mouth or throat irritation Nicotine Patch (Over- Apply to the skin the- counter – OTC) (rotating patch site daily). Releases steady dose of nicotine through skin. Nicotine Gum (OTC) Briefly chew, then “park” between cheek and gum. Nicotine is slowly absorbed through the lining of the mouth. Nicotine Nasal Spray (Prescription only) Use every one to two hours. Take a deep breath, hold it and spray once into each nostril. Exhale through the mouth. Nicotine is absorbed through the lining of the nose. • Flexible dosing • Faster release of nicotine compared with patches, gum or inhaler Nicotine Inhalers (Prescription only) Place mouthpiece of • Few side effects inhaler in the mouth. • Mimics hand-toBreathe in one to three mouth behavior of times, gently drawing smoking air into the mouth. • Faster release of Hold it in the mouth nicotine compared for few seconds before with patches breathing out. Nicotine is absorbed through the lining of the mouth. One week before stopping, take one pill for the first three days. After three days, begin two pills a day, eight hours apart (one in morning and one in late afternoon). • Few side effects • Easy to use • May be more helpful when used with patch, spray, gum or inhaler Bupropion HC1 (ZybanTM or WelbutrinTM) (Prescription only) • Do not take if using another form of bupropion. • Do not use if one has had seizures, epilepsy, significant head trauma, stroke, brain tumor, brain surgery or eating disorders. 36 www.njquit2win.com Therapy Varenicline tartrate (Chantix) (Prescription only) Use Pros Cons One week before • The only • Possible side effects: quitting begin taking a pharmacotherapy nausea, headache, white tablet (0.5 mg.) that works directly vomiting, gas, once a day after eating. on the addiction insomnia, abnormal On the fourth day take center in the brain dreams and changes one white tablet in the to reduce withdrawal in taste perception. morning and one in the symptoms These side effects evening after eating. • Convenient may be relieved On the eighth day (the with a lower dose of quit date) take one blue the medication tablet (1 mg.) in the • Do not take if morning and one in the pregnant, evening and continue breastfeeding or are this pattern for the under 18 years old remainder of the • Those who have 12-week course of kidney disease treatment. If the smoker should consult with is still smoke-free at the their doctors about end of treatment, taking a reduced smokers should consult dose with their doctors about taking another course of the therapy to ensure long-term cessation. While pharmacotherapies are effective in reducing the physical dependence on smoking, they do not address the psychological or behavioral dependence on it. Practical cessation counseling and social support coupled with pharmacotherapy substantially increases rates of success in becoming smoke-free. The decision to quit is not an easy one. Once smokers decide that they want to stop smoking, they should be aided to make this life-saving and life-enhancing goal a reality. 37 www.njquit2win.com SMOKING CESSATION COUNSELING AND PHARMACOTHERAPIES DO WORK NEW JERSEY HELPS RESIDENTS QUIT 2 WIN New Jersey Quit Services More than three quarters of New Jersey’s 1.15 million smokers want to quit, and the new Smoke-Free-Air Act, banning smoking in indoor public places and workplaces, including restaurants and bars, is motivating many to seek help in quitting. The Act, signed into law in January 2006 by Governor Richard J. Codey and implemented on April 15, 2006, ensures that workers have a safe workplace and that all nonsmokers, including children and senior citizens can breathe smoke-free air in the public places they visit. New Jersey was the 11th state to adopt such a law to protect its citizens. An additional benefit of the law is that it provides another incentive to New Jersey smokers to quit. Data from New Jersey’s free Quit Services, NJ Quitline and NJ QuitNet document this trend. From January through June 2006, 2,048 smokers used NJ Quitline, increasing by nearly three and a half times the 600 calls received during the same period in 2005.88, 89 The number of unique visitors to NJ QuitNet from January through June 2006 was 48,210 compared with 42,110 during the same time period in 2005, increasing the volume of unique visitors by 14.5 percent.90, 91 If smokers try to quit without help, only three percent of them will succeed. New Jersey was an early leader in providing effective smoking cessation services to help its residents succeed in quitting smoking and reduce smoking rates. In 2000, the NJDHSS Comprehensive Tobacco Control Program (CTCP) launched a unique package of three free or low-cost smoking cessation services to help New Jersey’s smokers succeed in quitting. These services are offered via telephone through NJ Quitline (1-866-NJ-STOPS) and online at NJ QuitNet (www.nj.quitnet.com). In addition, the State provides funding for eight NJ Quitcenters across the State to provide face-to-face counseling. NJ Quitcenters are located in Camden, New Brunswick, Newark/Union City, Somerville, Long Branch/Toms River, Jersey City, Somers Point and Trenton. This is the only state in the nation that offers smokers direct access to three different ways to quit smoking so that smokers can select the method best suited to their needs. As a result of these actions, adult smoking rates in New Jersey have declined from 19.8 percent to 17.4 percent from 2000 to 2005. The State’s goal for Healthy People 2010 is to reduce smoking rates in New Jersey to 15 percent by that date. New Jersey is committed to ensuring that all New Jersey smokers who want to quit get the help they need to succeed. 38 www.njquit2win.com New Jersey Quitline NJ Quitline, operated by the Mayo Clinic, is a toll-free service that provides access to trained counselors in 26 languages. NJ Quitline offers each caller one-on-one counseling with a designated counselor for the duration of the program. Counselors help smokers to develop a treatment plan that meets their individual needs. The initial call takes about 30 minutes. During this time, counselors assess the callers’ tobacco-use history, help set a quit date and define an appropriate quitting strategy. In addition, the counselors develop an individualized follow-up plan for each smoker. Smokers initially receive four free counseling sessions, and they may receive additional help if needed. NJ Quitline is proven to be highly successful. More than 30 percent of registered users report being smoke free six months after completing the program, the commonly accepted milestone for measuring success. This result is well-above the national success rate of 10 percent to 12 percent for structured cessation programs. New Jersey QuitNet Developed by cessation experts, NJ QuitNet is a free online service that provides a comprehensive individualized plan to help smokers quit. This treatment service is based on a technological innovation developed in 1995 by Join Together, a substance abuse resource center, and the Boston University School of Public Health. It is a tested resource and has become an internationally accepted Web-based tobacco cessation program that has been customized for New Jersey smokers. The service gives smokers online access to peer support groups and trained counselors 24 hours a day, seven days a week. In addition to its flexibility and anonymity, this service offers users a comprehensive Quitting Guide. This guide helps smokers plan a strategy for quitting, get referrals to local programs and learn about medications. Smokers can set a quit date, keep track of progress with a personalized quitting calendar and access important information about smoking-related issues. Through an online chat room, smokers can network with other people who are in the process of quitting or get advice from those who have successfully quit. New Jersey Quitcenters NJDHSS sponsors Quitcenters throughout the State. The addition of three Quitcenters in 2006 brings the current total of NJ Quitcenters to eight. These counseling facilities are located in Camden, New Brunswick, Newark/Union City, Somerville, Trenton, Long Branch/Toms River, Jersey City and Somers Point. Contact information for these Quitcenters is available at NJ QuitNet (www.nj.quitnet.com) or from NJ Quitline (1-866-NJ-STOPS). In addition, there are other Quitcenters, not funded by NJDHSS, that operate in other locations. 39 www.njquit2win.com These hospital-based clinics meet the needs of smokers who are highly addicted to nicotine but also highly motivated to quit. These smokers may have made several unsuccessful quit attempts and may have little chance of succeeding without intense treatment. At least two counselors, trained through a program of the University of Medicine and Dentistry of New Jersey – School of Public Health, work at each facility. NJ Quitcenters offer individual and group therapy and can provide advice on the appropriate use of pharmacological treatments. These clinics offer reduced-cost NRTs as well. Services are available on a sliding-fee scale according to income. Quit 2 Win Campaign With these services in place to help its residents, New Jersey still faces the challenge of increasing awareness of the services and understanding of how they work to help smokers succeed in breaking their addiction to cigarettes. Surveys and focus groups have shown repeatedly that smokers believe that they must quit smoking on their own. To counter this perception, smokers need to understand how the practical counseling techniques used in NJ Quit Services actually empower them to succeed. Smokers must make the commitment to quit, but the counseling services provide the tools that increase their chances of success. To address the challenge of limited media funding and expensive media markets, the NJDHSS launched a Quit 2 Win campaign in January 2005. The campaign issued a call to action to every individual, organization and institution in the State to help inform smokers about NJ Quit Services and how these services work to help smokers quit. Equally important is the campaign’s message about how difficult tobacco dependence is to break and how important support and encouragement are in helping smokers succeed in quitting. To arm New Jerseyans for this task, the NJDHSS created a Quit 2 Win microsite on the Internet and filled it with a variety of downloadable tools that individuals and organizations can use to inform smokers and those who want to help them quit. Materials include: • Poster/print ad. • Newsletter articles of varying lengths. • PowerPoint presentations on why smokers should quit and how NJ Quit Services help them succeed. • Digital video featuring two people, Jane and Jayson, who quit smoking using NJ QuitNet and NJ Quitline, respectively. • Digital video of college students who quit by using NJ QuitNet. • Fact sheets on NJ Quit Services and the Quit 2 Win campaign. • Be Smoke-Free in New Jersey: Quit 2 Win white paper on smoking and cessation. 40 www.njquit2win.com Smoke-Free New Jersey: A Breath of Fresh Air As New Jersey’s Smoke-Free Air Act was about to go into effect on April 15, 2006, NJDHSS and the Robert Wood Johnson Foundation joined forces to raise awareness and understanding of the new law and provide resources to facilitate compliance. To achieve this goal, the Robert Wood Johnson Foundation funded a statewide public education campaign, Smoke-Free New Jersey: A Breath of Fresh Air, with an initial $380,000 grant. The campaign includes a direct-mail component to businesses, billboard and print ads, and advertising on buses, the Internet and radio. In addition NJDHSS created a new Web page, www.smokefree.nj.gov as a resource center enabling people to download copies of the law, brochures, fact sheets, no-smoking signage and educational presentations. The page also includes a link to the www.NJQuit2Win.com, a Web-based guide to the State’s smoking cessation services. Be Smoke Free in New Jersey: Quit 2 Win Campaign NJDHSS took steps as part of the initiative with the Robert Wood Johnson Foundation to help smokers who want to quit. The Department extended its radio advertising campaign for NJ Quitline for one month following implementation of the Smoke-Free Air Act to encourage smokers to use this free and effective smoking cessation service. New Jersey anticipated a significant increase in the number of smokers trying to quit based on New York City’s experience. In the first year after New York City adopted a similar ban, smoking rates dropped by 11 percent — the largest decline in the city’s history.92 In addition, an Internet poll of 500 New Jersey smokers conducted on behalf of NJDHSS in March 2006 revealed that 13 percent were anticipating the implementation of the smoking ban by planning a quit date. NJDHSS also joined forces with three of the State’s premier health advocacy organizations to mount a statewide campaign to help smokers quit smoking called Be Smoke-Free in New Jersey: Quit 2 Win. This campaign, created to coincide with the implementation of the Smoke-Free Air Act, was launched in partnership with the American Cancer Society Eastern Division, the American Lung Association of New Jersey and the American Heart Association – Heritage Affiliate. The campaign informs smokers about the full range of services and tools available to help them succeed at quitting. The campaign focuses in particular on reaching smokers through their workplaces and doctors’ offices, two locations in which they easily can be reached. The partners are asking employers to use the resources available at www.NJQuit2Win.com, including fliers, fact sheets, posters, prepared newsletter articles and presentations to inform their employees. However, the campaign is most interested in persuading 41 www.njquit2win.com employers and union leaders to start a dialogue with smokers about quitting by conducting presentations, available in PowerPoint on the Web site. With regard to physicians, nurse practitioners and physician assistants, the partnership is encouraging them to intervene with patients by instituting a 2A’s + R (Ask, Advise, and Refer) process: Ask patients if they smoke; Advise smokers to quit and Refer them to NJ Quit Services and other resources available at www.NJQuit2Win.com. Clinicians will be able to access a downloadable referral slip for NJ QuitNet and NJ Quitline and the Web site. They will also have access to downloadable stickers that they can place on smokers’ files to facilitate follow-up discussions with these patients to check on their progress. CONCLUSION New Jersey is taking leadership on several fronts to reduce the unacceptable human and economic toll that smoking is taking on residents of the State. NJDHSS is committed to providing accessible and effective smoking cessation services to smokers who want to quit and to reducing the hazards of secondhand smoke by ensuring smoke-free workplaces and public spaces. 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